9 Retention in Maxillofacial Defects

Retention options in
Maxillofacial Defects
Presented by
Dr. RV Roshini
CONTENTS
 Introduction
 Etiology of Maxillary Defects
 Modes of retention
 Intraoral retention
 Extraoral retention
 Retention options in Surgical and Interim obturator
 Retention options in definitive obturators
 Retention by implant supported obturator
 Conclusion
 References
INTRODUCTION
 Maxillofacial defects are often a challenge to treat, to the Surgeon as

well as to the Prosthodontist.
 Almost all acquired palatal defects are precipitated by resection of

neoplasms of the palate and paranasal sinuses.
 The extent of the resection is dependent on the size, location and

potential behavior of the tumor.
Challenges could be due to-
Movable tissue bed
Inadequate materials available
Difficulty in retaining large prosthesis
The patient’s capability to accept the final result.

ETIOLOGY OF MAXILLARY DEFECTS
NEOPLASTIC DISEASES
 Squamous or epidermoid carcinoma -Fibro sarcoma –

Leiomyosarcoma
 Adenoid cystic --Rhabdomyosarcoma –Hemangiopericytoma --

Melanoma
 Mucoepidermoid
Mucoepidermoid carcinoma
 Adenocarcinoma
 Mesenchymal Tumors
 Malignant fibrous histiocytoma
INFLAMMATORY DISEASES
Squamous cell carcinoma
 Wegener granulomatosis Wegener granulomatosis
Infectious diseases
 Mucormycosis
 Aspergillosis
Traumatic injuries
Mucormycosis
 Cocaine abuse
 Avulsive wounds of the maxilla

INDICATIONS OF SURGICAL RECONSTRUCTION
 It is indicated in the following cases:
1) If the defect is the result of trauma
2) If the size of the defect is small
3) No susceptibility of recurrence
 Many patients prefer that their defects be masked with their own
Tip and ala of
tissues rather than with a prosthesis.
nose
INDICATIONS OF PROSTHETIC REHABILITATION
 Perceptions have changed regarding facial prostheses
- Improvements in materials used in facial prosthetics
- Facial prostheses achieve superior esthetic results
- Implant retained facial prostheses have achieved wide acceptance among

surgeons, prosthodontists and patients
Is indicated in the following cases:
1) Large defects that are difficult to be corrected by surgery.
2) When there is likelihood of recurrence. Prosthetic nose

3) Large soft palatal defects as they are difficult to restore surgically to
normal function.
SURGICAL PROCEDURES TO ENHANCE THE
PROSTHETIC PROGNOSIS
Management of the hard palate
Skin grafting
Management of the palatal mucosa
Management of the soft palate
Management of access to the defect
Placement of implants
HARD TISSUE SOFT TISSUE
UNDERCUTS UNDERCUTS
Yeshwante, B., Patil, S.J. and Baig, N., 2014. Retentive aids in Maxillofacial prosthesis. International Journal of Clinical Dental Science, 5(2).
INTRAORAL RETENTION
Anatomic retention
 Teeth
- Number, position, periodontal status
- Defect is small – remaining teeth stable – intracoronal

retainers might be considered.
- Defect is large – some / all of the remaining teeth are

weak – extra coronal retainers should be used.
- Clasps
Alveolar ridge
 Adhesion, cohesion, atmospheric pressure and interfacial surface
tension.
 Large ridge with broad ridge crest
 Broad, flat palatal contour

Areas within the defect
Residual hard Residual soft

palate palate
Anterior nasal Lateral scar

aperture band
Height of
lateral wall
Residual soft palate:
• The residual soft palate provides a posterior palatal seal- minimizes

the passage of food and liquids above the obturator prosthesis.
• Extension of the obturator prosthesis onto the nasopharyngeal side

of the soft palate- helps in providing retention.
Residual hard palate:
• The objective of prosthesis extension is to provide resistance to

vertical and horizontal displacement.
• The extension should not contact the septum or the turbinates.
Anterior nasal aperture:
• The anterior nasal aperture may be entered unilaterally or bilaterally,

