15 Fabrication of Nose

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Fabrication of a nose prosthesisKenneth E. Brown, Commander (DC) USN*Naval Hospital, Great Lakes, Ill.

lhhe h uman nose, because of its prominence and commanding role in establishingfacial character, is a difficult structure to replace. 1 Construction of a nose prosthesissupplying adequate function and esthetics requires both prosthodontic and artisticskills., 3 This article describes the technical and artistic procedures involved infabricating a nose prosthesis.IMPRESSION TECHNIQUE

I. Place the patient in a supine position and drape the face.2. Pack moist gauze into the nasal defect to prevent intrusion of impression ma-

terial into the nasal cavi ty.3. Place a wax collar around the face to confine the impression material. A

generous encompassment of the face is required to provide a working moulage withsuffic ient perspective for sculpturing (Fig. 1) .

4. Temper reversible hydrocolloid impression material to a tissue-tolerable rangeof 11 O F. and paint it generously over the skin surface.

5. Use bent paper clips to provide retention for a subsequent plaster reinforce-rnent (Fig. 2).

6. Cover the congealed hydrocolloid and imbedded paper clips with a layer ofquick-setting plaster.

7. After the plaster has set, remove the entire irnpression and examine it foraccuracy of registration.8. If acceptable, box the impression with wide paper rnasking tape and poura working cast (Fig. 3).SCULPTURING THE PROSTHESIS

1. Seat the patient where he can be easily observed.2. Cover the defect site on the working cast with 0.001 tinfoil to facil itate

easy removal of the eventual clay-sculptured nose form.Th e opinioris and assertions contained herein arc the private ones of the author and are

not to be construed as officia l or reflecting the views of the Navy Department or naval serviceat large.

*Chief, Dental Service.


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544 Brown

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

3. Using common artists clay, develop the nose form. Patient observation, pre-surgical moulages, photos, or a sample of classic sculpturing will assist in recon-structuring the defect.

4. Build the clay sculpture to normal contours and end it in a natural line(fold) of the skin of the face. This will provide good peripheral adaptation and al-low the edges of the finished prosthesis to be concealed (Fig. 4) .4

5. Personality and character may be incorporated in the sculpture by developinga prominent arch or a flat nasal bridge. Slight asymmetry given to the aiae, nares;columella, and lateral slopes of the nose provides a natural appearance.

6. As the sculpture reaches the final stages, it can be removed from the workingcast and held against the face of the patient for further evaluation.EXTERNAL DIE CONSTRUCTION

1. Notch the working cast at three equally separated points beyond the marginof the clay sculpture to create aligning keys in the periphery of the dies to be pro-duced.


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Fabrication of a nose prosthesis 545

Fig. Fig. 4

Fig. 3. The working moulage provides enough of the facial architecture and features to facili-tate sculpturing.Fig. 4. The tinfoiled cast shows a proportioned clay sculpture of the nose.

Fig. 5. The cross section illustrates a boxed sculptured nose poured in refractory investment.The plaster reinforcement is represented by the bottom st ippled section. Irreversible hydro-collo id impress ion material with retentive paper clip s is the white center sectio n. The pouredrefractory investment is the top shaded section.

2. Place a wax collar around the clay sculpture in position on the moulage andextend it outward to include the notches in the cast,

3. Use a free-flowing irreversible hydrocolloid (double the water requirementrecommended by the manufacturer for standard dental impression procedures), andduplicate the form o f the surface within the boxing.

4. Again reinforce the impression with plaster as previously described.5. Remove the impression from the working cast and check for accuracy and

detail of the registration.Deelas tic, Kerr Manufacturing Co., Detroit, Mich.


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546 Brown

Fig. 6. Thr refractory cast is shown on which the extrrnal surface die will 1~11 fabricated andbelow a cut-away view of thr wax up with spru ing (square) and venting colum~ts (round ;.

Fig. 7. The working moulage is boxed and a cut-away view of impression material with papelclips is il lustrated.Fig. 8. A boxed impression of the facial defect is registered directly by a sc:c~n d rrversiblehydrocolloid impress ion. Bent paper clip s are imbedded in both impres sions to art as retentiveloops for plaster backing reinforcement (shaded layrrs).

6. Surround the impression with a collar of palmer masking tape. and pour a re-fractory cast using gray investment* prepared in the proportions recommended b)the manufacturer (Fig. 5 ) .

7. Cover the entire tissue representation of the investment (refractory) rastwith three layers of baseplate wax to ,give a castin,q of sufficient thickness For dimen-sional stability.

*Ransom and Randolph Co., Toledo , Ohio.


