Materials used for maxillo facial construction2/endodontic courses

MATERIALS USED
FOR MAXILLO-
FACIAL
REHABILITATION
INDIAN DENTAL ACADEMY
Leader in continuing Dental Education
www.indiandentalacademy.com

CONTENTS
 INTRODUCTION
 HISTORY
 OBJECTIVES OF MAXILLO-FACIAL
PROSTHESES.
 IDEAL REQUISITIES OF MAXILLO-FACIAL
MATERIALS.
 CRITERIA FOR MAXILLO-FACIAL
MATERIALS
 TYPES OF MATERIALS
 A)IMPRESSION PHASE
 B)MODELLING PHASE
 C)FABRICATION PHASE

COLORATION
CAD-CAM MAXILLO-FACIAL
PROSTHESIS
SUMMARY
CONCLUSION
REFERENCES

INTRODUCTION
“It is the God-given right of every human
being to appear human.”

HISTORY
 Early records indicate that artificial eyes,ears,and
noses were found on Egyptian mummies.
 The Chinese also made facial restorations with
waxes and resins of various types.
 In sixteenth century, Tycho Brahe , an astronomer
lost his nose and replaced it with an artificial nose
made of silver and gold.
 The London Medical Gazette of 1832 describes
the case of the “Gunner with the Silver Mask”.
This case demonstrated that metals could be used
in maxillofacial prosthesis.
 To produce light weight metallic restorations , the
electrode position of various kinds of metals on a
wax matrix was also introduced.

 Ambroise Pare : the first to use an obturator to
close palatal perforations.
 In 1728 : Pierre Fauchard used perforations of
palate to retain artificial dentures
 In 1880 : Kingsley described artificial appliances
for the restoration of congenital as well as
acquired defects of the palate , nose and orbit.
 In 1894 : Tetamore described and illustrated nine
cases of nasal deformities that received prosthetic
restorations.He stated that these artificial noses
were made of a “very light plastic material” that
approximated the natural colour. They were
secured on the face by bow spectacles.
 At the end of 19th
century , certain workers were
making facial restorations with vulcanite.

OBJECTIVES OF MAXILLO-
FACIAL PROSTHESES
 Restoration of esthetics or cosmetic
appearance of the patient.
 Restoration of function.
 Psychologic therapy.
 Therapeutic or healing effect.
 Protection of tissues.

IDEAL REQUISITES OF
MAXILLO-FACIAL
MATERIALS
 Biocompatibility
 Flexibility
 Color and translucency
 Chemical and environmental stability
 Thermal conductivity

 Ease of Processing
 Strength
 Ease of duplication
 Dimensional stability
 Weight

CRITERIA FOR MAXILLO-
FACIAL MATERIALS
A) Processing Characteristics –
1. Visosity at ambient temperature - <75000 cps
2. Color - colorless
3. Solubility parameter (required - 9-11 cal 1/2
range for conventional colorants)
4. Pot life (working time) - 15-60 mins.
5. Curing temperature - <100 deg C
6. Curing time - 1-2 hrs.

B) Performance Characteristics - (mechanical and physical
properties)
1. Tear strength - 30-100 ppi
2. Tensile strength - 1000-2000 psi
3. Modulus at 100% elongation - 50-200 psi
4. Elongation at break - 400% - 800%
5. Glass transition temperature - < 0 deg C
6. Heat distortion temperature - > 120
deg C
7. Critical surface tension - 30-45 dynes/cm
8. Coefficient of friction - 0.4 - 0.6
9. Hardness - 25-35 Shore A
10.Water absorption - none

Materials used for maxillo-facial
reconstruction
 Surgical reconstruction
 (Alloplastic implantable
material)
 Dimethylsiloxane
 Polytetrafluoroethylene
 Polyethylene
 Polyesters-
 Polyethylene terphthalate
 Resorbable polymers
 Polyamide
 Acrylic
 Metals-stainless steel, viatalliun,
titanium.
 Cyanoacrylate
 Prosthetic reconstruction
 Impression phase
 Modeling phase
 Fabrication phase

