GNATOPROTETICA. IMPLANTOLOGIE / GNATOPROSTHETICS.
IMPLANTOLOGY
ASPECTE PRACTICE ALE EPITEZELOR ÎN TERITORIUL
MAXILO-FACIAL/
PRACTICAL ASPECTS OF OF EPITHESIS IN MAXILO-
FACIAL TERITORY
Prof.univ. Dr., Disciplina Clinica si Terapia Edentatiei Partiale Întinse, U.M.F. „Gr.T.Popa” Iasi
1
2Asist.univ. Dr., Disciplina Clinica si Terapia Edentatiei Partiale Întinse, U.M.F. „Gr.T.Popa” Iasi
3Prep univ., Disciplina Clinica si Terapia Edentatiei Partiale Întinse, U.M.F. „Gr.T.Popa” Iasi
4Doctorand, Disciplina Clinica si Terapia Edentatiei Partiale Întinse, U.M.F. „Gr.T.Popa” Iasi
Traumatismele de la nivel facial, patologia
tumorala, soldata cu pierderi de substanta, sunt
doar câteva aspecte ce îsi pun amprenta într-un
mod mutilant asupra pacientilor, modificându-le
semnificativ si uneori ireversibil comportamentul,
transformându-i din persoane active, sociale, în
adevarati damnati ai izolarii.
Rolul materialelor siliconice în ce priveste
integrarea biologica este deja cunoscut, însa
modificarile structurale induse de noi pot atinge
valente de înalta performanta în ce priveste
biocompatibilitatea, varietatea cromatica, conditie
sine que non în surmontarea defectelor faciale
congenitale sau dobândite atingând valente de arta
reconstructiva. Un aspect esential este reprezentat
de corelarea existenta între efectele structurii
materialului siliconic sintetizat si modalitatea de
retentie a epitezelor.
Variantele clinice ce reunesc diferitele
modificari structurale la nivelul materialului
siliconic coroborate cu diversele sisteme de fixare
reprezentate de implante, magneti, utilizarea
diversilor adezivi vor fi simulate prin crearea unui
model matematic prin analiza tridimensionala,
creind premizele de maxima superpozabilitate pe
situatia clinica, constituindu-se în structuri ghid ce
preced interventia chirurgicala corectiva si alegerea
modalitatii de protezare maxilo-faciala optime.
Traumtologia faciala având drept etiologie
accidentele si actele de violenta, accente de
dramatism conferind atacurile teroriste, realitate
cutremuratoare a contemporaneitatii, constituie un
procent ridicat din cadrul arealului de cauze ce
conduc la pierderi de substanta de întindere si
profunzime variabile cu profund impact asupra
comportamentului individului, mutilarea fizica
antrenând autoizolari si excluderi din sfera
cotidianului si firescului. În etiologia pierderilor de
substanta un loc important este ocupat de
patologia neoplazica, flagel necrutator al ultimului
mileniu. Tratamentul cancerelor orale face apel la
un arsenal terapeutic variat reprezentat de chirurgia
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Norina Forna 1, Magda Antohe2, Monica Andronache 2,
Teodora Tipau4, Catalina Iovu4, Cosmin Oniciuc3
Facial traumas, tumoral pathology with losses
of substance, are only a few aspects which are
mutilating the patients, modifying in an irreversibil
way their behaviour, affecting their social and
affective life.
High biocompatibility of the silicone based
materials is already well known and proved, but the
structural changes induced by us in the
biocompatibility, chromatic variety for the
reconstruction of the congenital facial defects can
be reconstructive art.
An essential aspect is the correlation between
the effects of the synthesized silicone base material
structure and its retention way.
Clinical variants with different structural
changes of the silicone base material corroborated
with the various retention systems like implants,
magnets, different adhesive agents will be
simulated by creating mathematic models,
tridimensional analysis, leading to guide structures
before the corrective surgery and the optimal
maxillo-facial prosthetics.
The etiology of the facial traumatology is
represented by the accidents, but also the violent
acts. Today, the terorism is a crude reality, having a
great impact over our society and represents the
highest rate on the scale of causes of facial
traumas. The various extents and depths of the
facial losses of substances have a profound impact
over the individuals’ social behavior, leading to
isolation.
An important role in the etiology of the facial
traumatology is played by the neoplasm pathology,
which is considered the scourge of the 21st
century. Oral cancer treatment includes a series of
therapeutical procedures as excision surgery,
chemotherapy, cervicofacial radium therapy (Koffi
NJ, 2001).
The osteoradionecrosis phenomenon implies
the use of the slender base maxillofacial prosthesis.
The main purpose of our research is to obtain the
material structure that will allow us to reach the
 GNATOPROTETICA. IMPLANTOLOGIE / GNATOPROSTHETICS. IMPLANTOLOGY

de exereza, chimioterapia, radioterapia cervico- optimum biocompatibility of the facial prosthesis

