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  3. 3. C O N T E N T s
  4. 4.  . INTRODUCTION
  5. 5. In evolving a successful prosthetic facial replacement ,3 factors are necessary: 1. Creative ability 2. Technical knowledge, & 3. Materials which will allow the prosthodontist to fully exploit these talents.
  6. 6. Objectives Of Maxillo-facial Prostheses Restoration of esthetics or cosmetic appearance of the patient Restoration of function Protection of tissues Therapeutic or healing effect Psychologic therapy CHALIAN,
  8. 8. Ideal Requisites Of Maxillo-facial Materials…… 1. Biocompatibility 2. Flexibility 3. Color and translucency 4. Chemical and environmental stability 5. Thermal conductivity BEUMER, CHALIAN
  9. 9. 6. Ease of Processing 7. Strength – 8. Ease of duplication 9. Weight 10.Dimensional stability BEUMER, CHALIAN
  10. 10. Processing Characteristics- 1.Low Viscosity at ambient temperature 2. Intrinsic and extrinsic Coloration possible 3.Low Solubility parameter 4. Sufficient working time 5. Low curing temperature Performance Characteristic (mechanical and physical properties) Tensile strength Tensile modulus Tear resistance Surface hardness JPD 1984:51;521-523 Criteria For Maxillo-facial Materials
  11. 11. Patient accommodation properties- • Non allergic • Non-carcinogenic • Chemical and environmental stability • Moderate cost • Hygienic • Easy adherence to living tissue JPD 1984:51;521-523
  12. 12. Classification Impression phase Modelling phase Fabrication phase
  13. 13. Prosthetic reconstruction
  14. 14. The impression serve 2 purposes: 1. Allows the dentist to accomplish the preliminary modeling without the patient present, which saves chairside time, eliminates unnecessary discomfort to the patient. 2. Patient education and teaching aids are also served with the resulting model.
  15. 15. Room Temperature Vulcanizing Materials- Advantages 1. Fine detail obtainable 2. Inherent strength. 3. Easy to obtain. Disadvantages 1. Needs backing. 2. Difficulty in adjusting setting time. 3. Retaining walls needed for confinement of material. 4. High cost. CHALLIAN
  16. 16. Modeling materials… Ideal Properties: • Malleable • sufficient body and strength • Should be possible to accept texture into this material which will be imparted to the finished mold. • The closer the color of the material to skin tone, less visual distortion LANEY
  17. 17. 1. Modeling clay (sculptor’s clay) water based clay , when allowed to dry, becomes a hard stone like substance. Advantages Inexpensive Readily available Consistency can be adjusted feathered on the edge Disadvantages gray in color, and the color differential causes visual distortion Must be kept moist at all times
  18. 18. 2. Plaster…… • Readily available • Inexpensive • Can be shaped or molded in its plastic state • Easily and quickly prepared for use Advantages • Lacks elasticity • Adding material to build contour is difficult • Tendency to flake on the surface • Cannot be used in undercuts Disadvantages
  19. 19. 3. PLASTOLENE… prepared modeling clay with oil base Advantages Takes texture well Always ready for use Easily malleable Requires comparatively little care Keep a feather edge Disadvantages more expensive Color does not match skin tone seep into stone model and affect the finished product
  20. 20. 4. Waxes…… keeps a feather edge Readily available Nominal cost Color similar to skin tone Advantages Model must be carved rather than sculpted Affect the finished product Brittle when cooled Disadvantages
  21. 21. Undertaker’s waxes Properties similar standard dental waxes, except for 2 characteristics: 1. Due to low melting point, body heat allow it to become malleable & modeled quite readily with the fingers and hands 2. The color is good in relation to skin tissue.
