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1. INDIAN DENTAL ACADEMY
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2. Contents
•Introduction
•Definition
•Role of implants in maxillofacial prosthesis
•Implant retained prosthesis v/s adhesive
retained prosthesis.
•Review of literature
•Implant design consideration in the
reconstruction of various maxillofacial defects:
– Orbital defects
– Nasal defects
- Auricular defects
Bone anchored hearing aids (BAHA)
Contents
Introduction
Definition
Role
Comparison
Review
Design
Summary
References

3. • Mid-facial defects
• Maxillary defects
• Mandibular defects
• Summary and conclusion
• References
Contents
Introduction
Definition
Role
Comparison
Review
Design
Summary
References

4. INTRODUCTIONContents
Introduction
Definition
Role
Comparison
Review
Design
Summary
References
• The face is the most noticeable part of the human
body . . . . . . .
• The aesthetic repair of facial tissue defects . . . . .
•Conventially adhesives were used . . . . . . . . . . .

5. MAXILLOFACIAL PROSTHODONTICS
“A branch of Prosthodontics concerned with
restoration, replacement of both stomatognathic
and associated facial structures by artificial
substitutes that may or may not be removed. It
encompasses prosthetic rehabilitation of patient
with oral, paraoral or facial defects, which may
be acquired (developmental/congenital) or
resulting from disease/trauma.”
Contents
Introduction
Definition
Role
Comparison
Review
Design
Summary
References

6. Role of Implants in Maxillofacial
Prosthesis
• Branemark P I (1977) and his associates were
pioneers
• The prosthetic restoration of dentoalveolar and
maxillofacial defects has significantly improved
with development of new materials and advances
in clinical, surgical and lab techniques.
Contents
Introduction
Definition
Role
Comparison
Review
Design
Summary
References

7. • The advances, specially the use of endosseous
implants . . . . . .
• Osseointegration establishes a direct structural
and functional connection between ordered living
bone and the surface of a load carrying implant.
• The concept of surface area, force and stress
distribution are of significant concern in an
implant retained prosthesis.
Contents
Introduction
Definition
Role
Comparison
Review
Design
Summary
References

8. • Bone stock in temporal , orbital and midface regions is
seldom adequate for the placement of implant so the
predominant limiting factor . . . . .
• To compensate for this, extra oral implants are short,
3-5 mm in length and posses peripheral flange
measured about 5mm in diameter. This flange
increases the implant surface area in contact with the
bone.
Contents
Introduction
Definition
Role
Comparison
Review
Design
Summary
References

9. • Perforations present in the flange . . . . .
Contents
Introduction
Definition
Role
Comparison
Review
Design
Summary
References

10. Contents
Introduction
Definition
Role
Comparison
Review
Design
Summary
References

11. IMPLANT RETAINED V/S
ADHESIVE RETAINED PROSTHESIS
DISADVANTAGES OF ADHESIVES
• Daily removal may damage the extrinsic colours and
may eventually result in margin loss.
• They tend to damage the prosthesis margin gradually
with daily use.
• Leads to allergic skin reactions.
• Require solvents for cleaning, which may cause
deterioration of the base material.
Contents
Introduction
Definition
Role
Comparison
Review
Design
Summary
References

12. Implant Retained Prosthesis
• Improved retention and stability
• Elimination of allergic skin reactions
• Ease and enhanced accuracy of prosthesis
placement
• Improved skin hygiene and patient comfort
• Decreased daily maintenance
• Increased life span of the prosthesis
• Enhanced lines of juncture between the prosthesis
and skin.
Contents
Introduction
Definition
Role
Comparison
Review
Design
Summary
References

13. Review of literature
• Michael A., William L., Ann Fyler, Gerry Funk in
1997 conducted a study on Effects of implant
anchorage on midface prostheses.
Selected 5 patients who were treated with 19
titanium implants to provide retention and stability
to the prosthesis. Analysis of the questionnaire
indicates an improvement in the quality of life of
the patients with an implant retained prosthesis.
Contents
Introduction
Definition
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Comparison
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Design
Summary
References

14. • Chang TL, Garnett N, Roumanas E, Beumer j ,
Frevmiller EG in 2002 conducted a study on
Implant-retained prostheses for facial defects: an
up to 14-year follow-up report on the survival
rates of implants at UCLA and concluded that It is
possible to achieve high survival rates of implants
in the auricular and piriform/nasal sites through
careful presurgical and radiographic planning.
The less favorable long-term survival of implants
in the orbital rim, especially at irradiated sites.
Contents
Introduction
Definition
Role
Comparison
Review
Design
Summary
References

