RETENTIVE AIDS IN MAXILLOFACIAL PROSTHESIS

JC PRESENTATION

It is the God given right of every human being to appear

human

NAME- ENU
PG I YEAR
INTRODUCTION
Maxillofacial prosthetics

Branch of dentistry that provide prosthese to restore tissue of

somatognatic system and associated facial structure that
have been affect by disease ,injury ,surgery or congenital
effect providing all possible function and esthetic
Indication

Accq Cong Trau

●
uired enital ma
Malignancy ●
Cleft palate and cleft lip Accident
Gunshot
●
Any other pathology ●
Microtia Animal attac k
 classification

In tra o ra l Ex tra o ra l

1.Obturator 1.Auricular
2.Speech aid 2.Occular
prosthesis 3.Orbital
3.Infant 4.Nasal
feeding 5.Mid face
prosthesis
Prosthetic materials
ACRYLICS

POLYUR SILICONE
Room temperature
ETHANE ELASTO
vulcanizing
S MERS

High temperature
vulcanizing
 Retentive aids in maxillofacial prosthesis

Kotewar shivani et al method of retentive for maxillofacial

prosthesis:A review IJCRT
 INTRODUCTION

 The Dentist in general and Prosthodontist in particular has a major role in

maxillofacial prosthetics because of his knowledge of anatomy, physiology and
pathology as well as his skill and experience in using materials that are
compatible with the patients remaining tissues.

 Retention has always been a problem in prosthodontics. Prosthodontists have

always been struggling with retention in a maxillofacial prosthesis .

 Increased retention improves comfort as well as the confidence in the patient

while wearing a facial prosthesis at work and in social settings.

 Advances in techniques used for retention of maxillofacial prosthesis and the

materials used have been remarkable in the past several years.
Method of retention

MECHANICAL

CHEMIC
ANATOMIC
AL

SURGICAL
 Anatomic method

It can be obtained by :-
Any undercut or any concavity in defect can be used as mode of
retention.

A n a t o m i c r e te n ti o n

Extraoral Intra oral

Extra oralCan be achieved from hard and soft
retention
tissue of head and neck region.

examples –bony wall of defect,and

cartilaginous remant of ear

Deep undercuts create difficulties in insertion and removal of

prosthesis.
Intraoral retention

 The success of intraoral retention relates to the size and location of the defect
and outcome of the surgery.

 Intraoral retention includes the use of both hard and soft tissues

 Anatomic undercut areas are a welcome feature in the postsurgical case. They
may be found in the palatal area, cheek, retromolar, labial, septal, posterior
nasal pharyngeal or anterior nasal spine areas and lateral scar band.

 Additional aids to anatomic retention include proper occlusion, proper post

dam, and surface adhesion.
 MECHANICAL RETENTION

Mechanical retention of facial prostheses is the

oldest method of retention reported in the field of
facial prosthesis.
Mechanical Retention Mechanical anchorage includes:
1. Eye glasses and frames.
2. Extension from denture.
3. Precision attachments.
4. Elastic and non-elastic straps.
5. Magnets.
Eyeglasses:-

Can be used to retain nasal,auricular and orbital

prosthesis.
It also help in masking the border of prosthesis.
2. Extension from Denture:

Most primitive type of retentive aids namely cast clasps, retentive clips
and acrylic buttons are still being used as they are the most
economical amongst the others
a)Cast clasps:

The most common method for retaining an intraoral

prosthesis uses a cast metal clasp which enters an undercut.
The properly designed and fabricated clasp will provide
stability, and reciprocation, as well as retention
b.) Retentive clips:
Retentive clips are metallic or plastic clips that snap over
the bar used as a superstructure connected to the
implants.
Retentive clips are useful in retaining facial prostheses in
patients with good dexterity and where retention is to be
maximized in areas with little muscle force.
c)Acrylic buttons:
Acrylic buttons – retained facial prostheses usually have an acrylic
substructure that fits into the defect and one or more mushroom – shaped
acrylic projections (buttons) attached to the substructure. Metal buttons are
also widely used for retention. The final prosthesis is fabricated so that it
will snap over the mushroom buttons for retention.
Precision Attachments:
Bar clips are most commonly used precision attachment that connects
the prostheses and implant and between different parts of prosthesis.
Telescopic crowns and extracoronal ball attachments are used to
increase and improve retentive force in maxillofacial prosthesis cases
4. Elastic and Non-Elastic Straps:

They are used with extraoral prosthesis.

