Facial implant and implant retained craniofacial prostheses nn

Facial Implant And ImplantRetained Craniofacial Prostheses

Dr Pallawi Sinha

CONTENTS
1. Introduction
2. Advantages of Maxillofacial implants over conventional adhesives.
3. Patient assessment and selection
4. Treatment planning.

5.

Surgical technique for placement of Maxillofacial implants.

6. Auricular prosthesis.
7. Ocular prosthesis.

8. Nasal prosthesis.
9. Midfacial prosthesis.

.

10.skin response at abutment site
11.Follow up and management
12.Review of literature.
13.References

Prosthesis with osseointegrated implants and quality of life.
J Craniofac Surg. 2010 Jan, Vol. 21, No. 1, pp. 94-6.

• The use of facial prostheses such as wax ears has been
reported in ancient Egypt.

• The first historically documented evidence comes from
sixteenth century, when the French surgeon Ambroise
Pare describes the first nose prostheses from gold, silver
which were held to the face by a string tied around the
head.

Prosthesis with osseointegrated implants and quality of life.
J Craniofac Surg. 2010 Jan, Vol. 21, No. 1, pp. 94-6.

• In late 19th century Claude Martin conceived an
idea of an immediate prosthesis using tissue
excised from the maxilla and mandible as a
template for fabricating complex appliances.
• In 20th century, while the quality of lifelike
craniofacial prostheses was improved with
introducing of silicone materials, the problem of
their retention, which is important for aesthetics,
function, and comfort, was not entirely solved.

• With increasing aesthetic requirements conventional
fixation tools such as skin adhesives, skin pockets,
skin loops, and glasses became unsuitable.
• It was Branemark, who first placed a modified extraoral
implant for a bone- anchored hearing aid in 1977 and a
bone-anchored auricular prosthesis in 1979.
• These events changed the concepts of prosthetic
maxillofacial reconstruction.
• Since then, osseointegrated extraoral implants are widely
used for retention of orbital, ear, and nose prostheses.

• The implants had a dramatic impact on patient
acceptance of facial prostheses.
• Patients like the security, comfort, and convenience of
implant-retained prostheses.
• These benefits that are not attainable with earlier
methods of retention.
• Maintenance of fine feathered margins and simple
positioning of an implant-retained craniofacial
prosthesis greatly increased their aesthetic qualities

• Methods of retention of craniofacial prostheses
The anchorage of prostheses can be achieved in four ways :
1) anatomical anchorage : Already existing anatomical structures such
as undercut areas in the cavities of an orbital defect
2)mechanical anchorage : spectacle frames
3) chemical anchorage :

using adhesives

4) surgical anchorage :

using surgically created retention elements

Advantage of Maxillofacial implants over
conventional adhesives
• Improved retention and stability of prosthesis.
• Elimination of occasional skin reactions to adhesives.
• Ease and enhanced accuracy of prosthesis placement.
• Improved skin hygiene and patient comfort.
• Decreased daily maintenance associated with removal and
reapplication of adhesives.
• Increased longevity of prosthesis.

• Enhanced aesthetics at the lines of junction between the
prosthesis and skin.

Facial trauma: general principles of management.
J Craniofac Surg. 2010 Jul; Vol.21, No. 4, pp. 1051-3.

• Acquired facial defects, especially after radical surgical
operations result in huge functional, cosmetic and
psychological handicap in patients.
• For large defects ,two paths can be followed, those of
either
1)plastic surgery
2)prosthetic rehabilitation.

• The procedures involved in plastic surgery are
extremely suitable for the correction of less complex
aesthetic units or partial defects of the ear, nose and
orbital cavity.
• Particularly mobile areas such as the lips are difficult to
be adequately treated with prostheses and should
definitely surgically reconstructed, even if the
remaining defect is treated with a prosthesis.
• Plastic surgical reconstruction of these defects is
frequently limited due to unfavorable conditions, such
as vascular compromise of the surgical bed due to
radiotherapy, insufficient residual soft and hard
tissues.


• The choice between surgical reconstruction and
prosthetic restoration of large facial defects remains a
difficult one and depends on the size and etiology of the
defect, as well as on the wishes of the patient.


• For large defects, a multidisciplinary approach is
recommended, combining flap reconstruction and
implant-retained prosthetic rehabilitation to achieve
optimal results.
• Facial prostheses are constructed by maxillofacial
surgeon, implantologists, prosthodonticts and
technician, as an alternative treatment when facial
defects cannot be surgically fulfilled.

