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WINTER 2011 VOLUME 11 ISSUE 1 | ISSN 1366-4697 | www.impt.co.uk
PROSTHETISTS
&TEC
HNO
LOGISTSTHEINST
ITUT
EO
FM
AXIL
LOFA
CIAL
THE JOURNALOF MAXILLOFACIAL PROSTHETICS & TECHNOLOGY
Advancement & knowledgefor the benefits of patients.
Contents
Note from the editor
Articles of interest
Featured articles
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Editorial team & IMPT Council 2012
2012 Congress abstracts
Instructions for authors
Ian Kenneth MacLeod – an obituary
Fabrication of a hollow and a foam filled breast prostheses - a case study.
Survey about attitudes, opinions, and experience of maxillofacial prosthetists and technologists in the UK towards maxillofacial silicone prostheses.
Analysis of lecturing patterns at IMPT scientific congresses 1963 – 2011.
A review of current MPT practice in the provision of the prosthetic nipple areola complex.
Custom made nasal septum obturator.
Technical note. Profile dressings: the first restorative approach for head and neck external resections.
A modification to prevent vertical compression in intermediate silicone wafers for orthognathic surgery.
Sally Lane MIMPT
Muhanad M. Hatamleh AIMPT, PhD, MPhil, DPS, MScColin Haylock FIMPT, MBEJason Watson MIMPT, B Med ScDavid C. Watts BSc, PhD, DSc
Mr Adrian Kearns MIMPT, DPSCaroline Reed AIMPT, BSc (Hons), DPS
Dianne Bowers, Maxillofacial ProsthetistChris Maryan FIMPT, Principal LecturerPeter Gough, Senior Lecturer
Carmen Orbaneja Botija MIMPT
Carmen Orbaneja Botija MIMPT
Gavin J Carmichael MIMPT, FOTA, LBIDST, RDT
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IMPT WINTER 2011 3www.impt.co.uk
Note from the editor
IMPT WINTER 2011 5www.impt.co.uk
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.
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
Welcome all IMPT members to the new IPMT e-journal!
“I would urge the membership to consider putting forward articles for submission to your journal”
Mr Barry Edwards MIMPT, MScEditor
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.
President
President Elect
Chair
Secretary
Minutes Secretary
Treasurer
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Regulatory Lead
Journal Editor
Website Editor and Communications Officer
NHS Liaison Officer
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Education Officer
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Co opted CouncilMember
Co opted Council Member
Company Solicitor
Steven Dover FDSRCS (Eng), FRCS (Eng)
Adrian Farrow
Sarah Parkinson FIMPT, BSC (Hons)
Fraser Walker FIMPT, MSc, LCGI
Mrs Paramjit Kaur SandhuMIMPT, BSc (Hons), DPS, Pg Cert
Richard EggletonFIMPT
Liz Gill MIMPT, BSc (Hons)
Mark CutlerFIMPT, MBE
Barry EdwardsMIMPT, MSc
Jason WatsonMIMPT, BMed, Sci
David AllenFIMPT
Adrian KearnsMIMPT, DPS
Dr Mohamed BamberFIMPT, Phd
Carol WinterMIMPT
David ThompsonMIMPT
Karen Boyd-Glen MIMPT, GCGI
Stefan EdmonsonMIMPT, BSc (Hons), DPS
Barbara Anne Thompson MIMPT, BSC, DPS, PgCert
Naimesha PatelMIMPT, MSc
Steven Hutchinson MIMPT, MSc, DPS
Fraser MacnamaraMIMPT (Hons)
Council Members
6 WINTER 2011 IMPT THE JOURNAL OF MAXILLOFACIAL PROSTHETICS & TECHNOLOGY
PROSTHETISTS
&TEC
HNO
LOGISTSTHEINST
ITUT
EO
FM
AXIL
LOFA
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Editorial team & IMPT Council 2012
IMPT WINTER 2011 7www.impt.co.uk
Hampson & Partners
All correspondence relating to membership of The IMPT should be sent via post or email to:
All correspondence to The IMPT should be sent via our website or email:
Mr. Barry Edwards MIMPT, MSc
Ginny KingsmillBDS, PhD, FDS, RCS (Rest Dent)
Dr Richard Bibb
Dr Harry Reintsema
Steve Worrolo
Chris Maryan
Peter Evans
Mark Cutler MBE
Colin Haylock MBE
Ken Sneddon
Fraser Walker
Steven Dover
Philip Federspiell
Andrew Brown
Mohit Kheur
Dr Trevor Coward
Joern Brom
K.F. Moos OBE
K. Thomas
J. Collyer
Naimesha Patel MIMPT, MSc
info@impt.co.ukwww.impt.co.uk
