1. RESTRATION OF FACIAL DEFECTS
NASAL & MID FACE DEFECTS

2. Facial defects can result from:
1-Truma.
2-Treatment of neoplasm.
3-Congenital malformation.
Most of facial defects is caused by resection of epithelial neoplasms.
Common carcinomas affect the skin of the head & neck region are basal cell carcinoma , squamous cell carcinoma& malignant melanoma.

3. Rehabilitation of facial defects
Surgical reconstruction verses prosthetic restoration:
It depends on :
1-the size of the defect.
2-the etiology of the defect.
3-the age of the patient.

4. Nasal defects

5. Anatomy of the nose

6. Anatomy of the nose The nose is formed of:
A- Internal structures: it includes
1-Nasal cavity.
2-Nasal conchae ( anterior, middle& posterior).
B-external structures: it includes
1-The tip of the nose(columella).
2-The dorsum of the nose.

7. Anatomy 3-The bridge of the nose. 4-ala of the nose. 5-The nares.
6-The nosolabial folds.

8. Surgical reconstruction of defects
For reconstructing of the nose four basics should be followed:
1-Adequate flap length.
2-Avoiding tension.
3-Providing a base for the new nose.
4-Establishing one-piece reconstruction.

9. Prosthetic restoration of nasal defects
The majority of nasal defects are secondary to treatment of neoplasm.
Most partial nasal defects are restored with surgery while total nasal defects are restored prosthetically.

10. Materials used for facial prothesis
1-Acrylic resins (not use now).
2-Acrylic copolymers.
3-Vinyle polymers & copolymers(Mediplast
4-Polyurethane elastomers. (Epithane-3)
5-Silicone elastomers: it is available in two forms:
-HTV.
-RTV.
Most commonly used materials for facial restoration.

12. Before and after surgical reconstruction

13. Before &after surgical reconstruction

14. Pre-prosthetic consideration
1- the surgeon should remove the nasal bone as well as the rest of the nose.
2-the wound should not be closed primarily.
3-The placement of split thickness skin over exposed tissue bed areas is preferable.
4-Prior to surgery ,facial impressions & photographs should be obtained.
5-Psychological evaluations & consultations should begin prior to the resection.

15. Main problems of nasal prosthesis
1-Retention of large nasal restoration.
2-Esthetic of the prosthesis.
3-Color matching.
There are internsic & externsic coloration.
The internsic coloration are more stable while extrinsic coloration wear rapidly because of ultraviolet rays & surface oxidation.

16. Impressions
Prior to surgery ,facial impressions are preferred because they provide useful information for clinician.
Steps:
1-The pt is in upright position.
2-Elastic impression materials is used as
Irreversible hydrocolloid.
3-The nasal passage should be blocked out with gauze.

17. Impressions
The gauze used to cover the middle nasal conchea because it contains ridges & part of impression materials may cut inside it and act as foreign body.
Prosthodontist prefer irreversible hydrocolloid because it has low tear strength & high flow.
Facial impression is carried out for the pt.

18. Steps of impressions
4-Using the preliminary cast ,master impression tray is fabricated confined to the defect area.
5-A syringe is used to inject impression material to areas of difficult access.
6-Taking care not to compress the tissue bed.
6-After setting of the impression, a master cast of dental stone is prepared.

19. Steps of impressions

20. Steps of impressions

21. Steps of impressions

22. Types of nasal prosthesis
1-Temporary nasal prosthesis.
2- Definitive nasal prosthesis.

23. Temporary nasal prosthesis
-Approximately 3-4 weeks following surgery.
-Heat polymerizing methyl methacrylate is preferred because it can be relined with a temporary denture reliner.
-Retention of the prosthesis is accomplished with medical grade skin adhesive.

24. Definitive nasal prosthesis
-After 3-4 months fabrication of definitive
prosthesis is carried out.
-Flate defects in which the nasolabial folds remain are the easiest to restore prosthetically.
-In most pts the residual tissue bed is highly mobile therefore prosthesis of highly flexible materials are advised.

25. Classification of nasal restoration
It can be classified according to the means of retention into:
1-Adhesives: medical grade adhesive
Disadvantages :
a- Applied periodically.
b- sometimes allergic.
c- difficult to clean the skin & prosthesis.

26. Classification 2- Eye glass frame. 3- Implant :
Bone in and around facial defects into which osseointegrated fixtures can be placed depends on the size, location of the defect and integrity of the residual structures.
a-The piriform area of the floor of the nose.

27. Classifications
b- The superior surface of the maxilla offer sufficient bone to place fixtures.

28. Before & after prosthetic restoration

29. Before & after prosthetic restoration

30. Where is the face !

31. Mid face defects

32. Restoration of large mid face defects
Advanced tumors of the midfacial region resulting in surgical defect which may involve loss of both extraoral & intraoral structures, including portions of the nose, upper lip, cheek, and orbital contents.
Also segement of the maxilla, mandible, associated soft tissue, and teeth may be involved.

33. Complications
Loss of integrity of the oral cavity results in difficulty in mastication, swallowing, control of saliva, and speech production.
These functional disabilities combined with cosmetic disfigurement which lead to sever psychological impact on the pt

34. Prosthetic prognosis It depends on:
1- The size & location of the surgical defect.
2-Movable tissue bed may complicate the function of the prosthesis & compromise its retention.
3-The status of lower lip function is another prognostic indicator.
4-The adaptability of the pt.

35. When surgical reconstruction is not possible slight modifications may be useful to the prosthodontist as:
1-Retention of the teeth that can be used to support & retain the prosthesis.
2-Preparation of the soft tissue bed that will create undercut areas for retention.
3-Placement of skin grafts to minimize tissue contraction.

36. Types of facial prosthesis
1-Temporary midfacial prosthesis.
(can be delivered 10 days after surgery).
2-Definitive mid facial prosthesis.
Modeling plastic & thermoplastic waxes can be used to record the movement of the tissue.
After the tray is border molded, the impression is completed with elastic impression material.

37. Most pts preferred one-piece restoration due to:
1-Food impaction in & around the interface of two piece restoration.
2-Two-piece prosthesis are more difficult to control and manipulate than one piece restorations.
Retention of the facial prosthesis is accomplished by straps, adhesives, tape, eyeglass frames, engaging usable undercuts, teeth, or combination of these methods.

38. Placement of extraoral implants
1- It can be placed in frontal bone area.
2-Zygomatic arches.
3-Maxillary tuberosity.
4-Premaxilla.

39. Before & after prosthetic restoration

41. Thank you