History of maxillofacial

prosthesis
By
DR. MOATAZ BARAKAT

Introduction

Although the origin of the first maxillofacial

prosthesis is uncertain, it is widely accepted that
attempts to replace missing structures date to
ancient times.
It is admitted that much of knowledge of maxillofacial
injuries and their treatment has been derived from
the treatment of battlefield causalities. (Hippocrates
460-370 B.C.)

History of management
of fractures

 5000 B.C. in the city of Babylon, Hammurabi drew up a

legal code on clay which contains one of the first written
references to the treatment of fractures:

If a physician set a broken bone for a man,

or cure his diseased bowels, the patient shall
give five shekels of silver to the physician.

 1600 B.C. in Egypt, the work of a military surgeon in a case

of a dislocated mandible was documented and translated
Put your thumbs upon the ends of the two rami of the mandible inside his
mouth and your two claws (groups of fingers) under his chin, and thou shouldst
cause them to fall back so that they rest in their places.

Simple jaw fractures were treated by bandages from

embalmer, and soaked in honey and white of egg.

 About the same period in ancient india, techniques were

developed for use of pedicle flaps from the forehead or
cheek to repair defects of the nose or lips.
In 460 B.C., Hippocrates described his treatment of
dislocation of mandible similar to that advocated by ancient
Egyptians, however he would appear to have been the first
to advice with wiring in the case of mandible fracture
'If the teeth at the wound be distorted and loosened when the bone is adjusted,
they should be connected together, not only two but more of them, with a
gold thread if possible, but otherwise with a linen thread, until the bone be
consolidated.'

 The first European medical school was

established at Salerno in Italy. Salicetti in 1275
A.D. gave in his book precise instructions upon
the treatment of fractures of the mandible. But in
a later edition in 1492, teeth wiring was adviced
'This done, tie the teeth of the uninjured jaw to the teeth of the
injured jaw
in this way.

This seems to have been the first clear indication

of using the teeth in the stable upper jaw for
immobilization of the lower jaw.

History of management
of acquired and congenital anomalies

 In reviewing the early history it is of interest to note that

the obturators were devised mainly in the field of acquired
defects and they were adapted later to serve in the area of
congenital defects.

 Demosthenes (384-323 B.C.), the famous Greek orator,

have used pebbles to obturate a congenital cleft lip and
palate he was suffering from.
In 1522 Hollerius, proposed to stop the open cleft with wax
or sponge.
In 1566 Petronius stated that closure of the cleft can be
made by wax, cotton or with a gold plate or any thing that
can give the same concave form of the palatal vault.

 During the late 16th century, one

of the most famous surgeons
Ambrose Pare was credited to
be the first to refer to
Obturateurs derived from the
latin word Obturo which means
stop up.
Pare described two appliances
to restore the palatal defect
caused by disease or gunshot
wounds

 The first Obturateur as he described, is made of a plate of

gold or silver a little bigger than the cavity itself and on the
upper side a little sponge is placed

 The other design has a button which engages the undercut

in the nasal cavity

 Pare also was known for the introduction of artificial noses

and eyes which were constructed of beaten silver and
suitably painted.

 Pierre Fauchards (1679-1761) authoritative work, Le

Chirurgien Dentiste , accredited him with the title Father
of dentistry.
He devoted four chapters of the second part of his book to
a detailed discussion of five different obturators and the
methods of their construction.

 The first two designs were made for dentate patients, and
the third and fifth for edentulous patients. The oral
component of the first two designs was metal, while that of
the third and fifth was part metal and part ivory, to which
prosthetic teeth were attached as required.

 Fauchard generally used human,

hippopotamus, or ox teeth, or
tusks from the walrus or elephant
as material from which prosthetic
teeth could be made.
The first three and the fifth
designs essentially depend on
the same retentive principle.
Instead of relying on sponges to
retain his prostheses, Fauchard
used a design consisting of two
metal wings that were inserted
through the perforation in a
vertically upright position.

 The metal wings were then

adjusted into a horizontal
position by means of a
threaded screw. These then
engaged on the nasal side of
the defect, providing retention
for the prosthesis.

