RETENTION OF MAXILLOFACIAL PROSTHESIS

RETENTION OF MAXILLOFACIAL PROSTHESIS

In maxillofacial prosthetics there exists a broad variety of types of

methods for gaining retention, stabilization, and immobilization as
required. Close evaluation of a case with the surgeon before and
during surgery helps in finding means to create irregular defects for
enhancing anatomic retention.17

The following methods of retention are discussed for intraoral and

extraoral prostheses.

Intraoral Prosthesis and Its Retention

Anatomic Retention

Intraoral retention includes the use of both hard and soft tissues,
that is to say, teeth and mucosal and bony tissues. The success of
intraoral retention relates to the size and location of the defect and the
outcome of the surgery.

For instance, a small defect of the palate can be closed by a

conventionally designed removable bridge. This may merely provide an
obturation benefit or it may be a combination of obturation benefit or it
may be a combination of obturation plus a replacement for missing
teeth. Further, it may have a speech bulb extension added to a
pharyngeal extension, and then it would be a combined obturator,
bridge for mastication, and speech therapy appliance.

Anatomic undercut areas are a welcome feature in the

postsurgical case. These may be found in the palatal area, cheek,
retromolar, labial, septal, posterior nasal pharyngeal, or anterior nasal
spine areas.

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Large alveolar ridges and high palatal vaults generally provide

more retention than flatter ridges. This anatomy may still not provide a
completely stable replacement, depending upon the presence of lower

natural teeth or previously acquired undesirable denture habits by the

patient.

A melanoma of the palate. B. Postsurgical view of the excised palate with anterior
ridge intact for retention purpose. C. obturator inserted and retained by existing soft
and hard tissues. D. prostheses in occlusion.

In the larger defect cases encompassing both the maxilla and

mandible, as in a commando operation, skill, ingenuity, and the
operator's thoroughness, coupled with the patient's adaptive ability, can
result in a "one of a kind" successful prosthesis.

Additional aids to anatomic retention include proper occlusion,

proper post dam, and surface adhesion.

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Mechanical Retention

Under this category, the operator has a myriad of devices and

proven techniques to consider and use as the case demands.

Temporary Mechanical Retention

This may be a stainless steel wrought wire of 18-gauge size

which can be quickly adapted to a cast of the remaining teeth to retain
the temporary prosthesis during the healing period. Some wire clasps
come preformed and can be readily incorporated into the acrylic palate
of an obrutator or saddle in a lower prosthesis or a previously existing
denture.

Other preformed stainless steel wire clasps include Adams,

Arrowhead, Akers, Roach, or Hawley labial wires.

Preformed stainless steel bands or crowns may be adapted to a

child or adult to increase retentive form of a mutiliated or conical tooth.
Extra soldered lugs or bands with prewelded brackets can be used to
provide undercuts on these crowns for better clasp retention.

Orthodontic bands and prewelded brackets to retain temporary prosthesis.

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When a maxillofacial prosthetist is not available, an old denture

can be wired in place to obdurate a maxillary hemisection. This wire
extention is internal to the infraorbital or zygoma bones.

Intraoral temporary retention may also be illustrated by the

construction and insertion of a tantalum tray to help retain a rib graft or
fractured mandibular segments during healing.

Bilateral perforated tantalum trays used for immobilization of mandibular segments.

Permanent Mechanical Retention : Cast Clasps.

The most common method for retaining a prosthesis uses a cast

metal clasp which enters an undercut. The properly designed and
fabricated clasp will provide stability, splinting, bilateral bracing, and
reciprocation, as well as retention.17

The cast clasp is most successfully adapted to a mouth

previously conditioned to receive it, i.e., a mouth with well-designed,
surveyed, and fitted castings over the abutment teeth. This metal
extension of the removable prosthesis is best referred to as the direct
retainer. By its construction, the direct retainer has contact with and so
engages the abutment tooth to extend around it by more than 180
degrees to resist displacement caused by reasonable dislodging forces.

The clasp extends into an undercut or infrabulge area of the

supporting tooth in order to gain retention. It prevents damage to the

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supporting tissues of the abutment teeth only if it is carefully designed

as a part of the partial denture.

Various qualities of clasp design influence the degree of retention.

These include the length, the diameter, the taper, the material and the
general contours of the retentive clasp, as well as the depth of the
undercut used.

Length of Retentive Clasp Arm : The ability of a clasp arm to flex and
relax as it passes over the height of contour and come to rest in an
undercut area is directly proportional to the cube of its length. As an
example, a clasp arm that is increased from 5 to 6mm in length, a 20%
change, will have its load deflection rate amplified by approximately
75%.

