CONTENTS

1) INTRODUCTION
2) ROLE OF OSSEOINTEGRATION IN MAXILLOFACIAL PROSTHESIS
3) IMPLANT RETAINED PROSTHESIS VERSUS ADHESIVE RETAINED
PROSTHESIS.
4) DISADVANTAGES OF ADHESIVE RETAINED MAXILLOFACIAL
PROSTHESIS.
5) IMPLANT DESIGN CONSIDERATIONS IN THE RECONSTRUCTION
OF VARIOUS MAXILLOFACIAL DEFECTS.
 Orbital defects.
 Nasal defects.
 Auricular defects.
- Bone Anchored Hearing Aids (BAHA)
 Midface Defects.
 Maxillary defects.
 Mandibular defects.
6) HISTORICAL DEVELOPMENT OF MAXILLOFACIAL MATERIALS
7) CHARACTERISTICS OF AN IDEAL MAXILLOFACIAL MATERIAL.
8) VINYL POLYMERS AND COPOLYMERS
9) ACRYLIC RESINS.
10)LATEXES.
11)SILICONES.
 Room Temperature vulcanizing silicones.
 Heat vulcanizing silicones.
12)POLYURETHANE ELASTOMERS.
13)COMMERCIALLY AVAILABLE NEWER MATERIALS.
14)PIGMENTS AND THEIR APPLICATION IN MAXILLOFACIAL
PROSTHESIS.
15)ADHESIVES.
16)SUMMARY AND CONCLUSION
17)REFERENCES.

1
INTRODUCTION

Congenital or acquired defects of the oral and maxillofacial region are

accompanied by dysfunction and disfigurement and produces significant
modalities and unique tissue management problems. If the esthetic and
functional impairments are not corrected or minimized, the patient may be
unable to resume a normal life. Maxillofacial prosthesis is the important tool
used in the rehabilitation of these defects. However, appropriate retention,
stability and support must be provided to the prosthesis if successful results are
to be achieved. Osseointegrated implants have been shown to be the most useful
asset in the retention, stability and support when compared to other conventional
prosthesis.

One of the most challenging tasks that polymer chemist, material

scientists and maxillofacial prosthodontist face is the development of a suitable,
durable and esthetic material to use in the rehabilitation of patients with orofacial
disfigurements. A durable and stable material that will retain the characteristics
of living tissue, such as colour, softness, flexibility and tear resistance and
should be available at reasonable cost should be used in the construction of
maxillofacial prosthesis.

Definition of Maxillofacial Prosthesis:

“Maxillofacial prosthesis is defined as the branch of prosthodontics

concerned with the restoration, replacement or both stomatognathic and
associated facial structures by artificial substitutes that may or may not be
removed. It encompasses prosthetic rehabilitation of patients with oral, paraoral
or facial defects, which may be acquired (developmental or congenital) or
resulting from disease or trauma”.

2
Osseointegration in Maxillofacial Prosthesis:

The prosthodontic restoration of dental-alveolar and maxillofacial defects

has significantly improved with the development of new materials and advances
in clinical, surgical and laboratory techniques. These advances specifically the
use of endosseous implants have improved retention, stability and esthetics,
resulting in more natural appearing and functioning prosthesis.

The term osseointegration is defined as a “direct structural and functional

connection between ordered, living bone and the surface of a load-carrying
implant”.

Over the years, procedures have been developed in which titanium

retention elements have been integrated in the bone tissue close to the defect,
thus providing anchorage for the prosthesis through mechanical or magnetic
retention.

The concept of surface area, force and stress distribution are of significant
concern with the implant retained facial prosthesis. Bone in the temporal, orbital
and midface regions is seldom adequate for placement of implants designed for
maxillofacial use.

The predominant limiting factor for maxillofacial impression is a decrease

in the bone thickness.

The craniofacial implants are fabricated of commercially pure titanium

and they are short about 3-5mm in length and possess a peripheral flange that is
about 5mm in diameter. The flange increases implant surface area in contact
with the bone, perforations in the flange add additional surface area and provide
mechanical stabilization and prevents undue penetration into the inferior
compartment.

3
 A two stage surgical procedure, basically the same as that used in the
intraoral application is employed. Surgical placement can be conducted with
local anesthesia. The implant sites are prepared and tapped in the usual manner.

Implant Retained Prosthesis Versus Adhesive Retained Maxillofacial

Prosthesis:

The major development in recent years has been the use of

osseointegrated implants for retention. The use of osseointegrated implants is
destined to have dramatic impact on restoration of facial defects. The retention
and support derived from these implants eliminates some of the primary
limitations of adhesive retained facial restorations.

1. Improved retention and stability of the prosthesis.

2. Elimination of occasional skin reaction to adhesives.

4
 3. Ease and advanced accuracy of prosthesis placement.

4. Improved skin hygiene and patient comfort.

5. Decreased daily maintenance associated with removal and reapplication

of skin adhesives.

6. Increased life span of the facial restoration when skin adhesives are used
for retention, they must be removed reapplied daily, leading to loss of
colourants at the margin of the prosthesis.

7. Enhanced lines of juncture between the prosthesis and skin when an

implant-retained prosthesis is fabricated, its margins can be made thinner
and positive pressure developed with the prosthesis.

Disadvantages of Adhesives used in the Retention of Maxillofacial

Prosthesis:

1. The adhesive retained prosthesis requires daily removal of the adhesive,

which may damage the extrinsic colors of the facial surface and may
eventually result in margin loss.

