Evolution of facial prosthetics: Conceptual history and biotechnological perspectives

Abstract

The reconstruction of cephalic defect and more precisely from the face is not a recent issue. Indeed, the use of facial masks in a symbolic perspective was reported in ancient Egypt. Few references to facial prostheses are then found. It is really only with the work of the French surgeon Ambroise Paré that the first surgical techniques concerning facial epithetics are described. Techniques and materials tend to evolve over the centuries. But then came WWI, which marked a major turning point and brought to light the broken faces and the impact of maxillofacial trauma. Rehabilitation became a major issue in society. The war was a driving force for change from both a surgical and prosthetic point of view, revealing in particular such brilliant designers as the American sculptor Anna Coleman Ladd. Today, the profession is undergoing a major upheaval, linked to the growing development of biotechnological constructions. This historical review aims to retrace the evolution of the rehabilitation of facial substance loss over the ages and to outline the prospects for the foreseeable future. (Int J Maxillofac Prosthetics 2021;4:2-8)

Full text

Evolution of facial prosthetics: Conceptual history and
biotechnological perspectives
Florent Destruhaut, DDS, PhD1 , Jean-Michel Caire, PhD2 , Antoine Dubuc, DDS, MSc3 , Philippe Pomar,
DDS, PhD1, Christophe Rignon-Bret, DDS, PhD4 , Adrien Naveau, DDS, PhD5
1 Department of Maxillofacial Prosthodontics, Paul Sabatier University, Rangueil hospital group, EvolSan Laboratory, Toulouse, France.
2 Institute for occupational therapists, Rangueil hospital group, Toulouse, France.
3 Paul Sabatier University, Rangueil hospital group, Toulouse, France.
4 Paris University, Charles Foix Hospital, Paris, France.
5 Department of Prosthodontics, University of Bordeaux, Bordeaux University Hospital, Saint-André hospital group, Bordeaux, France.
INTRODUCTION
“Prosthetics reconstruction is the oldest
branch of plastic surgery, predating even the
crudest surgical attempts at reconstruction”
according to Keith F. Thomas.1 Restoring facial
anomalies with some prosthetic appliance has
certainly been one of the oldest rehabilitations of
the human body because the symbolic richness of
the face has always raised a singular need for
social normality. This narrative review outlines the
major steps of the evolution of facial prostheses
throughout the centuries. The spotlight is on
practitioners who have elaborated new concepts
rather than on the techniques themselves (Fig 1).
The first part of this article deals with the origins of
facial prosthetics and its symbolic perspectives. The
second part focuses on the revolutionary designers
of facial prosthetics, such as Ambroise Paré
(1510-1590) and Pierre Fauchard (1696-1718).
Then, special tribute is paid to World War I (WW1)
practitioners, including the American sculptor Anna
Coleman Ladd (1878-1939). Finally, we propose the
future evolution of facial prosthetics, with special
emphasis on new biotechnologies.
ANCIENT HISTORY: THE EMERGENCE OF
FACIAL PROSTHESES
The wearing of artificial parts on the face
may have begun before antiquity, but this theory
lacks supporting evidence.2 However,
archaeologists found an artificial artifact inserted
in the left eye socket of a skull at Shahr-i Sokhta
(Iran) that could be dated around 3000-2900 B.C.3
The eye socket bore marks of thread, so the
artificial eye was worn when death occurred.
Moreover, in ancient Egypt tombs (about 2500
B.C.), gold masks have been found on mummies
with cosmetic gold and silver coins.4 These
discoveries revealed the first known techniques of
facial prosthetics and highlighted the social
importance of the face during ancient times.
Ancient India punished adultery by amputating
the nose, ears and hands.5 The Sushruta Samhita,
a famous treatise on Indian medicine from the Vedic
era, reported surgical reconstructions of the
nasal pyramid with a cutaneous flap taken from the
frontal region. The chances of success were lower
2
Int
J
Maxillofac
Prosthetics
2019;4:2-8.