Head bands(elastic strap) are used in cases of auricular
prosthesis.
Non-elastic straps are used along with buckles to make it
adjustable. It requires a head cap to gain anchorage from.
Orthodontic headgear assemblies like head cap and adjustable
strap extension are very useful for extensive maxillofacial
prosthesis
5. MAGNETS:
magnets gained popularity in the field of maxillofacial prosthesis due to their small size
and strong attractive forces.
magnets are used in nasal,orbital ,auricular prosthesis, large and small maxillary
defects and intra oral-extra oral combination prosthesis.
 ADVANTAGES DISADVANTAGES

 Ease of placement  Low corrosion resistance

 Easy replacement
 Small size with strong attractive
forces
 Ease of cleaning
 Can be used with implant
supported prosthesis
 They can be embedded on thin
sections of acrylic
 Tissue undercuts can be used for
additional retention of prosthesis .
3.CHEMICAL:
Chemical retention is achieved by adhesives. According to GPT-9,
maxillofacial prosthetic adhesive is “a material used to adhere external
prosthesis to the skin and associated structures around the periphery of
an external anatomic defect.”

1. The adhesive must be biocompatible, non toxic and non irritating.

2. The material should be odourless and moisture repellent.
3. The patient should find it easy to apply.
4.The material should dry quickly.
5.The bond should hold the prosthesis in place for atleast 12hours daily.
6.The adhesive must be easy to remove without injuring the skin and prosthesis.
 Adhesive

 Adhesive can provide the retention for both intraoral and extra oral defects.
They aid in intraoral retention when
 Surgical Defect Is Large
 When Palate Is Flat
 Missing Tuberosities
 Patient with diminished salivary flow due to pre and post radiation therapy.

 All are readily available ,easily applied and can provide satisfactory
retention for limited period of time.
. Several factors should be considered when selecting an adhesive system
for a facial prosthesis:

 The strength of the adhesive bond to skin and to the facial prosthetic
material.
 Biocompatibility of the adhesive.
 Design and material of prosthesis.
 Composition of the adhesive.
 Type & Quality of patient’s skin.
 Convenience of handling and removing the adhesive
 Adhesi
ve

Acrylic
resin
Silicon
adhesives adhesive

Pressure
sensitive
tapes
 Acrylic resin adhesive
Acrylic resin adhesive consists of acrylic resin dispersed in a water
solvent
Develop the
When it evaporated leave a rubber like substance bond with
another surface

Eg. Hydrobond(Epithane 3)

The adhesive can be easily removed from all the prosthetic material.
Silicone adhesives

Silicone adhesive are a form of room temperature vulcanizing (RTV) silicone

usually dissolved in solvent.

Once the adhesive is applied, the solvent evaporates & will results in tacky
adhesive.

That may form contact bonded to another surface such as skin.

 They are not affected by chemical, oils or sunlight.

Disadvantage –the material is low adhesive strength

Eg. Secure medical adhesive(SMA)

Pressure sensitive tapes:-
It is used in the retention of facial prosthese are applied by finger
pressure in absence of heat and solvent . The tape has adhesive
on both surface.
The bond weaker than that of acrylic adhesive
Advantage –Easy of application and cleansing after removal.

Indication -
Can be used material with poor flexibility
And for patient whose defect demonstrate little or no movement.
Some of the adhesives available are:
• Silastic MDX4-4210 medical grade
elastomer
• Silastic medical adhesive silicone type A
• Secure2 Medical Adhesive
• Epithane-3 Adhesive ES
• Skin-Prep protective dressing
• Uni-Solve adhesive remover
• Pros-Aide adhesive
• Epithane-3 adhesive
• Telesis Silicone Adhesive
• 3M bifaceis
• Hollister Medical Adhesive
Apply adhesive 6 to 7mm periphery of the surface. Not
to apply at the edges of the prosthesis to increase the
life of the prosthesis. Adhesive from the skin can be
removed with the help of adhesive remover e.g.
Plastic remover acetone ,hydrogen peroxide
 Effect of adhesive retention on maxillofacial prostheses. Part I:
Skin dressings
and solvent removers

CLINICAL IMPLICATIONS
Skin-Prep protective dressing applied to the skin before adhering
maxillofacial prostheses created a barrier that enhanced the strength of
the 2 adhesives tested up to 6hours. Secure2 Medical Adhesive was 3 to
5 times more retentive than Epithane-3 adhesive.
Uni-Solve adhesive remover did not affect the strength of either adhesive.

