this is basic seminar on implant retained maxillofacial prosthesis including that which are the different types of facial defects and how are they rehabilitated with implants.
5. • Body abnormalities or defects that compromise appearance,
function and accommodation sufficient to render an individual
incapable of leading a relatively normal life have usually
prompted responses that seek to bring the person to state of
acceptable normalcy.
Federspil PA. Implant-retained craniofacial prostheses for facial defects. GMS current topics in
otorhinolaryngology, head and neck surgery. 2009;8.
6. Congenital anomaly, trauma or tumour surgery.
Size or location of the defect.
Patient’s medical condition or personal desires.
Restores normal anatomy and appearance, protects the tissues of a defect, and
provides great psychological benefit to the patient.
Federspil PA. Implant-retained craniofacial prostheses for facial defects. GMS current topics in
otorhinolaryngology, head and neck surgery. 2009;8.
7. MAXILLOFACIAL PROSTHESIS
• Any prosthesis used to replace part or all of any
stomatognathic and/or craniofacial structures. (GPT 9)
9. Artificial eyes, ears, noses were found on egyptian mummies.
AMBROSE PARE (1517-1590):ears made of paper & leather, and
method of securing them with a head clip.
In 1728, Pierre Fauchard designed a prostheses supported with wings
that were positioned by patient from the oral side of obturator and made
use of floor of nose for retention
In 1889, CLAUDE MARTIN, a French man illustrated a variety of
prosthetic replacements including a particularily interesting attempt to
retain a porcelain nose prosthesis with an intraoral mechanism
Beumer III J, Marunick MT, Esposito SJ. Maxillofacial rehabilitation: prosthodontic and surgical
management of cancer-related, acquired, and congenital defects of the head and neck. Quintessence Pub.
2011;276.
10. • The problem of retention: KOLE and WIRTH in 1956.
• Branemark first placed modified osseointegrated fixtures in cranial
skeleton for the purpose of retaining a prosthetic ear in 1977
Beumer III J, Marunick MT, Esposito SJ. Maxillofacial rehabilitation: prosthodontic and surgical
management of cancer-related, acquired, and congenital defects of the head and neck. Quintessence Pub.
2011;276.
11. SCOPE OF MAXILLOFACIAL PROSTHETICS
Restoration of esthetics or cosmetic appearance of patient.
Restoration of function.
Protection of tissue.
Therapeutics or healing effect.
Psychologic therapy.
D’souza D. Role of implants in maxillofacial prosthodontic rehabilitation. Current concepts in dental
implantology. 2015 feb 25:179.
12. INDICATIONS FOR BONE-ANCHORED
PROSTHESES
If local or general contraindications concerning procedures of reconstructive
surgery exist
Poor general condition
During individual stages in plastic reconstructive surgery (interim prosthesis)
Following failed reconstructive procedures
The rejection of reconstructive procedures on the part of the patient
High aesthetic demands
D’souza D. Role of implants in maxillofacial prosthodontic rehabilitation. Current concepts in dental
implantology. 2015 feb 25:179.
13. ANCHORAGE OF PROSTHESES
• Already existing anatomical areas like
undercut areasANATOMICAL
• Spectacles
• Studs
• Springs
MECHANICAL
• AdhesivesCHEMICAL
SURGICAL Implants
D’souza D. Role of implants in maxillofacial prosthodontic rehabilitation. Current concepts in dental
implantology. 2015 feb 25:179.
14. ADVANTAGES OF BONE ANCHORAGE
• Enhanced retention
• Not affected by environmental factors (e.g.sweating)
• Insertion of the prosthesis into the proper position
• Transparent edges of silicone prostheses can be maintained longer than with adhesive
prostheses.
D’souza D. Role of implants in maxillofacial prosthodontic rehabilitation. Current concepts in dental
implantology. 2015 feb 25:179.
16. METAL BAR
• Screwed onto the percutaneous posts
• Requires parallel aligned percutaneous
posts
• Bar construction in the nasal and orbital
areas obsolete
D’souza D. Role of implants in maxillofacial prosthodontic rehabilitation. Current concepts in dental
implantology. 2015 feb 25:179.
17. MAGNETS
Facilitate cleaning and insertion of
the prosthesis
Used with non-parallel axes
Implants that are too close to one
and other
Individuals with hygiene problems.
D’souza D. Role of implants in maxillofacial prosthodontic rehabilitation. Current concepts in dental
implantology. 2015 feb 25:179.
18. CRANIOFACIAL IMPLANTS
Shorter ( 3 – 5 mm ),threaded and with the same
machined surface as the oral implants.