DOI:
10.26629/ijmp.2021.02
Articles
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License.
ABSTRACT
ARTICLE
INFO
The reconstruction of the loss of substances from the cephalic end and more precisely from the face
is not a recent issue. Indeed, the use of facial masks in a symbolic perspective was reported in
ancient Egypt. Few references to facial prostheses are then found. It is really only with the work of the
French surgeon Ambroise Paré that the first surgical techniques concerning facial epithetics are
described. Techniques and materials tend to evolve over the centuries. But then came WWI, which
marked a major turning point and brought to light the broken faces and the impact of maxillofacial
trauma. Rehabilitation became a major issue in society. The war was a driving force for change from
both a surgical and prosthetic point of view, revealing in particular such brilliant designers as the
American sculptor Anna Coleman Ladd. Today, the profession is undergoing a major upheaval, linked
to the growing development of biotechnological constructions. This historical review aims to retrace
the evolution of the rehabilitation of facial substance loss over the ages and to outline the prospects
for the foreseeable future. (Int J Maxillofac Prosthetics 2021;4:2-8)
Keywords
Maxillofacial prosthetics, narrative review, facial prosthesis, history.
Corresponding
Author:
Dr Florent Destruhaut
Department of Maxillofacial
Prosthodontics, Paul Sabatier
University, Rangueil hospital
group, 3 Chemin des Maraîchers
31062 Toulouse Cedex, France.
Phone
:+33 6 74 83 34 59
Email: destruhautflorent@yahoo.fr
Received:
21
September
2020
Received
in
revised
form:
27
January
2021
Accepted:
30
January
2021
International
Journal
of
Maxillofacial
Prosthetics
(iJMP)
REVIEW
ARTICLE

than today, which raises the hypothesis of undescribed
attempts at prosthetic reconstruction. Punitive mutilations
were also found in Mesopotamia, by the king
Hammurabi (1810-1750 BC) although known for his
medical and moral codes. The retaliation, punishing
those who mutilated one of their peers, certainly
encouraged some attempts at surgical grafting for
replacing missing parts.6
Writings from the Greco-
Roman period made little mention of facial prostheses:
Hippocrates,
Galien, and Celse were more interested
in long
bone fracture reductions and restraints than
in treating maxillofacial defects. However, some
Latin inscriptions found in Pompei and Herculanum
indicated the doors of “medicus ocularis” and “faber
ocularis”, suggesting the existence of an ocularist
profession.7,8
POST-CLASSICAL HISTORY: FACIAL
PROSTHESES OF THE KINGS
During the Middle Ages, the Byzantine belief
was that a man with a severed nose could not
become emperor (“rhinokopia”). The emperor
Justinian
(482-565) had his nose mutilated on
Leonce’s order.9 Reinstated for a second
reign in 705, Justinian used a gold prosthesis to
mask his nasal blemish during his second
reign, and was nicknamed "Rhinotmete". The
rhinokopia restriction was then replaced by the
blindness restriction, removing the emperor
Philippicos in 713 from his throne. Otton III
(980-1002), the Emperor of the Holy Empire,
made a historical visit in 1000 AD to the tomb
of Charlemagne at Aix-La-Chapelle (France). Otton
removed a tooth of Charlemagne as a relic and
replaced a piece of the cadaver’s broken nose with
a gold plate.10 Around the same time but further
east, Abulcasis (936-1013) described facial
prostheses made of ivory.8,11 Nicknamed the
“prince of doctors”, Abulcasis was known in odonto-
stomatology for his multiple surgical descriptions
during the time of the Caliphate of Cordoba.