Diameter of Retentive Clasp Arm : The influence of this factor has

been calculated to be inversely proportional to the fourth power of the
diameter. Thus, a very small increase in the cross-sectional diameter of
a clasp arm can significantly influence its ability to flex and relax.

Form of Retentive Clasp Arm : A tapered clasp arm has greater

flexibility than one of uniform contour. Proper tapering greatly enhances
the flexibility of a clasp arm.

Material of Retentive Clasp Arm : Since a wrought clasp is a fibrous

structure, it is more flexible than a cast clasp with it more brittle
crystalline structure. Also some cast metal alloys are inherently more
flexible than others. In comparing a representative type IV partial
denture gold casting with an example of the cobalt-chrome family of
alloys, a marked difference in the flexibility of the two materials is noted.

Contour of Retentive Clasp Arm : Two factors exert an influence

here. A clasp arm which is half-round, as most cast clasp arms are, is

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more flexible than a round clasp arm of the same diameter. The
contour of the clasp arm relative to its plane in space can also be a
factor. A clasp arm that transverses the tooth surface from the minor
connector on the proximal aspect to the point of retention near the
opposite proximal surface has both a horizontal and a vertical
component to its contour. As this clasp is asked to deform and pass
over a height of contour, deformation occurs in the horizontal
component by a stretching of the molecules on the side adjacent to the
tooth and by their compression on the side away from the tooth surface.
This requires a greater force than does the torsional movement or
slipping of molecules that occurs in the vertical component. Thus, the
path of the clasp arm across the tooth surface may affect its load
deflection rate.

Depth of Undercut Employed : This factor influences the amount of

deformation necessary to pass over the height of contour on an
abutment tooth. It is perhaps the most frequently varied factor in the
establishment of retention.17

RECIPROCATING CLASP ARM :

A retentive clasp is designed to deform as it passes over the

height of contour on the abutment tooth and to return to its original
passive state upon coming to place in the infrabulge area. The lateral
component of force necessary to cause the clasp arm to flex is
counteracted by an equal and opposite force against the tooth surface.
Since the abutment tooth is suspended by a series of ligaments that
permit minute amounts of physiologic movement, a part of this overall
action is compensated for by the displacement of the tooth. This
movement occurs each time the partial denture is seated in place and
each time it is removed. Repeated lateral displacement of this
magnitude to the abutment tooth would soon become pathologic and

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result in loss of support to the tooth on the side opposite the retentive
clasp arm. This support should be located on a line directly opposite
the retentive clasp tip and should be continuous throughout the period
of time that the retentive clasp tip is applying a force against the
abutment tooth.

Although it is certainly not mandatory, it is usually more

convenient to locate the retentive undercut on the bucal surface of the
abutment tooth. Reciprocation then is accomplished via a guiding plane
opposite the retentive undercut on the abutment tooth in combination
with a more rigid clasp arm on the direct retainer. This latter clasp arm
contacts the plane at the same time when the retentive clasp arm
contacts the suprabulge surface, and it remains in continuous contact
until the partial denture is completely seated.

Occlusal Rest :

This part of the direct retainer is that unit of the partial denture
frame designed specifically to fit within a prepared rest seat in the
abutment tooth. It serves several purposes : to provide a positive point
of orientation between the partial denture and its abutment; to resist
overseating the partial denture and subsequent impingement of the
periodontal tissues; and to serve as a point for the transmission of
stress to the abutment tooth as nearly along its long axis as possible.

Although a rest seat may take various forms, it is customarily

located on the occlusal surface of posterior abutment teeth or on the
lingual surface of anterior abutments.

TYPES OF EXTRACORONAL DIRECT RETAINERS 17

Cast Circumferential Clasp

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The cast circumferential clasp, of Akers clasp as it is sometimes

called, is one of the most frequently used clasp because of its reliability,
ease of fabrication, and adaptability. It is particularly indicated in
situations in which the prosthesis will be totally tooth-supported and
tilting leverages will not be encountered, in modification spaces, or on
the side of the arch opposite a unilateral edentulous space. It should be
avoided on abutments adjacent to a free end saddle replacement.

Cast circumferential clasp.

Cast-wrought Combination Circumferential Clasp

This is an adaptation of the first clasp from described, and it

substitutes a contoured wrought wire for the cast clasp on the retention
side. It may be used whenever the fully cast circumferential clasp is
indicated but, in addition, it may be used in a free end saddle situation.
Because of its greater ability to flex in any direction, tilting leverages are
more likely to be dissipated without adverse forces being directed
toward the abutment tooth.