• Development and application of osseointegrated
implants to facial defects has changed patient
perceptions of facial prosthetics.
• Implants allow convenient and secure positioning of the
prosthesis, leading to greater patient acceptance.
• Ball attachments, bars or magnetic abutments are a
method of choice in replacement of missing hard and
soft facial tissues.

In contrast to intra-oral implants, which are available in a
wide range of
shapes and with different surface
preparations, craniofacial extra oral implants are far less
diverse .
The most widely used is the Branemark extra-oral
craniofacial implant system. These implants are shorter
than the intraoral implants and have a perforated flange.

Maxillofacial implant
are

fabricated

fixtures

from

pure

titanium. They are available in
either 3 mm or 4 mm lengths
and with a 5-6 mm diameter
flange. The flange facilitates
initial

stabilization

of

the

implant and prevents undue

penetration
compartments.

into

interior

• Bone stock in temporal, orbital and midfacial regions is
not often adequate for the placement of implant so it is
a predominant limiting factor.
• To compensate for this, extra oral implants are short, 3-6
mm in length .

• It has been claimed that this flange increases the
implant surface area in contact with bone, facilitates
initial immobilization and prevents undue penetration
of the implant intracranially.
• Perforations in the flange are supposed to add
additional surface area and provide mechanical
stabilization

Exposure of the perforated flange creates a
protected environment for accumulation of debris
and microbial colonization with ensuing infection,
which can be difficult to control.

• Other component are similar to intraoral implant
but differ in size.

Cover screw

Healing abutment

Hex tool

abutment driver

Hex tool and abutment driver are used to
tighten the cover screw and healing abutment
respectively.

Extraoral implant systems
1)solitary Implants
2) Grouped Implants

1)solitary Implants
• Branemark system
• ITI systems

Grouped Implants:
grid and plate systems
which are secured with several smaller bone screws.
With these systems an implant can also bear several

percutaneous abutments

Other systems with solitary implants
• IMZ system: marketed by Friatec (Friadent),
• Dentsply Friadent: is currently marketing the
Ankylos system.
• Southern Implants : is marketing extraoral
titanium screws

Extraoral systems with solitary
implants
• Branemark system
• The Branemark system was the first implant system to
be used extraorally . The longest and most extensive
experience has been gathered with this system .
• For the extraoral area, titanium screws of a length of 3
and 4 mm (and 5.5 mm) are available.

• The flange was originally designed to avoid an intracranial
dislocation of the implant due to trauma. The flange is now
available in closed form. At present flangeless screws are
also available .
• Abutments can be held by a special clamp.
• Currently the Branemark system is being marketed by the
Cochlear Company under the brand name Vistafix.

2 )ITI systems
• With ITI implants (International Team for Implantology)
marketed by the Straumann company, a sand-blasted, large
grit, acid-etched surface was introduced, the so-called SLA
surface.
• The resulting roughness is two-staged: the greater roughness
of 20 µm is overlaid by a finer roughness of 2 µm intervals .

Grouped Implants
Epitec system
Epiplating system
Both Epitec system Epiplating system used
subperiosteally, but fixed with bone screws.

Epitec system
• The Epitec system, developed in 1991 by Mustafa Farmand and
the company Leibinger, represents a great advancement.
• The system consists of a mouldable quadratic titanium grid with
16 thread holes, the so-called 3D carrier plate, and self-tapping 2
mm titanium screws which are available in lengths of 4.5 and 6
mm.

• The 3D carrier plate has to be cut to the required
shape.
• Single extensions are not stable. Plate retention results
primarily from the use of these monocortical bone
screws.

• Due to the flexibility constructions extending into the
defect are currently no longer recommended.

Epiplating system
• The Epiplating system was developed in 2000 by the
Medicon company.

• It is the adaptation of the 2.0 titanium mini-plate system
produced by Medicon and used in traumatology.
• Specially adapted implants are available for the
auricular, orbital and nasal regions, as well as a universal
plate.

• The titanium plates of the Epiplating system are 2 mm
thick, 2 mm in width and are thus stronger than the
Epitec grid system.

• The thickness of the plate is 2 mm, appropriate for 4
thread turns, which counterbalances any tendency of
loosening of the percutaneous base posts or magnets.