MODERN HISTORY (EARLY MODERN PERIOD):
BIRTH OF MAXILLOFACIAL PROSTHETICS
Maxillofacial prosthetics was really born with
Ambroise Paré (1510-1590), whose clinical
knowledge tinged with military medicine provided
the first maxillofacial prostheses with surgical
anchorage (Fig 2). After three years of learning
anatomy through human dissections, he moved
from the largest hospital in the kingdom of France,
the Hôtel-Dieu in Paris, to Vitré to acquire practical
knowledge of surgery from a barber.12 He then
became a military surgeon, dealing with heavy
mutilations, until being appointed “Surgeon of the
King” of France (for Henri II and Charles IX). As an
anecdote, Paré and André Vésale (Surgeon of the
King of Spain) unsuccessfully tried to save Henri II
from a severe maxillofacial injury during the
Tournelles tournament (1559). In his book Dix livres
de chirurgie avec le magasin des instruments,
Ambroise Paré describes many surgical and
prosthetic procedures, including facial epitheses by
use of gold, silver, paper and linen, glued and held
in place by small laces (Fig 3).13 He also described
orbital prostheses and ocular shells.
Int J Maxillofac Prosthetics 2021;4:2-8. DOI: 10.26629/ijmp.2021.02
3
Destruhaut et al.
Fig 1. Chronological frieze: the milestones in the history of facial prosthesis through the great periods of human history.

The ocular shells were first described a century
ago on the Venetian island of Murano.14 However,
the first real corporation of ocularists was formed in
Germany, and their knowledge spread all over
Europe, educating the first reported French
ocularists Alphonse Desjardins and Auguste
Boissoneau. At this time, the famous Danish
astronomer Tycho Brahé (1546-1601) named a
supernova in the constellation of Cassiopeia, and
lost the central portion of his nose during a duel
relating to the birth of Pythagoras. A silversmith
made him different gold and silver nasal prostheses
to mask his gaping stigma.15 Still around the same
time, the “miracle surgeon” Gaspare Tagliacozzi
(1545-1599) was one of the first to perform facial
surgery. In Chirurgia nova de nasium, aurium,
labiorumque defectu per insitionem cutis ex
humero, he described his protocol for grafting a
nose from a flap of arm flesh.16 This efficient and
innovative operation, known as the “Italian method”,
was still used more than four centuries later, during
WWI.17
the processes of making facial epitheses with papier-
mâché and silver.18
MODERN HISTORY (LATE MODERN PERIOD):
MATERIALS AND TECHNIQUES FOR FACIAL
PROSTHESIS
During the industrial revolution (19th century),
the new materials available for facial prostheses
considerably improved their appearance. The rigid
and uncomfortable gold and silver were replaced by
lighter materials. Epitheses were then more
aesthetic, more functional, and became effective
therapeutics to mask disfigurement. Indeed, in
1851, Goodyear obtained vulcanite by incorporating
sulfur into rubber. This easy-to-handle and
colorable product could be used in both hard or soft
forms and became a major component of
conventional dental prostheses and facial
prostheses. Norman Kingsley (1829-1931) and
Apoléoni Preterre (1821-1893) also described the
use of vulcanite for facial prostheses (in 1864 and
1866, respectively). Then from 1879, Kingsley used
celluloid.19
Destruhaut et al.
4
Int J Maxillofac Prosthetics 2021;4:2-8. DOI: 10.26629/ijmp.2021.02
Fig 2.
Ambroise Paré, father of modern surgery and of maxillofacial
prosthetics (French Stamp, 1943).
During the 18th century, Pierre Fauchard
(1678-1761) added a significant milestone to facial
prostheses. His book Le Chirurgien-Dentiste ou
Traité des Dents (1727) was the first of its kind
dealing with dentistry as a comprehensive medical
specialty that included maxillofacial prosthetics (Fig 4).
Considered the father of dental surgery and
orthodontics, he revolutionized this handicraft,
worked all his life to raise the profession as a
science and fought against charlatans. Through his
encyclopedic writings, he set the foundations of the
maxillofacial dentistry trade for future generations to
improve on. Among other techniques, Fauchard described
Fig 3. Face mask made of glued paper and linen, painted and
enameled.13
At the end of the 19th century, a French
physician
and dentist, Claude Martin (1843-1911), gave
maxillofacial prosthetics a new dimension by
combining maxillofacial surgery and dental
prosthetics. For the first time in De la prothèse
immédiate appliqué à la resection des maxillaires,
Martin used the terms “surgical” and “prosthesis”
together.20 He described the use of translucent
ceramics for nasal prostheses after amputation,
providing satisfying skin simulation. Around the
same time, Karl Henning (Austria) proposed an
original and still-used method for restoring noses,
ears and cheeks.21 After creating an impression of
the patient’s face with plaster, the missing facial
organ was reconstructed with wax on the plaster
model. Then, the wax prototype was enclosed in a
multi-part muffle and removed by lost-wax casting.