Types of materials
IMPRESSION
PHASE
MODELING
PHASE
FABRICATION
PHASE

IMPRESION MATERIALS
REQUISITES:
1. Able to produce fine details
2. Be inherently strong
3. Easy to manipulate
4. Easy to obtain
5. Comparatively inexpensive
Various impression materials used in
maxillofacial reconstruction are:
 Reversible Hydrocolloid
 Irreversible Hydrocolloid
 Room Temperature Vulcanizing Materials
 Plaster of Pariswww.indiandentalacademy.com

REVERSIBLE HYDROCOLLOID
ADVANTAGES:
 Reproduces fine detail- records undercut
 Easy to manipulate
 Easy to obtain
 Comparatively inexpensive
 Easily applied to the patient in upright position
DISADVANTAGES:
 Requires rigid backing for sufficient strength
 Fragility in fine undercut areas
 Requires nearly two hours of preparation prior to making
the impression
 Needs intermediary to bond to the backing material

IRREVERSIBLE HYDROCOLLOID
ADVANTAGES:
 Reproduces fine detail- records undercuts
 Easy to obtain
DISADVANTAGES:
 Sets slowly at the required consistency ratio ( one and a half
to one )
 Requires retaining wall to hold the impression material in
the desired area
 Possibility of bubbles, necessitating remakes

ROOM TEMPERATURE
VULCANIZING MATERIALS
ADVANTAGES:
 Fine detail obtainable
 Inherent strength
 Easy to obtain
DISADVANTAGES:
 Needs backing
 Difficulty in adjusting setting time
 Retaining walls needed for confinement of
material
 High cost

PLASTER OF PARIS
ADVANTAGES:
 Fine detail obtainable
 Inherent strength
 Easy to obtain
 Low cost
DISADVANTAGES:
 Cannot reproduce undercuts without fracture
 Exothermic setting reaction
 Requires separating medium to prevent impression from
adhering to the model

IMPRESSION TECHNIQUES
ORBITAL IMPRESSION:
 Place the patient in a dental chair in the supine position.
 Green towels should be placed to protect the patient’s
clothes from spillage.
 Any cavities or tissue undercuts to be packed with vaseline
gauze.
 Areas of impression should be defined using ordinary
adhesive foam draught excluder tape.

 Patient is instructed to breathe gently through the mouth while you pinch the
nose to block the airway. Then the nostrils should be blocked off with cotton
wool plugs.
A thinner mix than for oral impression
is used to allow the material to flow
from the forehead down into the cavity
using spatula. Before the alginate sets
cotton wool or gauze napkins are
placed into the alginate to facilitate
retention for plaster of paris backing.www.indiandentalacademy.com

 When the alginate has set , plaster of paris mixed to a cream
consistency is poured on top.This is then allowed to set
thoroughly
 When removing the impression , the excluder should be
peeled away from the skin. The patient is then instructed to
wrinkle and screw his/her face. This will break the seal of
the alginate and the impression may be lifted off from the
forehead downwards.

 Any gauze packing will adhere to the alginate , but it should
be insured that nothing is left in the cavity area , by
counting each piece on removal.
 Any gauze or packing is removed from the impression and a
good quality stone plaster is poured. When set the
impression is removed and the model is trimmed.

IMPRESSION FOR EAR PRSTHESIS:
 Marks should be made with an indelible pencil in the defect area. These
marks are :
1. The junction of the helix
with the side of the head
2. The junction of the lobe
with the side of the head
Green towels should be placed to protect the patient’s clothes from spillage
 Patient should be positioned on their side to allow full access to the area.
 Various materials that can be used to define and contain the impression are :
 1. Plasticine strips
 2. Red boxing-in wax
 3. Draught excluder
 4. Margarine tubs

 Before pouring the alginate the external auditory canal
should be blanked off with cotton wool or vaseline gauze.
 Alginate mixed to a fluid consistency is then poured. There
will be no need to provide a plaster backing as the tub will
allow a good thickness of alginate.
 To enable a good carving to be made , an impression of the
existing natural ear should be taken. Cut a section out of the
tub just large enough to allow the ear to pass through.
Follow the previous stages when pouring the alginate ,
except that pour the back part of the helix first , so as to
provide support for the helix when the full amount of
alginate is added.
 Both the impressions are then poured in the normal way.