Coupling between abutment and prosthesis
Metal bar
Magnetic connections

• Typically, a metal bar is screwed onto the
percutaneous posts onto which the prosthesis can then
be clipped

advantage
• retention strength can be individually adjusted and
altered by bending the clips.

• The bar construction, however, requires substantially
parallel aligned percutaneous posts so that the least
possible strain occurs.
• This parallelism of the posts is never achieved in the
orbital area, and not always in the mastoid.

Magnetic connections:
• The advancement in magnetic connections represents
huge progress.
• They facilitate the cleaning and insertion of the
prosthesis by the patient. For this reason in the nasal
and orbital areas magnets are used almost exclusively
today.

Patient assessment and selection
• Maxillofacial reconstruction based on the principles of
osseointegration is always an elective procedure.
• Many factors and variables need to be considered
carefully, including age, the presence of any disease
progress, the significance of any previous therapy,
alternative available treatments and the patient's own
wishes.

Adrenal disorders:
• Patients with a history of adrenal gland disease, whether
hyper functioning or hypo functioning, face similar
problems related to dentistry and stress.
• The body is unable to produce increased levels of steroids
during stressful situations and cardiovascular collapse
may occur.

• Recent Myocardial Infarction (MI):
• If surgery is done within 3 months of MI, the risk of
another MI is 30%.
• If within 3 – 6 months, it is 15%.
• After 12 months the incidence of recurrent MI stabilizes
at about 5%.
• Osteoporosis:
The bone density affects the treatment plan, surgical
approach, length of healing and the nature of loading.

Fibrous Dysplasia:
• A disorder in which fibrous connective tissue replaces
areas of normal bone.
• It is found twice more commonly in women than men
and may affect a single bone or multiple bones, twice
more commonly in the maxilla than mandible.
• Implant dentistry is contraindicated in the regions of this
disorder

• Paget’s disease:

• A slowly progressive chronic bone disorder where both
osteoblasts and osteoclasts are involved, but
osteoblastic activity is more predominant.
• The maxilla is more often involved than the mandible.
Implants are contraindicated in the regions affected by
this disorder

• Radiation therapy:

• Disruption of defense mechanisms, compromised Endoosseous
vascular system, and localized loss of osseous vitality are the
main insults to the tissues while the patient undergoes radiation
therapy.
• With regard to bone, the osteogenic potential of the periosteum
is most severely affected.
• All these conditions can severely limit the prognosis for
reconstructive procedures.
Such patients may be subjected to osteoradionecrosis and should
be treated with caution only after the dentist consults the
radiotherapist

The loss or absence of an eye may be caused by a
Congenital Defect,
Trauma,
Tumor
A Painful Blind Eye
Sympathetic Ophthalmia,
or
the need for histological confirmation of
a suspected diagnosis

Eye tumors are manifested by a number of symptoms:
dystopia,
bulbar motility dysfunction,
exophthalmia,
and diplopia.

Depending on the severity of the situation, the surgical
management may include one of 3 approaches:
evisceration, enucleation, or exenteration.
• Evisceration : is a surgical procedure
where the
intraocular contents of the
globe are removed, leaving
the sclera, Tenon's capsule, conjunctiva, extraocular muscles,
and optic nerve undisturbed ,the cornea may be retained or
excised.
• Enucleation is the surgical removal of the globe and a portion
of the optic nerve from the orbit.

• Orbital exenteration :is the en bloc removal of the
entire orbit, usually involving partial or total removal of
the eyelids, and is primarily performed in order to
eradicate a malignant orbital tumor.

• Loss of an eye can cause significant physical and
emotional problems. Replacement of the lost eye as
soon as possible after healing is to promote physical
and psychological healing for the patient and to
improve social acceptance.

• Prosthetic rehabilitation that restores these facial
deformity may improve the level of function and selfesteem for patients.

Total exenteration allows adequate spacing for proper
positioning of a prosthesis. A subtotal exenteration or a
partially filled orbit restricts the facial prosthesis to
being thin, with a less natural appearance.