faciala (Koffi NJ, 2001). (Taylor TD, 2000).
Fenomenele de osteo-radionecroza impun
utilizarea protezelor maxilo-faciale cu baza supla,
evolutia si diversificarea biomaterialelor în deplin
acord cu particularitatea cazului clinic constituind o
permanenta provocare în scopul unei integrari
biologice a substitutulu protetic (Taylor TD, 2000).
Noile metode de realizare cum ar Prototypingul
Rapid, dau posibilitatea combinarii protezelor
faciale traditionale cu potentialul tehnologiilor
moderne, conducând la îmbunatatirea finalitatii
clinice si a timpului de realizare.
Tehnicile avangardiste promoveaza etapa de (dupa O. Maurice, 2002 / after O. Maurice, 2002)
realizare a unei imagini CT în scopul planificarii
The new methods like Fast Prototyping are
elementului de retentie, element valabil în cazul
combining the traditional facial prosthesis
alternativei traditionale de realizare a protezei
advantages with the modern technologies potential,
faciale. În procesul de reconstructie tridimen-
optimising the clinical results, but also the
sionala a datelor provenite de la CT, portiunile
fabrication process.
lipsa se pot construi prin oglindirea partilor
The modern techniques use the CT images in
sanatoase sau cu ajutorul sistemului CAD.
order to obtain the proper retention element. In
Demn de remarcat în diagnosticul etiologiei
the process of tridimensional reconstruction in the
pierderilor de substanta si estimarea dimensiunilor
CT examination, the missing sections can be
acesteia este aportul imagistic. Folosind tehnicile
reconstructed by reflection of the healthy ones or
Rapid Prototyping se pot construi modele fizice
by the CAD system.
direct din datele virtuale tridimensionale. Pentru
The imagistic contribution is very important to
aplicatii medicale, asa numita stereolitografie s-a
diagnose the cause, but also the exact dimensions
dovedit a fi cea mai avantajoasa tehnica de Rapid
of the losses of substance. With Fast Prototyping
Prototyping, deoarece modelele de stereolitografie
techniques can be created physical models directly
prezinta cele mai fine detalii si sunt translucente.
from the tridimensional virtual data. For the
Cu ajutorul aparatului de stereolitografie straturile
clinical aplications, the so called sthereolithography
fizice sunt realizate prin polimerizarea unei rasini
was considered the most favourable technique of
acrilice lichide folosind radiatia Laser ultravioleta.
Fast Prototyping. This is because the
În ultima vreme cel mai frecvent se utilizeaza
sthereolithographic method offers the sharpest
siliconii de tip RTV si de tip MDX4210, acest
details and it is translucent. With the help of the
material având o textura si o culoare cea mai
sthereolithographic device, the physical strata are
apropiata de a pielii.
realised by polymerizing a liquid acrylic resin under
De obicei aceste proteze sunt mentinute de
UV laser radiation.
mijloace suplimentare de retentie cum ar fi
Silicone based materials like RTV and
protezele dentare deja existente daca este vorba de
MDX4210 are the most frequently used in this
o proteza de nivelul cavitatii bucale. În cazul în
field because of their skin-like texture and colour.
care distructiile osoase sunt majore se recurge de
Usually, the facial prosthesis are mainly retained
multe ori la aplicarea unor implante osoase ce vor
by suplementary retention elements like dentures.
servi drept mijloc de sustinere a acestor proteze.
In the case of major bone distruction, it is
În contextul în care chirurgia plastica a facut
recomended to insert endoosseous implants as
multe progrese în domeniul pierderilor de
retention systems.
substanta faciala un fapt de necontestat este ca
Even though plastic surgery has made major
protezele maxilo-faciale reprezinta o solutie
progresses over the past few years, maxillofacial
terapeutica ce rezolva în mod oportun situatiile
prosthesis remain the elective therapeutical
clinice ce nu pot fi corectate prin metode
solution for the clinical situations which can not be
chirurgicale reconstructive.
solved through reconstructive surgery.
O proteza maxilo-faciala poate fi conceputa
The patient’s aesthetic expectations are to be
astfel încât sa îndeplineasca cerintele estetice ale
considered, but the prosthesis retention is critical.
pacientului, dar retentia protezei este un punct
The retention with adhesive agents is realised only
critic. În scopul retentiei pot fi utilizati adezivi ce
at the skin level and it can affect the prosthesis’
fixeaza proteza la piele, dar problemele legate de

