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Finger Prostheses - Overcoming a Social Stigma: Clinical Case Reports

Dhruv Arora *, Shyam Singh**, R Shakila, SK Jagdish*, Santosh Anand*, VR Arun Kumar*, J Balaji*

ABSTRaCT
Maxillofacial prostheses replace lost body parts using articial substitutes like silicones. These prostheses support the patients psychologically and enhance their social acceptance. The authors describe rehabilitation of two patients with missing ngers using silicone prostheses. A 13-year-old boy with completely missing little nger and partially missing ring nger in his right hand was treated by using silicone prosthesis. The prosthesis was retained by using a ring. A 9-year-old boy with partially missing middle nger in his right hand was treated by using a silicone glove type of prosthesis. Implant retained prostheses were not considered due to the cost of the treatment. Use of glove type prosthesis or mechanical aids such as rings provides an easy and cost-eective alternative to implants. Such treatment can be opted for in cases of nancial constraints. Key words: Glove prosthesis, RTV silicone, nger prosthesis, mechanical retention

rosthesis refers to articial replacement of an absent part of the human body.1 These articial substitutes serve primarily to improve the patients appearance and to support them psychologically. They play an immense role in making the patient more socially acceptable.2 Reconstructive surgery cannot restore esthetics as much as prosthesis can and thus has limited role in case of lost body parts. The major role in rehabilitating the patient is thus played by the maxillofacial prosthodontist and the anaplastologist. Most of the prostheses are made from medical grade silicones.3 These silicones can be rendered to match to the skin color of the patient and give a more life-like appearance. Most of the silicones used for this purpose are room temperature vulcanizing silicones (RTV silicones). The advantages of RTV silicones include chemical inertness, exibility and elasticity.4 They can also be easily molded and colored. The prostheses can be retained either by mechanical methods or by

the use of adhesives. Use of magnets for retaining prostheses has also been tried.5 Implant retained prostheses have proven to be satisfactory, provided they are economically feasible.6,7 Retaining nger and hand prosthesis by using rings, bracelets, etc. are some methods of mechanical retention. Glove type prostheses are designed to snugly t over the remaining stumps to provide retention.8 This article describes rehabilitation of two patients with nger prostheses using such mechanical modes of retention. Methods
Case Reports Clinical Case 1

*Junior Resident ** Director, Professor and Head Associate Professor, Dept. Address for correspondence Dr Dhruv Arora Junior Resident, Dept. of Prosthodontics and Implantology Mahatma Gandhi Postgraduate Institute of Dental Sciences Govt. of Puducherry Institution, Gorimedu, Puducherry, Pondicherry - 605 006 E-mail: dhruv_doc1026@yahoo.co.in

A 13-year-old boy reported to the Department of Prosthodontics and Implantology for replacement of a missing tooth in the mandibular posterior region. During examination/the patient was found to have missing ngers in his right hand. A detailed history revealed that the patient lost his ngers 5-year-ago in a road accident. The amputated stumps were well-healed with completely missing little nger and partially missing ring nger (Fig. 1). The advantages and limitations of replacement of the nger were explained to the patient and his parents. Since a part of the ring nger was remaining, retaining the prosthesis by means of a ring was chosen. A ring of suitable size and width 407

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Figure 1. Pre-prosthetic photograph of case 1.

Figure 2. Pre-prosthetic photograph of case 2.

to mask the margin of the prosthesis was selected.

Clinical Case 2

A 9-year-old boy reported to the Dept. of Prosthodontics and Implantology for replacement of a missing middle nger in his right hand. The patient said that he lost his nger one year ago while ring crackers. Examination of the stumps revealed adequate healing with two-thirds of the nger remaining. Only the terminal one-third of the nger was lost (Fig. 2). The treatment procedure was explained to the patient and his parents. Retention of the prosthesis by using a glove type of nger prosthesis was chosen for this patient since two-thirds of the nger was remaining to provide adequate retention. Use of a ring will be unnatural in the terminal third of the nger or using the ring near the lower third would make the prosthesis longer, bulky and unesthetic. Use of implant retained prosthesis was not considered because both the patients could not aord such a treatment.
Fabrication of the prosthesis