Because the orbital walls are thin, only the superior,
lateral, and inferior orbital rims are suitable for
osseointegration of titanium implants

craniofacial osseointegrated implant -int j oral maxillofacial
Implants 1997;12;200-10

Surgical Procedure :
The osseointegration procedure is performed in two
stages.
In the first stage the titanium implants are placed into
the orbital rim and the implants are allowed to bond to
bone through osseointegration.
The second stage is performed 3 to 4 months later when
tissue penetrating abutments are attached to the initial
implants

craniofacial osseointegrated implant -int j oral
maxillofacial Implants 1997;12;200-10

Stage 1
It can be performed under general or local anesthesia.
A skin incision is marked with a marking pen along the
orbital rim at the designated locations.
The skin incision is made just anterior to the rim, and a
flap of skin, muscle, and periosteum is elevated to
expose the bony rim.

• The initial drilling is done with an exploring cutting bur,
which produces a small hole.

• The orientation of this hole should be directed toward
the center of the orbit. This allows space for any future
prosthesis.
• If the bone is adequate, a 3 - 4 mm spiral drill with a
countersink is used to form the final hole diameter

• Next, the threading of the hole is done with the
threading tap.
• This step is accomplished at the slow speed of 8 to15
rpm that allows the precise cutting of bone needed for
proper implant setting

.

• The titanium implant is selected for the hole depth (3
or 4 mm) and screwed into the threaded hole with an
implant mount on the drill

• The implant has a cover screw placed that is screwed
into the internal threads of the implant.

• .

• A topical antibiotic is applied with a pressure dressing.
This dressing is removed in 1 week.
• If the continuity of the orbital rim is disrupted, several
options are available for bony reconstruction to create
a bed for implant placement. Common sites for
autogenous bone grafts are the calvarial bone, iliac
crest, and fibula

Stage 2 :
This is done after 3 to 4 months.
The second stage involves the placement of Titanium abutments
and the proper thinning of the skin around them to prevent the
movement of skin adjacent to it.
This step prevents skin irritation and infection and allows integration
of the skin with the abutment. It is usually done under local
anesthesia

A trephine is used to cut an opening over the implant. An
abutment is placed through the opening and attached to the
implant with an internal screw. The abutment can be 3 or 4 mm
in height. The abutment is covered with a healing cap.
Antibiotic soaked gauze is wrapped around the abutment to
immobilize the skin.
Four to five weeks after stage 2, the patient is ready for
prosthesis fitting

• A multiple tray technique for implant-retained orbital
prostheses.(J PROSTHET DENT 1995;73:158-61.)

Making an impression of the orbital area, with accurate
transfer of the implants, can be a difficult procedure.
• A method of making an accurate transfer impression for
an implant orbital prosthesis was described.
A four-component tray technique is described.
proper reproduction of all soft and hard tissue detail and
the position of the implants.

• A multiple tray technique for implant-retained orbital
prostheses.(J PROSTHET DENT 1995;73:158-61.)

• After exposure of the implants and placement of healing
cuffs, make an irreversible hydrocolloid impression of
the defect .

Acrylic resin custom trays on preliminary model

• Pour the impression in dental stone.
• On the primary cast, place approximately 5 mm of
relief wax over the duplicated implant healing cuffs to
allow adequate space for impression material.
• separating medium

Fabricate the acrylic resin custom trays. Make two trays triangular
in shape and separated from each other to separate the defect into
superior and inferior parts.
Make a third middle tray over the other trays in position on the cast.

Make the external matrix (fourth) tray by lubricating
the external surfaces of the three internal trays on the
preliminary cast and form the matrix over the internal trays.

When set, remove the external matrix tray and perforate it with
round bur to enhance mechanical retention of the impression
material.

• Remove and polish the trays.
• Place appropriate abutments on implants.
• Try the fit of the trays and assess for adaptation to the defect.
• Lightly lubricate the hair in the region with a petroleum based
lubricant.
•

Place the implant transfer components in position.

Again assess the trays for unobtrusive fit over the implant
components.

Paint the trays with the proper adhesive and allow to
dry.
Make the inferior impression by syringing impression
material around the implant transfer parts, in the inferior
part of the orbit, and in the tray.
Gently seat the tray into place and remove the excess
material.

• Lightly lubricate the external aspect of the inferior impression
with petroleum jelly.
Make the superior impression in the same manner.
If a middle tray is used, check the clearance for the tray.
• Adjust the tray and make an impression with sufficient
impression material to allow joining of all impressions without
locking one tray to the other.

Adapt the external matrix tray over the impressions to
assess fit; then paint with adhesive and allow to dry.
With impression material at each end, gently seat the
external matrix tray over the impression trays and allowed
to set.

