1. Restoration of Facial Defects
Etiology and Basic Principles
John Beumer III DDS, MS
Division of Advanced Prosthodontics, Biomaterials and
Hospital Dentistry
UCLA School of Dentistry
*The material in this program of instruction is protected by copyright ©. No
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or by any information storage or retrieval system, without prior permission.

2. Restoration of Facial Defects
A difficult challenge. Both surgical reconstruction and
prosthetic rehabilitation have distinct limitations
v The surgeon is limited by the complexity of the structures to
be reconstructed, the availability of tissue, compromise of
the local vascular bed by radiation in tumor patients and the
need for visual inspection of oncologic defects
v The prosthodontist is limited by the properties of the
materials available, mobility of the tissues adjacent to the
defects and difficulty of establishing adequate retention for
large combination facial prostheses.

3. Table of Contents
v Etiology of facial defects
v Presurgical consultation
v Surgical reconstruction vs prosthetic rehabilitation
v Materials
v Alterations at surgery to enhance the prosthetic prognosis
v Nasal defects
v Orbital defects
v Auricular defects
v Large midfacial defects
v Basic principles
v Form and symmetry
v Surface texture
v Lines of juncture
v Coloration

4. Etiology
v Facial neoplasms
v Basal cell carcinoma
v Squamous carcinoma
v Malignant melanoma
v Craniofacial anomalies
v Microtia
v Trauma
v Self inflicted gunshot wounds

5. Facial Neoplasms
Basal cell carcinoma
v Benign
v Chronic immunosuppression dramatically
increases the rate (Berg and Otley, 2002;
Euvrad et al, 2003; Hasegawa et al,
2005).
v Locally destructive when unattended
v Clinical presentations:
v Small nodular lesions with a central ulcer
often covered with a crusted core

6. Basal cell carcinoma
v Treatment
v Surgical excision
v Mohs’ chemosurgery (Mohs,
1976; Nelson et al, 1997)
v Radiation
v 45-60 Gy

7. Facial Neoplasms
Basal cell carcinoma
Large defects result when:
v Tumors are left untreated for a number years
v Extensive recurrences

8. Facial Neoplasms
Large extensive basal cell carcinoma

9. Facial Neoplasms
These recurrent basal cell carcinomas extended far
beyond their original sites and required aggressive re-
resections resulting in large facial defects.

10. Facial Neoplasms
Basal Cell Carcinomas
These recurrent basal cell carcinomas extended far
beyond their original sites and required aggressive re-
resections resulting in large facial defects.

11. Facial Neoplasms – Basal cell carcinoma
Radiation therapy
Before After
In large tumors such as this one that have invaded
cartilage, only about 30% fail and require surgery

12. Basal cell carcinoma
Radiation Therapy
Patient developed a
Postradiation – Note
recurrence several
destruction of local
years later requiring
structures
extensive resection

13. Basal cell carcinoma
Mohs’ chemosurgery
v A tissue fixative is applied to the tumor volume
v These tissues are then removed surgically and the specimen is tagged
v The specimen is imbedded, sectioned and immediately examined
microscopically
v Persistent tumor is identified, its location confirmed and these tissue
areas are re-resected on the patient until the specimens are tumor free.
v The defects created are irregular and often residual facial structures
such as portion of the nose remain

14. Basal cell carcinoma
Mohs’ chemosurgery
These defects are more challenging to restore
prosthodontically because:
v The defect tissues are not lined with skin grafts. This makes it difficult to
engage the defect so as to enhance retention and the stability of the
prosthesis
v Residual facial structures are often displaced making it difficult to restore
the appearance of size and symmetry of the lost facial structures

15. Facial neoplasms
Malignant
v Usually well differentiated
v Can be locally destructive
v Advanced tumors can spread to the regional nodes
v Squamous carcinomas associated with chronic
immunosuppression and organ transplantation behave more

16. Facial neoplasms
Squamous carcinoma
Treatment
v Surgery
v Radiation therapy

17. Facial neoplasms
Squamous carcinoma
This tumor has been present for many years
and has destroyed much local tissue

18. Carcinomas arising from the nasal septum
These tumors are usually discovered late and require large
resections of the nose, upper lip and the maxilla.