MODELLING MATERIALS
REQUISITES:
1. Be malleable
2. Have sufficient body and strength to permit
sculpting a feather edge and yet able to withstand
slight abuse
3. Be possible to sculpt texture into this material
which will be imparted to the finished mold
4. Colour shold be easily reproducible
Various impression materials used in
maxillofacial reconstruction are:
 Modelling clay (Sculptor’s clay)
 Plaster
 Plastolene
 Waxes

MODELLING CLAY (SCULPTOR’S
CLAY)
Water base clay which when allowed to dry ,
becomes hard , stone like substance
ADVANTAGES:
 Consistency can be adjusted by adding water
 Lends itself to gross sculpting of sweeping planes
 Takes texture well
 Can be feathered on the edge
 Inexpensive
 Readily available
DISADVANTAGES:
 Must be kept moist all the times
 If the modelling clay is kept aside for any length of time the
cloth utilized to keep it moist tends to wipe out the finer
texture which has been incorporated into the model
 It is grey in colour and the colour differential causes visual
distortion www.indiandentalacademy.com

PLASTER
ADVANTAGES:
 Inexpensive
 Easily and quickly prepared for use
 Can be shaped or molded in its plastic state
DISADVANTAGES:
 Lacks elasticity
 Cannot be used in undercuts
 Relatively short setting time
 Has a tendency to flake on the surface
 Adding material to build contour is difficult

PLASTOLENE
A prepared modelling clay with oil base or filler’s
earth with oil base
ADVANTAGES:
 Always ready for use
 Requires comparatively little care
 Can take and keep a feather edge
 Easily malleable
 Withstands slight abuse well
DISADVANTAGES:
 Colour doesn’t match the skin
 Slightly more expensive than sculptor’s clay
 Oil base could seep into stone model and affect the finished
product

WAXES
ADVANTAGES:
 Colour is similar to skin tone
 Nominal cost
 Withstands abuse
 Takes and keeps a feather edge
DISADVANTAGES:
 Model must be carved rather than sculpted
 Oil base could seep into stone model and affect the finished
product
 Brittle when cooled

PROSTHESES MATERIALS
 Acrylic Resins.
Methyl Methacrylate.
Poly Methyl Methacrylate.
 Latex.
 Vinyl Polymers and Copolymers.
 Polyurethane.
 Silicone.
Room Temperature Vulcanizing.
Heat vulcanizing
 Ventured Structural Polymers.
Silphenylene elastomer.

ACRYLIC RESINS
 Methyl Methacrylate
 Plasticized methyl methacrylate
PALAMED
 Polymethylmethacrylate

IRREVERSIBLE HYDROCOLLOID
ADVANTAGES:
 Reproduces fine detail- records undercuts
 Easy to obtain
DISADVANTAGES:
 Sets slowly at the required consistency ratio ( one and a half
to one )
 Requires retaining wall to hold the impression material in
the desired area
 Possibility of bubbles, necessitating remakes nearly two
hours of preparation prior to making the impression
 Needs intermediary to bond to the backing material

Methyl Methacrylate
Material of choice in the past….
Limited use…..
 It is a clear, transparent liquid at room
temperature.
 Melting point - 48 deg C &
 Boiling point - 100.8 deg C,
 Density - 0.945gms/cubic cm
 Heat of polymerization - 12 Kcal/molecule.

 High vapour pressure & excellent organic
solvent.
 Polymerization can be initiated by UV light,
heat or chemicals
Disadvantages:
 Rigid nature of the material  tendency to
dislodge the prosthesis  irritation of
underlying tissues.
 Rigidity  difficulty in duplicating prosthesis

Advantages:
 Can be satisfactorily colored….
 Internally/externally coloring.
 Preferred for restoring defects….
 Useful in cases of rapidly changing defects …
 Easily available, economical & familiar.

Plasticized methyl methacrylate:
PALAMED
 formulated with a foaming agent…..
 foaming agent releases gas…..
 resulting product is spongy…..
 size of the pores varies directly with cross-
sectional thickness of the mold…..
 Palamed should be carefully
proportioned…..

 the molds are under filled by 10 % …..
 to compute the correct amount of
palamed…..
 tackiness of the surface…..
esthetically satisfactory material with a life
of six to seven months…..