depending on the extent of the defect to or beyond the midline and upon
the presence or absence of the nasal septum.
CASE REPORT ON GAINING RETENTION BY USING EXTENSION IN NASAL
APERTURE
Pigno, M.A. and Funk, J.J., 2001. Augmentation of obturator retention by extension into the nasal aperture: a clinical
report. The Journal of Prosthetic Dentistry, 85(4), pp.349-351.
• The anterior nasal aperture extension necessitated an unconventional path of
insertion for placement of the obturator.
• The obturator was placed in the posterior oral cavity and then moved in an
anterior-superior direction to engage the nasal aperture space before it was
fully seated
Pigno, M.A. and Funk, J.J., 2001. Augmentation of obturator retention by extension into the nasal aperture: a clinical
Lateral scar band:
• A scar band results after surgical resection at about the level of the
mucobuccal fold.
• Because of its lack of bone support, the lateral scar band also tends to
stretch with continued use.
• This stretching may necessitate sequential additions to the prosthesis which
may be limited by cosmetic requirements and prosthesis size and weight.
Height of lateral wall:
• In addition to the physical engagement of the four structures mentioned, the

lateral wall of the defect can be utilized for indirect retention.
• A high lateral wall of an obturator will undergo less vertical displacement with
a given defect wall flexure than will a shorter prosthesis lateral wall.
Mechanical Retention
 Intermediate prosthesis
 Stainless steel wrought wire of 18-gauge
 Wiring the denture to infraorbital or zygomatic bones to obturate a maxillary

defect is recommended for edentulous patients.
 Upper through circumzygomatic wiring and lower through circumandibular.
 Commonly used interim retentive means are: Clasps, Fixation wire, Suture,
Screw and Bone pin, preformed stainless steel bands or crown.
Retention options in Immediate Surgical
Obturators
Bone screw retention
 Palatal bone screw through a pre-drilled hole in the

midpalate at the anterior peak of palatal vault.
 13-16mm,self tapping screw should be used
 Titanium screws used for mandibular fracture

Suture Retention
 Preferred in previously irradiated patients where bone screw is

contraindicated
 Sutures placed at the periphery of the prosthesis may be

secured into the soft tissues at the height of the vestibule.
 Individual 2-0 silk sutures can be used

Retention options in Interim obturators
 The surgical obturator can be used as an

interim obturator in cases where the
changes are minimal
 The prosthesis may be rebased or relined

with soft lining material to compensate for
inadequacies
Permanent Mechanical Retention
 Cast Partial Dentures
 Prefabricated Precision Attachments
 Semiprecision Attachments, Custom-made

Swing lock attachment:
 Snap-on Attachment
 Overlay (Telescoping) Crown and Thimble Crown
 Gate Type or swing Lock Device
 Implants
Retention options in Definitive Obturators
 Constructed 4-6 months after the surgery
 Should be given only when the defect has healed and is

dimensionally stable.
 Construction of the definitive obturator will vary with the type of

resection and the presence or absence of teeth.
 Improper design can lead to- stresses on abutment teeth and chronic
irritation to soft tissues.
Unhealed defect, necrosis of tissues
 Magnets
 The magnets were embedded beneath the premolar and molar of the bases of
the dentures with like poles oriented toward each other. But the disadvantage
of this system was the large size required to achieve adequate repulsive force
to retain the dentures in place when the jaws were apart.
 Magnets were used as retentive aid for sectional dentures, hemi-

maxillectomy, obturators , complete dentures, extensively atrophied ridges.
 Adhesives
 Large surgical wound
 Flat palate
 No undercut present in the anterior –posterior lateral septal wall
 The maxillary tuberosities are nonexistent
 No soft tissue undercuts in the area of surgery
 Patient's diminished salivary flow due to pre-and postradiation therapy.

EXTRAORAL RETENTION
 Anatomic Retention
 Nasal prostheses: Partial and complete removal of nasal tissue can create a
variety of anatomic possibilities for retention due to sub defect spaces
provided by the nasal cavity and maxillary sinus.
 Partial removal of nose can be treated by a patch type of prosthesis using soft
projections into the undercuts for retention .
 If the maxillary sinuses are open, they provide a large lateral space for
retention.
 Soft extension into the superior undercut can anchor the bridge area of the
prosthesis.
 Auricular prosthesis
- Partial removal of ear or partial reconstruction

can leave tissue which may be adequate for
support of prosthesis.
- The open external auditory canal can be used for

retention and location of total-ear prosthesis for
properly selected patients.
- This area of retention when used with a medially

tensioned eyeglass temple piece over the superior
margin can reduce or eliminate the need for
adhesives in retaining the ear prosthesis.
Orbital prosthesis
These defects generally presents

with intact orbital rim and a
larger defect space behind the
rim. Utilizing these undercuts
prosthesis can be retained.
Two piece orbital prosthesis showing anatomic retention