Int J Maxillofac Prosthetics 2021;4:2-8. DOI: 10.26629/ijmp.2021.02
5
with the American Red Cross to run workshops for
masks.27 After obtaining official approval from the
Armed Forces Health Service, Coleman Ladd then
traveled to various French regions to help disfigured
patients.28 She was awarded the Legion of Honor in
1934 for her work and dedication to the WWI
“broken faces”. These numerous patients faced
psychosocial difficulties in reintegrating with the
family and society. The recognition of the Studio for
Portrait Masks (1918-1920) by maxillofacial
specialists, military authorities and French political
circles helped dictate laws for protection of “broken
faces”. The Union of the Wounded Faces emerged
from this need and provided shelters for this new
community. The French “broken faces” association
(Gueules Cassées) still exists and protects
mutilated soldiers.29
The First World War had already highlighted the
importance of surgical-prosthetic symbiosis. In
1917, Major Valadier, a French-American dental
surgeon and Captain H. Lawson Whale, a plastic
surgeon, published on the interest of multidisciplinary
management of maxillofacial trauma.30,31
CONTEMPORARY TIMES: FROM SILICONIZED
PROSTHETIC SKIN TO FACIAL GRAFTS
The second half of the 20th century was marked
by progress in organic chemistry and the advent of
silicone. Silicone was discovered in 1934, when
researchers from Dow Chemical and Corning Glass
developed a new electrical insulation by combining
the properties of glass with those of organic
plastics. In 1943, the first silicone applications were
military-oriented, dampening the vibrations of Air
Force navigation tools and isolating spark plugs
from aircraft and marine engines.32 In 1959, a Dow
Corning Centre for Medical Research was
established to clarify and develop, in collaboration
with hospital research, the indications for silicone in
medicine and surgery. In 1962, Silastic Medical
silicone elastomers were available to the medical
trade. Silicone is still the preferred material for
making epitheses, among other prostheses, such
as breast prostheses (Fig 5).33 In 1979, Anders
Tjellström performed the first implant-supported
auricular epithesis, and the osseointegration works
of Per-Ingvar Brånemark and Tomas Albrektsson
improved bone fixation possibilities for all implant-
supported prostheses (Fig 6).34, 35
THE BIOTECHNOLOGY FUTURE OF THE
MAXILLOFACIAL PROSTHESIS
The current facial prosthetics evolution is still driven
by the development of materials and technologies
(
computer-aided design/computer-assisted manufacturing
[CAD/CAM]).36-38 However, facial prostheses are
still the complementary and reliable alternative that
fills the gap left by the limitations of surgery. This may
Destruhaut et al.
Fig 4. Pierre Fauchard, father of dental surgery and orthodontics
(French Stamp, 1961).
MODERN HISTORY (LATE MODERN PERIOD):
WWI AS A TURNING POINT
During WWI, more than 60 million men fought
for four years; the war produced 500,000 cranio-
facial injuries, including 10-15,000 “serious facial
injuries”. Although these maxillofacial injuries were
commonly treated, their prevalence increased
considerably and surpassed the efforts of the rare
specialists of the field, such as prosthodontists,
dental technicians and maxillofacial surgeons.22
However, the large number of “broken-face”
patients contributed to the development and
recognition of maxillofacial prosthetic rehabilitation.23
In 1917, the American sculptor Anna Coleman Ladd
(1878-1939) ran workshops to make facial masks
for the WWI “broken faces”. Working from the
writings of Francis Derwent Wood,24 she collaborated
with French maxillofacial surgeons Hippolyte
Morestin and Léon Dufourmentel and gave a series
of lectures about facial prosthesis fabrication at the
Pasteur Institute.25,26 On March 18, 1918, she and
the French sculptor Jane Poupelet signed a contract
Gelatin and glycerin paste were poured into the
space within the muffle with vulcanite or rubber.