2. Adhesives tend to damage prosthesis margin gradually with daily use and
may tend to loose adhesive bond if perspiration present.

3. Adhesives will leads to an allergic skin reaction if used for longer time.

4. Silicon adhesives require silicone solvent for cleaning, which may cause
deterioration of base material.

5
Implant Designs used in the Reconstruction of Orbital Defects:

Restoration of an orbital defect presents a special problem. The normal

eye moves constantly, whereas the artificial eye is fixed, the eyelid does not
move and gaze does not change direction.

The application of implants in orbital defects reduces the need for

adhesives and enables easy application and removal of the prosthesis.

Problems associated with adhesives in the temporal region are more

prevalent in the orbit. The blind duct characteristics of an orbital defect
combined with the margin sealing using adhesives enhance moisture
accumulation behind the prosthesis. Chronic moisture accumulation on the skin
is characterized by marked inflammation, affecting the health of soft tissues.
This inflammation may cause discomfort and adversely affects the fit and
esthetic quality of the prosthesis. Extra oral implants can provide support and
retention for orbital prosthesis, that are far superior to those achieved with skin
adhesives.

For an orbital prosthesis, the implants are ideally placed around the defect
within the orbital rim. Because of the bone anatomy placement is often limited to
the superior and lateral aspects of the rim. The implants should be placed within
the confines of the defect and parallel or slightly inward in relation to the frontal
plane, so as not to interfere with the ideal contours of the prosthesis.

In more extensive orbital defects, implants can be placed in the zygoma or

maxilla.

6
Various Retention Options:

In the orbital defects basically five retention options used:

1. Bar end clips.

2. Bar and magnets.

3. Individual magnets.

4. Ball attachments.

5. Combination of these.

Bar Construction with Retentive Clips:

A bar construction is a wire soldered to the gold cylinders and mounted

onto the abutments by gold screws. This type of attachment will provide a good
load distribution on the implants. Retentive clips are placed on the inner aspect
of the acrylic plate, providing a rigid and secure position for the prosthesis. This
type of construction provides good retention for large defects that has implants
only in the upper orbital rim to support the prosthesis.

Individual Magnets:

The individual retention system consists of a magnet cap that is threaded

onto the abutment and a magnet placed into the fitting side of the prosthesis. In
an orbital defect with implants in the upper and lower orbital rim the individual
magnet system is recommended. This type is especially recommended when
there is shallow defect with insufficient space for a bar and clip construction.

7
Advantages:

1. Easy for patients to maintain good hygiene around the abutments.

2. Easy to put on and take off the prosthesis.

Ball Attachments:

When there is shallow defect, the ball attachments are one opinion of
retention because they occupy little space behind the prosthesis. Three implants
creating tripod are imperative to provide satisfactory retention and stability.

Console Abutment:

In cases with small closed defects where two implants are inserted in the
upper rim and one exists in the lower orbital rim and where the directions of
implants are at difficult to angles to each other, prosthetic abutment options are
improved by the use of a console abutment. This device can alter the angle of
one fixature relative to another thereby facilitating prosthesis attachment.

8
Case Reports:

1. A 71 year old man underwent a left orbital exenteration due to

adenocarcinoma of the lacrimal gland. Four implants were placed in the
orbital rim. Individual magnets placed on to the abutments retained the
prosthesis.

2. Photographs showing a woman with right orbital defect, which was due
rhabdomyosarcoma. The surgery was done when patient was at the age of
15 years. She had several prosthesis retained using glasses and adhesives
but none of them were esthetically and functionally satisfying to the
patient. Eventually three implants were placed in the orbital rim,
providing mechanical retention for the prosthesis with a gold bar and clip.

9
 3. Photograph showing a lady who had a successful prosthesis ranging from
hard acrylic retained by spectacles through direct adhesive fixation when
offered osseointegration she was very keen. Three Neo-mini magnets are
retained using three implants on supraorbital rim.

Implant Designs used in Reconstruction of Nasal Defects:

Nasomaxillary or Nasolabial defects cause functional and esthetic

problems, which may require load-bearing capability by the fixture sites
especially lip forces dislodge the prosthesis.

Implants to anchor a nasal prosthesis can be placed in the maxillary and

frontal bones. The placement of implants should be within the confines of the
outer contours of the prosthesis. Location of the frontal sinuses and the superior
margin of the prosthesis are limiting factors in the placement of implants in the
superior aspect of the defect. If the implants are placed within the inferior aspect
of the defect, care must be taken so that access is available for retentive
components.

10
Case Reports:

1) A 57 year old female had the entire nasal tip and approximately
50% nasal bridge as well as part of the alar cartilages removed to eliminate
squamous cell carcinoma. Nasal prosthesis, which was fabricated failed to be
adequately secured using an adhesive.

The patient was treated with two 10mm dental implants placed into
approximately 3mm into the anterior maxilla through the nasal fossa.

A cast gold bar was fabricated to connect the implant abutments.

Magnetic attachments were cast into the superior and inferior aspects of the gold
bar and clip attachments were fabricated to fit into the middle portion of the gold
bar. A resin housing retained by undercuts in the silicone prosthesis secured
magnetic and clip attachments. Magnets assist the patient in orienting the
prosthesis while clip attachments provide definite retention.

11
2) A 70 year old woman underwent an excessive nasal resection due
to recurrent squamous cell carcinoma involving the nasal tip, septum and the
right cheek. Two implants were placed in the maxillary bone. A gold bar was
fabricated to splint the two fixtures so that silicone prosthesis could be
mechanically retained by gold clips.