gained from the conformer.
Gurjar, R., Kumar, S., Rao, H., Sharma, A. and Bhansali, S., 2011. Retentive Aids in Maxillofacial Prosthodontics-
A Review. International Journal of Contemporary Dentistry, 2(3).
 Hard tissue
- Hard tissues 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.
 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 not a part of the prosthesis, In addition to eyeglasses, an elastic
strap may be of use to hold the glasses on and help retain the prosthesis.
 Eyeglass
A possible means of retaining a nasal prosthesis

by utilizing newly designed eyeglass frames for
the patients who has had the bridge of the nose
surgically removed. The eyeglass frame should
be opaque in color rather than translucent to
prevent retention marks from becoming visible.
Orbital, nasal and ear prosthesis are attached to

these frames.
Hair band retained prosthetic reconstruction of bilaterally missing ears: A
case of congenital atresia of external auditory canals and pinna
(A) Trial of the hair band
retained prosthesis after
attachment.
(B) Final trial of the

prostheses.
(C) Extrinsic staining

done.
(D) Prosthesis finally

verified for fit, esthetics
Right side defect Left side defect
and comfort; and
delivered to the patient.
Minati C, Shanmuganathan N, Jain BS, Padmanabhan TV. Hair band retained prosthetic reconstruction of bilaterally missing ears: a case of congenital
atresia of external auditory canals and pinna. J Prosthodont Res. 2014 Jan;58(1):62-7. doi: 10.1016/j.jpor.2013.10.003. Epub 2014 Jan 22.
 Acrylic buttons and retentive clips
- 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.
- The final prosthesis is fabricated so that it will snap over the mushroom buttons for retention.
- Retentive clips are metallic or plastic clips that snap over the bar used as a superstructure
connected to the implants. Retentive clips have more retentive ability in terms of breakaway
retentive force than magnets.
 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.
Rehabilitation of a mandibular segmental defect with magnet retained
maxillofacial prosthesis
Mantri S S, Mantri S P, Rathod C J, Bhasin A. Rehabilitation of a mandibular segmental defect with magnet
retained maxillofacial prosthesis. Indian J Cancer 2013;50:21-4
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.
 These may include interfacing pastes, liquids, sprays, or double-coated tapes.

 Disadvantages
 Continual use of adhesives can reduce their effectiveness
 Allergic or irritational responses
 Patients with poor dexterity may have difficulty in applying the adhesives or 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 prosthesis when the adhesive must be reapplied
each time it is used.
 Some aromatic based adhesives may curl thin margins of a prosthesis, making esthetic
placement difficult.
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
Various forms of adhesives-
 Acrylic resin adhesives:
Eg: Pros-Aide adhesive, Epithane -3
 Silicone adhesives:
Eg: Hollister Medical Adhesive, Dow Corning 355 Medical

Adhesive
 Pressure – Sensitive Tapes:
Eg: 3M bi-faceis
 Implants
- For nasal prosthesis, preferred site is maxilla region and

anterior floor of nose ,with tissue bar and clip design.
- For ocular prosthesis, preferred site is supraorbital rim or
lateral rim of orbit.
- Defect of midface- three to four implants are required.
- Auricular prosthesis – minimun of two implants are
required.
Implant retained obturators
ADVANTAGES:
• Retention
• Enhanced support
• Improved stability
• Improved masticatory performance
Implant Sites:
• Complete maxillectomy patient- anterior maxillary segment

• Maxillary tuberosity- less density of bone
• Posterior alveolar process- at least 10mm of bone available
• Pterygoid plates- longer, mesially inclined implants
• Residual elements of Zygoma
Zygomaticus Implants:
• Difficult to create a zone of immobile tissue around implants

• Oral hygiene maintenance is difficult
• They do not engage properly as they are placed parallel to occlusion
The ERA System uses either an individual female implant abutment or plastic female patterns that can be
incorporated into a bar. The male portion of the attachment is a nylon piece of varying retentive quality.
The attachment is resilient, stable, and can be easily serviced.
Tissue Bar design for implant supported obturators:
• Implants are united with a rigid, precision- fitted tissue bar with attached
retentive elements
• Addition of occlusal rests on the bars between the implants
• O-ring attachment is better than bar-clip or bar-ERA design attachment
The aim of the study was to compare the masticatory performance and oral
health-related quality of life (OHRQoL) of edentulous maxillectomy patients
with and without implant-supported obturator prostheses.
• Nineteen edentulous maxillectomy patients with completed prosthetic