15. • Chang TL, Garnett N, Roumanas E, Beumer J in
2005 conducted a study to assess the treatment
satisfaction with facial prosthesis. He divided the
subjects into two groups adhesive retained
prosthesis and implant retained prosthesis and
concluded that the implant-retained facial
prosthesis offers significant enhancement over an
adhesive-retained prosthesis with respect to ease
of use and retention during a variety of daily
activities, resulting in greater use of the
prosthesis.
Contents
Introduction
Definition
Role
Comparison
Review
Design
Summary
References

16. AURICULAR DEFECTS - IMPLANT
DESIGNS
• The replacement of missing ear can be attempted
surgically and prosthetically by an array of
techniques.
• Surgical reconstruction of the external ear often
requires numerous surgical procedures spanning
several years. The resulting structures may not
closely resemble contralateral ear or be positioned
to provide facial balance.
Contents
Introduction
Definition
Role
Comparison
Review
Design
Summary
References
Auricular

17. • Prosthetic replacement may produce anatomically
correct and aesthetically pleasing prosthesis that
is often difficult to position correctly and
successfully retain in place.
• The use of transcutaneous implants in the
temporal region is an effective reconstruction
option. In this the artistic replication of the
anatomic structure can be combined with a
retention system that reduces trauma to the
adjacent tissues.
Contents
Introduction
Definition
Role
Comparison
Review
Design
Summary
References
Auricular

18. • Placement of implants in temporal bone is critical
for the aesthetics. Ideally placement of implants
should involve the use of a surgical guide.
• For this a diagnostic wax up of the proposed
prosthesis is generated replicating the anatomic
features.
• Using this wax pattern, a surgical guide . . . . . . . .
Contents
Introduction
Definition
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Comparison
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Design
Summary
References
Auricular

19. • 2-3 implants are sufficient for satisfactory
retention .
• Tjellstrom et al – ideal position of implants have
to be 18-20 mm from the center of the external
auditory meatus.
Contents
Introduction
Definition
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Comparison
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Design
Summary
References
Auricular

20. • On the right side the position are at 7,9 and 11
o’clock position and on left side the corresponding
positions are at 1,3 and 5 o’clock.
Contents
Introduction
Definition
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Design
Summary
References
Auricular

21. • The distance between the fixtures should be
atleast 15 mm if possible depending on the
anatomic situation.
Contents
Introduction
Definition
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Auricular

22. Contents
Introduction
Definition
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Auricular

23. Contents
Introduction
Definition
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Comparison
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Design
Summary
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Auricular

24. ATTACHMENTS USED
• One system involves the use of a gold alloy bar
approximately 2 mm in diameter which is
soldered to the gold cylinders and attached to
abutments, for this retention clips are
incorporated into the prosthesis providing
attachment to the bar.
Contents
Introduction
Definition
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Comparison
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Design
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References
Auricular

25. • The use of this system provides excellent
retention :
– But it will limit the access for performing hygiene procedures
– Require extension of the base of the prosthesis to cover the
bar
– Difficult to use for patients with poor dexterity.
Contents
Introduction
Definition
Role
Comparison
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Design
Summary
References
Auricular

26. • Second retention system is by the use of magnets –
gold alloy bars may be fabricated to retain the
magnets.
Corresponding magnets are placed in the silicone
prosthesis.
Magnets are 6 mm in diameter and 2 mm in
thickness
But the use of the bar magnet system increases
the overall dimensions of the retention structures
enhancing problems with hygiene and aesthetics.
Contents
Introduction
Definition
Role
Comparison
Review
Design
Summary
References
Auricular

27. • An alternative technique which employs a magnet
keeper that connects directly to the abutments.
The advantages are :
– Improved access around abutments for hygiene purpose
– Easy concealment of the system with in the normal contours
of the prosthesis
Contents
Introduction
Definition
Role
Comparison
Review
Design
Summary
References
Auricular

28. BONE ANCHORED HEARING AIDS
(BAHA)
• Impaired hearing  difficult to cope with
important aspects of life.
• 10 years of experience  importance of BAHA.
• Two groups suited for BAHA
– external auditory canal atresia
– chronic otitis media  not suited for conventional air
conduction hearing aids
Contents
Introduction
Definition
Role
Comparison
Review
Design
Summary
References
Auricular
BAHA