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Volume 26Number 5 Fabrication of a nose prosthesis 547

Fig. 9. The refractory cast is created from the double-impression procedure made by a directregistration of the primary impress ion of the working moulage. A cut-away view of the cas tswax-up with it s sprue and venting column show that the resulting surface die is an exactduplication of the defect site.

8. Strategically place a sprue of adequate size, and sufficien t escape vents tofacilitate complete and accurate casting (Fig. 6).

9. Place a sheet-metal collar around the waxed refractory cast, positioning thewax sprue column a half inch from the surrounding metal collar. The less insulativeinvestment in the sprue area is created to allow greater acc ess for heat concentration.

10. Fill the metal band enclosure containing the positioned waxed cast withproperly prepared refractory investment, total ly investing the cast, sprue, and vent-ing columns.

11. After the manufacturers recommended setting time has elapsed (generallyrequiring overnight), take the investment mold to the boil-out tank and eliminatethe wax.

12. Place the mold in an oven and bring it up to a casting temperature of300 F., and allow sufficient heat soaking to insure total heat penetration. Thetotal heating time is approximately 90 minutes.

13. Cast the die by slowly pouring molten linotype metal into the sprue untilthe venting colum ns show complete filling. Accurate casting is insured by directinga blowpipe flame on the inventment in the sprue area to maintain a molten reservoirupon which the solidifying casting can draw.

14. After casting, retrieve the metal die, clean it, and examine it for possiblesurface defects.TISSUE-CONTACTING DIE CONSTRUCTION

1. Remove the clay sculpturing from the working moulage.2. Using a wax collar, surround the defect area, again including the marginal

surface notching created for aligning keys.3. Make an impression of the boxed area, again using free-flowing irreversible

hydrocolloid material and reinforcing it in the fast-setting plaster (Fig. 7) .


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548 Brom

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

4. Retrieve the impression and, if satisfactory, surround its pcriphcry withpaper masking tape.5. Coat the impression with a thin film of glycerin to luhticatc the surface.6. Register the contours of this prepared impression by pouring anothrr mix

of irreversible hydrocolloid directly over its surface and reinforce it with fast settingplaster (Fig. 8).

7. Separate the two reinforced impressions and examine for accuracy of registnt-tion.

8. If this irreversible hydrocolloid registration is satisfactory, box and pour ZLrefractory cast with gray investment. Ihis cast, made from the double-impressionprocedure, is used to create the tissue-contacting surface die in a manner similar-to that described for fabricating the external surfact : die (Fig. 9) .

9. Prim and smooth the borders of the two dies to insure their accuratc al)-proximation.PAINTING

1. Seat the patient in good illumination for ac,curatc evaluation of skin tone andcolor highlights.

2. Pour a generous amount of a closely matching stock skin-colored vinyl resinon a large glass mixing slab.

3. Place small pools of base color vinyl resin ted, yellovv, brown and blue -around the perimeter of the mixing arca on the glass slab.*Realastic Industries, 1000 Forty Street, Oakland, Ca lif


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Fabrication of a nose prosthesis 549

Fig. 11. External and tissue contacting surface dies are properly aligned (above). The as-sembled mold (below) is held together with common spring clamp s. Sprues and ventingcolum ns are left on dies to act as handles for their manipulation.

4. Develop the desired intrinsic skin color by slowly incorporating small amountsof various base colors into the major pool of the selected stock color vinyl resin.

5. Small pools o f slightly varying color from that o f the major color blendingare made up to supply contrastin g hues and color highlights to the prosthesis.PROCESSING

1. Preheat the dies in a dry-heat oven held at a temperature of 195 C. for 1hour, allowing complete heat saturation.2. Kemove the external surface die from the oven first and place it on an

electric hot plate to maintain its ternperature during application of the colored


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550 Brown I. l,-o&et. DentSovembrr. 1971

Fig. 12. The completed prosthes is is shown in various aspec ts. The nares are trimmed forfree respiratory exchang e.

vinyl resin. The use of asbestos and mitten and pliers is required to manipulatethe heated die.

3. Apply a thin coating of clear vinyl resin to the heated die to give the outersurface of the finished prosthesis a slight translucent effect .

4. Dust red nylon fiber flocking onto the translucent layer to simulate skinvascularity.

5. Return the die to the oven for 5 minutes to congeal the primary coatingby heat.

6. Develop the color characterization by applying the separately blended colorsto the die surface. Keep in mind during the paint-on application of the variouscolor shades that the high contours of the die surface are the rescessed and shadowedareas of the finished prosthesis and should receive the dark colors, while the lowval leys and depressions in the prosthesis are prominences needing lighter tonedtreatment (Fig. 10).