Attach a flange in the coronal part of the fixture
Abutments: Bone anchored hearing aid (BAHA)
Bone anchored epistheses(BAE)
Federspil PA. Implant-retained craniofacial prostheses for facial defects. GMS current topics in
otorhinolaryngology, head and neck surgery. 2009;8.
19. LENGTH OF FIXTURE
Determined by the thickness of cranial bones.
Temporal bone thickness 4mm
Longer fixtures in frontal bone, zygoma and
maxilla
Skin over abutment is reduced.
In pediatric cases, skull bone thinner so utilization
of semi-perimeable membrane at first stage
surgery.
Federspil PA. Implant-retained craniofacial prostheses for facial defects. GMS current topics in
otorhinolaryngology, head and neck surgery. 2009;8.
20. EXTRAORAL IMPLANT SYSTEM
Solitary implants
Grouped implants
Federspil PA. Implant-retained craniofacial prostheses for facial defects. GMS current topics in
otorhinolaryngology, head and neck surgery. 2009;8.
22. BRANEMARK SYSTEM (VISTAFIX)
• First implant system used extraorally
• 3-4mm length
• Closed flange or flangless
• Special clamps for abutment
Federspil PA. Implant-retained craniofacial prostheses for facial defects. GMS current topics in
otorhinolaryngology, head and neck surgery. 2009;8.
23. ITI SYSTEMS
• International team for
implantology
• Sand blasted, large grit, acid
etched surface (SLA)
• Two staged roughness
• Diameter of 3.3mm and
countersunk depth of 3.5 or
5mm with a coned seat.
Federspil PA. Implant-retained craniofacial prostheses for facial defects. GMS current topics in
otorhinolaryngology, head and neck surgery. 2009;8.
24. GROUPED
IMPLANTS
• Kole and Wirth(1956), Subperiosteal
implants
• Wisil- cobalt chrome alloy
• Adapted to bone surface without
anchored into bone
• Prothesis attached to implant projecting
from skin
• Forces are distributed across the plate
Epitec
system
Epiplating
system
Federspil PA. Implant-retained craniofacial prostheses for facial defects. GMS current topics in
otorhinolaryngology, head and neck surgery. 2009;8.
25. EPITEC SYSTEM
Mostafa Farmand and Leibinger
company (1991)
3D carrier plate and self-tapping 2
mm titanium screws
Stability, many connecting bridges
between screws
Retention from 1mm thick
connecting bridges of 3D carrier
plate covered by bone
Federspil PA. Implant-retained craniofacial prostheses for facial defects. GMS current topics in
otorhinolaryngology, head and neck surgery. 2009;8.
26. EPIPLATING
SYSTEM
• Federspil and M.Schneider (2000)
• 1mm thick but 2mm in width
• Tapped holes, thickness of the
plate 2mm
• To anchor the plates, titanium
• Screws of 2 mm in breadth and
lengths: 4, 5.5 and 7 mm.
Federspil PA. Implant-retained craniofacial prostheses for facial defects. GMS current topics in
otorhinolaryngology, head and neck surgery. 2009;8.
27. SURGICAL TECHNIQUE
Stage 1: Bone drilling and insetting
implant
Stage 2: Soft tissue reduction
Hair free surrounding skin area
Percutaneous abutment insertion
Surgical technique varies for solitary
and grouped implant systems.
Federspil PA. Implant-retained craniofacial prostheses for facial defects. GMS current topics in
otorhinolaryngology, head and neck surgery. 2009;8.
29. ORBITAL
PROSTHESIS
D’souza D. Role of implants in maxillofacial prosthodontic rehabilitation. Current concepts in dental
implantology. 2015 feb 25:179.
30. Placement of implants is limited to the superior and lateral aspects of the
rim.
Placed within the confines of the defect and parallel or slightly inward in
relation to the frontal plane.
D’souza D. Role of implants in maxillofacial prosthodontic rehabilitation. Current concepts in dental
implantology. 2015 feb 25:179.
31. Evisceration is the removal of the
contents of the globe while leaving
the sclera and extra-ocular muscles
intact.
Enucleation is the removal of the
eye from the orbit while preserving
all other orbital structures.
Exenteration is the most radical of
the three procedures and involves
removal of the eye, adnexa, and
part of the bony orbit
D’souza D. Role of implants in maxillofacial prosthodontic rehabilitation.
Current concepts in dental implantology. 2015 feb 25:179.
32. Evisceration and Enucleation easily rehabilitated using custom made
ocular prostheses
Exenteration surgical procedures are far more extensive
Large prostheses do not function well with adhesives or eye glasses
alone
Application of implants in these large orbital defects reduces the need for
adhesives
D’souza D. Role of implants in maxillofacial prosthodontic rehabilitation. Current concepts in dental
implantology. 2015 feb 25:179.