  22. 22. Fabrication phase materials Extraoral materials – acrylic resin vinyl chloride polymers polyurethane silicone Intraoral materials -- silicones poly (methyl methacrylate) At present silicones and polyurethane materials are considered most desirable - strength, even though both are somewhat difficult to color. J of Biomedical material research 2004:8(4);349-363
  23. 23. Extra oral materials 1. Poly-methyl methacrylate - Palamed 2. Polyvinyl polymers and copolymers - Realastic (poly vinyl chloride) - Mediplas (polyvinyl acetate chloride) 3. Elastomers a) Polyurethane - epithane 3 b) Silicone - HTV - RTV BEUMER
  24. 24. 1. Acrylic resin Indications:  Preferred for restoring defects which require minimal movements. e.g. fabrication of orbital prostheses. • Useful in cases of rapidly changing defects where relining is mandatory. BEUMER
  25. 25. Advantages 1. Easy to work with & to maintain. 2. Durable. 3. Easy to reline with a tissue conditioner or reliner. 4. Both extrinsic & intrinsic coloring can be performed. 5. Compatible with most adhesive system & can be cleaned easily. Disadvantages 1. Rigidity 2. Does not have the feel of skin. 3 High thermal conductivity. 4. Poor margin esthetics. 5. Surface gloss present. BEUMER
  26. 26. Palamed  Cross linked co-polymer of methacrylics and acrylics.  Consists of base powders and stain concentrates, solvent liquid.  Shade guide is provided for base shade powders and stain concentrates.  Produces a soft, resilient skin with a spongy central mass, light weight  The sculptured wax is weighed to achieve the recommended ratio according to the weight ratio table. CHALLIAN, BEUMER
  27. 27.  In 1943 Tylman claimed that MMA could be combined with plasticizer ( PALAMED)  Plasticized MMA resin has been formulated with a foaming agent.  Palamed must be carefully proportioned because too much will result in a stiff heavy unstable product or too little will result in incomplete filled mold with large pores. BEUMER
  28. 28. Use of visible light cure resin system in maxillofacial prosthetics  VLC resins underwent polymerization without substantial exothermic reaction. Biologic testing indicated–  they are non toxic & biocompatible.  Useful in the replacement of large full- thickness defects in the cranium & other regions.  Also used in mandibular augmentation Advantages :
  29. 29. 2. VINYL POLYMERS & COPOLYMERS  Most widely used plastics for fabrication of MFP  Copolymers of vinyl chloride & vinyl acetate  Properties are superior to those of natural rubbers in flexibility & resistance to sunlight & aging  Clinical usefulness may extend from 1-6 months Vinyl plastisol  Introduced in 1940.  Vinyl resins are relatively rigid in their pure state, made flexible by addition of plasticizers.  In its plastisol stage the material is a thick liquid formed by dispersion of small vinyl particles in plasticizer BEUMER
  30. 30. Advantages 1. Inexpensive & easy to manipulate 2. Can be remade by resoftening & reheating. 3. Hydrophilic properties. Disadvantages 1. Prosthesis made from plastisol looses its flexibility with aging & become hard & distorted. 2. Degradation & destruction by UV light. 3. Linotype Metal molds are used which are expensive. 4. Stains easily BEUMER
  31. 31. 3. Elastomers Elastomers have been used for over 50 years now to fabricate facial prostheses for individuals missing facial anatomy due to resection, trauma or even congenital anomalies. BEUMER
  32. 32. a) Polyurethane elastomer • ……But only Epithane-3 facial restorations.  3 component system Part A - polyol Part B- isocyanate Part C- initiator such as dibutyltin dilaurate or stannous octate)  Varying amount of isocyanates will change the physical properties of final products. BEUMER