29. WHY BAHA IS DIFFERENT?
• Sound reception – AIR condition via auditory
canal & bone conduction via jaws & skull bones.
• Air conduction hearing aids:
• most common hearing aids
• placed behind the ear/inside the auditory canal
• limited use as occlusion of auditory canal
• worsens chronic inflammation/infection.
BAHA uses the principle of osseointegration to
overcome these problems. In this the sound
conduction is through the bone directly to the
internal ear.
Contents
Introduction
Definition
Role
Comparison
Review
Design
Summary
References
Auricular
BAHA

30. Contents
Introduction
Definition
Role
Comparison
Review
Design
Summary
References
Auricular
BAHA

31. Contents
Introduction
Definition
Role
Comparison
Review
Design
Summary
References
Auricular
BAHA

32. BAHA - INDICATIONS
1. Chronic otitis media with conductive & mixed
hearing loss where the use of air conduction device
is contraindicated.
2. Congenital malformation of external or middle ear.
3. Chronically draining ears.
4. Chronic external otitis.
5. Bone conduction pure-tone average of 45 dB or less
& speech discrimination of 60% of greater.
Contents
Introduction
Definition
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Comparison
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Design
Summary
References
Auricular
BAHA

33. BAHA - CONTRAINDICATIONS
1. Patients with drug & alcohol addictions.
2. Emotionally unstable and developmentally
retarded patients for the reason of handling &
hygiene.
Contents
Introduction
Definition
Role
Comparison
Review
Design
Summary
References
Auricular
BAHA

34. BAHA - PROCEDURE
• One stage surgical procedure ↓LA.
• Placement of Ti implant & abutment in mastoid
cortex.
• Maintenance of hair free area around the abutment is
required.
• After osseointegration, abutment is loaded with the
mechano-electric transducer system.
Contents
Introduction
Definition
Role
Comparison
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Design
Summary
References
Auricular
BAHA

35. BAHA – COMPONENTS
• Implant & cover screws are made up of pure Ti.
• Flange implants - 3.75 x 3 mm
- 3.75 x 4 mm
Contents
Introduction
Definition
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Comparison
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Design
Summary
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Auricular
BAHA

36. ORBITAL DEFECTS – IMPLANT
DESIGNS
• Problems associated with adhesives in the
temporal region are more prevalent in the orbit.
• The blind duct characteristic of an orbital defect
+ marginal seal using adhesives  entrapment
of moisture behind the prosthesis 
inflammation and discomfort
- will adversely affect the fit and quality of the
prosthesis.
Contents
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Orbital

37. • For an orbital prosthesis the implants
– Reduces the need for adhesives.
– Easy application and removal of the prosthesis.
– It can be repositioned quickly without fear.
– It will provide orbital aeration and improves health.
Contents
Introduction
Definition
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Comparison
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Orbital

38. • Implants are ideally placed around the defect,
because of bone anatomy placement is often
limited to superior and lateral aspect of the rim.
• It is not only the position but also the direction
and no. of implants that should be considered. If
possible it is more favorable to have more than
two fixtures placed both in the upper and lower
orbital rim.
Contents
Introduction
Definition
Role
Comparison
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Design
Summary
References
Orbital

39. In extensive orbital defects, implants can be placed in
zygoma/maxilla
Contents
Introduction
Definition
Role
Comparison
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Design
Summary
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Orbital

40. Contents
Introduction
Definition
Role
Comparison
Review
Design
Summary
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Orbital

41. VARIOUS RETENTIVE OPTIONS
• Bar and clip attachments
• Bar and magnet attachments
• Individual magnets
• Ball attachments
•Console attachment
• Combination of above
Contents
Introduction
Definition
Role
Comparison
Review
Design
Summary
References
Orbital

42. BAR AND CLIP ATTACHMENTS
• It is a wire soldered to the gold cylinders & attached to the
abutments by gold screws.
• Retentive clips are placed on the inner aspects of the prosthesis.
• Good load distribution on the implants.
• Good retention for large defects which have implants in the
upper orbital rim to support the prosthesis.
Contents
Introduction
Definition
Role
Comparison
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Design
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Orbital

43. Contents
Introduction
Definition
Role
Comparison
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Design
Summary
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Orbital