This paste was colored with yellow ochre and
vermilion pigments to mimic the skin color. When
the dough hardened, the artificial organ was
removed from its mold and edges were regularized.
For clinical fitting, the epithesis was glued with
some mastic solubilized in ether. This revolutionary
method offered aesthetic and comfortable epitheses
made with an inexpensive and easy-to-use process
in a short time. Their characteristics were closer to
human tissue than all previous attempts.

be the case for the surgical rehabilitation of patients
after exenteration, which may be limited by the volume
of the defect, the general condition of the patient or the
wish not to undergo further surgery.39 In this case
referral to a maxillofacial prosthetic team is
recommended. The surgical-prosthetic symbiosis is an
indispensable prerequisite for the realization of an
aesthetic rehabilitation. The use of acrylic or silicone
elastomer materials allows today to obtain aesthetic,
light and economical prostheses.40 In order to add
animation to the gaze of patients rehabilitated by
ocular prosthesis, some practitioners have replaced
the static iris by a dynamic photo iris.41 Indeed, surgery
has always been the main driving force for
maxillofacial prosthetics evolution.36 The rationale
behind the “surgery-first” trend is the patient’s
preference for a definitive versus a “provisional”
treatment.
with the collaboration of Amiens University Hospital
Center, the Catholic University of Louvain (Belgium),
and Lyon University Hospital Center. For this first
(partial) facial transplant on a 38-year-old woman, a
triangle graft including a nose and mouth was
performed. In 2007, Henri-Mondor Hospital (Paris-
Créteil, France) performed the second face
transplant on a 27-year-old patient with severe Von
Recklinghausen’s disease, an incurable pathology
with facial distortion. In 2010, a 30-year-old
Spaniard, accidentally disfigured five years earlier,
benefited from “total grafting of the face,” the face
from a brain-dead donor, at Vall d'Hebron University
Hospital. This operation required a team of 30
surgeons, anaesthetists and nurses, led by Joan
Pere Barret, head of the department of plastic
surgery at the Barcelona hospital. Then in 2017, a
first post-mortem human head transplant was
performed by Sergio Canavero and Xiaoping Ren,
paving the way to a future procedure with a live
recipient patient.42
Some other directions for facial prosthesis
evolution could emerge from the increase in
converging
technologies, such as nanotechnology,
biotechnology,
informatics and cognitivism.43 In that
transhumanism
progressively affects medical
therapeutics by adding biotechnology devices to
patients, facial prosthetics will certainly help
increase the patient’s biological functions.
Benefitting from advances in
neurosciences, haptic
medicine, and nanotechnology,
facial prosthetics
could be involved in creating cyborgs, the
association of man and machine. The term “cyborg”
was coined by Manfred Clynes (1925-2020), a
neurophysiologist in the 1960s, as a contraction of
“cybernetic” and “organism”. It was reintroduced
into the scientific literature by Donna Haraway,
biologist, anthropologist and philosopher, in her
Cyborg Manifesto.44 Instead of being passive, facial
prostheses could ensure true neurophysiological
interactions with their wearers via the complex
phenomena of hybridization and vicariance (substitution).
These new devices would become closer to
“maxillofacial amplification prostheses” by improving
the world perception through restored sensory
properties and new extra-sensory properties.
A recent example of cybergology evolution was
from Stelarc, the artist who in 2006 conceived the
Extra Ear project.43 The morphology and structure
of an auricular pavilion was designed and equipped
with a miniature microphone that recorded the
artist’s surrounding noises. Then in real time,
Internet users could intercept the sound frequencies
around the artist via his website. The concept was
to provide an extra-sensory function through
hybridization to create a “connected humanity”. Stelarc
stated that beyond the concept of hybridization, this
piece of art represented access to new biotechnology
to exceed one’s own sensory and motor abilities.