  33. 33. ADVANTAGES - They can be made elastic without compromising edge strength. - Flexibility well suited to defects with movable tissue beds - Colored extrinsically & intrinsically - Superior cosmetic results. DISADVANTAGES - Difficult to process consistently - Isocyanate is moisture sensitive & toxic - The presence of moisture in the air, leads to production of CO₂ resulting in porous elastomer. BEUMER
  34. 34.  Water contamination is difficult to control  Requires thorough dehydration before processing if stone molds are used  Poor compatibility with existing adhesive systems  Difficulty in clearing adhesive from prosthesis.  Not color stable.  Clinical usefulness less than 6 months ( approx. 3mths.) BEUMER
  35. 35. Silicone Elastomer • Properties of silicone • Disadvantages of silicone • Classification of silicone • HTV silicone • RTV silicone • Advantages of HTV over RTV
  36. 36. b) Silicone elastomer  The silicon elastomers -- introduced -1946,  Silicones are a combination of organic and inorganic compounds.  The first step in their production is the reduction of silica to elemental silicon.  Then by various reactions the silicon is combined with methyl chloride to form Dimethyl dichloro siloxane, which, when it reacts with water, forms a polymer BEUMER
  37. 37.  Polymers – translucent , watery , white fluids .  Fillers -- additional strength.  Anti-oxidants & vulcanizing agents -- transform the raw mass from a plastic to a rubbery resin during processing  Cross linking makes the silicones especially resistant to degradation from ultra-violet exposure. BEUMER
  38. 38. Disadvantages of silicones  Poor strength  Receive colors poorly or with difficulty  Some are opaque resulting in prosthesis that are cold and lifeless.  Microbial growth  Poor wet ability  Good only with silicone adhesives
  39. 39. Classification of silicone • Based on the Mechanism • Acc. to Application • Based on chemistry JIADS VOL 1 ISSUE 2 APRIL- JUNE 2005;
  40. 40. Based on the Mechanism • Room temperature (RTV) • High temperature (HTV) Acc.to Application • Implant grade - FDA requirement • Medical grade - external use • Clean grade - packaging • Industrial grade - industrial applications Based on chemistry • Polydimethyl siloxanes • Methyl vinyl /dimethyl siloxanes • Phenyl methylsiloxanes • Fluoro dimethyl siloxanes Industrial use JIADS VOL 1 ISSUE 2 APRIL- JUNE 2005;
  41. 41. HTV Silicone 1. 1 or 2 component system with putty like consistency 2. 2 primary catalysts - platinum salt (addition) and dichlorobenzoyl peroxide (condensation). 3. Filler - very pure, finely divided silica (size 30 ) 4. Processing of heat cured silicones requires sophisticated instrumentation and high temperature. BEUMER
  42. 42. • Excellent thermal stability • Biologically inert • Color stable when exposed to ultraviolet light Advantages • Opaque, lifeless appearance • Not adequate elasticity in function • Metal Molds Disadvantages HTV Silicone
  43. 43. HTV silicone  Silastic S-6508  Silastic 370, 372, 373  Silastic 4-4514  Silastic 4-4515  MDX 4-4159  SE- 4524U  Q7- 4635  Q7- 4650  Q7- 4735 These silicones can be preformed into various shapes for alloplastic implantation or facial prostheses. BEUMER. CHALLIAN;
  44. 44. RTV Silicone  Available as clear solutions  A viscous silicone polymer that includes a filler & a catalyst –  Stannous octoate is the most common catalyst .  Fillers usually diatomaceous earths - improve strength, but significant loss of translucency occurs. This problem primarily exists typically with Silastic 382 & 399.
  45. 45. 2 types of RTV Condensation type Orthoalkyl silicate cross- linking agent Stannous octate catalyst Addition type Hydro-methyl siloxane cross-linking agent Chloroplatinic acid catalyst
  46. 46. ADVANTAGES: - Color stable - Biologically inert - Easier to process - Retain physical & chemical properties at wide range of temperature - Stone molds can be used DISADVANTAGES: - Poor edge strength - Costly - Cosmetic appearance of the material -- inferior to that of polyurethanes, acrylic resins, polyvinyl chloride.