44. INDIVIDUAL MAGNETS
• It consists of a magnet cap that is threaded onto the abutment
and a magnet is placed into the tissue surface of the prosthesis.
• Used for orbital defects with the implants in the upper and
lower rims.
• Recommended for shallow defects with insufficient space for a
bar and clip construction.
• Advantages:
– Easy to maintain hygiene
– Easy to use
Contents
Introduction
Definition
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Orbital

45. Contents
Introduction
Definition
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Comparison
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Summary
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Orbital

46. BALL ATTACHMENTS
• Preferred in cases of shallow defects as they occupy little space
behind the prosthesis.
• Three implants creating a tripod are required to provide
satisfactory retention and stability.
Contents
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Orbital

47. Contents
Introduction
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Orbital

48. CONSOLE ATTACHMENT
• Preferred in cases of small closed defects where 2
implants are inserted in the upper rim and 1 exists in
the lower orbital rim and the direction of the
implants are at difficult angles to each other.
• It can alter the angle of implants relative each other.
Contents
Introduction
Definition
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Orbital

49. Contents
Introduction
Definition
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Orbital

50. CASE REPORTS
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Orbital

51. Contents
Introduction
Definition
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Comparison
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Summary
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Orbital

52. NASAL DEFECTS - IMPLANTS
DESIGNS
• In Naso maxillary and Nasolabial defects, the total
or near total resection of the nose creates
functional and aesthetic problems.
• Prosthesis must be extended to the surrounding
areas . . . . . . . .
• For nasal defects, implants can be placed in the
maxillary & frontal bones.
• They should be in the confines of the outer
contours of the prosthesis.
Contents
Introduction
Definition
Role
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Nasal

53. • Implant success is highest when implants are
placed in the superior surface of the maxilla and
used to retain the inferior aspect of the nasal
prosthesis.
• Implants in the superior aspect of the nasal defect
usually can not be placed. . . . . . . . . . .
Contents
Introduction
Definition
Role
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Design
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Nasal

54. • Because implant retention is possible at the
inferior aspect of the prosthesis only, it is critical
that design of the retentive elements of the
prosthesis incorporate two planes of retention.
• Generally a U shaped retentive bar connected to
the implants at the base of the U will provide three
points of retention, the two vertical struts and the
horizontal crossbar.
Introduction
Definition
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Nasal

55. Case ReportCase Report
Introduction
Definition
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Comparison
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Design
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References
Nasal

57. Introduction
Definition
Role
Comparison
Review
Design
Summary
References
Nasal

58. MIDFACE DEFECTS – IMPLANT
DESIGNS
• Midface defects often result from ablative
procedures used to control malignancies of nasal
& maxillary structures.
• It may result in a small soft tissue defect/a
massive defect involving intra & extra oral
structures.
• As the size of the defect expands . . . . . . .
 complexity of prosthetic rehabilitation
increases.
• This type of defect can be retained by connecting
both intraoral and extraoral prosthesis together by
the help of magnetic retention.
Introduction
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Mid Face

59. • This will enhance the retention of the facial
prosthesis but may adversely affect its stability .
• Movement of the intraoral prosthesis. . . . . . . .
• This can be grouped under three main categories:
– Maxillary facial defect opposing edentulous mandible
– Maxillary facial defects opposing bilateral posterior
edentulous mandible
– Maxillary facial defects with natural posterior vertical stops
Introduction
Definition
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Design
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Mid Face

60. Maxillary Facial defect opposing
Edentulous mandible
• In this type of defect the biting force will be
reduced and this will be beneficial .
• The use of implants in conjunction with a
maxillary obturator prosthesis may improve the
retention and stability of the prosthesis
• An attempt to rehabilitate mandible with implants
is contraindicated.
Introduction
Definition
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Mid Face

61. Introduction
Definition
Role
Comparison
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Design
Summary
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Mid Face

62. Maxillary Facial defect opposing Bilateral
posterior Edentulous mandible
• When this situation is combined with the defect of
anterior maxilla, significant stress may be applied to
the implants.
• As sufficient bone stock is present only in the
posterior midface structures ( zygoma, infraorbital
rim, pterigoid plates ) if implants are placed here it
will establish a lever with the location of the fulcrum
at the oral retention bar. . . . . . . .
• If the rotational movement is restricted . . . . . . .
Introduction
Definition
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Mid Face

63. Introduction
Definition
Role
Comparison
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Design
Summary
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Mid Face