7. After each application of colored resin, return the die to the oven for 5minutes to allow the resin to set.


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Volume 26Numbrr 5 Fabrication of a nose prosthesis 551

Fig. 13. The adaptation of the appliance to the facia l co ntours adequately covers the defect.

8. Apply the blended stock color vinyl resin in a generous layer over the entiresurface of both dies. (The tissue-contacting die need not be color characterizedsince this surface is not visible when appliance is worn).

9. Assemble the dies according to the keyed margins, making sure that thereis no congealed vinyl resin adhering to the peripheral margins to prevent completeclosure of the mold.

10. Secure the assembled mold with large spring jaw clamps and place in theoven to cure for 15 minutes at temperature of 195 C. (Fig. 11).

11. Occasionally rotate the mold in the oven during curing to prevent poolingof the resin within the mold.

12. Kemove the mold from the oven after curing and immerse it in ice water.13. Disassemble the cooled mold and carefully retrieve the prosthesis.14. Inspect the prosthesis closely for air bubbles, thin areas, and accurate dupli-

cation of color.1.5. Trim the orifices of the nares and internal surfaces to allow free respiratory

exchange (Fig. 12).16. Hold the processed appliance gently against the patients face and check

the peripheral adaptation (Fig. 13 ) .EXTRINSIC COLORING AND ATTACHMENT

1. Apply small amounts of xylene-suspended base pigments to the externalsurface for additional color enhancement.


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552 Brown

Fig ;. 14. (A) The right lateral aspect of the fact has a clin ical defect rmulting from cxtrrlsur gica l resection in cancer ireatmcnt. (R) The right lateral aspect of thr lacr> with thP Ithe sis in place re-establishes tissue contours. (C) Ihe lrft lateral aspect shows :L clc~fici~ nc-the bridge of the nose. (I)) The left latmal aspect shows adequate rrcontrmrillg anal gym!ten tive adaptation.

maba:

2. Tone down excessive extrinsic coloring by wiping the surfacxb \\ith syklistened gaux.3. Warn the patient against the USC of c.osrnctics on the prosthesis since the

;cs used in their compounding arc dclcterious to the vinyl resin resiliency.4. Instruct the patient to keep the skin area receiving the appliance clean ;

mt:-

ui l

IYld


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Volume 26Sumber 5 Fabrication of a nose prosthesis 553

Fig. 15. (A) A nasal defect h as resulted from surgica l treatment of an extensive basal cellcarcinoma. (B) The nasal prosthesis covers the surgica l defect and provides a satisfactory cos-metic restoration. Kate the slight deviation given to the bridge of the prosthes is to simulate theoriginal form of the patients nose which had previously been broken.

free of natural oil secretions to improve adhesive retention. This can be done bywiping the skin in the attachment area with ethyl alcohol before the prosthesisis applied.

5. Rehearse the patient in the technique of skin-adhesive application and thecorrect placement of the appliance (Pigs. 14 and 15).

6. Instruct the patient in the routine cleansing of the prosthesis and warnagainst the halard of color change associated with smoking.SUMMARY

This article presents an outline of the steps involved in constructing a noseprosthesis. A two-piece metal mold is made for processing thermally cured vinylresin. Pertinent considerations in executing the impression procedures, sculpturing,coloring, and processing are presented to insure an esthetically acceptable prostheticreplacement.

The author gratefully acknowledges the assist ance of Commander J. S. Lindsay, DC,USN, Head, Oral Surgery Division, Naval Iiospital, Great Lakes, III., in reviewing and

editing the text.References1. Miglani, D. C., and Drane, J. B.: Maxillofacial Prosth esis and Its Role as a Healing Art,

J. PaosrrrEr. DEST. 9: 159-168, 1959.2. Bulbulian , A. H.: Maxillofacial Prosthe tics; Evaluation and Practic al Applica tion in Pa-

tient Rehab ilitation, J. PROSTHET. DEST. 15: 554-569, 1965.


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554 Brown3. Strain, J. C., Maxillofacial Prosthe tics, J. PROS THET . DENT. 11: 790-793, 1961.4. Fonseca, E. P., The Importance of Form Characterization and Retention in Facial Pro,-

thesis, J. PROSTHET. DENT. 16: 338-343, 1966.5. Tashm a, J., Coloring Somatop rosthescs, J. PROSTHET. DENT. 17: 303-305, 1967.

NAVAL FORCES AIIVISORY GROUPVIETNAM MAXILLOFACIAL TEAMF.P.O. SAN FRAX~IS~O, CALIF. 96626

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15 Fabrication of Nose