Polymethylmethacrylate
transparent resin of remarkable clarity.
 extremely stable.
 does not discolor in UV light, and
exhibits remarkable aging properties.
takes up water ……

Properties:
 Tensile strength 8000 psi
 Elongation (%) 2-10
 Specific gravity 1.18
 Modulus of elasticity 4.5 psi x 106
 Thermal conductivity 4-6 x 10-4
cal/sec

LATEX
 Natural latex
 Synthetic latex
 Silicone foam rubber

VINYL POLYMERS AND
COPLOYMERS
 Vinyl chloride and vinyl acetate…..

Introduced in 1940…..
Susceptible to degradation …..
In the pure state…..
quality of the cured vinyl plastisol is time
dependant…..

 Method:

Property Polyvinyl
chloride
Polyvinyl
acetate
Specific gravity 1.16-1.53 1.35-1.45
Water absorption, 0.15-0.75 0.07-0.40
Tensile strength (psi) 1500-3000 5000-9000
Modulus of elasticity (MPa ) 4.32 3.5-6
Compressive strength(psi) 900-1700 8000-13000

POLYURETHANE
Polyurethane, urethane or “isocyanate”
polymers
Three component system…..
Formulation is very technique sensitive…..

The formation of polyurethane …..
Diisocyanate + polyol
initiator
Polyurethane

Advantages:
life-like feel.
flexibility compatible with flesh.
excellent strength and elastic properties.
Can be easily stretched several times in
length without deformation.
Can be intrinsically and extrinsically
colored

Disadvantage:
Quite susceptible to ULTRAVIOLET
LIGHT.
Limited duration of use.
Technique sensitive.
Product- Epithane-3

Procedure

SILICONE ELASTOMERS
 synthetic materials
 constitute a special class of chemical polymers,
polydimethylsiloxane
 composed of an alternating chain of silicone and
oxygen atoms.
 by adjusting the length of this silicon-oxygen
chain…..

 can only be produces synthetically.
 two-step process: creating a carbon-silicon bond,
then making the silicon-oxygen bond that forms
the chain.
 In the first step, an organic chloride vapor +hot
silicone powder in the presence of a copper
catalyst series of molecules (carbon, silicon,
and chlorine atoms.)
 In the second step, the chlorine is replaced with
oxygen through a process of hydrolysis and
distillation to produce the silicone product .

 the silicon oxygen bond is much stronger than the
carbon-carbon bond of organic polymers, silicones
make better electric insulators and are more resistant
to oxidation.
 In addition, the silicon-oxygen chain is easily
twisted, and the organic side groups can rotate
freely around the bonds. As a result, silicones have
weak forces of attraction, low surface tension, and
low freezing points.

 Silicone elastomers retain their elasticity, strength
and flexibility in temperatures ranging from
-108ºF (-78ºC) to higher than 570ºF (300ºC).
 silicone polymer is vulcanized; this changes it
from a liquid or putty like paste to a solid rubber.

RTV Silicone Elastomer
 composed of comparatively short chain
silicone polymers…. partially end-blocked
with hydroxyl groups.
cross-linking agent such as
tetraethyoxysilane (ethyl orthosilicate).
addition of a catalyst such as stannous
octoate condensation takes place.

Advantages:
Simple fabrication technique.
Faster fabrication technique, compared to
other materials.

 Disadvantages:
 Air entrapment, while mixing with the catalyst.
 Inadequate tear resistance.
 Incorporation of silica to improve tensile strength,
compromises translucency of the material, making
intrinsic coloring difficult.
 “ZIPPER EFFECT ”
 Silicones are stiffer than flesh.

HTV Silicon Elastomer
Mechanism for formation
Polydimethyl siloxane (diorganopolysiloxane)
Benzoyl peroxide
Cross-linking of methyl groups
+
Benzoic acid
+
heated

 superior strength
 more translucent than RTV silicones.
 Cut & rolled in the milling machine before
packing into molds. Colors & fibers incorporated
during rolling.
 Dow corning products- MDX 4-4514, MDX 4-
4515 & MDX 4-4516
 Factor II- MDX 4-4210

VENTURED STRUCTURAL
POLYMERS
 Silphenelyenes: are combinations of carbon and
silicone polymers and therefore they have many
advantages of both the polymers.
 Consists of 3 unit kit – base resin,
tetrapropoxy silane (cross linking agent) & an
organotin catalyst.
 Formulated as viscous, pour able, RTV liquid.
Advantages:
 High tensile strength & low modulus of elasticity.
 Feels like skin
 Incorporation of fillers  ↑tear strength

COLORATION
 Intrinsic coloring:
 According to Chalian et al (1972, 1974), intrinsic
coloring in HTV silicones is accomplished with a
milling machine.
Metallic oxides/pigmented silicone concentrates are
generally used & red fibers may be incorporated to
simulate blood vessels.
Coloring in RTV silicones (MDX 4-4210) is
accomplished by adding various dry earth
pigments.
 According to Chalian et al (1972) & Beder (1974),
the intrinsic colouring is more effective than
extrinsic techniques due to longer service life.