64. Maxillary facial defect with natural
posterior vertical stops
• Vertical stops on natural molars and premolars
may represent the most desirable occlusal
condition.
• The use of residual maxillary dentition for
stabilizing the obturator and development of an
occlusion that inhibits anterior contacts may
provide best opportunity for restricting obturator
generator movement of the facial prosthesis.
Introduction
Definition
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Comparison
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Mid Face

65. Introduction
Definition
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Design
Summary
References
Mid Face

66. • Jensen O T etal ( 1992 ) conducted a study to
identify all potential locations for implant
placement in the midfacial region, and depending
upon this he suggested a Craniofacial site
classification for the Osseointegrated Implants :
– Alpha sites
– Beta sites
– Delta sites
Introduction
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Mid Face

67. • Alpha sites: 6 mm or more in axial bone volume
available.
E.g. - anterior maxilla through the nasal fossa & the
zygoma; zygomatic arch and lateral periorbital
region.
• Beta sites: 4-5 mm of bone available.
E.g. - superior, lateral & inferolateral orbital rims,
temporal bone & zygoma.
• Delta sites: marginal sites with 3 mm or less of bone
available.
E.g. - locations in temporal bone, piriform rim,
infraorbital rim, zygomatic buttress.
Introduction
Definition
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Mid Face

68. Introduction
Definition
Role
Comparison
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Design
Summary
References
Mid Face

69. Introduction
Definition
Role
Comparison
Review
Design
Summary
References
Mid Face

70. Hard and Soft Palate Defects
• Loss of supporting teeth in these cases results in
compromises in prosthetic retention and support.
• Endosseous implants in residual maxilla must be of
sufficient no. , length and distribution to resist the
anticipated complex forces of mastication and
dislodgement.
Introduction
Definition
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References
Hard
Palate

71. • Four implants suggested as minimum no. for support
of overdenture prosthesis.
• For obturator prosthesis  no. of implants has to be
increased
• Anchorage can also be gained by zygoma and
pterigoid regions.
Introduction
Definition
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Hard
Palate

72. • Soft palate defects are normally associated with
bilateral maxillary support.
• Since occlusion is not a consideration in soft
palate defects, the primary function of implant is
to retain the prosthesis and to support the
occlusion that is more directly placed above the
implants themselves.
Introduction
Definition
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Soft
Palate

73. CASE REPORTS
Introduction
Definition
Role
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Hard
Palate

74. Introduction
Definition
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Summary
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Hard
Palate

75. Mandibular defects
• Mandibular discontinuity subsequent to ablative
tumor surgery managed by reconstruction to
establish continuity.
• Endosseous implants in the grafted bone will
allow placement of a dental prosthesis that does
not create deleterious compressive forces on the
graft and also the prosthesis will gain retention,
stability and support from the implants.
Introduction
Definition
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Mandibular

76. • Implants can be placed in grafted fibula
Introduction
Definition
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Mandibular

77. Summary and conclusion
Patients with facial and intraoral defects will seek
treatment to address the loss of comfort, function
or natural appearance.
It is the maxillofacial prosthodontists
responsibility to provide prosthesis that do not
injure the remaining structures.
As anatomy is altered, Endosseous implants are
used to provide retention, support, and stability
for maxillofacial prosthesis when the residual
anatomy is no longer capable of fulfilling these
functions.
Introduction
Definition
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References
Summary

78. References
• Archuri M.R., Rubenstein J.T.: Facial implants,
DCNA 1998; 42: 161-75.
• Izzo S.R., Berger J.R., Joseph A.C.,& Lazow S.K.:
Reconstruction of after total maxillectomy using
an implant-retained prosthesis: A case report.
Int J Oral Maxillofac Implants 1994; 9: 593-95.
• Jensen O.T., Brownd C & Blacker J: Nasofacial
prosthesis supported by osseointegrated implants.
Int J Oral Maxillofac Implants 1992; 7: 203-11.
• Thomas K. F.: Prosthetic Rehabilitation.
Quintessence publications, 1994
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79. • Thomas D Taylor – clinical maxillofacial
prosthetics.
• D E Tolman , Ronald D – Extra oral application of
osseointegrated implants. Journal of maxillofacial
surgery
• J J Gary , M Donovan – Retention designs for
bone anchored facial prosthesis. Journal of
prosthetic dentistry 1993:70; 329-32
• John A Hobkirk , Roger M Watson – Color Atlas
and Text of Dental and Maxillofacial Implantology
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80. THANK YOU