Pauline E PaulMIMPT, MSc
Muhanad Hatamleh AIMPT, BSc, Mphil, MSc, Dip (Max Fac), PhD
Peter Ward Booth FDS FRCS
Jason WatsonMIMPT, BmeD, Sci
Adrian KearnsHonorary Registrar IMPT Department of Maxillofacial Prosthetics
Barbara Anne ThomsonMIMPT Pg Cert, BSc,Dip (Eng)
Willwell Cottage,Wilford Road,Ruddington,NottinghamNG11 6NA
T. 01159 215 848www.handpdesign.co.uk
Royal Surrey County Hospital NHS Foundation Trust,Egerton Road, Guilford,Surrey GU2 7XX
registrar@impt.co.uk
Queen Victoria Hospital, Maxillofacial Department, Holtye Road, East Grinstead, West Sussex RH19 3DZ
barry.edwards@qvh.nhs.uk
Clinical Lecturer, Barts and the London School of Medicine and Dentistry, Queen Mary University London, London E1 2AD
Leicester, UK
Groningen, NL
Birmingham, UK
Manchester, UK
Wales, UK
East Grinstead, UK
London, UK
East Grinstead, UK
Glasgow, UK
Birmingham, UK
Germany
East Grinstead, UK
India
London, UK
Germany
Scotland
Southend, UK
East Grinstead, UK
Caroline ReedAIMPT, BSc (Hons), DPS
Principal Maxillofacial Prosthetist,Maxillofacial Laboratory, Neurology Building, Southern General Hospital, 1345 Govan Road, Glasgow G51 4TF
School of Dentistry, University of Manchester, Higher Cambridge Street, Manchester M15 6FH
Maxillofacial Surgeon, Howbourne Oast, Buxted TN22 4QD
Consultant MPT Healthcare Scientist, Maxillofacial Laboratory, Nottingham University Hospitals Trust, West Block B Floor, Derby Road, Nottingham
Maxillofacial Laboratory, Neurology Building, Southern General Hospital, 1345 Govan Road, Glasgow G51 4TF
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.
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.
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Contacting The IMPT
Analysis of lecturing patterns at IMPT scientific congresses 1963 – 2011
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.
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
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 – 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.
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•
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
8 AUTUMN 2011 IMPT THE JOURNAL OF MAXILLOFACIAL PROSTHETICS & TECHNOLOGY IMPT AUTUMN 2011 9www.impt.co.uk
Abstract
Introduction
Method
Results and discussion
Caroline Reed AIMPT, BSc (Hons) DPS, Maxillofacial ProsthetistMaxillofacial Laboratory, The Queen Victoria Hospital NHS Foundation Trust, Holtye Road, East Grinstead, West Sussex RH19 3DZ
Mr Adrian Kearns MIMPT DPS, Consultant Maxillofacial ProsthetistMaxillofacial Laboratory, Royal Surrey County Hospital NHS Foundation Trust, Egerton Road, Guildford, Surrey GU2 7XX
“There have been 25 IMPT scientific congresses since 1965, 477 lectures have been delivered, totalling over 145 hours”
Figure 1. Total congress lectures 1963 - 2011.
Prostheses 30%
Overview 12%
Materials 12%
Implants 11%
Oro-facial/intra-oral 10%
Education and Administration 8%
Orthognathic 6%
Trauma 5%
Computer Technology 4%
Miscellaneous 2%
830%
6%
2%
11%
12%
8%
12%
4%
10%
5%
39
51
24
49
5718
30
56
145
Figure 2. First ten congresses 1963 - 1981.
Prostheses 26%
Oro-facial/intra-oral 21%
Materials 14%
Implants 11%
Overview 7%
Education and Administration 6%
Miscellaneous 5%
Orthognathic 5%
Trauma 5%
Computer Technology 0%
526%
5%
5%
11%
6%
14%
7%
21%
5%
6
11
5
21
7
5
14
25
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.
10 AUTUMN 2011 IMPT THE JOURNAL OF MAXILLOFACIAL PROSTHETICS & TECHNOLOGY IMPT AUTUMN 2011 11www.impt.co.uk
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
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.
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.
Individual lectures
Table 1 shows the leading lecture contributors and the
total time of their combined presentations.
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).
Acknowledgements
Conclusion
Lecturing
Figure 3. Last ten congresses 1993 - 2011.