  47. 47. ADVANTAGES OF HTV OVER RTV 1. Less chances of air bubble entrapment, since hand mixing of catalyst & pigments with the elastomer is avoided. 2. Increased tear strength mechanical durability, & chemical resistance. 3. Increased biocompatibility and flexibility
  48. 48. FOAMING SILICONES  The purpose -- reduce the weight of the prosthesis.  After the silicone is processed, the gas is eventually released leaving a spongy material.  ADV--The formation of the bubbles within the mass can cause the volume to increase by as much as 7 times.  However, the foamed material has reduced strength and is susceptible to tearing. This weakness can be partially overcome by coating the foam with another silicone BEUMER Silastic 386:
  49. 49. Recent Advances MPDS- Silicone block copolymer Polyphosphazenes Silphenylenes MDX4-4210
  50. 50. MDX 4 - 4210  Low temperature, vulcanizing silicone polymer  Provided as a two component kit  The polymerization reaction is addition reaction with no by product  Very colour stable JIADS VOL 1 ISSUE 2 APRIL- JUNE 2005;
  51. 51. Advantages of this material  Most importantly it has a high tear strength compared to RTV silicones  Unusually thin edges can be designed in a prosthesis without the risk of damage during wear & removal.  Accelerated aging tests have shown that the elastomer is very color stable. JIADS VOL 1 ISSUE 2 APRIL- JUNE 2005;
  52. 52. SilPhenylenes  Arylene silicone polymer - synthesized & formulated as a pourable, viscous, RTV liquid  Transparent ,Reinforced with silica fillers.  Three component kit –  Base elastomer,  Tetrapropoxysilane (cross linking agent) and  Organotin catalyst JIADS VOL 1 ISSUE 2 APRIL- JUNE 2005;
  53. 53. Improved property  Unusual combination of high-tensile strength & low modulous (relative to other conventional RTV silicones)  Improved edge strength  Superior coloration  Feel like skin JIADS VOL 1 ISSUE 2 APRIL- JUNE 2005; BEUMER
  54. 54. MPDS -- Silicone Block Copolymers (Methacryloxy propyl-terminated poly dimethyl siloxane)  It is introduced to improve some of the drawbacks of silicone elastomers, such as decreased tear strength, low percent elongation & bacterial growth over prosthesis.  Methacrylate - (ADHEOPHILIC) reduces the hydrophobicity which enhances the adhesive bond strength to non-silicone-based adhesives
  55. 55. Polyphosphazenes  Fluoro elastomer has been developed for use as a resilient denture liner (NovusTM, Hygienic Corp.)  It has the potential to be used as a maxillofacial prosthetic material.
  56. 56. New organosilicone maxillofacial prosthetic materials Lai, wang, Delong, Hodges.  The purpose of this study is to evaluate the physical properties of new prosthetic materials based on methacryloxypropyl terminatedpolydimethylsiloxane (MPDS-MF) and to compare the properties with those of A-2186.  The hardness of MPDS-MF is similar to A-2186. However, tensile strength, tear strength, ultimate elongation, and adhesive bonding strength of MPDS-MF are higher than those of A-2186 Dental Materials 18 (2002) 281 ±286
  57. 57. Effect of nano-oxide concentration on the mechanical properties of a maxillofacial silicone elastomer,  The purpose of this study was to evaluate the effect of different concentrations of nanosized oxides of various composition on the mechanical properties of a commercially available silicone elastomer.  Nanosized oxides (Ti, Zn, or Ce) were added in various concentrations to a commercial silicone elastomer (A-2186),  Incorporation of Ti, Zn, or Ce nano-oxides at concentrations of 2.0% and 2.5% improved the overall mechanical properties of the silicone A-2186 maxillofacial elastomer. (J Prosthet Dent 2008;100:465-473)
  58. 58. Coloration  Defined as one that has a distribution of pigments equivalent to that of human skin and whose overall colour appears to change precisely as does that of a human skin under all types of illumination. – Chalian  Coloration of the prosthesis varies with the materials used and the preference of the clinician.  Basic skin tones should be developed into a shade guide for the materials that are used.  The base shade selected should be slightly lighter than the lightest skin tones of the patient because the prosthesis will darken by either extrinsic or intrinsic coloration. TAYLOR
  59. 59.  Coloration techniques can be divided into 3 groups: Extrinsic, intrinsic or combination technique.  The combination technique is widely used because it produces prosthesis with a more natural appearance.  The color match of the prosthesis depends largely on the skill of the clinician, color activity of the individual and light source.  At present the procedure is done using an empirical trial and error method having no standardization for future reference. TAYLOR