Destruhaut et al.
6
Int J Maxillofac Prosthetics 2021;4:2-8. DOI: 10.26629/ijmp.2021.02
Fig 5.
Silicone nasal prosthesis (Rangueil Hospital Group, France).
Fig 6.
Ombredanne’s bar: the beginning of extra-oral implants
(Rangueil Hospital Group, France).
At the beginning of the 21st century, facial
rehabilitation made new inroads with the first
attempts at facial transplants and the subsequent
ethical questions. To date, more than a dozen facial
transplants have been performed worldwide
(France, United States, China and Spain). The world
premiere of facial transplants was held in France in 2005

Destruhaut et al.
In 2007, Stelarc completed his project and implanted
in its forearm a biopolymer ear structure that was
gradually covered by skin and became an
internalized structure. The hybridization was
achieved by the intimate histological connection of
the bio-object with its skin substrate. Equipped with
a receiver, this third ear allowed Stelarc to become
an internet portal providing others with the
possibility
to use his body. The hybridized body with
microphone bioprosthesis became a collective
experience.
These technological devices may also benefit
from the bioengineering revolution that will soon
allow for bioprinting of graft prostheses with an
intimate integration in the organic maxillofacial
support.45 Indeed, the CAD/CAM guidance of free
vascularized flap transplantation with dental implant
placement has been a revolution in the field.30 In
this context, an interesting improvement would be
to provide the patient with a composite graft CAD/
CAM-driven to match perfectly the defect, being
scalable, on-demand, with complex anatomical
design, and layer-by-layer controlled distribution
(Fig 7).46 Ear and nose reconstruction by tissue
engineering can benefit from 3D printing, replacing
the cartilage scaffold with printed polymers.47,48 In
China, some of these 3D-printed ears were recently
transplanted in patients with microtia, with follow-up
periods ranging from 6 months to 2.5 years.33 Most
of the protocols usually begin with designing the
missing organ prototype from medical imaging of
the
patient and 3D printing the piece with a
biodegradable material to obtain the scaffold with
the organ shape. In the meantime, the patient’s
chondrocytes are cultured in vitro for expansion.
Then, cells are seeded on the scaffold before
transplantation under the skin. In terms of 3D
printing of biological components, the most mature
studies reported protocols for printing with a
biodegradable scaffold, biological proteins and
chondrocytes at the same time.48 A proof-of-
concept ear was even bioprinted with a conductive
electronic antenna perceiving sounds that the
normal human ear could not.48 The infused silver
nanoparticles enabled a readout of signals from
cochlear-shaped electrodes, thus enhancing
auditory sensing for radiofrequency reception and
opening the possibility for listening to stereophonic
music. Human grafting of bioprinted facial parts is
not yet available but, in the future, could be
delivered in situ, directly in the patient to fill in the
defect and regenerate missing tissue.
CONCLUSION
The desire to preserve or restore facial features
is an obvious human concern that harks back to the
most remote times of humanity. Maxillofacial
prosthetics constitutes a very ancient dental and
medical discipline whose purpose is to replace an
Fig 7. Digital advances in facial prosthesis.
absent or altered maxillofacial organ with an
artificial device. The prosthesis may be a bio-object
whose design goes beyond its trivial conception
because it carries psycho-social considerations
associated with identity and relational and symbolic
issues. With this historical account, we highlight the
evolution of facial prostheses over the centuries,
paying tribute to their designers, in order to better
understand the current and future challenges. The
facial prosthesis of tomorrow, at the singular
crossroads of cybergology and bioprinting, will
incorporate transhumanist aspirations. The improved
prosthetic human may pass from the status of a
patient to that of a hybrid, whose fate will have to be
determined within the framework of a phenomenological
approach.
ACKNOWLEDGEMENTS
The authors thank Margit Heiske (researcher)
and Thierry Letellier (researcher) for proofreading.
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