Prostheses 27%
Education and Administration 12%
Overview 17%
Materials 11%
Implants 9%
Computer Technology 7%
Oro-facial/intra-oral 6%
Orthognathic 6%
Trauma 6%
Miscellaneous 1%
227%
6%
1%
9%
12%
11%
7%
15%
6%
6%
31
23
15
42
15
18
17
31
75
Table 1. Most lectures at congress.
Number of lectures Name Total minutes
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
Table 2. Lectures and influences of ex-Roehampton MfPs.
Name Maxillofacial Laboratory
Lectures since arrival at unit
Lectures by MfPs before
arrival
Lectures by other MfPs since arrival
*Bristol employs one MfP
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
Fabrication of a hollow and a foam-filled breast prostheses - a case study
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
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.
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
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
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
Abstract
Introduction
Case study
Methods and materials
Sally Lane MIMPT, Maxillofacial Laboratory, Russells Hall Hospital, Dudley Group of Hospitals NHS Trust, West Midlands DY1 2HQ
“The weight of the prosthesis was 675g and this was the patient’s main concern. It caused discomfort and back pain”
12 AUTUMN 2011 IMPT THE JOURNAL OF MAXILLOFACIAL PROSTHETICS & TECHNOLOGY IMPT AUTUMN 2011 13www.impt.co.uk
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 patient’s bra.
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 patient’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.
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).
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.
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.
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.
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.
Figure 1. Alginate two-part mould.
Figure 2a. Application of silicone in a two-part mould.
Figure 2b. The addition of gauze for stability.
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
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 – 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.
Figure 3a. Pouring the hollow wax pattern.
Figure 4a. Expansion of the silicone foam within the wax pattern becoming visible as it travels up through the funnel.
Figure 3b. Wax template taken from the mould and replaced back on to the plaster model.
Figure 4b. The exposed foam on the underside of the pattern.
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
Results and discussion
“The hollow prosthesis weighed 247g, a difference of 428g... reducing the weight by almost two thirds”
14 AUTUMN 2011 IMPT THE JOURNAL OF MAXILLOFACIAL PROSTHETICS & TECHNOLOGY IMPT AUTUMN 2011 15www.impt.co.uk
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.
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.
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.
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.
7. Collins Pocket Reference – Ready Reference. 2nd revised edition, 7th April 1994.
References
available and should be considered as a treatment
modality for patients in these circumstances.
The production of both hollow and foam-filled
custom made breast prostheses provide considerable
improvements when compared to the stock items
I would like to thank Mr. David Heath, Senior Chief
Maxillofacial Prosthetist, Russells Hall Hospital, for his
continued support.
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.
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.
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.
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
Acknowledgements
Figure 5a. The definitive hollow prosthesis.
Figure 5b. The definative foam-filled prosthesis.
Survey about attitudes, opinions, and experience of maxillofacial prosthetists and technologists in the UK towards maxillofacial silicone prostheses
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.
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
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 non-
professional 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
Abstract
Introduction
Muhanad M. Hatamleh AIMPT, PhD, MPhil, DPS, MSc, Author for correspondenceSchool of Dentistry, University of Manchester, Higher Cambridge Street, Manchester, M15 6FH, UKColin Haylock FIMPT, MBE | Jason Watson MIMPT, BMedSc | David C. Watts BSc, PhD, DSc
“Ninety-six IMPT members responded to the questionnaire,indicating an overall response rate of 43.6%”
16 AUTUMN 2011 IMPT THE JOURNAL OF MAXILLOFACIAL PROSTHETICS & TECHNOLOGY IMPT AUTUMN 2011 17www.impt.co.uk
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.
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.
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%
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).
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
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
Results
Table 1. Most of MPTs indicated it is very important to have maxillofacial prostheses free of air bubbles.
Table 2. Effects of air bubbles on maxillofacial silicone prostheses.
Table 3. Steps utilized in minimising porosity within silicone prostheses.
Importance
Possible effect
Step
*Number of respondents for this question was 49.
*Number of respondents for this question was 49.
*Number of respondents for this question was 47.
*Number (%)
*Number (%)
*Number (%)
Very important
Important
Not important
Aesthetics compromised
Bacterial colonisation of porous fitting surfaces
Effects on prosthesis colour
Difficulty in finishing margins
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
36 (76.6%)
9 (19.2%)
2 (4.2%)
41 (83.7%)
33 (67.3%)
28 (57.1%)
23 (46.9%)
35 (71.4%)
12 (24.5%)
11 (22.4%)
10 (20.4%)
5 (10.2%)
1 (2.0%)
24 (68.6%)
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).