Making the impressions and casts the impression material chosen was alginate. A plastic container of sucient length and diameter was chosen to conne the impression material. The containers were tried on the patients hands to provide adequate clearance of at least 5 mm around for the impression material. Regular setting alginate was mixed using cold water to increase the working time and poured into the containers. The patients were asked to dip their hands vertically into the container without touching the sides or the bottom of the container. The material was allowed to set and the hand was removed quickly in a jerking motion after the material was set. Impressions of both the aected and normal hands were made. The impressions were poured in stone and casts were made. The normal hand was used as a reference to duplicate the size, shape and orientation of the ngers. Selection of a donor and making wax patterns a donor hand for making the wax patterns was essential to avoid the laborious task of sculpting. Using the cast of the normal hand as reference, a donor hand was selected for each patient from among the patients visiting our department. Impressions of the ngers of the donors were made using condensation silicone in putty consistency. Wax was molten and poured into the putty

The basic steps in fabrication of the prostheses for both the patients were the same and hence described together. Attachment of the ring to the prosthesis for case 1 was done after the prosthesis was fabricated. 408

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Figure 3. Post-prosthetic photograph of case 1.

Figure 4. Post-prosthetic photograph of case 2.

impressions. After the wax cooled down, it was retrieved from the impression and tried on the casts. Final carving and adjustments were made to blend the margins with the respective casts. The completed wax patterns were tried on the patients.

RTV silicones mixed with colors were packed into the moulds. Curing was done for 24 hours at room temperature. Prostheses were nished using alpine stones and silicone burs. Methods of Retention
Clinical Case 1

Color matching and incorporation of nail the most critical step was to match the color of the prostheses to the patients skin color. The basic skin color was observed. The colors were mixed with the silicone to obtain the base color. Maximum eorts were made to match the color of the prostheses. The nails were made from cold cure clear acrylic resin. They were properly shaped and trimmed to the required size. Around 1 mm of nail bed was carved in the wax patterns and the nails were incorporated in that space. Stump preparation in order to fabricate a glove type prosthesis reduction of the stumps were necessary. A reduction of 1-1.5 mm was done on the stone casts.9 This would produce prosthesis with a smaller diameter which can be stretched over the amputated stumps to provide retention. Procesing and nishing the patterns were asked and a two part mould was obtained after dewaxing.

The retention for this patient was by using a ring of suitable size. The ring was attached to the prosthesis by means of cyanoacrylate glue initially. The prosthesis was tried on the patient and position was nalized. The cyanoacrylate glue was later replaced by silicone by asking the prosthesis and adding silicone to attach the ring (Fig. 3).
Clinical Case 2

Retention of the prosthesis for this patient was achieved by fabricating glove type prosthesis as described (Fig 4). Discussion Successful prosthetic rehabilitation of these patients is a challenging task, but it is our duty to make the best use of the available materials and techniques to enable these patients to re-enter the society as condently as possible; this may be considered every patients right. More than functional and esthetic requirements, there is one more dimension attached to these prostheses, which is 409

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psychological well-being. It is worth remembering that we cannot give the patient a living prosthesis of real tissues. The day prosthesis behaves and looks like a real tissue, will be the day when perfection is achieved. References
1. The glossary of prosthodontic terms. J Prosthet Dent 2005;94(1):10-92. 2. Miglani DC, Drane JB. Maxillofacial prosthesis and its role as a healing art. J Prosthet Dent 1959; 9(1):159-68. 3. Huber H, Studer SP. Materials and techniques in maxillofacial prosthodontic rehabilitation. Oral Maxillofac Surg Clin North Am 2002;14(1):73-93. 4. Kanter JC. The use of RTV silicones in maxillofacial prosthetics. J Prosthet Dent 1970;24(6):646-53. 5. Javid N. The use of magnets in a maxillofacial prosthesis. J Prosthet Dent 1971;25(3):334-41. 6. Pekkan G, Tuna SH, Oghan F. Extraoral prostheses using extraoral implants. Int J Oral Maxillofac Surg 2011;40(4):378-83. 7. Manurangsee P, Isariyawut C, Chatuthong V, Mekraksawanit S. Osseointegrated nger prosthesis: An alternative method for nger reconstruction. J Hand Surg Am 2000;25(1):86-92. 8. Kini AY, Byakod PP, Angadi GS, Pai U, Bhandari AJ. Comprehensive prosthetic rehabilitation of a patient with partial nger amputations using silicone biomaterial: A technical note. Prosthet Orthot Int 2010;34(4):488-94. 9. Thomas KF. Prosthetic Rehabilitation. Quintessence, London 1994:127-8.

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