3) A 75 year old woman underwent a rhinectomy due to basal cell

carcinoma. Three implants were placed into the nasal remnant and maxilla.
At second stage surgery, abutments were connected on to the fixatures. A
gold bar was attached to the abutments, and gold clip retention was used for
silicone prosthesis.

12
Implant Designs used in the Reconstruction of Auricular Defects:

For an auricular prosthesis, implants are placed in the post-auricular

region. This area corresponds to the location of helix and antihelix.

Tjellstrom and his associates described that the location of implants

should be 18-20mm from the center of the external auditory meatus.

For an auricular prosthesis, two to three implants are normally sufficient

for satisfactory retention and the ideal position is approximately 20mm from the
center of the external auditory canal. This position will helps in the construction
of bar in proper contour with antihelix ridge to enable the anaplastologist to
make a prosthesis that is deep enough to produce a good cosmetic result.

13
Retention Systems or Attachments:

Two retention systems are used separately or combined.

1. Use of a gold alloy bar approximately 2mm in diameter, which is

soldered to the gold cylinders and attached to the abutments. Retention
clips are incorporated into the prosthesis providing attachment to the bar.

2. Retention technique by use of magnets.

Gold alloy bars may be fabricated to retain the magnets, which are
connected to the abutments. Magnets are commonly 6mm in diameter and
2mm in thickness. The bar structure must be designed to contain housing
to hold magnets, which are sealed into acrylic resin.

Case Reports:

1. Photographs of a young woman underwent multiple procedures for right

auricular reconstruction of a microtia. The patient history indicated that a
silicone elastomeric framework had been used in the reconstruction of the
auricle. The results were unacceptable to the patient, who elected to
undergo reconstruction with the bone-anchored auricular prosthesis. The
silicone elastomer framework was removed, and the tissue bed in area of
prosthesis was recontoured. Two implants were placed to retain the
prosthesis on a bar and clip system.

14
 2. Photographs showing selected prosthetic steps for rehabilitation of a left
auriculectomy due to squamous cell carcinoma. Initially, the prosthesis
was anchored on two fixtures, but the final results were not satisfactory
because of the gap on the front edge. To provide larger base plate, three
more fixatures were used. Magnets were used instead of a bar for easier
cleaning of the prosthesis. The baseplate was split and sprung to keep the
front edge in contact with the skin and reduce stress on the implants.

Bone Anchored Hearing Aids (BAHA):

Impaired hearing makes it difficult for many people to successfully cope

with important aspects of their daily life. More than 10 years of experience in
Sweden has demonstrated the usefulness of the osseointegrated bone anchored
hearing aid. Two groups of patients are typically good candidates for
osseointegrated bone anchored procedures; patients with external auditory canal
atresia, who are not candidates for reconstructive surgery of the canal and
middle ear and patients with chronic otitis media who cannot or will not tolerate
an air conduction aid.

15
Why is the bone anchored hearing aid (BAHA) different?

We receive sound in two ways: by air conduction via the ear canal and by
bone conduction transmitted through the jaws and skull bone.

Air conduction aids, which are placed inside the ear canal or behind the
ear, are the most familiar. Some hearing impaired people are unable to use this
kind of device. Some suffer from chronic inflammation or infection of the ear
canal made worse when the ear canal is occluded.

The BAHA system uses the principle of osseointegration to overcome

these problems. A small titanium screw is implanted behind the ear where it
osseointegrates.

Indications:

1. Chronic otitis media with conductive or mixed hearing loss where the use
of an air conduction device is contraindicated.

2. Congenital malformation of the external/middle ear where an air

conduction hearing aid is contraindicated.

3. Patients suffering from chronically draining ears and who uses an AC

device.

16
 4. Patients with chronic external otitis.

5. Patients who have a bone conduction pure-tone average of 45dB or less

and speech descrimination of 60% or greater.

Contraindications:

1. Contraindicated in patients with drug and alcohol addiction.

2. Emotionally unstable and developmentally delayed or retarded patients

for the reason of handling and hygiene.

Procedure:

A one-stage surgical procedure under local anesthesia allows placement

of the titanium implant and abutment in the mastoid cortex. Removal of hair
follicles from the skin immediately surrounding the abutment or placement of a
split-thickness skin graft is critical to maintain a hair-free region around the
abutments. After osseointegration, the abutment is loaded with the
mechanoelectric transducer system.

17
Various Bone Anchored Hearing Aids:

BAHA classic 300 is available in two colours, light and dark. It is

presented as a patient kit including the hearing aid, four plastic inserts, five ‘O’
rings mounting instruments, battery and abutment cover.

18
Surgical components:

All fixtures and cover screws are made of pure titanium:

Flange fixtures 3.75 x 3mm

Flange fixtures 3.75 x 4mm

Implant Designs used in the Reconstruction of Midface Defects:

Midface defects often result from ablative procedures used to control

malignancies of nasal and maxillary structures. The surgeries may produce a
small soft tissue defect or a massive defect involving intraoral and extraoral
structures. As the size of the defect expands to involve the intraoral structures,
the muscles of facial expression, and the muscles of mastication, the complexity
of the prosthetic rehabilitation increases.

Defects which involve palatal and extraoral structures are frequently

retained by connecting the intraoral and extraoral prosthesis together. This
process involves the use of adhesives combined with the magnetic retention
between the two prosthesis. This technique enhances retention for the facial

19
prosthesis but may adversely affects its stability. Movement of the intraoral
prosthesis is transferred to the facial prosthesis producing a noticeable and
unnatural appearance. Removal of either prosthesis may adversely affect the
retention of other requiring it also to be removed. As with orbital and auricular
prosthesis, rehabilitation in the midface region with the endosseous implants will
enhance retention, stability and esthetic of the prosthesis.