 Extrinsic coloring
 J.E.Ouellete (1969) described spray coloring of
silicone elastomer maxillofacial prosthesis.
Pigments selected to match the patients’ skin are
mixed in proper proportions with clear elastomers &
solvents & the mixture is sprayed on to the prosthesis
until the desired color is obtained.
 According to Schahf (1970), the colour easily peals
off or rubs off during manipulation of the prosthesis
or during daily cleansing.
He introduced tattooing for surface characterization
using standard artist’s oil paints which were applied
on to the prosthesis surface using tattooing machine.

CAD-CAM MAXILLO-FACIAL
PROSTHESES
 Acquisition of the “Facial Impression”- A laser
data of the patients facial defect.
The unit consists of two laser beams and two
change coupled device camera. Then the image
from the camera is transferred into an image
processor to generate three dimensional image.
 Production of wax model- Two alternative
CAD-CAM three dimensional modeling
techniques i.e. Laser litrographaic model and
numerically controlled milling model are
connected to fabricate the prototype wax model.

 Completing the final silicone facial prostheses-
The prototype wax model is tried on the patients
face to check for the fit and proper adaptation of
the margins as well as the shape. The wax model
is then flasked and fabricated in the conventional
way.

REVIEW OF LITERATURE
 Dorsey J. Moore et al (1977) in their study
evaluated a polymeric material MDX-4-4210
Elastomer (which was not in use at that time) for
its modulus of elasticity, resistance to tear
propagation and hardness. They compared this
material to Silastic 382 (commonly used for
maxillo-facial prostheses).They concluded that
– MDX 4-4210 had a modulus of elasticity approximately
one-fourth that of Silastic 382.
– MDX 4-4210 had better resistance to tear propagation
than Silastic 382.
– MDX-4-4210 was softer than silastic 382.

 Juan B.Gonzalez (1978) in his study evaluated
polyurethane elastomer with polyvinyl resins
and polysiloxanes. The criteria used for
comparison were the properties an ideal
material should have. He concluded that
polyurethane was relatively better material
compared to polyvinyl resins and polysiloxanes.

 Juan B.Gonzalez (1978) in his study evaluated the effect
of altering the component ratio of polyurethane on its
physical and mechanical properties, such as, surface
hardness, tensile strength, initial modulus and percentage
of elongation. He concluded that-
– with every increase of 0.1 gms of Part B or the
addition of the catalyst there was an increase in
surface hardness, tensile strength, initial modulus of
elasticity.
– Whereas there was decrease in percentage elongation
with the same alterations in formulations.

 E.R.Doootz, A.Koran, R.G.Craig (1994)
evaluated the effect of accelerated aging on the
physical properties of three maxillo-facial materials
i.e. MDX 4-4210, A-2186, Cosmesil. The samples
were processed according to manufactures
instructions and then stored in humidor for 24 hrs
followed by placement in an accelerated-aging
chamber. Each material was evaluated for tensile
strength, tear resistance, shore A hardness,
percentage of elongation before and after
accelerated aging.www.indiandentalacademy.com

 They concluded that cosmesil substance showed
maximum effect, and MDX 4-4210 the least
change in their properties, of aging.
 -Cosmesil showed a decrease in tensile strength,
decrease in elongation, increased hardness and
 -an increase in tear rersistance.

 Mark A. Pigno, Millicent C. Goldschmidt and James
C. Lemon (1994) evaluated the efficacy of antifungal
agents incorporated into facial prosthetic silicone
elastomer. The purpose of the study was -
1. to determine whether fungal growth is associated
with the black discoloration of the prostheses.
2. to determine the inhibitory effect of antifungal agents
nystatin and clotrimazole incorporated into the silicone .
3. to determine the longevity of the antifungal action.