obturator treatment in the upper jaw participated in this study.
• In nine patients, the obturator prosthesis was supported by implants in the
remaining bone of the midface and/or skull base to improve retention.
Buurman, D.J., Speksnijder, C.M., Engelen, B.H. and Kessler, P., 2020. Masticatory performance and oral health‐related
quality of life in edentulous maxillectomy patients: A cross‐sectional study to compare implant‐supported obturators and
conventional obturators. Clinical oral implants research, 31(5), pp.405-416.
(a) Bar construction was made on the dental implants to support the obturator, where the space was
too large between two implants, magnet abutments were used as alternative retention method.
(b) Retentive parts in the obturator prosthesis.
(c) Panoramic radiography showed the position of dental implants in remaining bony parts of the
midface or skull base
Buurman, D.J., Speksnijder, C.M., Engelen, B.H. and Kessler, P., 2020. Masticatory performance and oral health‐related quality of life in
edentulous maxillectomy patients: A cross‐sectional study to compare implant‐supported obturators and conventional obturators. Clinical
oral implants research, 31(5), pp.405-416.
(a) Bar construction was made on the dental
implants to support the obturator.
(b) Retentive parts in the obturator prosthesis.
(c) Frontal view of the obturator.
(d) Palatal view of the final prosthesis.
(e) Frontal view many years (>8) after implant-
supported obturator delivery.
(f) Panoramic radiography showed the position of
dental implants in remaining bony parts of the
midface or skull base
• Masticatory performance was measured objectively by the mixing ability test
(MAT) and subjectively by three OHRQoL questionnaires: (a) the Oral Health
Impact Profile for EDENTulous people (OHIP-EDENT), (b) the Obturator
Function Scale (OFS), and (c) the Dutch Liverpool Oral Rehabilitation
Questionnaire version 3 (LORQv3-NL).
• Results: : Patients with implant-supported obturator prostheses had

significantly better masticatory and oral function, reported fewer chewing
difficulties, and had less discomfort during food intake than did patients with
a conventional obturator
Nasal Epithesis Retained by Basal (Disk)
Implants
Retentive bars placed on basal (disk) Postoperative radiograph Frontolateral view of the patient after
implants after osseointegration. placement of the nasal prosthesis
Konstantinovic, V.S., Lazic, V.M. and Stefan, I., 2010. Nasal epithesis retained by basal (disk) implants. Journal
of craniofacial surgery, 21(1), pp.33-36.
Microimplants and maxillofacial
rehabilitation
 Patients with craniofacial birth defects present with extreme skeletal deformities and
often require a multi-pronged approach for achieving acceptable esthetic results.
 Use of these microimplants for support helped in distraction osteogenesis procedures

involving the mandible, maxilla, or midface.
 They can also be useful to present an alternative treatment plan in patients who
refuse orthognathic surgery.
D’Souza, D., 2015. Role of implants in maxillofacial prosthodontic rehabilitation. Current concepts in dental
implantology, pp.179-209.
CONCLUSION
 Methods for attaching and holding extraoral facial prostheses must be

as invisible as possible to make them aesthetically pleasing.
 Patient acceptance is significantly enhanced because of the quality of

the retention.
 Whatever method of retention is chosen it must be-“patient friendly”

i.e. the patient must be able to cope with the system and above all
trust it completely and have full confidence when using the prosthesis.
REFERENCES
 Gurjar, R., Kumar, S., Rao, H., Sharma, A. and Bhansali, S., 2011. Retentive Aids in Maxillofacial Prosthodontics-A
Review. International Journal of Contemporary Dentistry, 2(3).
 Taylor, Clinical and Maxillofacial prosthetics.
 Pigno, M.A. and Funk, J.J., 2001. Augmentation of obturator retention by extension into the nasal aperture: a clinical
 Parr GR, Tharp GE, Rahn AO. Prosthodontic principles in the framework design of maxillary obturator prostheses. J
Prosthet Dent. 1989 Aug;62(2):205-12.
 Tirelli, G.I.A.N., Rizzo, R., Biasotto, M., Di Lenarda, R., Argenti, B., Gatto, A. and Bullo, F., 2010. Obturator prostheses
following palatal resection: clinical cases. ACTA otorhinolaryngologica italica, 30(1), p.33.
 Depprich, R., Naujoks, C., Lind, D., Ommerborn, M., Meyer, U., Kübler, N.R. and Handschel, J., 2011. Evaluation of the
quality of life of patients with maxillofacial defects after prosthodontic therapy with obturator
prostheses. International journal of oral and maxillofacial surgery, 40(1), pp.71-79.
• Beumer, J., Curtls, T.A. and Marunick, M.T., 1996. Maxillofacial rehabilitationprosthodontic and
surgical considerations. Ishiyaku Euroamerica.
• Drake, R., Vogl, A.W. and Mitchell, A.W., 2009. Gray's anatomy for students E-book. Elsevier Health
Sciences.
• Keyf, F., 2001. Obturator prostheses for hemimaxillectomy patients. Journal of oral