MEDICINA STOMATOLOGICA, vol. 9, nr. 2-3, 2005 43

 GNATOPROTETICA. IMPLANTOLOGIE / GNATOPROSTHETICS. IMPLANTOLOGY

retentie si de integritatea marginilor protezei vor
persista. Utilizarea implantelor ancorate la os
pentru mentinerea protezelor faciale poate mini-
maliza problemele legate de retentie si se pot
obtine substitute protetice acceptabile din punct de
vedere pshihologic. Accentele de biocompati-
bilitate sunt strâns legate de structura biomateriale-
lor utilizate, predominant siliconica.
Cele mai frecvente pierderi de substanta sunt
cele intraorale, solutionarea lor imediata
concretizându-se prin doua cazuri clinice, la care
pierderea de substanta este consecinta interventiei
de extirpare a unor formatiuni pseudotumorale:
fibrom, respectiv granulom cu celule gigante.
margins integrity. The endoosseous implants are
increasing the retention but also the aesthetics. The
silicone based materials have the highest
biocompatibility. In the last century, were studied
the polysiloxanes having an inorganic skeleton and
due their properties they have many practical
aplications. In the beginning they were even called
miraculous substances [3-10].
The most frequent losses of substance are the
intraoral ones, their immediate solution being
shown in these two clinical cases - the loss of
substance is a consequence of the oral maxillofacial
surgery intervention, the excision of pseudo tumor
formations.

Aspectele intraorale ale pierderilor de substanta

Aspects of intraoral losses of substance
În ambele cazuri s-au elaborat epiteze ce au ca In the both cases, we elaborated epitheses
scop refacerea continuitatii arcadei dentare, which aim the restoring of the alveolar and dental
asigurându-se în egala masura refacerea estetica si arch continuity, equally assuring aesthetic and
functionala prin camuflarea pierderii de substanta. functional rehabilitation by covering the loss of
În aceste situatii clinice, varianta imediata poate substance. In these clinical cases, the immediate
fi reprezentata de constructii amovibile sau de option is represented by removable prosthesis or
epitezele conjuncte ce au o greutate redusa si nu fixed epithesis with low weight, which do not
suprasolicita suportul restant. overstress the restant support.

Un aspect important în ce priveste elaborarea An important aspect of epithesis elaboration is

epitezelor este reprezentat de reproducerea cu the fidelity of the previous morphology restoring,

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fidelitatea a morfologiei anterioare, care în ambele
cazuri prezinta incongruente.
Aceste elemente îsi gasesc solutionarea prin
scanarea fotografiilor anterioare edentatiei ale
pacientului, ce vor fi grefate pe structura unui
model matematic ce simuleaza pierderea de
substanta, analizându-se toate detaliile de forma si
structura ale arcadei dentare si regiunilor dento-
mucoase adiacente.
Aceste constructii conjuncte presupun un
algoritm tehnologic ce trebuie riguros respectat,
scheletul metalic necesitând retentii, în scopul
aplicarii componentei fizionomice la nivelul
structurilor dentare si a aplicarii materialului acrilic,
a carei structura poate fi flexibila, împiedicând
traumatizarea suportului muco-osos prin pasajul
alimentelor. Retentia finala a epitezei este asigurata
de includerea structurilor dentare limitrofe,
asigurându-se în acelasi timp refacerea arcului
anterior, conducând astfel la augmentarea
stabilitatii constructiei protetice.
Solutia terapeutica finala va fi reprezentata de
echilibrarea bio-mecanica ce va include grefele,
solutiile implantare, coroborate cu augmentarea
suportului osos afectat.
Aspectul final al epitezei
Final aspect of the epithesis
CONCLUZII
1. Pierderile de substanta intraorala reprezinta o
mutilare grava, al carei tratament imediat prin
elaborarea epitezelor reprezinta o indicatie
terapeutica de electie.
2. Respectarea algoritmului tehnologic de aplicare
a retentiilor este o etapa esentiala pentru
asigurarea unei stabilitati eficiente a
componentei fizionomice.
3. Aportul modelarii matematice în simularea
defectului osos si a constructiei epitezei este
remarcabil, oferind conditii ideale de integrare
armonioasa a substitutului protetic.
MEDICINA STOMATOLOGICA, vol. 9, nr. 2-3, 2005
which shows incongruence in both cases.
These elements will be achieved by means of
scanning the previous photos and they will be
grafted on the structure of a mathematic model
which simulates the loss of substance and analyses
all the form and structure details of the dental arch
and the adjacent mucous arias.
These fixed prosthetic constructions are the
results of a rigorous technological algorithm, the
metallic frame will need special retentions in order
to apply the aesthetic compound; the acrylic
material can be flexible, protecting the muco-
osseous support from traumatism of the aliments
passing.
The final retention of the epithesis is achieved
by including the marginal teeth, assuring the
restoring of the anterior dental arch, thus leading
to the augmentation of the prosthetic construction
stability.
The final therapeutically solution will consist in
the bio-mechanical balance, which will include the
implants correlated with the augmentation of the
bony support.
CONCLUSIONS
1. The intraoral losses of substances is a sever
mutilation and its elective immediate treatment
indication is the elaboration of epitheses.
2. Following the technological algorithm of
retentions applying is an essential step in
assuring an efficient stability of the aesthetic
compound.
3. The mathematic models have a remarkable
contribution to the simulation of the osseous
defect and to the epithesis construction,
offering ideal conditions for a harmonious
integration of the prosthetic substitute.
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