Jenson D.T. et al (1992) described available sites for implant placement

in the midfacial region, and they suggested a craniofacial site classification for
osseointegrated implants.

1. Alpha sites: These are 6mm or greater in axial bone volume available for
dental implants. The most common areas of the facial skeleton having
that much bone available are the anterior maxilla through the nasal fossa
and the zygoma and the zygomatic arch and the lateral periorbital region.

2. Beta sites: These will have 4 to 5 mm of bone available permitting the use
of 4mm craniofacial implant. These areas are superior, lateral and
inferolateral orbital rims as well as much of the temporal bone and
zygoma.

20
 3. Delta sites: These are marginal sites with 3mm or less of bone volume
available. Locations in the temporal bone, pyriform rim, infraorbital rim,
nasal bone, zygomatic buttress and zygomatic arch require the use of
3mm craniofacial implants.

Case Reports:

1) A 58 year old male had a 10 years of history of adenocystic

carcinoma of the midface with early metastasis to the right lung. Definitive
excision of the midfacial lesion included radical rhinectomy, 90% of total
maxillectomy complete upper labilectomy, and bilateral partial
malarectomies.

Treatment of the patient was followed by reducing the right and left
zygoma by about 50% and two 18mm implants were placed into molar bone
bilaterally using the curve of the zygomatic arch and one implant was placed in
the zygomatic area, where 4-5mm of bone was available. After 6 months
implants were exposed and 5.5mm abutments were placed.

Gold bar was fabricated on each side to allow for clip attachments.
Magnetic attachments were positioned on the facial surface of the maxillary
obturator.

21
2) A 77 year old man underwent wide resection for a basal cell
carcinoma, which included left orbital extenteration and partial left nasal
resection. Four implants were placed into the supraorbital rim and maxillary
area. At the second stage procedure, console abutments were connected to
the four implants, providing magnetic retention for the final prosthesis.

3) A 61 year old woman underwent an enbloc resection of the nose

and anterior maxilla due to squamous cell carcinoma. Five implants were
placed in the alveolar ridge to retain obturator and one implant was placed in
the nasal bone to anchor a nasal prosthesis. The intraoral and extraoral
frameworks were attached by a connection system with screws and screw
nuts.

22
4) The photograph showing surgical defect involving nose and cheek,
which was operated due to basal cell carcinoma. A nasal prosthesis extended
to include, cheek defect was given to the patient with adhesives. On review
of 10 months later, the margins of the prosthesis were damaged during
cleaning the adhesives from the prosthesis. The osseointegrated implant
retained prosthesis was discussed with the patient. Three implants were
subsequently placed, one on each of alar extensions and one at the lateral
margins of the cheek. A 5mm abutment was fitted with right alar implant and
4mm abutments were fitted on other two implants.

Implant Design Considerations in Maxillectomy Defects:

Most tumors requiring maxillary resection arise either from the paranasal sinus
or palatal epithelium or from the minor salivary glands present in the
submucosa. Resection of these tumors requires either a radical or a total
maxillectomy.

23
Prosthetic rehabilitation in maxillectomy should not only provide closure
between the oral and nasal cavity but also substitute for teeth and support for the
upper lip and the anterior soft tissues of the face. Since most of the skeletal
components for anchorage have been removed at surgery and the anchorage
should be obtained from zygoma and in the pterygoid region.

Implant Design Considerations Mandibular Defects:

The management of malignant tumors associated with the tongue, the mandible
and adjacent structures represent a challenge for the surgeon and prosthodontist,
with respect to control of the primary disease and rehabilitation after the
treatment. The most common intraoral sites for squamous cell carcinoma are the
lateral margin of the tongue and floor of the mouth. Both locations predispose
the mandible to the invasion of tumor, often necessitating its resection along
with large portions of the tongue, the floor of the mouth, and the regional
lymphatics.

24
HISTORICAL DEVELOPMENT OF MAXILLOFACIAL MATERIALS

Even before dentistry attained its status as a profession, some surgeons

had recognized the limitations inherent in grafting tissue for repair of certain
maxillofacial deficiencies and had argued the use of prosthesis as an alternate
method.

1. Early records indicate that artificial eyes, ears and noses were found in
Egyptian mummies. The Chinese also made facial restorations with
waxes and resins of various types.

2. Ambroise Pare (1517-1590), the famous French surgeon appears to be the

first medical writer on maxillofacial prosthetic materials. He
recommended a prosthetic nose, which could be made of silver and
attached to the face by strings, with the line of junction at the lip being
camouflaged by an artificial moustache.

3. Tycho Brahe, a Danish astronomer of the 16th century, lost his nose in a
duel and replaced it with an artificial nose made of silver and gold.

4. Pierre Fauchard (1678-1761) described that the wings that could be

positioned by the patient from the oral side of the obturator and made use
of the nose for retention.

5. The London Medical Gazette (1832) described a case of the “Gunner with
the silver mask”. A French soldier whose face was seriously injured in the
battle. The left half of the mandible almost carried away, alveolar process
was fractured, along with the teeth of the left maxilla and right half of the
mandible. A physician designed a prosthetic restoration, which was
looked like a mask.

25
6. William Morton (1868) constructed a nasal prosthesis using porcelain for
a Boston lady whose nose was lost due to malignant disease. The
prosthesis was attached to spectacles.