rehabilitation, 28(9), pp.821-829.
• Soltanzadeh, P., Su, J.M., Habibabadi, S.R. and Kattadiyil, M.T., 2019. Obturator fabrication
incorporating computer-aided design and 3-dimensional printing technology: A clinical report. The
Journal of prosthetic dentistry, 121(4), pp.694-697.
• Buurman, D.J., Speksnijder, C.M., Engelen, B.H. and Kessler, P., 2020. Masticatory performance and
oral health‐related quality of life in edentulous maxillectomy patients: A cross‐sectional study to
compare implant‐supported obturators and conventional obturators. Clinical oral implants
research, 31(5), pp.405-416.

9 Retention in Maxillofacial Defects

Uploaded by

Document Information

Original Description:

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

9 Retention in Maxillofacial Defects

Uploaded by

Copyright:

Available Formats

Retention options in

 Etiology of Maxillary Defects

 Retention options in Surgical and Interim obturator

 Retention options in definitive obturators

 Retention by implant supported obturator

 Maxillofacial defects are often a challenge to treat, to the Surgeon as

 Almost all acquired palatal defects are precipitated by resection of

 The extent of the resection is dependent on the size, location and

Movable tissue bed

Inadequate materials available

Difficulty in retaining large prosthesis

The patient’s capability to accept the final result.

 Squamous or epidermoid carcinoma -Fibro sarcoma –

 Adenoid cystic --Rhabdomyosarcoma –Hemangiopericytoma --

 Malignant fibrous histiocytoma

 Avulsive wounds of the maxilla

 It is indicated in the following cases:

1) If the defect is the result of trauma

2) If the size of the defect is small

 Perceptions have changed regarding facial prostheses

- Improvements in materials used in facial prosthetics

- Facial prostheses achieve superior esthetic results

- Implant retained facial prostheses have achieved wide acceptance among

Is indicated in the following cases:

1) Large defects that are difficult to be corrected by surgery.

2) When there is likelihood of recurrence. Prosthetic nose

Management of the hard palate

Management of the palatal mucosa

Management of the soft palate

Management of access to the defect

- Number, position, periodontal status

- Defect is small – remaining teeth stable – intracoronal

- Defect is large – some / all of the remaining teeth are

 Adhesion, cohesion, atmospheric pressure and interfacial surface

 Large ridge with broad ridge crest

 Broad, flat palatal contour

Residual hard Residual soft

Anterior nasal Lateral scar

• The residual soft palate provides a posterior palatal seal- minimizes

• Extension of the obturator prosthesis onto the nasopharyngeal side

Residual hard palate:

• The objective of prosthesis extension is to provide resistance to

• The anterior nasal aperture may be entered unilaterally or bilaterally,

• In addition to the physical engagement of the four structures mentioned, the

 Stainless steel wrought wire of 18-gauge

 Wiring the denture to infraorbital or zygomatic bones to obturate a maxillary

 Upper through circumzygomatic wiring and lower through circumandibular.

 Palatal bone screw through a pre-drilled hole in the

 13-16mm,self tapping screw should be used

 Titanium screws used for mandibular fracture

 Preferred in previously irradiated patients where bone screw is

 Sutures placed at the periphery of the prosthesis may be

 Individual 2-0 silk sutures can be used

 The surgical obturator can be used as an

 The prosthesis may be rebased or relined

 Prefabricated Precision Attachments

 Semiprecision Attachments, Custom-made

 Overlay (Telescoping) Crown and Thimble Crown

 Gate Type or swing Lock Device

 Constructed 4-6 months after the surgery

 Should be given only when the defect has healed and is

 Construction of the definitive obturator will vary with the type of

 Magnets were used as retentive aid for sectional dentures, hemi-