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.
Discussion
Table 6. Record of prostheses requiring remake.
Whether it is helpful to keep such record?
Do you keep record of cases required remake?
Yes No
Yes
Not sure Total
Total
No
35 1 137
10
78.7%
21.3%
94.6% 2.7% 2.7% 100.0%
4 1 5
40.0% 10.0% 50.0% 100.0%
39 2 6 47
83.0% 4.3% 12.8% 100.0%
Table 4. Brands of silicone elastomers used by MPTs .
Manufacturer (brand series)
Total number of silicone/materials mentioned was 100.
* Please note the ‘only’ indicates the silicone manufacturer without specifying the brand name.
Percentage (%)
27%
21%
10%
8%
8%
5%
5%
3%
3%
2%
2%
2%
2%
1%
1%
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
Table 5. Challenges that MPTs face during fabricating maxillofacial prostheses.
Challenges
* Mutli answer question of 49 respondents per each answer.
*Number (%)
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%)
Prosthesis maintenance (longevity)
Prosthesis maintenance (colour change)
Prosthesis construction (colouring)
Prosthesis design (sculpture)
Prosthesis construction (bonding)
Prosthesis design (material)
Communication
Patient dissatisfaction
Others
Table 7. Percentages of hands-on training courses that MPTs attended during the last year.
Number of courses attended
*Number of respondents for this question was 39.
*Number (%)
1-5
6-10
11-15
16-20
Over 20
21 (53.9%)
12 (30.8%)
2 (5.1%)
2 (5.1%)
2 (5.1%)
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.
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 related-
factors, including air bubble formation during mixing, are
18 AUTUMN 2011 IMPT THE JOURNAL OF MAXILLOFACIAL PROSTHETICS & TECHNOLOGY IMPT AUTUMN 2011 19www.impt.co.uk
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
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
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.
Conclusions
“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).
bacterial colonisation. Packing silicone under pressure
was the most common technique to reduce inclusion of
air bubbles.
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.
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;18:1675-1681.
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.
References
“DCW gratefully acknowledges the support of the
Alexander von Humboldt Foundation, Bonn, by a
Humboldt Research Award.”
Acknowledgement
The questionnaire distributed to MPTs.
Appendix A
!
!
Custom-made nasal septum obturators
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.
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
A CT scan of the patient’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 epoxy-
based 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
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.
The models can also be sterilised for reference purposes
in theatre.5
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.
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.
against tearing, obtain maximum clasping and a
smooth finish.
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
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.
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).
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 6 (below) shows the standard contour from a
sagittal view. The edges are rounded to protect them
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
20 AUTUMN 2011 IMPT THE JOURNAL OF MAXILLOFACIAL PROSTHETICS & TECHNOLOGY IMPT AUTUMN 2011 21www.impt.co.uk
Abstract
Introduction
Materials and methods
Carmen Orbaneja Botija, MIMPT, Maxillofacial ProsthetistPoole Hospital NHS Foundation Trust, Longfleet Road, Poole, Dorset BH15 2JB
Figure 6. Contour shown for nasal obturator, sagittal view.
Figure 3. Medical model of defect area.
Figure 1. CT image of the sinuses.
Figure 5. Doughnut shaped model.
Figure 8. Three-part mould.
Figure 4. Silicone impression of working area.
Figure 2. Image obtained from a scan of the defect area.
Figure 7. Location mark on obturator and model.
Figure 9. Final result on 3D resin model.
!
!
!
!
!
!
!
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
22 AUTUMN 2011 IMPT THE JOURNAL OF MAXILLOFACIAL PROSTHETICS & TECHNOLOGY IMPT AUTUMN 2011 23www.impt.co.uk
References
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
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
required to construct a new obturator.
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.
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.
Discussion
Conclusion
Acknowledgements
“Nasal obturators constructed following the technique described are an accurate and inexpensive treatment option”
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.
A review of current MPT practice in the provision of the prosthetic nipple areola complex
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.
Results:
The results built a comprehensive picture of
current practice.
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.
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
Abstract
Introduction
Dianne Bowers, Maxillofacial Prosthetist, Maxillofacial Laboratory, St Luke’s Hospital, Bradford UKChris Maryan FIMPT, Principal Lecturer, School of Biology Chemistry & Health Science, Manchester Metroploitan University, Manchester UKPeter Gough, Senior Lecturer, School of Biology Chemistry & Health Science, Manchester Metroploitan University, Manchester UK
24 AUTUMN 2011 IMPT THE JOURNAL OF MAXILLOFACIAL PROSTHETICS & TECHNOLOGY IMPT AUTUMN 2011 25www.impt.co.uk
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
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).