7. Tetamore (1894) described and illustrated nine cases of nasal deformities,

that were treated by nasal prosthesis which were made of “very light
plastic material”, that approximated the natural colour. They were secured
on the face by bow spectacles.

8. Towards the end of nineteenth century, vulcanite having already proved

its value in prosthodontics, it replaced most of the earlier materials such
as cellulose acetate, ceramic and metals.

9. In Germany (1913) the gelatin-glycerin compounds attracted much

attention. The material was easy to compound and simple to manipulate,
and one that possessed pliability translucency, and adaptability of
intrinsic colouring to match the skin.

10. The most significant contribution of the prevulcanized latex era was that
it provided the impetus in the early 1930s to further research towards the
desirable qualities of latex.

11. Bulbulian and Clarke (1965) introduced prevulcanized latex in the

construction of maxillofacial prosthesis.

12. Fonder and Winnetka (1955) presented an article titled “Dental materials
and skills in oral and maxillofacial prosthesis”. They used acrylic resin
for fabrication of cleft palate, missing ears, noses and other missing parts
of the face.

13. Lontz J.F. (1990) described the use of most of the general biomedical
materials like acrylic polymers, polyurethanes, and silicone elastomers in
the fabrication of various maxillofacial prosthesis.

26
Characteristics of an Ideal Maxillofacial Material:

1) Material should have physical and mechanical properties similar to

the human tissue being replaced.

a) Variable consistency.

b) Dimensional stability.

c) Allow detail reproduction.

d) High edge strength.

e) High elasticity.

f) Light weight.

2) Material must be compatible with the human tissue, non-toxic, non

allergic and easily cleaned.

a) Non-porous but permeable.

b) Odorless.

c) Resistant to microbial contamination.

d) Should not release any toxic byproducts; no toxic

components to harm operator.

3) Material must be capable of adherence to human tissue, by

adhesive or other mechanical means:

a) Should permit easy removal of adhesive without damage

to the patient or material.

b) Material must be sufficiently strong to incorporate

frameworks for implant or other mechanical retention.

27
4) Material must be compatible with intrinsic and extrinsic means of
colouring or staining.

a) Capable of layering in the mold for depth and vitality in

colouring.

b) Translucency, surface texture and should have sheen

consistent with tissue.

c) Should permit extrinsic colouring without modifying

surface characterization.

5) Material should have relatively simple polymerization process, not

sensitive to minor processing variables, and require materials and molding
procedures commonly used in dentistry.

a) Capable of adjustments, repair and reline.

b) Can be bonded or laminated to other materials for better

properties.

c) Modified at margins.

d) Readily available at reasonable cost.

6) Completed prosthesis must maintain these properties for an

acceptable period of service (at least 1 year).

- Prosthesis must have an acceptable service life of at least 1 and

preferably 5 years.

- Material must be capable of relining or readapting to the tissues

surrounding the defect to prolong service life.

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Vinyl Polymers and Copolymers:

The most widely used materials for the fabrication of maxillofacial prosthesis
are vinyl polymers and copolymers. The amount of vinyl acetate in the polymer
varies from 5-20%. In the elastomeric form, when properly compounded, the
vinyls exhibit properties, which are superior to those of natural rubber in
flexibility and resistance to sunlight and aging.

The vinyl are derivatives of ethylene (CH2 = CH2)

H H
| |
C = C
| |
H H
The vinyl acetate
H H
| |
C = C
| |
H C =O
|
H – C – H

Vinyl chloride is polymerized in the presence of free radical catalyst to form

polyvinyl chloride:

H H H H H H
| | | | | |
–C –C – C – C – C – C –
| | | | | |
H Cl H Cl H Cl

29
Vinyl acetate forms polyvinyl acetate on polymerization:
H H H H
| | | | | |
–C –C – C – C – C – C –
| | | | | |
H O H O O
| | |
C=O C=O C=O
| | |
CH3 CH3 CH3
Polyvinyl chloride is a clear, hard and odourless resin. It darkens when
exposed to ultraviolet light and heat, and it requires heat and light stabilization to
prevent discoloration during fabrication and use.

Polyvinyl acetate is stable to light and heat but has an abnormally low softening
point (35°-40°C).

Physical properties Flexible vinyl Rigid vinyl

Specific gravity 1.16-1.35 1.35-1.45

Tensile strength 1,500-3.500 5,000-9,000

Compressive strength 9,00 – 1,700 8,000-

13,000
Impact strength Ft.lb/inch Varies depending on
plasticizer 0.4-20
Thermal conduction 10-4 cal/sec
(°C) 3.0-4.0 3.0-7.0

Water absorption (24 hrs %) 0.15-0.75 0.07-0.4

These materials were extensively used in the beginning but their use
decreased due to the various factors like excessive shrinkage, long processing
time, discoloration and hardening of the margins due to plasticizer migration and
loss. They absorb sebaceous secretions and tend to get soiled due to their
tackyness.

30
Realistic:

Realistic is a polyvinyl chloride compound (PVC) which solidifies into a

flexible material when heated materials of this chemical composition are subject
to deterioration by UV light, ozone, peroxide and tetraethyl lead. These materials
are esthetically satisfactory, but possess a short shelf life.

Realistic is extremely easy to handle. Tinting can be accomplished both

internally and externally using a variety of colouring agents. Ferrous pigments
incorporated into the mixture give the longest shelf life and the best esthetic
results. Because of the short life of this material, metal molds are suggested so
that additional prosthesis can be made from original modeling.