19. Facial neoplasms
Malignant melanoma
These tumors require aggressive surgical excision.

20. Congenital anomalies
Microtia
Implant retained auricular prostheses have
become a viable option. Why?
v High levels of implant predictability (Parel and
Tjellstrom, 1991; Jacobsson et al, 1992; Sugar and
Beumer, 1994; Roumanas et al, 2002).
v Consistently excellent esthetic results
v Fewer and less invasive surgical procedures
v Reduced cost as compared with surgical reconstruction

21. Trauma
l Self inflicted gunshot wounds

22. Mucormycosis and aspergillosis
This patient required removal of the orbital contents to
control the infection resulting in facial disfigurement.

23. Surgical reconstruction vs prosthetic
restoration of large facial defects
v Many patients prefer that their defects be
masked with their own tissues rather than
with a prosthesis
v Not all patients can accept an artificial
facial prosthesis
v Surgical reconstruction is preferred with
small nasal defects.
v Acceptable results have been achieved by
some surgeons with staged reconstruction
of congenital ear defects (Brent, 2002)
The tip and left ala have been surgically reconstructed in
this patient.

24. Surgical reconstruction vs prosthetic
restoration of large facial defects
Reconstruction of total rhinectomy
defects is extremely difficult with
current techniques and the results
are unpredictable

25. Surgical reconstruction vs prosthetic
restoration of large facial defects
Perceptions have changed
regarding facial prostheses
v Improvements in materials used in
facial prosthetics
v Facial prostheses achieve superior
esthetic results
v Implant retained facial prostheses
have achieved wide acceptance
among surgeons, prosthodontists
and patients (Flood et al, 1998;
Markt et al, 2001;Chang et al 2005)
Prosthesis for a total rhinectomy defect

26. Patient acceptance – Implant retained
facial prostheses
Improved because:
v Quality of the retention
v Improved esthetics that
result from accurate
and repeatable
positioning
v Thinner margins
possible to better
accommodate mobile
tissues
v Ease of maintenance

27. Surgical reconstruction vs prosthetic
restoration of large facial defects
Prosthetic restorations are favored
v When recurrence of tumor is likely
v Because of the need to monitor surgical
site for recurrence
v With large defects – Reconstruction of
large defects is difficult, time consuming
and technically difficult and the outcomes
are unpredictable
v When the defect tissues are heavily
irradiated

28. Presurgical Consultation
Issues
v Psychosocial
v Impressions
v Photographs
v Explain the limits of the prosthetic rehabilitation
v Brief review of prosthetic care procedures

29. Presurgical Consultation
Psychosocial issues
v Challenges confronting patients
v Mortality
v Morbidity
v Functional impairments
v Esthetics
v Quality of life - Social function
v Challenges confronting the provider
v Establish lines of communication
v Maintain empathy and compassion while at the same time maintaining
the ability to motivate the patient to perform needed home care
procedures

30. Presurgical Consultation
Psychosocial issues
v Family members or significant others may be important
assets in communicating needed information to the patients.
v Because these initial consultations are often conducted under
stressful conditions (the patient has frequently jus been informed of
the diagnosis and treatment) patients frequently do not absorb all the
information delivered by the prosthodontist.
v When the patient and/or their families are having difficulty
understanding the challenges and their responsibilities for
home care referral to a clinical psychologist or social worker
is advised.

