Maxillofacial prosthetics: theory and practice Retention 11

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Retention of Maxillofacial Prosthesis
I-Retention of Intraoral Prostheses
A-Anatomic Retention:
This includes the use of both hard and soft tissues (teeth, mucosal and bony tissues).
Large alveolar ridge and high palatal vaults generally provide more retention than flatter
ridges. Anatomic undercut areas play an important role in retention of prosthesis. The
success of intraoral retention relates to the size and location of the defect and the type of
the mouth, dentulous or edentulous e.g.
For edentulous patient with any palatal perforation, retention in the classical sense of
complete denture is impossible. Even in dentulous patient with resected maxilla, clasping
only will not give better results. The movement of the prosthesis will make stress on the
abutment teeth and may result in loss of the abutment. So more than one method of
retention should be used.
B-Mechanical Retention: (Temporary or Permanent)
Temporary Mechanical Retention:
1- A stainless steel wrought wire of 18-gauge size can be quickly adapted to a
cast of the remaining teeth to retain the temporary prosthesis during the
healing period. Preformed stainless steel wire clasps include Adams, Akers,
or Hawley labial wires may be used
Preformed stainless steel bands or crowns with prewelded brackets can be adapted to increase
retentive form of a mutilated or conical tooth.
2- wiring the denture to infraorbital or zygomatic bones to obturate a
maxillary defect is recommended for edentulous patient..
Retention of prosthesis: Upper through circumzygomatic wiring and
lower through circummandibular wiring.
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Permanent Mechanical Retention:
1-Cast clasps
The most common method for retaining a prosthesis is the use
of cast metal clasps. There are many different types of cast
metal clasps e.g. cast circumferential clasp, ring clasp and I-
Bar clasp .
2-Prefabricated precision attachments:
These attachments can be placed into cast crowns for the best esthetic and mechanical
retention.
3-Semiprecision attachments, custom made
This attachments are formed in the wax pattern, using a specially shaped mandrel
mounted on the parallelometer .
4-Snap-on attachment
A Baker bar or Anderson bar is the rod
connecting two crowns of abutment, and
the clip engages this rod.
5-Overdentures
Improved retention may be obtained by one of the several attachment devices or by lining
the overdenture with one of the resilient denture liners to utilize available tooth
undercuts.
6-Overlay (Telescoping) Crown and Thimble Crown
This type is used when an overlay denture is planned or an
extremely malposed tooth is needed for stability.
It is also indicated when a major change in the vertical or centric dimension occur , as in
cleft lip-cleft palate, and prognathic mandibles.
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7-Swing-lock attachments
Swing-lock partial denture design using long
flexible arm to engage anterior and posterior
abutment teeth. The swing-lock design should not
be used at all unless splinting of the posterior teeth
is first accomplished.
8- Retaining buccal flange
Retaining buccal flange engaging both tooth and tissue undercuts
9-Using the undercuts in the defect
Soft silicone material is used to engage the undercuts in the
defect more aggressively.
10-Engagement of the skin graft and scar band formed at the
skin graft-mucosal junction .
J unction of oral mucosaand skin graft lining can give accessory retention and should be
used whenever possible.
(A) J unction of oral mucosa and skin graft, (B) Lateral defect space traced in compound showing construction of
scar band and extension to lateral shelf created by tumor removal.
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11-Magnets
Small steel magnets are embedded beneath the molar and premolar teeth of upper and
lower dentures and arranged with similar poles opposite each other. At least two magnets
are required for the lower denture and four magnets for the upper denture.
This effective method of retention may be useful in cases of hemi-maxillectomy, or
extremely atrophied ridges. The use of magnets in two piece prosthesis is advocated.
12-Using of springs
The opposing arch can be used to assist in the retention of the maxillary prosthesis by
attaching a spiral spring to the prosthesis in the premolar region. These spiral springs are
made of coiled stainless steel or gold-plated base metal and have their ends attached to
swivels in the premolar areas on both sides of upper and lower dentures.
(A) Spring - retained prosthesis, (B) Spring - retained denture with obturator.
Nylon springs of continental origin are available and have the advantage of being thin
and not collecting food .
Their life is limited to about six months, and the method of their attachment to the
denture, which is a nylon ball and socket joint, is not very efficient. If this were improved
they would be very satisfactory.
The disadvantages of nylon springs are:
1-The constant pressure may cause excessive alveolar
absorption
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2-The mucous membrane may not tolerate the constant pressure.
3-The inner surfaces of the cheeks may become sore from frictional contact with the
springs.
4-Lateral movements are extremely restricted.
5-Collecting foods and become unhygienic.
13-Implants in the intact side
Improved retention may be obtained by one of the several attachment which can be used
with the implants.
14-Adhesives (fixatives), Prosthetic Adhesives, 1970
These materials improve fit, comfort and retention of the prosthesis by producing a high
viscous layer between the denture and its supporting tissues.
This material is necessary to aid retention in the following cases:
a- Large surgical wound.
b- Flat palate.
c- Nonexistent maxillary tuberosities.
d- Missing of soft tissue undercuts in the area of surgery.
e- Diminished salivary flow due to pre-and postredication
therapy.
f- loss immediate upper denture due to alveolar absorption .
The requirements of adhesives are
1. Highly adherent;
2. Nontoxicthat is, nonirritating to the tissues;
3. Elastic at the point of contact to the skin;
4. Non injurious to the prosthesis;
5. Highly durable;
6. Easily cleansed from the surface of the prosthesis as well as from the soft tissue involved.
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Disadvantages
1-It gives a temporary retention .
2-It has an unpleasant feel when pressed out from beneath the denture.
3-It is of little use for retaining lower dentures.
4-Its constant use may cause constipation.
The troubles with adhesive
Difficult to clean
They collect dirt and are unhygienic
Unreliable (swimming, sweating or greasy skin)
Awkward to position correctly
The application of the adhesive may be messy and time-
consuming.
The edges of the prosthesis must often be thickened or reinforced with fabric to resist
tearing that may occur as the adhesive is cleaned from the prosthesis on a daily basis.
The adhesive may cause skin irritation,
Retention by the skin adhesive may be unreliable, especially if the prosthesis is large, the
weather humid, or if the patient has oily skin. Proper positioning of the prosthesis is difficult in
the absence of key anatomical landmarks; especially if the patient has compromised manual
dexterity or visual acuity.
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II-Retention of Extra-oral Prosthesis:
A-Anatomic retention
The dynamic extra-oral retention depends on many factors. These factors are related to
the size and location of the defect, tissue mobility, undercuts and the wright of the
prosthetic material.
Both hard and soft tissues should be used; The hard tissue act as a base and provide a
better seal of the prosthesis with the use of adhesive. While the soft tissues are more
troublesome because of their flexibility, mobility, lack of support, low resistance to
displacement.
B-Mechanical retention
In cases of large defects involving half of the face additional retention is needed beside
the use of adhesives.
The use of eye glasses with elastic strap as an indirect mechanical retention to retain the
prosthesis.
The magnets may be imbedded in a nasal or orbital prosthesis to retain it to the maxillary
obturator.
C-Adhesives
The adhesives aid retention, marginal seal, border adaptation, and recures the prosthesis
against accidental dislodgment. Generally, each material provides its own adhesive
according to its physical and chemical properties.
D- Combination of anatomic, mechanical and adhesive retention:
In case of large facial replacements all available means of retention should be used to
obtain better stability and retention.