Mediplas:

It is a heat curing plastisol that is basically a polyvinyl organic

compound. These are available in a variety of premixed base colours, which can
be further tinted to match the patient’s skin tones.

Like all the polyvinyl resins, this product is affected by ultraviolet light,
peroxide, ozone and tetraethyl lead. The substrate is changed and the prosthesis
become yellow when exposed to these factors.

In processing these materials, an initial set is obtained at 100°C, but the

material does not reach full strength until the temperature reaches 140°C. About
10 min at 140°C is generally required for polymerization of mediplas in an
plaster or metal mold.

Fine margins can be produced with mediplas, except that these margins
are unsupported, they tear easily. An insert of white nylon stocking material will
strengthen them.

Acrylic Resins:

31
 Acrylic resins are used in the fabrication of both intraoral and extra oral
prosthesis. The acrylic resins are derivatives of ethylene and these contain vinyl
group in their structural formula. These are obtained from acids CH=CHCOOH,
and methacrylic acids CH2 = C (CH)3 COOH. Both of these acids polymerize by
additional polymerization. Although the polyacids are hard and transparent, their
polarity related to the carboxyl group, causes them to be soluble in water. The
water tends to separate chains and to cause a general softening and loss of
strength.

Methyl methacrylate:

Methyl methacrylate is a clear, transparent liquid at room temperature

with melting point of –54.4°F (-48°C), boiling point 100.8°C, density of 0.445
gram/cubic centimeter and heat of polymerization of 12.0 kilocalories /
molecule. It exhibits a high vapour pressure, and it is an excellent organic
solvent. The polymerization can be initiated by UV light or heat and chemical
initiators.

Advantages:

1. These can be satisfactorily coloured to match individual skin tone. The

tinting/colouring can be done internally and externally. To prevent the
external tinting from wearing off, a thin coat of clear organic acrylic is
painted over the surface of external staining.

2. These materials are preferred for restoring defects that require minimal
movements like eye and ear prosthesis.

3. These materials can also be of value with rapidly changing defects, where
the ease of relining facilitates all the necessary abutments.

4. These materials are easily available and have less cost and are familiar to
all the practitioners.

32
Disadvantages:

1. The main complain incurred by the patient is the rigid nature of the
material. Prosthesis with rigid margin will tends to dislodge the prosthesis
and irritates the underlying structures.

2. The rigid property will leads to difficulty in duplicating the prosthesis.

Latexes:

These are soft, inexpensive materials that may be used to create life like
prosthesis. Unfortunately, these materials are weak, degenerate rapidly and
exhibit colour instability. Consequently, latexes are infrequently used in the
fabrication of maxillofacial prosthesis.

Synthetic latex is a tripolymer of butyl acetate, methyl methacrylate and

methyl methacrylamide. These are superior to natural latex. This material is
nearly transparent. Colorants are sprayed onto the reverse or tissue side of the
prosthesis, there by providing enhanced translucency and improved blending.
Despite these advantages, technical process is lengthy and resultant prosthesis
last only a few months.

Silicones:

Silicones were introduced around 1946, but only in the past few years
they have been used in the fabrication of maxillofacial prosthesis.

These are most commonly used materials for facial restorations but
properties like poor tear strength and life less appearance have limited them from
universal acceptance.

Silicones are a combination of organic or inorganic compounds. They are

manufactured from silica. Silica is first reduced to silicon and then it reacted
with metal chloride to form dimethyl-dichloro-siloxane. Dimethyl-dichloro-

33
siloxane reacts with water to form a polymer, which is a translucent, white
watery fluid. Polydimethyl siloxane commonly referred to as a silicone, which is
made from these fluid polymeris.

Commercially available rubber form polymers have fillers for additional

strength. Antioxidants and vulcanizing agents are added to transform the raw
mass into a rubbery resin during processing. “The process of crosslinking the
silicone is known as vulcanizing”.

Depending on the means used to activate the vulcanizing process,

silicones are classified as heat vulcanizing and room temperature vulcanizing
silicones.

Room Temperature Vulcanizing Silicones:

RTV silicones are composed of comparatively short chains; together with

cross-linking agent (ethyl ortho silicate) with the addition of a catalyst (stannous
octolate), condensation takes place between the polymer and cross-linking
agents.

These materials are either transparent or opaque white, and before the
catalyst is introduced, dry earth pigments are added to match the colour of the
individual skin. The prosthesis can be cured in a stone mold.

RTV silicone formulated with silica fillers to enhance tensile strength and
to mask yellowing or discoloration sacrifice. Considerable translucency, making
it difficult to attain proper internal (intrinsic) colouration. Discoloration in some
RTV grades of silicone compromises esthetics.

To correct for these deficiencies, a transparent RTV grade silicone

(Dowcorning MDX 4-4210) is an improved alternative but requires considerably
longer curing time of upto 16 hours. The curing time can be reduced by heating

34
upto 150°C for as little as 5 minutes. The improvement in tear resistance is
significant.

RTV silicones are supplied as a single paste systems that are coloured by
the addition of dyed rayon fibres, dry earth pigments and / or paints.

Heat Vulcanizing Silicones:

HTV silicones are supplied as semisolid or putty like materials, which

require milling, packing under pressure, and a 30-minute heat application cycle
at 180°C, pigments are milled into these materials. As a result of intrinsic
colouration HTV silicones display better strength and colour stability compared
to RTV silicones.