Kiat-amnuay S, Gettleman L, Khan Z, Goldsmith LJ. Effect of adhesive retention on maxillofacial prostheses. Part I:
skin dressings and solvent removers. J Prosthet Kiat-Amnuay S, Gettleman L, Khan Z
 ADVANTAGES DISADVANTAGES

 Ease of application and  Some patient may develop

manipulation allergic and irrigational
 Readily available response .
 No need to undergo any surgical  Poor hygiene may limit the
procedure effectiveness of a prosthesis.
 Less expensives as compared to  Damage external pigmentation.
implants  Difficulty in applying the adhesive
or adhesive retained prosthesis
repeatedly to the proper position.
 Problem with adhesive

 Sebum – fatty substance release from gland can cause barrier

between skin and adhesive.

 Moisture – can affect the action of adhesive.

 Hair- prevent adhesive layer contacting skin.

 Solvent – continue use of removal solvent can be allergic to skin

Case reports
 Enhanced retention of maxillofacial prosthetic obturator using percision
attachments
European journal of dentistry CASE REPORT

A 65 year old man reported and major complain of the patient lack
of retention and instability of prosthesis, impaired speech ,
mastication and leakage of liquid into oral cavity.

E/o –collapsed midface and diplopia

I/o-resctioning of hard palate ,alveolar bone,teeth ,soft
tissue
Teeth present -21,22,23,24
Past history – Patient was
diagnosed with Epidermoid
carcinona of maxillary sinus,
was treated by maxillectomy
A unique method for retaning orbital prosthesis with attachment system
CASE REPORT

52 Year Old Female Patient Reported With Complained Of

Facial Disfigurment Due To Loss Of Right Eye.

H/O- Adenoid Cystic Carcinoma Of Lacrimal Gland

That Followed By Extenteration Of Orbit .
Patient Main Concerned Was Esthetics.
Hybrid maxillofacial prosthesis
Thomas S ,Shyam Mohan A ,Rupesh PL
CASE REPORT
J Indian Prosthodont Soc

A Male Pateint Of 52 Year Reported .On Examination It Was

Found A Case Of Congenital Palatopharyngeal Malformation
Of Palatal Insuffiiciency With Bilateral Cleft Lip

I/O – missing teeth 11,12

 Rehabilitation of a rhinocerebral mucomycosis patient.
J Indian Prosthodont soc CASE REPORT

A 17 year old male patient reported with postoperative ocular and

palatal defects ,
C/o–patient was facial disfigurement and disturbed speech.
E/O-enucleation of the right eye
I/O-palatal defect as in continuation with occular defect.
Extra oral implant as retentive aid for maxillofacial prosthesis

R Chelakara et al Extraoral implant as retentive aid for

maxillofacial prosthesis :A Review. The Journal Of Applied
Dental And Medical 2016 Jan 2 (2) :135-42.
 Implants

The successful clinical development of intraoral implant to

retain denture and other prosthetic replacement for
missing teeth has led to use of implants to retain the
extra oral structure.

 The use of extraoral implants provide excellent support

and retentive abilities to improve aesthetics as well as
quality of life
Design for craniofacial implant

1.Length of implant
depend upon the bone
thickness.

2.It should be shorter

and threaded.

3. It has extension
/flange in coronal part
of the fixture
Craniofacial implant classification

Alpha site

1.Amount of bone-
more than 6 or 6mm
2.Site for implant-
• Anterior aspect of
maxilla
• Zygomatic arch
• zygoma
 Beta site
Amount of bone-4-5
mm
Site for implant-
lateral and
inferloateral orbital
margin.
mastoid margin of
zygoma.
 Gamma site:-

Amount of bone-
less than 3 mm.
Site of placement-
Infraorbital margin
Zygomatic arch
 Defect Location for implant placement

1. Maxillectomy Residual premaxilla

2.Maxillectomy with resorbed ridge Zygomatic implant

3.Auricular prosthesis Mastoid region

4.Nasal prosthesis Maxilla region and anterior floor of nose

5.Occular /Orbital prosthesis Supra orbital rim or lateral border

 Bar clip

attachment
VARIOUS Ball attachment
RETENTION system
SYSTEM

Magnetic
System
Bar clip attachment

Most commonly used

 Metallic bar clip system present expensive
laboratorial procedure

Advantage - Good load distribution on the implants.