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Wrought - cast combination Akers clasp

This clasp is somewhat more complicated for the technician to

fabricate, and it is slightly more susceptible to distortion by the patient
and more likely to fracture after repeated usage. It lends itself well to
use in the anterior region because of its more esthetic appearance. It
has greater adaptability than many of the cast clasps and, because of
its line contact with the enamel surface, it has less tendency to catalyze
recurrent decay.

T-Bar Cast Circumferential Combination or Roach-Akers Clasp

This clasp provides a cervical approach to the tooth surface and

affords the opportunity to take advantage of an existing distobuccal or
distolabial undercut. It is indicated in either unilateral or bilateral distal
extension situations.

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PROXIMAL
Cast Roach - Akers combination clasp.

It has the reputation of treating the abutment tooth more kindly in

that situation in which rotation of the base, under load, is a problem.
Unfortunately, it also is noted for creating a food trap that requires
meticulous attention by the wearer.

Ring or Ring-around Clasp

This clasp form also uses an undercut adjacent to the edentulous

area but reaches it by circumnavigating the tooth. It is especially
applicable for use on lone-standing molar abutments distal to the
edentulous space that are tipped or tilted to an exorbitant degree.

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Mandibular molar ring clasp and modification

There are other clasp forms, and modifications thereof, that lend
themselves to certain situations; however, those illustrated can serve
adequately as a rather complete armamentarium for the restorative
dentist.

Prefabricated Precision Attachments

These attachments can be placed into cast crowns for the best in
esthetic and mechanical retention. Construction problems exist here,
and much more precise measures are necessary for success.

These preformed attachments are most useful in rehabilitating

cleft lip and cleft palate cases. They can be used with or without a
reciprocal arm.

Semiprecision Attachments, Custom-made

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This attachment is formed in the wax pattern, using a specially

shaped mandrel mounted on the parallelometer. A reciprocal arm is
always necessary.

Snap-on Attachment

This is also a preformed precious-metal precision piece designed

to retain and to stabilize a prosthesis. A Baker bar or Anderson bar is
the rod connecting two abutment crowns, and the clip engages this rod.

A. Baker snap-on attachments soldered to the cast frame work. B. cross-arch

splinting. using 11. gauge bar

This attachment is usually used in combination with other

retentive means such as a clasp, precision attachment, or thimble-
telescoping crown.

Overlay (Telescoping) Crown and Thimble Crown

This is often used when an overlay denture is planned or an

extremely malposed tooth is needed for stability but is not considered
for orthodontia. It is also used when a major change in the vertical or
centric dimension is indicated, as in cleft lip-cleft palate, prognathic
mandibles or resected mandibles.

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A thimble crowns cemented on

prognatic patient. B. telescoping
crowns imbedded in the denture.
C. superimposed denture inseted in
the mouth to correct the vertical and
centric dimensions. (Courtesy of
Dr. J. Borkowski).

Magnets

Magnetized metal discs in denture teeth or magnetized metal

rods can be inserted into the edentulous ridge and the overlying saddle
extension or can be easily inserted into the dentures themselves.

A
B
A. Stock repelling magnets. B. Magnets invested and waxed under the occlusal surface.

Magnetic retention is at the most an aid but not of itself an

effective method to properly retain a nonstabile denture. This

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consideration may be useful in a hemimax-illectomy case or extremely

atrophied ridges.

Gate Type or swing Lock Device.

This retentive aid helps gain partial retention for many loose or
periodontally involved teeth. This retentive means can be used when
most other methods should be considered first.

A, Close-up view of swing lock

device. B. tissue side view of
obturator with swing lock. C,
obturator is retained in the mouth
by a gate type device.

Intermaxillary "George Washington" Springs

These come preformed and can be inserted into an upper and

lower set of dentures to help stabilize them on the ridges during
function.

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A, "George Washington" spring inserted in the buccal flanges of maxillary and mandibular
dentures. B. maxillary obturator is retained by "George Washington" springs.

Auxiliary Retentive Devices121

These include buccal-lingual continuous clasp, valve seal.

Furchard wing device for clefts, guide planes, surface adhesion, and
denture surface adhesion, devices such as Porcelene and Durabone.

Screws

These are specially made custom parts.

Implants

Implants include tantalumtray, acrylic mandible and wire, and

intraosseus wire.