Chalion (1976) and Lontz, Schweiger, and Burger (1974) had found that
HTV is superior compared to RTV. A major advantage of this material is the
faster colouring procedure, which is generally entirely intrinsic and
polychromatic. Its major disadvantage is the requirement for milling machine
and a press. Metal molds are required for the fabrication, because high tensile
strength of HTV silicones is such that there is a high risk of damaging the mold
during retrival.

Heat Vulcanizing Silicone Technique:

- Heat vulcanizing silicones are translucent, milky white, semisolid

materials. Dow corning had made three consistencies available:
MDX4 – 4514, MDX4 – 4515, MDX4 – 4516.

- Chalion et al 1972; Beder 1974; Lontz et al 1974 recommended

MDX4-4514 as a material of choice for extraoral prosthesis.

- These silicones are cut and rolled in the milling machine before
they are packed in the molds. Intrinsic colours and fibers are

35
 incorporated with HTV while it is being rolled in the milling
machine.

Room Temperature Vulcanizing Silicone Technique:

Dow Corning manufactures different kinds of RTV silicones. They are

either clear or translucent MDX4-4210, semitransparent, such as silastic 399; or
opaque and white such as silastic 382. The differences among these RTV are in
their curing time and strength.

Silastic 399:

It resembles white vasaline in its raw state, applied with base and two
catalysts. When mixing with catalyst, the cross linking agent becomes somewhat
milky, but it can be worked for several hours, when catalyst two is added it set
upto translucent rubber in 10-15 minutes.

Silastic 382 RTV:

It is a medical grade silicone. This product is in the form of a thick, white

liquid and comes with a separate container of an organometallic catalyst, which
when combines with silicone, vulcanizes without the use of heat or pressure. The
working time varied from 2 to 6 minutes depending on the amount of catalyst.

Silastics-6508:

In the raw state it is similar to sticky modeling clay. It must be vulcanized

at 260°F and formed in pressure molds. It requires much more sophisticated
handling.

Silphenylene

Silphenylene is an analene silicone polymer. It is synthesized and

formulated as a pourable, viscous, RTV liquid. The material consists of 3-unit

36
kit, the base resin, tetrapropoxy silicone (cross linking agent) and a catalyst. This
elastomer has high tensile strength and low modulus of elasticity. It feels like
skin. Recent studies indicate that the incorporation of modified filler may
substantially improve the tear strength.

Derma sil:

It is a self-curing silicone, clear base material and catalyst is used to

initiate the reaction. Pigments are added to this to obtain proper shade. The
material become dull in appearance, it an excess pigment is used. The margins
are quite fragile and should be reinforce with nylon stocking material.

Polyurethane Elastomers:

Polyurethane is the most recent addition to the materials used in the

maxillofacial prosthetics. These are characterized by the linkage or presence of
urethane.

These elastomers are synthetic proportions of long chain linear polyesters

or polyethers reacted with diisocynates. These can be thermoplastic or
thermosetting polymer systems.

Components:

1. Hard segments – Extended diisocynates.

2. Soft segments – Polyesters and inolyanates.

3. Catalyst – Stannous octate or dibutylin diacirate.

4. Colouring agents – Inorganic colourants are specially preferred.

These elastomer when properly processed, are chemically inert resistant

to solvents and ozone, odourless, abrasion resistant have high tear and tensile
strength, require the use of plasticizers to attain or control their flexibility.

37
 These materials do not harden with wear and are dimensionally stable
when processed. They can be coloured easily, internally and externally.

Commercially Available Newer Materials:

Newer materials representing a variety of polymer classes offering unique

characteristics have recently been made commercially available:

1. Acrylic resin copolymer – Palamed Kulzer.

2. Vinyl polymers and copolymers – Realistic – Prosthetic Services, Calif.

Mediplast – Standard arts, Butler.

3. Polyurethane elastomers – Epithane-3 Daro products, Butler.

4. Silicone elastomers (RTV and HTV) – MDX4-4210, Silastic-372, 373

Dow corning mich.

Cosmosil – Principality UK (HTV)

Elastosil M3500 Waker/chemic

(RTV)

Episil – Dentamid (RTV)

Silskin 2000 Dupery Health Care

(RTV)

Dow Corning MDX4-4210:

38
 It is a very useful silicone, but problems with the viscosity of these
materials are a major problem, which can be controlled by addition of silk in
thickening agent. The cosmesil colour system also works very well with these
materials. This material is recommended, where soft silicone is required. The
degree of softness may be varied by the addition or reduction of the percentage
of catalyst added.

Another colour system is popularly used with MDX-4-4210 is the range

of ferrosilicone pastes and cosmetic pigments

Palamed:

Chemically Palamed is a cross-linked copolymer of methacrylics and

acrylics, and its molecular structure causes it to have an inherent softener. It
consists of a liquid and a powder which when combined, form dough like
material. This material is packed into the close molds and cured in a hot water
bath. When processed, the prosthesis has sponge like center and a continuous
skin like covering proper packing of the molds is critical in obtaining
satisfactory final prosthesis.

The molds are underfilled by 10% to permit expansion material and

formation of the foam like center. It is necessary to use exact weight equivalent
to palamed-to modeling materials.

Epithane:

Epithane is a polyurethane system. The various components which

epithane consists are:

a. Polyol components (mixture of polyesters).

b. Diicynate components.

c. An organic catalyst.

39
 Generally, these materials produce prosthesis, which are soft and more
flexible, which can be obtained by increasing ratio of polyol components to
diisocynate in vulcanized mixture. The disadvantage of this polyurethane is
deteriotion of prosthesis and occasional skin irritation.