 The fourth design was made for a

patient who had lost her upper
incisor teeth and had a defect that
communicated with the floor of the
nose.
This prosthesis was made of ivory,
which was shaped with an
elevation that extended into the
defect and to which was attached a
sponge.

 Although authors were greatly influenced by Fauchards

designs , but they diagreed the introduction of extensions
through the palatal defect

Bourdet in 1757, described two obturators made of a thin

sheet of metal which were attached around the teeth by
means of ligature.

 Delbarre modified the design

by using metal extensions
around teeth which in some
way resemble the
contemporary partial denture
design
Hence, Delbarre was the first
one to use metallic bands
(clasps) around teeth.

 In 1776, Verdial constructed an appliance with a uvula

made of sponge.
The appliance was made of spanish leather and lined with a
thin layer of sponge, the sponge uvula was attached with
elastic silver wire.
Foucou in 1780, attempted to restore the defect in the
velum by highly elastic bands or metallic plates. The plate
extended from the palate backwards covering the defective
part of the soft palate.

 Delbarre, in 182o described in

his book a very complicated
appliance covering the palate
completely.
It was carved of metal and the
superior surface had a
depression to accommodate
the nasal palatine process.
He attached a movable part
made of elastic gum to restore
the velum and uvula.

 One hundred years elapsed after Fauchard until another

revolutionary improvement on the practice occurred
In 1828, James Snell published his book on obturators
which may be considered the first document dealing
congenital cleft palate as a separate entity.
He constructed a gold plate on a model obtained from the
defective part and attached to the posterior part two flaps
of india rubber to fill the deficiency in the soft palate.
A small piece of the same material was attached by a gold
wire to simulate the uvula.

 It wasnt until 1867 that Suersen introduced the basic

principles behind the design of speech aid device as it is
presently known.
He explained the anatomy and physiology of the
pharyngeal area, and he was the first to draw attention to
the action of the superior constrictor in velo-pharyngeal
closure.
The constrictor muscle contracts the cavum pharyngo-palatinum, the
pharynx wall bulging out and it is chiefly on the action of this muscle
that I base the system of my artificial plates

 He used hard caoutchouc to

construct his one piece
obturator which covered the
tissue in the hard palate and
extended into the pharyngeal
space to terminate in an
Apophysis broad enough to
fill the defect.

 Near the end of the 19th century vulcanite was widely

accepted for use in maxillofacial prosthetics.
Polymethyl methacrylate (PMMA) was first used as a
denture base material in 1936.
Lloyd suggested that methyl methacrylate has the
advantages of light weight and adaptability through
processing. For more than 80 years, methyl methacrylate
has remained the dominant material for fabricating most
removable dental prostheses, including maxillofacial
prosthesis

 Historically, maxillofacial prostheses were made of cloth,

leather, wrought or cast metal and vulcanite.
William Morton (1800-1990) was credited with fabrication of
a nasal prosthesis using enameled porcelain to match the
complexion of a patient.
In 1913, Gelatin-glycerin compounds were introduced for
use in facial prosthesis in order to mimic the softness and
flexibility.
From 1936 to 1960, Acrylic resin was introduced in the
dental profession.
The introduction of various kinds of elastomers resulted in
major changes. Barnhart was the first to use silicone rubber
for construction and coloring of facial prosthesis.

 Newer materials representing a variety of polymer classes

offering unique characteristics have recently been
introduced which are as follows:
- Acrylic resin copolymer
- Vinyl polymers and co-polymers
- Polyurethane elastomers
- Silicone elastomers

Materials of the 3rd Millennium

Remerdale stated that the materials of the 3rd millenium
are expected to be translucent and should have
pigmentation ability to match any skin color.

On the Horizon

 Modern technology may provide better solutions for

replicating extensive maxillary defects during prosthesis
fabrication.
Computerized tomography/magnetic resonance (CT/MRI)
imaging techniques hold promise for providing a method of
generating 3-dimensional computer models.

 Computer-aided design and computer-aided manufacturing

(CAD/CAM) methods can then be used to fabricate the
definitive prosthesis.
The goal is to fabricate a more accurate prosthesis in less
time. As an added advantage, since the information is
contained in an STL file, the prosthesis can be modified, as
tissue changes occur without necessarily remaking an
impression.