Suction Cups

Inflatable balloon suction sups are used for maxillary resection.

Adhesives

These become necessary to aid retention when the surgical

wound is large, the palate is flat, the anterior posterior lateral septal
wall is not undercut but rather angles away from the natural palate, the
maxillary tuberosities are nonexistent, the soft tissue undercuts in the

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area of surgery are missing, or the patient's salivary flow is diminished

due to pre-and postradiation therapy.

Occlusion

The proper cusp height and fossa depth as dictated by a healthy

mandible and related to the motion sequence recording from the healthy
temporomandibular joint can also assure denture stability and retention.

EXTRAORAL RETENTION

Anatomic Retention

This necessitates the use of both hard and soft tissues of the
head and neck area. Retention of the dynamic extraoral area depends
on many factors for a successful end result. These factors are related to
the location and size of the defect, tissue mobility or lack thereof,
undercuts, and the material weight of the final prosthesis.

Hard tissue

Hard tissue act as a base against which to seat the prosthesis

and to provide a better seal of the prosthesis with the use of an
adhesive. Examples would be any bony wall of a defect with which part
of the prosthetic device will come in contact or a cartilaginous remnant
of the ear.

Soft tissues

Soft tissues prove to be more trouble some because of their

flexibility, mobility, lack of a bony basal support, lower resistance to
displacement when a force is applied, deficiencies as a base for firmly
securing the surgical adhesive during cementation, and the physiologic
nature of squamous ectodermal tissues. An example of this would be
the orbital prosthesis

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A, left orbital exenteration. B, cross A, right orbital exenteration. B. tissue side

section of orbital prosthesis and tissue of orbital prosthesis and ocularrosthesis.
side view of prosthesis. C, orbital C. orbital prosthesis retained by tissue
prosthesis inserted in the defect. undercuts and auxillary nasal extension

MECHANICAL RETENTION

Additional retention is mostly

needed in unusual cases such as large
defects involving half of the face or
heavily radiated tissues when the use of
adhesives is not feasible. It is advisable
to use eyeglasses as an indirect
mechanical retention which at the same
time hides the margins of the prosthesis.
The eyeglasses should be free of and Eyeglasses are seated over the auxillary
not a part of the prosthesis, In addition nasal extension. Also note lateral button
and rod for additional support when
adhesive is contraindicated.
to eyeglasses, an elastic strap may be of use to hold the glasses on
and help retain the prosthesis.

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A, extensive left facial defect. B. facial prosthesis retained by eyeglasses, button, rod
and nasal extension.

Magnets

These may be imbedded in a nasal prosthesis or orbital

prosthesis to help secure it to a maxillary obturator which may be in
contact with the above prosthesis.

Highton R60 produced magnetic systems were chosen for testing,

five closed field systems and one open field system. The closed field
systems were (1) Innovadent, (2) Magnedent (large and medium), and
(3) Jackson (Solid State Innovation) regular and mini magnets.

Six magnet-keeper systems were tested to determine the

relationship between an air gap and the resulting breakaway force. The
maximum retention was obtained, when the magnet and keeper were in
apposition. However, as the air gap increased in 0.1 mm increments,
the breakaway force diminished rapidly initially and, then began to taper
off at 0.2 to 0.3 mm.

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Ideally, the preferred placement of the magnet into the denture is

with a carefully controlled system to provide an air gap. Then the
magnet is attached with a minimal amount of autopolymerizing acrylic
resin.

Magnets have been used as aids to denture retention for many

years with some success. The development of new cobalt and rare
earth magnet alloys has greatly extended the potential application of
magnetic retention in removable partial dentures, complete
overdentures, fixed partial dentures, and sectional dentures.

Effects of magnetic fields on tissues have been investigated

extensively, with conflicting results, but reports describing dental
applications for magnets claim no damaging tissue effects. The close-
field magnetic retention system described avoids any possibility of
magnetic field effects on tissues by using paired magnets and a fixed
and detachable keeper in a modified horseshoe arrangement. The
detachable keeper is cemented or screwed to a decoronated, root-
treated tooth. The denture-retention element, consisting of paired
magnets and a fixed keeper, abuts the keeper in the tooth root and
holds the denture in place by magnetic attraction. When in position,
there is no external field surrounding the denture or tooth root. This
arrangement also doubles the available retention.

The shape, size, and configuration of the two magnets and fixed
and removable keepers were chosen to provide maximum retention in a
magnetic denture retention unit of a size convenient for most
applications. The retention provided is approximately 300 gm per unit.