33. • Supero- lateral rim and
infero- lateral rim
• Three implants both in
upper and lower orbital rims
• For irradiated patients,
hyperbaric oxygen therapy
• 6-8 months for
osseointegration
• Neodymium magnets for
retention
D’souza D. Role of implants in maxillofacial prosthodontic rehabilitation. Current concepts in dental
implantology. 2015 feb 25:179.
34.
35. HYPERBARIC OXYGEN THERAPY
Administration of 100 % oxygen at higher than normal atmospheric
pressure
Amount of dissolved oxygen in the plasma increases.
Resistance to infection, activation of fibroblasts, collagen deposition,
angiogenesis, and epithelization
HBO did not promote cancer growth, and that the use of HBO in patients
with malignancies was considered safe.
Moen I, Stuhr LE. Hyperbaric oxygen therapy and cancer—a review. Targeted oncology. 2012 Dec 1;7(4):233-42.
36. preventive HBO therapy can reduce the risk of implant failures in irradiated
patients, due to improved vascularity which leads to reduced risk of
radiation-induced damages to tissue, and thus, HBO can be the effective
treatment protocol, while planning for the implant treatment in irradiated
maxillofacial patients.
38. Maxillary and frontal bones.
Frontal sinuses and the superior margin of
prosthesis, are limiting factors
If implants are placed with in the inferior
aspect of the defect, care must be taken so
that access is available for prosthetic
instrumentation and retentive components.
D’souza D. Role of implants in maxillofacial prosthodontic rehabilitation. Current concepts in dental
implantology. 2015 feb 25:179.
39. Anterior nasal floor is an excellent implant site because of availability of ample bone and
good vasculature.
The implants should be placed in the anterior portion of defects to facilitate hygiene
access but not so far as to emerge through mobile tissues of upper lip.
40. Loss due to malignancy related surgery or severe mid face trauma
Limited success with tissue or bony undercut or spectacles as retention
Triangular implant placement, two at alar base and one at nasal bridge
Retention by clips or magnets connected by metal bar
D’souza D. Role of implants in maxillofacial prosthodontic rehabilitation. Current concepts in dental
implantology. 2015 feb 25:179.
43. • Two-three implants in temporo-mastoid region
• Between 8 o’clock or 9 o’clock and between 10 and 11
o’clock
• 18-20 mm/2cm from the center of external auditory
meatus.
• Implant placement limited by the location of the mastoid
air cells
D’souza D. Role of implants in maxillofacial prosthodontic rehabilitation. Current concepts in dental
implantology. 2015 feb 25:179.
44. • Metal bars, clips or combination for retention
• Two abutments for bar construction
• 3 magnets are used
• Classic auricular plate with 2 tapped holes with the
Epiplating system
D’souza D. Role of implants in maxillofacial prosthodontic rehabilitation. Current concepts in dental
implantology. 2015 feb 25:179.
45.
46. OBTURATORS
A maxillofacial prosthesis used to close, cover or maintain the integrity of the oral
and nasal compartments resulting from congenital, acquired, or developmental
disease process, such as cancer, cleft plate, osteoradionecrosis of the palate
47. Based on the time of placement, classified as: surgical, interim and
definitive.
Surgical obturators : placed immediately after surgery
Interim obturators: placed immediately after removal of the surgical
packing
Definitive obturator : when the surgical defect has stabilized,
approximately 3 to 12 months after definitive surgery
D’souza D. Role of implants in maxillofacial prosthodontic rehabilitation. Current concepts in dental
implantology. 2015 feb 25:179.
48. Surgical reconstruction of maxillary defects impossible
Lack of contralateral mucogingival support
Implants enhance the stability and retention of maxillary obturators
Root of the zygomatic arch
D’souza D. Role of implants in maxillofacial prosthodontic rehabilitation. Current concepts in dental
implantology. 2015 feb 25:179.
53. CLASSIFICATION OF MAXILLECTOMY AND
MIDFACE DEFECT
The surgical defect is classified according :
Vertical dimension : involvement of the orbit and skull base and the
resultant mainly aesthetic deformity
Horizontal or palatal: nasal septum, contralateral sinuses, and alveolus
Brown JS, Shaw RJ. Reconstruction of the maxilla and midface: introducing a new classification. The
Lancet Oncology. 2010 Oct 1;11(10):1001-8.