31. Presurgical Consultation
v Impressions
v Photographs
v Explain the benefits and limits of prosthetic rehabilitation
v Esthetics – Prostheses in movable tissues
v Limits of the physical properties of facial materials
v Retention – Skin adhesives vs Implants
v Brief review of prosthetic care procedures

32. Materials used for facials prostheses
Ideal biologic properties of
processed facial materials
v The cured and any released materials should
not irritate the supporting tissues
v The cured and any released materials should
be non-allergenic
v The cured and any released materials should
be nontoxic

33. Materials used for facials prostheses
v Ideal physical and mechanical properties of
processed facial materials
v The cured material should not transfer heat or cold to supporting
tissues
v The cured material should be resistant to abrasion
v The cured material should be light weight
v The cured material should have high tensile strength
v The cured material should have low surface tension and low water
sorption to resist staining
v The cured material should not be dissolved by solvents, primers or
adhesives
v The cured material should be odorless
v The cured material should not support the growth of micro-
organisms

34. Materials used for facials prostheses
v Ideal physical and mechanical properties of
processed facial materials
v The cured material should be chemically inert
v The cured material should be cleansable with common
disinfectants without loss of detail at the surface or margins
v The cured material should be dimensionally stable
v The cured materials’ flexibility should mimic that of the tissues it
replaces
v The cured material should be stable at a range of temperatures
v Thin feather edges of the material should not tear
v The material should be inexpensive
v The material should have lifelike translucency

35. Materials used for facials prostheses
v Methyl methacrylate
v Polyurethanes
v Silicones

36. Methyl methacrylate
Developed in the 1930’s
Desirable properties
v Color stable
v Easy to color
v Easy to process
v Margins can be feathered
v Excellent cosmetic results
Undesirable properties
v Rigidity
v The material transfers heat or
cold to supporting tissues

37. Polyurethane elastomers
Desirable properties
v Excellent edge strength
v Margins can be feathered
v Elasticity
v Colorability
v Excellent cosmetic results
Undesirable properties
v Not color stable when exposed to
ultraviolet light secondary to surface
oxidation
v Limited life span (3-6 months)
v Difficult to process particularly under
humid conditions
v Poor compatibility with adhesive
systems

38. Silicone elastomers*
Desirable properties
v Color Stable
v Easy to process
v Colorability
v Reasonable edge strength
v Margins can be feathered
v Color stable when exposed to
ultraviolet light
v Lifespan – 1-3 years
Undesirable properties
v Lack of flexibility
v Extrinsic coloration tends to wear off
*A detailed discussion of the silicone elastomers can be
found in Powers J and Kiat-annuay. ”Materials” in
Rehabilitation of Facial Defects (Ch 5) in Maxillofacial
Rehabiliation 3rd edition. Eds Beumer J, Marunick M
and Esposito S. Quintessence Publishing Co. Chicago,
Ill 2011. pgs. 260-71

39. Materials used for facial prostheses
Common problems
To date, none of the commercial materials satisfy all
the requirements of the ideal material. Each of the
materials available has its strengths and weaknesses.
Even though each type of maxillofacial elastomer has
its own unique physical and mechanical properties,
they all share a few common clinical problems which
can be grouped into two categories.
v Discoloration of the prosthesis over time
v Degradation of static and dynamic mechanical
properties of the polymeric materials.

40. Materials used for facials prostheses
Future research should concentrate on several
major goals:
v Improvement of the physical and mechanical properties of
existing materials available or development of new alternative
materials so that replacement materials will behave more like
human tissue and increase the service life of the prosthesis
v Identification of color stable coloring agents for coloring facial
prostheses that are compatible with different types of
elastomers
v Development of a scientific method of color matching to
human skin
v Development of a scientific color formulation system that
conforms to the color matching tool to objectively replicate
human skin shades

41. Alterations at Surgery to Enhance the
Prosthetic Prognosis
v Nasal defects
v Auricular defects
v Orbital defects
v Large midfacial defects
Key factor: During resection and
closure surgeon should attempt to
leave adjacent tissues undisturbed

42. Alterations at Surgery to Enhance the Prosthetic
Prognosis - Nasal Defects
These are ideal defects. Why?
v The nasal bones have been resected
v The nasal labial folds are in normal
position and of normal depth
v Cheek contours are undisturbed
v The upper lip is in normal position and of
normal contour
v The floor of the nose has been lined with
skin
v The anterior portion of the septum has
been removed providing good access to
the defect

43. Alterations at Surgery to Enhance the
Prosthetic Prognosis – Nasal Defects
With ideal defects such as these an excellent
cosmetic result can be obtained and the prosthesis
will be well retained

44. Unfavorable nasal defects
In this patient,
primary closure of
wound resulted in
deficient lip
contours and
distortion of left
nasolabial fold. The
lip is retracted and
elevated.