The magnet alloy, Co5Sm, is very hard but brittle and it can
corrode in the mouth. To prevent this occurring in service, end plates
protect the composed magnet faces. The plates, of the same stainless

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steel alloy as the keepers, prevent magnet corrosion and reduce wear
at the denture-retention keeper-element interface in service.

The incorporation of magnets into prostheses can contribute to

the resolution of a problem of retention of surgical prostheses. Although
magnets have been in use in maxillofacial prosthetics for some time as
components of combined intra-extra-oral prostheses, their adaptation to
other problems should not be overlooked. Magnets provide positive
looking potential, and, once positioned, afford definite and continuous
retentive qualities. However, a through evaluation of the problem must
be made to determine the feasibility of their use. 134

Snap Buttons and Straps

These are also used on a large extraoral prosthesis.

Adhesives

Retention can be enhanced and may rely entirely on the use of a

surgical grade extraoral adhesive. In general, each material provides its
own adhesive because of its inherent physical and chemical properties.
The adhesives aid retention, marginal seal, and border adaptation. This
secures the prosthesis against accidental dislodgment.

Most modern prosthetic replacements are secured with

adhesives. These may include interfacing pastes, liquids, sprays, or
double-coated tapes. All are readily available, easily applied, and can
provide satisfactory retention for limited periods of time.

However, there are several disadvantages for the continual use of

adhesives which can reduce their effectiveness. Some patients will
develop allergic or irritational responses to adhesives which may persist
even with a chance in the type of adhesive. Radiated patients may be
particularly subject to such responses. Patients with poor dexterity or

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coordination may have difficulty in applying the adhesives in placing an

adhesive-retained prosthesis repeatedly to the proper position.
Prosthesis margins secured to very mobile or unsupported tissue may
need constant reattachment if facial movement tends to disturb the
adhesive bond. Poor hygiene may limit the effectiveness of a
prosthesis when the adhesive must be reapplied each time it is used.
Some aromatic base adhesives may curl thin margins of a prosthesis,
making esthetic placement difficult. Even routine adhesive removal
may damage external pigmentation if pressure is applied to both sides
of the prosthesis.120

Mucosal Inserts :

The patient who has been edentulous and has an atrophic maxilla
has few alternatives for the security and function of a prosthesis. The
atrophy of the alveolar ridge, in the maxilla, does not usually allow
sufficient depth of bone in the posterior region in relation to the floor of
the maxillary sinus for the placement of endosteal implants. Similarly,
atrophic resorption of the mandibular alveolar ridge precludes endosteal
implant reconstruction due to the proximity to the inferior alveolar canal
and its contents.

Examine the patient's denture and evaluate the accuracy of fit

and occlusion. If any discrepancies are noted, carry out a reline
procedure. A waiting period of two to four weeks should be anticipated
to circumvent any ill-fitting areas.

Two rows of inserts are usually fabricated into the tissue-bearing

surface of the denture. One row is on the crest of the ridge from the
bicuspid region posteriorly and the other is on the palatal slope.
Fourteen inserts are usually inserted. The inserts should be placed

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sufficiently apart so there is no tissue impingement between them,

therefore, god hygiene can be maintained.

Combination of anatomic, Mechanical, and Adhesive Retention

Large facial replacements need to use all available means of

retention, The prudent use of some or all available retentive means plus
any original improvisation by the prosthodontist can lead to better
stability and retention.

Resilient lining material for the retention of maxillofacial

prostheses

Resilient lining materials have taken their place in complete

denture prosthodontics since their first reported clinical application in
1943. On denture-bearing areas (basal seat) where thin mucosa is
located over sharp residual alveolar ridge crests, the stresses of
mastication tend to be localized, resulting in tissues which are
overloaded. Such tissues are frequently painful and subject to recurrent
traumatic ulceration. When resilient denture liners cover these tissues
they artificially replace the missing connective tissue of the submucosa,
which when present permits a more equal distribution of the kocclusal
loads imposed on the basal seat.

The retention of some maxillofacial prostheses is a continuing

problem. Frequently the congenital or acquired abnormalities do not
permit the application of accepted techniques for the retention of either
removable partial or complete prostheses. The use of a resilient lining
material possessing the properties of permanent resilience and
dimensional stability can be of considered assistance for such patients.
The improved tolerance of sensitive oral mucosa to occlusal loading is
an additional reason for the incorporation of resilient materials in a
variety of maxillofacial prostheses.

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A resilient lining material provides primary retention for

prostheses that may be difficult or impossible to obtain by other
means.110

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