Cosmesil/ Silskin-2:

Cosmesil is a heat vulcanizing silicone and silskin-2 is a room

temperature vulcanizing silicone. These are available in elastomer and colour
systems.

The curing temperature for cosmesil is 70°C for 2 hours; Silskin-2 is

cured by heat (1 hour) or 24 hours under bench press.

Pigments and their Application in Maxillofacial Prosthesis:

Duplicating skin with respect to texture, contour, and above all colouring
is very difficult. Colour occupies an extremely important position, and every
effort must be made to duplicate normal skin color so that the prosthesis will
look realistic.

Skin colors vary in different physiologic and pathologic conditions, such

as anemia, an indifferent emotional state, which may lead to pallor or flushing.
The color depends on capillary blood flow and oxygenation, the thickness of
epidermis, and the presence of pigments such as melanin and carotene.

Carl J.A. et al (1992) conducted a survey to analyze the effect of

environmental factors on maxillofacial elastomers. They reported various
intrinsic and extrinsic pigments for colouring the prosthesis.

40
Intrinsic colouring Extrinsic colouring
- Dry earth pigments - Dry earth pigments.
- Rayon fibers - Artists oils.
- Artist’s oils. - Silicone paste.
- Kaolin. - Ferro paste.
- Silicon paste. - MDX-4-4210
- Ferro paste. - Dyes.
- Artists acrylic latex. - Tatoo
- Cosmesil pigments. - Water colours
- Dermafil pigments

John J.G. et al (1998) reviewed the pigments used silicone elastomers.

41
Intrinsic colouring:

According to Chalian et al (1972, 1974) intrinsic colouring in HTV

silicone prosthesis is accomplished with a milling machine.

Metallic oxides or pigmented silicone concentrates are generally used,

and red fibers may be incorporated to simulate blood vessels.

Intrinsic colouring in RTV silicone (MDX-4-4210), which is supplied as

a transparent viscous material is accomplished by adding talk, to make the
material opaque, and various dry earth pigments are added.

For accurate measurements, these pigments are mixed with RTV thinner
in the ratio of 3 grains of pigment to 10ml of RTV thinner, and stored in a small
bottle with a dropper.

Extrinsic colouring:

1) Bartlett, Pineda and Moore (1971) recommended extrinsic colouring of

maxillofacial prosthesis using medical adhesive-silicone type A medical
adhesive has been thinned with xylene, a small amount of it is placed in a
number of individual medicine cusp, each cusp is tinted with selected
inorganic pigments, and the adhesive is then applied to the surface with
cotton swab. Skin like texture can be achieved by dabbing a patch of lint
free gauze over the area.

2) Ouellete (1969) described spray colouring of silicone maxillofacial

prosthesis, pigments selected to match the patient’s skin are mixed in
proportion with clear elastomer and solvent. The mixture was sprayed on
the prosthesis until the desired hue obtained. The catalyst spray is applied
over the sprayed pigment solution and curing was done at 50°C for five
minutes.

42
 3) According to Schaaf (1970), the colour peels off or rubs off during
manipulation of the prosthesis or during daily cleansing. He stated that
additional layer of material obliterates the surface texture of the
prosthesis. He introduced tattooing for surface characterization using
standard artists oil paints, which were applied on the surface of prosthesis
using tattooing machine.

4) According to Chalian et al (1972) and Beder (1974), the intrinsic

colouration is more effective than the extrinsic techniques because it
produces longer casting results. Intrinsic colouration some times followed
by minimal characterization is helpful for achieving skin like colour.

5) Firtell and Bartlett (1969) and Roberts (1971) suggested that, in many
cases, the basic tone of the prosthesis should be made of a lighter colour.
Lighter basic tone can be obtained by intrinsic coloring of the prosthesis
and that should be followed by minimal surface characterization
according to needs of a given patient.

ADHESIVES:

Historically, facial prosthesis has been retained with various mechanical

devices. It is now widely accepted that most patients may be served by the use of
suitable adhesive for retaining facial prosthesis.

A number of adhesives are available and these are generally polymeric

compounds that have been modified with solvents and tackifying fluids.
Selection of adhesive is based on the biocompatibility, retention properties and
ease of applicability and removal on daily basis and the nature of the material
from which the prosthesis is fabricated.

Udagama (1975) reported that Biface adhesive tape is suitable for

polyvinyl chloride resin: Davol may be used with polyvinyl chloride and

43
polyurethane. Medico adehsive may be used with polyvinyl chloride, silicone
and acrylic and epithane-3 adhesive works well with both polyvinyl chloride and
silicone.

INSTRUCTIONS TO THE PATIENTS:

- Patient should be encouraged to avoid prolonged exposure to

sunlight and to use brimmed hats and sunglasses.

- Instruct to avoid cosmetics on the prosthesis.

- Patient should avoid smoking, which will cause staining of the

nasal prosthesis.

- Once a day the prosthesis should be taken off and the adhesive
should not be removed using gentle thumb pressure.

44
SUMMARY AND CONCLUSION:

The highly successful results have been obtained with the implant
retained maxillofacial prosthesis. The use of osseointegration in maxillofacial
prosthodontics overcomes the many limitations associated with conventional
prosthesis. This will continue a revolution in maxillofacial rehabilitation.

The maxillofacial materials currently available still do not meet patient

needs. The possibility of fabricating high quality life like prosthesis on the facial
region would require a perfect material comprising of all the required properties
of an ideal material.

45
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