45. Unfavorable defect.
Note deficient cheek lip contours and superior displacement
of upper lip. Because of distortion of cheeks and retraction
of lip, size and contours of prosthesis were made to be
compatible with existing contours and did not reproduce
preresection nasal size and contour. The angle formed lip
and bottom of the nasal prosthesis is unfavorable

46. Unfavorable nasal defects
The nasal bones have
been retained and the
lip was tied to the nasal
mucosa resulting in
significant superior
retraction of the upper
lip. It is not possible to
fabricate an acceptable
nasal prosthesis on
such a patient.

47. Unfavorable nasal defects
v Retention of the nasal bones
v Retraction of the upper lip
Problems created
a) Nasal bones affect position of the nasal tip
b) Lip will always appear too short even if
nasal tip of the prosthesis is shortened
Result: Unesthetic c) Nasal prosthesis will always appear too
prosthesis large because of the lip retraction and
presence of the nasal bones

48. Unfavorable nasal defects
Total rhinectomy defects better than partial
rhinectomy defects
v Margins are more exposed
v Distortions and displacement of residual nasal
elements make it difficult to restore proper size and
symmetry

49. Alterations at Surgery to Enhance the
Prosthetic Prognosis
Lining the floor of the nose with a skin graft
v Limits contracture and elevation of the upper lip
v Maintains the position of nasolabial folds (the alar
groove should blend continuously with nasolabial fold)
v Provides a platform upon which the prosthesis sits

50. Alterations at surgery to enhance the
prosthetic prognosis
Orbital defects
v Linethe orbit with skin
v Avoid distortion of the eye brow
v Do not close the defect with flaps
v Do not retain the eyelids

51. Alterations at Surgery to Enhance the
Prosthetic Prognosis
Orbital Defects
This orbital exenteration defect is close to ideal. The
entire contents of the orbit have been removed and
the orbital walls lined with skin. However, the position
of the eyebrow is somewhat distorted.

52. Alterations at Surgery to Enhance the
Prosthetic Prognosis
Orbital Defects
v Lateral facial orbital defect resurfaced with a free flap
leaving sufficient space for an orbital prosthesis.
v Orbital prosthesis in position.

53. Alterations at Surgery to Enhance the
The lids were retained following orbital exenteration. There is
insufficient space for an orbital prosthesis. If an orbital
prosthesis is contemplated, they should be removed.

54. Alterations at Surgery to Enhance the
This orbital defect was filled with a flap. As a result,
there is insufficient space for a prosthesis.

55. Alterations at Surgery to Enhance the
The eyebrow has been altered in this patient
making it more difficult to restore facial
symmetry with an orbital prosthesis

56. Alterations at surgery to enhance the
prosthetic prognosis
Ear defects
v Total auriculectomy defects are easier to
restore than partial auriculectomy defects
v Retain the tragus
v Line the defect with a split thickness skin
graft
v Avoid the use of flaps with hair follicles
v When appropriate, place osseointegrated
implants

57. Alterations at surgery to enhance
the prosthetic prognosis
v Retain the tragus.
v Line site with split thickness skin graft. Why?
The tragus helps hide the anterior margin of the prosthesis

58. a
Alterations at surgery to enhance the
prosthetic prognosis
Unfavorable ear defects
Large displaced ear fragments. Bilateral symmetry with
opposite ear cannot be achieved with the prosthesis

59. Alterations at surgery to enhance the
prosthetic prognosis
Unfavorable ear defects
Partial ear defects are more difficult to restore because:
v Blending margins is more difficult
v Bilateral symmetry may be impossible to restore

60. Alterations at surgery to enhance the
prosthetic prognosis
Unfavorable ear defects
This defect has been lined with a hair bearing scalp flap.
Problems that result:
v Difficult to use skin adhesives
v We are unable to place osseointegrated implants through skin with hair
follicles.