Disadvantage- risk of damaging the bar during construction of
prosthesis
This system is mainly preferred for auricular posthesis.
The construction technique of the bar system is very fragile
Passive alignment between bar and implant should be insured
in order to achieve the force distribution .
To hold the clip in the prosthesis ,an acrylic plate is prepared.
Bar system take up some more space in the prosthesis,
silicone structure should be thick to hide the reflection of grayish
color of substrate and prevent the silicone from breaking.

Distance between tissue and bar

should be 1.5 mm, is important to
allow for the easy cleansing
Magnetic System

Consists of a magnet cap that is threaded onto

the abutment and a magnet is placed onto the
tissue surface of the prosthesis.
Indicated
 When abutment are not parallel
 Shallow defects with insufficient space for a bar and clip attachment.

Advantages
• Ease of removing and inserting
• Makes the wearing and daily care beneficial
• Easy hygiene control
• Reduce probability of infection
Ball attachment system

 Three implants creating a tripod

 Provide satisfactory retention and stability

Advantages-
• Induces less stress to implant
• Absence of bar optimizes more hygiene
• Provides freedom of movement

Disadvantages -Wear of the rubber ring

 Stability of the prosthetic screws of three types of craniofacial
prostheses retention systems
Gabriel et al.
J Korean Assoc Oral Maxillofac Surg 2016;42:352-357.
 This study aimed to evaluate the stability of prosthetic screws from three types of
craniofacial prostheses retention systems (bar-clip, ball/ O-ring, and magnet) when
submitted to mechanical cycling.

 Twelve models of acrylic resin were used with implants placed 20 mm from each other and
separated into three groups:
(1) bar-clip (2) ball/O-ring and (3) magnet ,with four samples in each group. Each sample
underwent a mechanical cycling removal and insertion test (f =0.5 Hz) to determine the torque
and the de torque values of the retention screws.
The results of this study indicate that all prosthetic screws will loosen slightly after an initial
tightening torque, also the bar-clip retention system demonstrated greater loosening of the
screws when compared with ball/O-ring and magnet retention systems.
 Implants in Nasal prosthesis

 Primary site for implant placement are floor of the nose, anterior region of
maxillla
 Usually 4mm or longer fixtures are used.
 7-10 mm are used in case of supporting both intraoral and
extraoral prosthesis. Such implants are called bifunctional
implants as they support oral prosthesis at one end and
extraoral prosthesis at the other end.
 Healing period is 6-8 months.
 Retentive mechanisms used are mini magnets and bar and clip.
Impant retained nasal prosthesis for a patient following partial rhinectomy.
J Prosthodont Case Report

A 58 year old male diagnosed with basal cell carcinoma of

nasal vestibule had undergone partial rhinectomy.

C/C- I have stopped looking at the

mirror after the nose surgery
because of my unpleasant
appearance

On clinical examination- absence of entire

cartillage of nose ,ala and part of
nasalseptum due to surgery
 Implants in Auricular prosthesis

Indications-
are major cancer resection, radiation therapy, severely compromised
local tissue, failed autogenous reconstruction.

Location and number of implant :-

LOCATION ●
Mastoid region

NUMBER OF Two implant sufficient for auricular prosthesis.

●

IMPLANT
Point to remember:-

Distance between two implant-15 mm

Distance between implant and auditory
canal-20mm

Position of implant:-
8 and 11 ‘o clock
position for the right
1 and 4 ‘o clock
position on left ear
  Healing period is usually 3-4 months.

 Advantages
 Easier maintenance of prosthesis.
 Easier positioning of prosthesis and improved
retention compared to other mechanical aids

Retentive mechanism used are – BAR AND CLIP

BALL AND SOCKET
MAGNETIC RETENTIVE
Implant supported auricular prosthesis
Indian journal of dental research CASE REPORT

A 18 Year Old Male Patient Diagnosed With Bilateral

Congenital Microtia .
 Implants in Orbital prosthesis

These are indicated in patients with loss or absence of an eye caused by

a congenital defect, trauma, tumour, painful blind eye.

Location and placement of implant :-

 Superior , lateral are possible site for implant.

 Additional implant or two was often placed in the
inferior orbital rim or zygoma.
 The implant should not be angled facially as it may
interfere in the prosthesis contour.
 Length of the implant used is usually 3-4 mm.
 There should be 10 – 12 mm space between the implants to allow
access for hygiene.