 They concluded that-
– The SEM studies of the sample revealed the
black discoloration to be associated with fungi
of genus penicillium.
– Clotrimazole inhibited fungal growth even after
repeated testing over several months.
– Nystatin exhibited no inhibitory action.

 J.H.Lai, J.S.Hodges(1999) conducted a study to
evaluate the effect of processing parameters on
physical propeties of the silicone maxillofacial
prosthetic materials.They compared the physical
properties i.e. hardness,tensile srength, ultimate
elongation and tear strength of A-2186 cured in
stainless steel molds and stone molds.
 They concluded that hardness, tensile strength and
ultimate elongation of A-2186 cured in stainless
steel mold is higher than those cured in stone
mold.

 M.G.J.Waters, R.G.Jagger, G.L.Polyzois (1999)
conducted a study to evaluate the wettability and
surface energy of commercially available silicone
material and acrylic material. Contact angle and
surface energies were measured by using a
dynamic contact angle measuring technique.
 They concluded that the surface energy and
wettability of silicone materials was less compared
to that of acrylic resin.

SUMMARY
Acrylic Resins.
Methyl Methacrylate.
Poly Methyl Methacrylate.
Latex.
Vinyl Polymers and Copolymers.
Polyurethane.
Silicone.
Room Temperature Vulcanizing.
Heat vulcanizing
Ventured Structural Polymers.
Silphenylene elastomer.

CONCLUSION
 Because no material presently available for
external maxillo-facial prostheses is
completely durable, periodic replacement is
a major problem.

REFERENCES
 J.E.Ouellete, Spray coloring of silicone elastomer
maxillofacial prostheses. J.Prosthet.Dent.
1969;22:271-275.
 V.A.Chalian, A.A.Majid, W.R.Leckrone, Milling
machine for coloring heat-vulcanizing silicone
materials in maxillofacial prostheses.
J.Prosthet.Dent. 1974;31:78-82.
 Council on Dental Materials and Devices,
Maxillofacial prosthetic materials. JADA.
1975;90:844-848.
 Dorsey J .Moore et al : Evaluation of polymeric
materials for maxillofacial prosthetics,
J.Prosthet.Dent. 1977;38:319-326.

 Jaun B.Gonzalez :Polyurethane elastomer for facial
prostheses, J.Prosthet.Dent. 1978;39:179187.
 Jaun B.Gonzalez: Physical and mechanical behaviour
of polyurethane elastomer formulations used for
facial prostheses, J.Prosthet.Dent. 1978;39:307-318.
 D.H.Lewis, D.J.Castleberry, An assessment of recent
advances in external maxillofacial materials.
J.Prosthet.Dent.1980;43:426-432.
 Mark A. Pigno, Millicent C. Goldschmidt and James
C. Lemon, The efficacy of antifungal agents
incorporated into facial prosthetic silicone elastomer.
J.Prosthet.Dent. 1994;71:295-300.

 E.R.Doootz, A.Koran, R.G.Craig: Phsical
properties of three maxillofacial materials as a
function of accelerated aging, J.Prosthet.Dent.
1994;71:379-383.
 J.H.Lai, J.S.Hodges, Effect of processing
parameters on the physical properties of the silicone
maxillofacial prosthetic materials.
Dent.Materials.1999;15:450-455.
 M.G.J.Waters, R.G.Jagger, G.L.Polyzois,
Wettability of silicone rubber maxillofacial
prosthetic materials. J.Prosthet.Dent.1999;81:439-
443

 Gupta A., Jain D. Materials used for
maxillofacial prosthesis reconstruction: A
literature review.J.I.P.S;2003:3(1): 11-15.
 Rahn A.O., Boucher L.J. Maxillofacial
prosthetics: Principles and Concepts.W.B
Saunders Company 1970,pgs 113-69.
 Lontz J.F. State-of-the-art materials used for
maxillofacial prosthetic reconstruction. DCNA
1990; 34: 307-25.

 Chalian V.A., Drane J.B., Standish S.M.
Maxillofacial prosthetics. W&W
Company 1972, pgs 284-304.
 Laney W.R., Chalian V.R. : Maxillofacial
Prosthetics ;Post graduate dental handbook, PSG
company 1979. Pgs-257.

Materials used for maxillo facial construction2/endodontic courses

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Materials used for maxillo facial construction2/endodontic courses