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.
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.
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.
Method
Results
“Alternate questionnaires were available for prosthetists and laboratory managers”
Figure 1. Number of referrals per year.
60%
50%50%
27%
18%
5%
40%
30%
20%
10%
0%0-20 20-50 50-75 75-100
Referrals mainly come from plastic surgeons, with the
lowest percentage of referral rates coming from general
practitioners, see figure 2.
Table 1. Method of construction of NAC prostheses.
What is the most common technique that you use for the construction of nipple prostheses?
Laboratory Manager (%)
Prosthetist (%)
Open Mould
Flask & Pack
Other
27.27
68.18
4.55
51.72
44.83
3.45
Table 2. Methods of retention.
What is the most common type of retention used? Laboratory Manager (%)
Prosthetist (%)
Adhesive
Suction
Sticky Gel
Petroleum Jelly
Other
31.82
27.27
18.18
4.55
18.18
48.28
17.24
13.79
10.34
10.34
Table 3. Pressure sensitive adhesives provided.
Laboratory Manager (%)
Prosthetist (%)
Total(%)
Cosmesil
Technovent Cream Adhesive G602
Technovent B460 thin
Klebi
Daro hydrobond
Secure
Prostick-Shermans
Hollister medical adhesive
Nil
8
1
0
0
1
4
0
1
6
9
2
1
1
1
1
1
0
0
46
8
3
3
5
14
3
3
16
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.
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 patients’ 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.
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.
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.
Figure 2. Referring disciplines.
60%
70%
50%
4.559.09
22.73
63.64
40%
30%
20%
10%
0%GP General Surgery Breast Care Nurse Plastic Surgery
Discussion
26 AUTUMN 2011 IMPT THE JOURNAL OF MAXILLOFACIAL PROSTHETICS & TECHNOLOGY IMPT AUTUMN 2011 27www.impt.co.uk
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.pdf7. 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 custom-made 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, 139-145, 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.pdfhttp://www.ncbi.nlm.nih.gov/pubmed/3967113?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum
References
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.
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 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.
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
“The majority of respondents stated that life expectancy of the prosthesis is approximately 6 to 12 months...”
A modification to prevent vertical compression in intermediate silicone wafers for orthognathic surgery
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 Hospitals’ 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.
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
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.
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.
Abstract
Introduction
Method and materials
Gavin J Carmichael FOTA, MIMPT, LBIDST, RDT, Principal MPTEast Lancashire Hospitals NHS Trust, Maxillofacial and Orthodontic Laboratory, Burnley General Hospital, Casterton Avenue, Burnley, BB10 2PQ
Figure 1. Maxilla impacted. Figure 2. Checking planned autorotation.
! !
28 AUTUMN 2011 IMPT THE JOURNAL OF MAXILLOFACIAL PROSTHETICS & TECHNOLOGY IMPT AUTUMN 2011 29www.impt.co.uk
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.
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 3. Wax strip flattened to form template.
Figure 6. Showing relationship of loops.
Figure 4. Lateral view of finished strip to illustrate perforations.
Figure 5. 0.7 mm soft wire woven into support.
!
!
! !
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.
References
Figure 8. Labial view showing label.
Figure 9. Upper occlusal view showing projection of loops.
!
!
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.
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.
Conclusion
Discussion
“The method outlined gives a number of advantages over that previously described for intermediate wafers”
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).
Figure 7. Lingual view of completed wafer.
!
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
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.
Technical noteProfile dressings: the first restorative approach for head and neck external resections
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
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.
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).
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).
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).
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).
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
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
Absorbent self-adhesive soft silicone dressing, which
incorporates a thin sheet of polyurethane foam (Mepilex
Border or similar, Mefix tape and Mepilex border:
Mölnlycke Healthcare, AB Box 13080, SE-402 52,
Göteborg, 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.
The following article describes a technique
of using anatomical dressings which replicate
a resected area soon after surgery to re-establish
patients’ 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.
Keywords
Surgical dressing, external resection
30 AUTUMN 2011 IMPT THE JOURNAL OF MAXILLOFACIAL PROSTHETICS & TECHNOLOGY IMPT AUTUMN 2011 31www.impt.co.uk
Abstract
Introduction
Materials and methods
Carmen Orbaneja Botija, MIMPTMaxillofacial Prosthetics Service, Poole Hospital NHS Foundation Trust, Longfleet Road, Poole, Dorset BH15 2JB
Figure 3a. Stretch bandage and soft thermoforming blank.