61. Large Midfacial Defects
v Skin grafts should be used to line
v All raw tissue surfaces
v All potential support surfaces
v All useful undercuts
v Attempt to avoid distortion of facial contours adjacent to the
defect. Avoid primary closure
v If the upper lip is resected do not attempt to reconstruct it
v Place implants at the time of surgical ablation

62. Large Midfacial Defects
Skin grafts should be used to line
v All raw tissue surfaces
v All potential support surfaces
v All useful undercuts

63. Large Midfacial Defects
Favorable vs Unfavorable Defect
Skin lined vs nonskin lined defect
a b
Compare these two defects. In “a” the maxillary sinus is lined with respiratory
mucosa and the septum has been retained. Such a defect cannot be
effectively engaged to help retain, support or stabilize the oral – facial
prostheses. Patient “b” presents with a more favorable defect. The walls of
the maxillary sinus have lined with skin and the septum has been removed.
Hence, the defect can be positively engaged with the facial prosthesis to
facilitate retention, stability and support of the oral – facial prostheses.

64. Large Midfacial Defects
If the more than half of the upper lip is resected do not
attempt to reconstruct it
Problems
vScarring of the reconstructed lip may limit oral access
vThe reconstructed upper lip retracts superiorly and is unable
to interact effectively with the lower lip to achieve lip
seal. Speech and saliva control are thereby rendered
ineffective
vThe cosmetic result is usually unacceptable

65. Large Midfacial Defects
a
b
In the previous two patients the non functional
reconstructed lip was overlaid with the facial
prosthesis. Both speech and the esthetic result were
enhanced. In patient (b) a moustache has been used
to camouflage the lip margin.

66. Large Midfacial Defects
Placement of implants at the time of tumor resection
v Lateral portion of defect was restored with a free flap
v Implants were placed at the time of tumor ablation. When the
surgical site is healed the implants are fully osseointegrated
and can be used to retain, stabilized and support the proposed
oral – facial prostheses

67. Alterations at surgery to enhance the
prosthetic prognosis
Advantages: Placement of implants at the time
vLimits the number of surgeries of surgical ablation is particularly
vAccelerates rehabilitation – When necessary when large facial
the surgical site is healed and ready defects are anticipated
for a prosthesis, the implants are
osseointegrated

68. Alterations at surgery to enhance the
prosthetic prognosis
Advantages: This practice is recommended
vLimits the number of surgeries even if the patient is to receive
vAccelerates rehabilitation – When postoperative radiation (see
the surgical site is healed and ready lecture “Implants in Irradiated
for a prosthesis, the implants are Patients”)
osseointegrated

69. Basic Principles
v Form and symmetry
v Surface texture
v Lines of juncture
v Coloration

70. Form and Symmetry
Issues
Ideal, and symmetrical contours?
v Yes,but only if the defect is favorable. However, if there
are significant distortions of existing facial contours, the
prosthesis must be tailored accordingly
Restore bilateral symmetry?
v Usually not, particularly if the defect is unfavorable

71. Form and Symmetry
If the defect is favorable ideal symmetrical
contours are developed. Note the various
sizes, shapes, colors and surface textures

72. Form and Symmetry
There were distortions of the existing facial contours in
both of these patients and the prosthesis was adjusted to
accommodate to these alterations.
v Nasal defect with significant v Patient presented with naso-
elevation of the lip on the right. labial fold higher on the right
Nasal prosthesis in position. than on left. The note
Right ala was reduced in size difference in size of ala
and elevated to better blend with between right and left.
existing contours.