  60. 60. Intrinsic coloration:  Intrinsic coloration is the color applied within the mold during the casting procedure.  A three dimensional quality is accomplished by incorporating subsurface details such as blood vessels, freckles and moles. TAYLOR
  61. 61.  Knowledge of primary, secondary and complementary colors is helpful in selection of chroma. Primary Color Secondary Color Complementary Color 1) Red Red+Yellow=orange Red-Green 2) Yellow Yellow+blue=Green Yellow-Violet 3) Blue Blue+Red=Violet Blue-Orange. TAYLOR
  62. 62.  Spectrophotometers used to measure patient skin color Kaolin Powder Calcined White G-102 used to create opacity with silicone products Basic Skin Pigments for intrinsic stain Dry Pigments Flocking / Fibres for intrinsic stains Veins
  63. 63. Accelerated color change in a maxillofacial elastomer with and without pigmentation  This study attempted to determine whether predictable color changes occur when 3 pigments are individually incorporated into a specific silicone elastomer.  The materials included an RTV elastomer; 1 natural inorganic pigment, burnt sienna and 2 synthetic organic pigments, Hansa yellow and alizarin red.  Acceleration was achieved…  If left indoors with exposure to normal levels of daylight, the observed color change of the specimens would likely occur but take more time. (J Prosthet Dent 2001;85:614-20.)
  64. 64.  Once the base color is identified, laminar glazes are applied to simulate the skin complex appearance.  Laminar glazes are layers of color painted into the mould before packing the base color and this is combined with placement of threads and flocks for blood vessel simulation.  Common colors for laminar glazes are:  Red bluish glaze .  Golden tan glaze  Dark brown glaze  Opaque Yellow White color  Dark blue or purple  Opaque, Pink to red helix color TAYLOR
  65. 65. Base color is compared to patient skin with red bluish glaze , layered over a base color Red bluish glaze is painted into the first layer of mould Tweezers and periodontal probe to place thread for blood vessel simulation Syringe used to inject silicone into the helical group Instrinsically painted mould prior to packing the base color
  66. 66. Extrinsic Coloration:  It is more predictable  It should be used sparingly  Apply the extrinsic pigments in small amounts and on the surface of the prosthesis in a stippled fashion. Curing can be done by placing in an air-circulating oven at 90°centigrade.  Additional glazes are applied and cured by using air drier. TAYLOR
  67. 67.  Application of extrinsic color Blending the Seam Application of kaolin to Compressed air used to Cured surface of the prosthesis eliminate excess kaolin TAYLOR
  68. 68. In vitro evaluation of color change in maxillofacial elastomer through the use of an ultraviolet light absorber and a hindered amine light stabilizer.  This study evaluated color stability when an ultraviolet light absorber and hindered amine light stabilizer were mixed in the maxillofacial elastomer containing either organic or inorganic pigments.  The materials used were an RTV silicone elastomer, 1 natural inorganic dry-earth pigment (burnt sienna) and 2 synthesized organic pigments (hansa yellow and alizarin red), ultraviolet light absorber (UVA) and hindered amine light stabilizer (HALS).  UVA and HALS were shown to be effective in retarding color changes. J Prosthet Dent. 2004 May;91(5):483-90
  69. 69. Adhesives Introduction Classification Problem with adhesives
  70. 70. Introduction  Adhesives are expected to retain prostheses during ordinary & extreme facial expressions, build-up of sebaceous secretions & water & change of weather conditions.  Most facial prostheses are retained with a medical grade adhesive.  Selection depends -- Biocompatibility, -- Retentive properties -- Ease of applicability -- Removal on daily basis -- Nature of the material from which prosthesis is fabricated. BEUMER
  71. 71. Classification of Adhesive  Rubber-based liquid adhesives (natural & latex)  Silicone  Cyanoacrylates
  72. 72. Pressure-sensitive tape (double-coated polyethylene, 3M surgical tape)  These materials are backing strips composed of cloth, paper, film, foil, or laminate coated with a pressure-sensitive adhesive.
  73. 73.  The bond weaker than that of rubber adhesives.  Advantages - the ease of application & cleaning after removal.  Indication for biphasic tape is with materials that have poor flexibility & nonmobile tissue beds.