Figure 4. Plaster positive model and putty negative model in Erkopress flask.
Figure 6. Second design, orbital and auricular dressing with bandage above.
Figure 1a. Standard dressing.
Figure 2a. Impression.
Figure 1b. Nasal profile dressing.
Figure 2b. Model.
Figure 1c. Glasses can be worn.
Figure 2c. Wax carving.
Figure 5. First design, nasal dressing with bandage underneath.
Figure 7. Third design of profile dressing: lateral aspect.
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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/mepilex-border.html
32 AUTUMN 2011 IMPT THE JOURNAL OF MAXILLOFACIAL PROSTHETICS & TECHNOLOGY IMPT AUTUMN 2011 33www.impt.co.uk
References
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.
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.
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.
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.
Conclusion
Acknowledgements
Discussion
“The third design described has two advantages”
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.
Articles of interest
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.
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.
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.
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.
Finally, this is a good paper should you ever
need proof of the need for immediate obturation
following maxillectomy.
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
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
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
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
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
Compiled by Caroline Reed AIMPT, BSc (Hons), DPSMaxillofacial Prosthetist, Queen Victoria Hospital, East Grinstead
Abstracts2011 IMPT Congress, Birmingham, UKLecture Program
34 AUTUMN 2011 IMPT THE JOURNAL OF MAXILLOFACIAL PROSTHETICS & TECHNOLOGY IMPT AUTUMN 2011 35www.impt.co.uk
10 years’ experience with Zygomatic Implants for extra oral prosthetics
Results with titanium mini plates for bone anchorage of craniofacial prostheses
The validation of an improved articulator system for orthognathic model surgery
The effectiveness of pressure splints on keloid scars
Evolution not Revolution: Integrating advanced digital technology into maxillofacial prosthetics
3D modelling and surgical planning in free tissue transfer; a short case series and review
Peter Ll. Evans MIMPT
Consultant in Maxillofacial Prosthetics
Maxillofacial Laboratory, Welsh Centre for Burns Plastics
and Maxillofacial Surgery, Morriston Hospital,
Swansea SA6 6NL, UK; peter.evans2@wales.nhs.uk
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.
Philippe Federspil
Consultant Ear Nose and Throat Surgeon; Heidelberg,
Germany; Vice President of the IASPE
University Hospital Heidelberg, Oto-Rhino-Laryngology,
Heidelberg, Germany
Purpose:
For the past 30 years, the Brånemark 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
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.Andrew Richmond MIMPT
Principal Maxillofacial Prosthetist
Maxillofacial Laboratory,
Nottingham University Hospitals Trust, Derby Road,
Nottingham; andrew.richmond@nuh.nhs.uk
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.
Graham Marshall MIMPT
Maxillofacial Laboratory, University Hospitals of Leicester
NHS Trust; graham.marshall@uhl-tr.nhs.uk
A two-year retrospective audit to evaluate the
effectiveness of pressure therapy in keloid scars.
James Dimond MIMPT
Principal Maxillofacial Prosthetist
Maxillofacial Prosthetics, 2nd Floor, Old Queen Elizabeth
Hospital, Edgbaston, Birmingham, B15 2TH;
james.dimond@uhb.nhs.uk
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
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.
Lecture 1
Lecture 2
Lecture 4
Lecture 5
Lecture 6
Lecture 3
36 AUTUMN 2011 IMPT THE JOURNAL OF MAXILLOFACIAL PROSTHETICS & TECHNOLOGY IMPT AUTUMN 2011 37www.impt.co.uk
A new watusi collar used in the treatment of neck burn hypertrophic scarring
Prosthetic rehabilitation following Meningococcal Septicaemia
Extrinsic sealants - is it all in the timing?
A new patient consultation for a patient with a maxillary defect
Spectacles Adaption for Pressure Point Responsive Blepharospasm
Cranioplasty defects: a review of cases and the development of a classification for referral, identification and audit purposes
Evaluation of cranioplasty plate design and fabrication in the UK
Obturator versus surgical reconstruction of the maxillectomy patient
Yvonne Moore MIMPT
Maxillofacial Prosthetist
Glasgow Royal Infirmary, Prosthetics Laboratory, 2nd Floor
Walton Building, Castle Street, Glasgow, G31 2ER;
yvonne.moore@ggc.scot.nhs.uk
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.