 The most commonly used retentive mechanisms with implants are

magnets.
 Healing period is usually 6-8 months.
 Implant Retained Orbital Prosthesis
THE JOURNAL OF INDIAN PROSTHODONTIC SOCIETY
CASE REPORT

11 Year Old Female Patient Reported With Swelling And Pain

In Upper Right Eyelid.On Histopathological Dignoisis
Revealed The Rhabdomyosarcoma.
Surgical Exenteration Of Eye was Done .
After Completion Of Treatment Regime, Patient Was Reffered
For Orbital Prosthesis.
 Zygomatic implant

Remote bone anchorage using zygoma implant for

extensive maxillofacial defect is another option.

When patient present with maxillary defect that do not

have ideal residual anatomy, it may be possible to place
zygoma implant .

Maxillectomy and severely resorbed maxilla are

challenging the restore with removable prosthese.
Zygomatic implant reduce the complication associated with
bone grafting and simplify the rehablitation of atrophic maxilla
and maxillectomy
Maxillofacial rehabilitation with zygomatic implants in a oncology
patient.
J oral maxillofac surg CASE REPORT

A 53 Year Old Female Patient Had Presented With Tumour More

Than 3mm In Diameter In Right Nasolabial Region . On Clinically
Examination There Was Swelling On Palpation . Later Patient
Diagnosed With Adenoid Cystic Carcinoma With Bone
Involvement .

Treatment –Surgical Treatment was Done With Partial

Palatectomy .
 Care and Cleaning of Maxillofacial Prostheses

 There is no doubt that the care and cleaning of maxillofacial prosthesis

have contributed to the success of treatment.

 For cleaning external prostheses, the recommendation is to use water

and neutral soap as the main method, and use Chlorhexidine as an
excellent auxiliary method.

 In addition, other auxiliary cleaning methods such as Hydrogen Peroxide

an Isopropyl Alcohol may be used.
 With regard to taking care of the adjacent tissues, in general,
the recommendation is to remove the prosthesis before going to
sleep to prevent trauma and nocturnal contamination by
bacteria and fungi due to the presence of humidity resulting
from transpiration and condensation and causing tissue irritation
and inflammation.

MC Goiato, CR Zucolotti, DN Mancuso, DM Santos, EP Pellizzer.Care

and Cleaning of Maxillofacial Prostheses. J Craniofac Surg 2010;21:1270-3
Adhesive available in INDIA
Skin preparation
Pro aid adhesive(Medical grade adhesive)

It is water-based adhesive for the skin. It

adheres for long periods without irritation

 . It is safe to use on all skin including

sensitive areas.

 It gives a strong bond and has high water

resistance. It is non-toxic and completely safe.
 INSTRUCTIONS

•Shake well before opening

•Clean skin and prosthesis with rubbing alcohol.

•Apply 1 thin layer of adhesive with a cotton applicator stick.

•Let dry completely until clear.

•Repeat with a second layer.Apply the prosthesis in the correct position and hold for 10
seconds.

•To remove prosthesis, gently peel from one corner and pull from skin.

•Clean skin with mineral oil, then use soap and water. Clean prosthesis with rubbing
alcohol.
 Ingredients

Water, acrylic emulsion

Glycerol
Gum
 Sorbitol
Benzyl alcohol (as preservative)
 WATER BASED ADHESIVE

It is water based adhesive for

prosthetics .
 TECHNIQUE

Shake the bottle well to remix any ingredients that may have settled
while sitting.

Pour a small amount of Prosthetic Adhesive into a mixing cup and use
a disposable applicator.

. For a strong bond between the skin and appliance, apply adhesive to
the skin, as well as the prosthetic and allow the adhesive to become
tacky before prosthetic application.
 Adhesive can take up to 1-2 minutes to become tacky
depending on the amount of adhesive applied.

When removing large prosthetic appliances, it is

recommended to find a wear spot in the border of the
prosthetic begin removing around the edges.
 INGREDIENTS

Acrylic/Acrylates Copolymer
Residual Monomers
 Ammonium Hydroxide
Polyacrylate Thickener
Adhesive remover
 CONCLUSION

A variety of technique and equipments are available to retain a

maxillofacial prosthesis. To chose the right retentive aid the
prosthodontist needs to be familiar to all the available options
because he carries the responsibility to plan the prosthetic
rehabilitation that suits the patient. Optimum results may be difficult
to achieve in all cases of maxillofacial defects but thorough
evaluation of the situation and careful judgment and treatment
planning can give acceptable quality of prosthesis improving the
patient's quality of life.
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maxillofacial prosthetic obturator using precision attachments: Two case reports.
European journal of dentistry. 2012 Apr;6(2):212.

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 R Chelakara et al Extraoral implant as retentive aid for

maxillofacial prosthesis :A Review. The Journal Of Applied
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