  74. 74. Silicone adhesives (Holister)  Are a form of RTV silicone dissolved in solvent.  Once applied, the solvent evaporates & a tacky surface forms that form bond with another surface  Despite their low adhesive strength, they have good resistance to moisture & weathering with low water sorption
  75. 75. Acrylic resin emulsions (Epithane-3, ProsAide)  Composed of acrylic resin dispersed in water solvent when evaporated, leaves a rubber-like substance.  Other materials -- synthetic rubber, vinyl acetate, reclaimed rubber, vinyl chloride, styrene, & methacrylic  Penetration & wetting -- controlled by addition of surfactants or altering the particle size of the dispersion.  Increasing the viscosity -- prevent penetration into porous surfaces.
  76. 76. Problems with Adhesives  Patients with poor manual dexterity or coordination may not be able to apply the adhesive or position the prosthesis in a consistent manner.  Margins adjacent to mobile tissue require constant reattachment with facial movements.  Allergic or irritational responses may persist.  Some aromatic base adhesives may curl thin prosthesis margins.
  77. 77.  Poor hygiene limit the wearing of a prosthesis , because of interference with adhesive qualities.  Routine removal of adhesive -- remove the external pigmentation
  78. 78. Limitations of the Maxillofacial Materials…
  79. 79.  No single maxillofacial material is ideal for every patient 1. Continued effect of sunlight and vascular dilatation & contraction on the natural tissues cannot be duplicated in the prosthesis. 2. Variations of skin tone when the patient is exposed to different light sources (e.g., incandescent, fluorescent, & natural light) cannot be duplicated in the prosthesis 3. The prosthesis cannot duplicate the full facial movement of the non defective side
  80. 80. 4. Varying physiologic conditions of the patient in everyday living (e.g., lack of sleep, infectious diseases, and edema resulting from interrupted lymph drainage caused by surgery) cannot be duplicated in the prosthesis. 5. Inflammation caused by recent surgery, which subsides with time -- necessitates remaking the prosthesis. 6. Lack of predictability of the life of the prosthesis, because of variations among patients (i.e., secretions, smoking, and environment
  81. 81. Conclusion…
  82. 82. References 1. “Maxillofacial Prosthetics”, Chalian 2. “Maxillofacial prosthetics” Laney WR 3. “Clinical maxillofacial Prosthetics” Thomas D Taylor 4. Oral and maxillofacial rehabilitation by Buemer. 5. Robert Sanchez, comparision of physical properties of two types of polydimethyl siloxane, MDX4-4210 and new material A-2186 JPD 1992:67(5);679
  83. 83. 6. Effect of nano-oxide concentration on the mechanical properties of a maxillofacial silicone elastomer, Ying Han, DDS, MS,a Sudarat Kiat-amnuay, DDS, MS,b John M.Powers, PhD,c and Yimin Zhao, DDS, PhDd, J Prosthet Dent 2008;100:465-473 7. New organosilicone maxillofacial prosthetic materials Lai, wang, Delong, Hodges, Dental Materials 18 (2002) 281 ±286 8. Accelerated color change in a maxillofacial elastomer with and without pigmentation, John J. Gary, Eugene F. Huget and Larry D. Powell, J Prosthet Dent 2001;85:614-20. 9. In vitro evaluation of color change in maxillofacial elastomer through the use of an ultraviolet light absorber and a hindered amine light stabilizer, J Prosthet Dent,2004 May;91(5):483-90
  84. 84. 10. An in vivo evaluation of adhesives used in extraoral maxillofacial prostheses. Haug SP, Richard GE, Margiotti E, Winkler MM, Moore DJ, J Prosthodont 1995 Mar;4(1):11-5. 11. . Mechanical behavior of three maxillofacial prosthetic adhesive systems: A pilot project, John F. Wolfaardt, Victor Tam, M.Gary Faulkner, Narasimha Prasad, The journal of prosthetic Dentistry,vol 68;6:December 1992, Pages 943– 949 12. . JPD 1984:51(4):523-226.