Caroline Reed BSc (Hons) DPS
Maxillofacial Prosthetist
Queen Victoria Hospital, Holtye Road, East Grinstead,
West Sussex, RH19 3DZ; caroline.reed@qvh.nhs.uk
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.
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.
Steve Bailey MSc MIMPT Dip CDT RCSEng
Maxillofacial Prosthetist
Maxillofacial Unit Pilgrim Hospital, Sibsey Rd, Boston,
Lincolnshire; steve.bailey@ulh.nhs.uk
To include: 1.Examining the patient intra oral examination
– 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.
Dave Allen FIMPT
Queen Victoria Hospital, Holtye Road, East Grinstead,
West Sussex, RH19 3DZ; dave.allan@qvh.nhs.uk
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.
Dr Muhanad Hatamleh
AIMPT, PhDd, MPhil, BSc (Hons), DPS
Manchester Dental School and Nottingham University
Hospitals Trust, UK; muhanad.hatamleh@manchester.ac.uk
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.
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.
Dr Richard Bibb PhD, BSC (Hons)
Loughborough Design School, Bridgeman Centre,
Loughborough University, Ashby Road, Loughborough,
Leicestershire, LE11 3TU; r.j.bibb@lboro.ac.uk
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 lead-
time. A hemi-craniotomy case was chosen as an example
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 lab-
based techniques.
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
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.
Lecture 7
Lecture 8
Lecture 9
Lecture 10
Lecture 12
Lecture 14
Lecture 13
Lecture 11
of digital technology along with its limitations, and
the benefits that can be gained for the maxillofacial
prosthetist, surgical team, and, ultimately, the patient.
38 AUTUMN 2011 IMPT THE JOURNAL OF MAXILLOFACIAL PROSTHETICS & TECHNOLOGY IMPT AUTUMN 2011 39www.impt.co.uk
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
Rehabilitation in Head and Neck Oncology: Advantages of implants and digital technology (or not?)
New trends utilising old methods
Three-part-mould technique
A Rapid Prototype (RP) jigsaw technique in the manufacture of a titanium orbital floor implant
A critical comparison of digital technologies in nasal prosthesis production
Jason Watson MIMPT, BSc (Hons)
Consultant Maxillofacial Prosthetist
Maxillofacial Laboratory, Nottingham University Hospitals
Trust, Derby Road, Nottingham; NG7 2UH
jason.watson@nuh.nhs.uk
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.
Hitesh Koria MIMPT, BSc (Hons)
Maxillofacial Prosthetist
Maxillofacial Prosthetics, 2nd Floor, Old Queen Elizabeth
Hospital, Edgbaston, Birmingham, B15 2TH
hitesh.koria@uhb.nhs.uk
Since the start of the implant programme in 1988, there
have been significant changes in practice. The ‘ideal’
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.
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.
Matt Pilley MIMPT
Specialist in Clinical Prosthetics
University Hospitals of Leicester, Maxillofacial Laboratory/
Prosthesis Clinic; m.pilley@uhltr.nhs.uk
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.
Joern Brom AIMPT
Anaplastologist of the IASPE.
Brom Epithetik, Mittermaierstrasse 25, 69115 Heidelberg,
Germany; info@brom-epithetik.de
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.
Gareth Robinson MIMPT, DPS
Principal Maxillofacial Prosthetist
Worcestershire Royal Hospital, UK
gareth.robinson@worcsacute.nhs.uk
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.
Dr. Dominic Eggbeer PhD, BSc (Hons)
PDR, UWIC, Western Avenue, Cardiff, CF5 2YB;
deggbeer-pdr@uwic.ac.uk
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.
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.
Lecture 15 Lecture 17
Lecture 19
Lecture 20
Lecture 21
Lecture 16 Lecture 18
40 AUTUMN 2011 IMPT THE JOURNAL OF MAXILLOFACIAL PROSTHETICS & TECHNOLOGY IMPT AUTUMN 2011 41www.impt.co.uk
The development of measuring tools for artificial eye research
An IMPT Survey: The design and manufacture of retention mechanisms for auricular prostheses
Evaluation of a new method of face-bow registration
Evaluation of colour stability in ocular prostheses
Using the Spectromatch Reality colouring system
Keith Pine BSc MIMPT, MBA
P.O. Box 31 306, Milford, Auckland 0620, New Zealand;
keith.pine@kp-assoc.co.nz
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.
Steffan Daniel BSC, MSc
PDR UWIC, Western Avenue, Cardiff, UK. CF5 2YB;
stdaniel@uwic.ac.uk
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
elainebaird1@hotmail.co.uk
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.