54. VERTICAL DIMENSION
Class 1 Maxillectomy with no oro-antral fistula
Class 2 Low maxillectomy
Class 3 High maxillectomy
Class 4 Radical maxillectomy
Class 5 Orbitomaxillary defect
Class 6 Nasomaxillary defect
Brown JS, Shaw RJ. Reconstruction of the maxilla and midface: introducing a new classification. The
Lancet Oncology. 2010 Oct 1;11(10):1001-8.
55. HORIZONTAL OR PALATAL ASPECT
Class 2: palatal defect , alveolus not involved
b: less than or equal to ½ unilateral
c: less than or equal to ½ bilateral or
transverse anterior
d: greater than ½ maxillectomy
Brown JS, Shaw RJ. Reconstruction of the maxilla and midface: introducing a new classification. The
Lancet Oncology. 2010 Oct 1;11(10):1001-8.
56. Surgical reconstruction after first cancer resection, such as microvascular
free flaps or rotation flaps
Zygoma implants reconstruct full arch even in case of conspicuous bone
defects with no indication to grafting procedures
Midfacial resections with oronasal communication, zygoma implants
communication to support an extraoral nasal prosthesis.
Brown JS, Shaw RJ. Reconstruction of the maxilla and midface: introducing a new classification. The
Lancet Oncology. 2010 Oct 1;11(10):1001-8.
61. D’souza D. Role of implants in maxillofacial prosthodontic rehabilitation. Current concepts in dental
implantology. 2015 feb 25:179.
• Skin penetration Adverse Skin reaction
• Saliva and the cleaning properties of the tongue contribute significantly
towards maintaining good condition in the oral implant area.
0
• No reaction
1
• Reddish
2 • Red and moist
3
• Granulation tissue
4
• Skin infection
Holgers et al
63. Compared with a control group of non-irradiated patients, implant failures
are higher after previous radiotherapy. High implant failures were
especially seen after high dose radiotherapy and a long time after
irradiation. All craniofacial regions were affected, but the highest implant
failures were seen in frontal bone, zygoma, mandible, and nasal maxilla.
The lowest implant failures were seen in the oral maxilla. The use of long
fixtures, fixed retention, and adjuvant HBO decreased implant failures.
66. An implantation should be considered after puberty in adolescents.
A temporary solution is offered by an adhesive retained prosthesis.
In case of malformations in children it should not be forgotten that the
young patients should indeed be cared for and their wishes be respected
D’souza D. Role of implants in maxillofacial prosthodontic rehabilitation. Current concepts in dental
implantology. 2015 feb 25:179.
71. The use of Computed Tomography (CT) and Magnetic Resonance
Imaging (MRI) in conjunction with Rapid Prototyping (RP) have
revolutionized the methods of impressions .
3D optical imaging
3D laser eye-safe scanners
D’souza D. Role of implants in maxillofacial prosthodontic rehabilitation. Current concepts in dental
implantology. 2015 feb 25:179.
72.
73. • New alloys like tantalum, niobium, zirconium, and
magnesium
• Non oxide ceramics like silicon nitride and silicon carbide
• Polymer/magnesium composites
D’souza D. Role of implants in maxillofacial prosthodontic rehabilitation. Current concepts in dental
implantology. 2015 feb 25:179.
74. Nanotechnology, tissue engineering along with the concepts of stem cell
technology are new fields of maxillofacial reconstruction.
Regeneration of new osseous tissue in vivo for placement of implants
Regeneration of a complete ear or nose from the stem cells of the
person or a donor
D’souza D. Role of implants in maxillofacial prosthodontic rehabilitation. Current concepts in dental
implantology. 2015 feb 25:179.
75. CONCLUSION
The discovery of osseointegration has been arguably one of the
most beneficial medical breakthroughs especially in the head and
neck region. These implants have also revolutionized the scope and
the efficacy of rehabilitation of the entire craniofacial region.
The science of craniofacial implantology will ensure that the
patients receive the most comprehensive rehabilitation that can be
offered and ensure that their early return to form and function.
76. REFRENCES
• D’souza D. Role of implants in maxillofacial prosthodontic rehabilitation. Current
concepts in dental implantology. 2015 feb 25:179.
• Brown JS, Shaw RJ. Reconstruction of the maxilla and midface: introducing a new
classification. The Lancet Oncology. 2010 Oct 1;11(10):1001-8
• Federspil PA. Implant-retained craniofacial prostheses for facial defects. GMS
current topics in otorhinolaryngology, head and neck surgery. 2009;8.
• Maxillofacial rehabilitation: Keith F. Thomas
• Osseointegration in maxillofacial prosthesis part II.Extraoral applications Prosthet
dent 1986;55:600-06.