73. Form and Symmetry
v Maxillectomy-orbital exenteration
defect. Note deficient cheek
contours.
v Orbital prosthesis in position.
Symmetry is restored in orbital
region but not in cheek. The
contour of zygomatic-malar area
was not restored. Cheek portion
was blended with existing cheek
contours.
v Note how eyeglass frames and
shadows cast by them help
camouflage the defect.

74. Form and Symmetry
v Contour of columella
v The margin is visible on the upper lip. In most
patients it is advisable to place margin beneath
the height of contour of columella

75. Form and Symmetry
After recontouring the columella and tucking its
margin beneath the tip of nose the appearance of the
prosthesis is improved.

76. Surface Texture
A simple stipple is required for most ear prostheses.

77. Surface texture
v Stipple, lines and grooves
must be slightly more
prominent than those on the
adjacent skin. Why?
v Some of the surface detail is
lost during flasking, processing
and the application of extrinsic
colorants.

78. Surface Texture
Orbital defects require much more surface detail
Large orbital defect. Surface texture of suborbital area and
cheek have been faithfully reproduced. Note that texture of
sculpting is slightly more prominent than skin. This is so because
some detail is lost during processing and extrinsic coloration.

79. Surface Texture
Proper surface texture for an orbital prosthesis.
Note orbital skin folds are carefully reproduced.

80. Surface Texture
v Ideal orbital exenteration defect. Defect is lined with skin,
eyebrow is in reasonable position and adjacent facial contours
are not distorted.
v Orbital prosthesis in position. The globe is properly
positioned, the lid contours are excellent as is the coloration.
v What is lacking in this prosthesis?
v Sub orbital skin texture has not been reproduced

81. Margins (Lines of Juncture)
Nasal Defects
v Blend alar groove with
nasolabial folds
v Hide columella margin
beneath the nasal tip
v Feather exposed margins
v Hide exposed margins
beneath eyeglass frames

82. Margins – Lines of Juncture
Note the margins (lines of junction) are difficult
to detect in these patients

83. Margins (Lines of Juncture)
A B
vTragus hides some of the anterior margin (A)
vWithout a tragus the margin anteriorly is carefully thinned (B)
vEar lobe margins represented by a line in the skin

84. Margins (Lines of Juncture)
v The eye glass frames
help to hide the
margins of orbital
prostheses
v In this orbital prosthesis
the surface texture has
been faithfully
reproduced

85. Coloration
Intrinsic vs extrinsic
I prefer extrinsic coloration to create and highlight the
surface detail because:
vIt is easier to train residents in this technique as opposed to intrinsic
coloration methods
vMore consistent esthetic results can be obtained with this method
vThis method is more time efficient. Multiple prostheses can be efficiently
fabricated with this technique

86. Coloration - Extrinsic
v Shade guides will ensure consistency in
color and translucence of base.
v Coloration is accomplished under
corrected light conditions.

87. Coloration - Extrinsic
v Small ear defect.
v Prosthesis engages undercuts behind ear and in concha.
v Completed prosthesis.

88. Coloration - Extrinsic
Nasal and ear prosthesis. Note excellent color
matching, surface texture reproduction and marginal
adaptation.

89. Coloration - Extrinsic
Shadows and skin creases must be embellished with
paint because of the translucence of the material.

90. Coloration - Extrinsic
Shadows must be embellished with paint
because of the translucence of the material

91. Coloration - Intrinsic
a b c
Some clinicians prefer
intrinsic methods d
because:
v The surface detail does
not wear off as easily as
compared to extrinsic
methods.
v Surface texture is better
maintained

92. Coloration - Intrinsic
a b c
Method and Technique:
v Catalyzed silicone colors (a). d
v Painting initial color into mold (b).
v Each layer is allowed to partially
catalyze before the subsequent
one is added (c)
v Subsequent color layers in mold.
v Base shade added to mold (d).

93. Coming soon
vRestoration of nasal defects
vRestoration of auricular defects
vRestoration of orbital defects
vRestoration of midfacial defects

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