Holly Turner BSC
Trainee Maxillofacial Prosthetist
Maxillofacial Prosthetics, 2nd Floor, Old Queen Elizabeth
Hospital, Edgbaston, Birmingham, B15 2TH
holly.turner1985@gmail.com
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.
Lawrence Dovalski MIMPT, BSc
Maxillofacial Laboratory, Welsh Centre for Burns, Plastics
and Maxillofacial Surgery
lawrence.dovgalski@wales.nhs.uk
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.
Lecture 22
Poster 1 Poster 2
Poster 3
Lecture 23
Abstracts2011 IMPT Congress, Birmingham, UKPoster Program
42 AUTUMN 2011 IMPT THE JOURNAL OF MAXILLOFACIAL PROSTHETICS & TECHNOLOGY IMPT AUTUMN 2011 43www.impt.co.uk
The Nasal Hook
Production and use of a customized space-saving inhalation mask
Custom-made attachments for auricular prostheses
The socket’s response to artificial eye wear
The physical, chemical and biological nature of deposits on artificial eyes
Muciod discharge associated with artificial eye wear
Protocol for the management of keloid scars - a technical perspective
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.
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.
Caroline Reed BSc (Hons), DPS
Queen Victoria Hospital, Holtye Road, East Grinstead, West
Sussex, RH19 3DZ; caroline.reed@qvh.nhs.uk
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.
Keith Pine MIMPT, BSc, MBA
P.O. Box 31 306 Milford Auckland 0620 New Zealand
keith.pine@kp-assoc.co.nz
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.
Keith Pine MIMPT, BSc, MBA
P.O. Box 31 306 Milford Auckland 0620 New Zealand
keith.pine@kp-assoc.co.nz
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
Keith Pine MIMPT, BSc, MBA,
P.O. Box 31 306 Milford Auckland 0620 New Zealand
keith.pine@kp-assoc.co.nz
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.
Andrew Traynor MIMPT, BSc, DPS
University Hospital Birmingham, Queen Elizabeth Hospital,
Edgbaston, Birmingham B152TH
Tel: 0121 627 2314
Fax: 0121 6272302
andrew.traynor@uhb.nhs.uk
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.
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.
Poster 4
Poster 5
Poster 7
Poster 9
Poster 10
Poster 8
Poster 6
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.
44 AUTUMN 2011 IMPT THE JOURNAL OF MAXILLOFACIAL PROSTHETICS & TECHNOLOGY
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.
Poster 11
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.
Original articles and editorial correspondence should be
e-mailed directly to the current editor Barry Edwards at
barry.edwards@qvh.nhs.uk
Articles of interest should be e-mailed to Caroline Reed at
creed1@nhs.net
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
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The editor reserves the right to make editorial and literary
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do not necessarily reflect the opinions or policies of
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Papers that contain the results of human and/or animal
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made clear that a high standard of ethics was applied
in carrying out the investigations. Appropriate ethical
approval should be gained from the relevant ethical
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was carried out and that subjects gave informed consent
to take part.
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In order for the Institute of Maxillofacial Prosthetists and
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and copyright protection of material published in the
journal copyright must be explicitly transferred from the
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The author/s may be assured that no limitation will
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acknowledgment is made to this journal as the original
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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
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Articles should be typed in size 12 Times New Roman
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method and materials, results, discussion and conclusion.
Images should be set into the text in the appropriate
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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
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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.
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Should be appropriate to the nature of the paper. It
should be noted that headings enhance the readability
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Introduction
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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
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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
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ten. All references must be referred to in the text.
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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
46 AUTUMN 2011 IMPT THE JOURNAL OF MAXILLOFACIAL PROSTHETICS & TECHNOLOGY
Instructions for authors
IMPT AUTUMN 2011 47www.impt.co.uk
directly below each image with Figure number and text.
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If the author has presented the paper previously please
include details of where and when the paper was
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tomography (CT) scan.” The abbreviation can then be
used throughout the text from this point onwards without
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imperial is acceptable for contributions from the USA.
48 AUTUMN 2011 IMPT THE JOURNAL OF MAXILLOFACIAL PROSTHETICS & TECHNOLOGY IMPT AUTUMN 2011 49www.impt.co.uk
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.
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.
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.
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. Ian’s absence at this year’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.
50 AUTUMN 2011 IMPT THE JOURNAL OF MAXILLOFACIAL PROSTHETICS & TECHNOLOGY
Ian Kenneth MacLeod – an obituary
IMPT AUTUMN 2011 51www.impt.co.uk
Ian Kenneth MacLeod !