Disassemble the impressions in reverse order.
Place the appropriate implant transfer analogs in the
impressions

Reassemble the impressions and use sticky wax to secure
them together .
Box and pour the impression in dental stone

This technique provides for a vertical path of removal for the
implant transfer copings in the superior and inferior borders
of the orbit

• The advantages of this method are accuracy and removal
of impressions on implants that are placed in opposing
positions in a limited space, which prevents the removal
of a one-piece impression.

An impression technique for implant retained orbital
prostheses. J Prosthet Dent 2008;100:52-55)

• This article describes an impression technique for an
implant-retained orbital prosthesis;
• implant impressions in the conventional manner was
not possible due to improper implant positioning.
This article describes an impression technique for
transferring the implant position to the definitive
cast when the position of implants prevents the
use of impression copings.

• An impression technique for implant retained orbital
prostheses. J Prosthet Dent 2008;100:52-55)
1. Pack moist gauze, into the orbital defect, and place the magnets
on the center of the magnetic abutments .

Make an impression of the magnets, abutments, and defect
area using irreversible hydrocolloid impression material.
Box and pour the impression with dental stone.

• To provide clearance from the underlying skin, place 1
layer of baseplate wax onto the surface of the cast.
Trim the wax neatly around the replica cast of the
magnets.
• Apply a coat of separator to the cast.

Mix the autopolymerising acrylic and place it on the cast,
bridging the spaces between the adjacent replica of the
magnets.
• Allow the acrylic resin to polymerize and remove the
substructure from the cast. Trim the excess acrylic resin
with a carbide bur.
• For optimal results, allow the resin substructure to
polymerize for 24 hours.

• Remove the magnets and wind polytetrafluoroethylene
(PTFE) tape around the abutments.
• Place the tape around the abutments to block out the
undercuts. Replace the magnets.

Polytetrafluoroethylene tape around magnetic abutments to protect
acrylic resin-to-skin contact

• Place the substructure on the magnets and verify
adaptation. Trim the acrylic resin as needed to ensure
fit.

Verifying adaptation of substructure to magnets.

• Lute the substructure to the magnets with
autopolymerising acrylic resin .
• Allow the applied acrylic resin to polymerize.
• Remove the substructure that now incorporates the
magnets. Remove the polytetrafluoroethylene (PTFE
)tape.
• Trim the excess acrylic resin with a carbide bur.

• Pack moist gauze into the orbital defect. Lubricate the
skin and eyebrow with petroleum jelly .Place the acrylic
resin substructure onto the magnetic abutments. Place
light-body vinyl polysiloxane impression material under
the acrylic resin and over the tissue site with a syringe,
working outward from the abutments

• Gently apply the tip of the syringe close to the skin,
and move it back and forth in a small semicircular
motion from the area covered with impression material
into the uncovered area to minimize the trapping of air
bubbles in the impression

Apply adhesive over the vinyl polysiloxane and allow it to
dry.
Mix the autopolymerizing acrylic tray resin.
Place a thin layer of resin over the impression. Apply a
continuous stream of compressed air with water spray
during the exothermic phase of polymerization.

• Remove the impression with the incorporated
substructure from the defect site.
• Connect the implant analogues to the magnets
• Box and pour the impression in dental stone .
• Allow the stone to set. Recover the cast and acrylic
resin substructure for use .

• Fabricate the orbital prosthesis from silicone.

• The advantage of this technique is that the transfer of
the spatial relationships of the implants from the
defect to the definitive cast is ensured without using
impression copings.
• A disadvantage of the procedure is the requirement of
an additional appointment to make the definitive
impression.

• An ocular prosthesis can be either readymade (stock) or
custom-made.
• Stock prosthesis comes in standard sizes, shapes, and
colors. They can be used for interim or postoperative
purposes.
• Custom eyes have several advantages including better
mobility, even distribution of pressure due to equal
movement thereby reducing the incidence of
ulceration, improved fit, comfort, and
adaptation, improved facial contours, and enhanced
esthetics gained from the control over the size of the
iris, pupil, and color of the iris and sclera.

• Surgical and Prosthetic Considerations to Rehabilitate an
Ocular Defect Using Extraoral Implants: A Clinical Report
Journal of Prosthodontics 21(2012) 205–208

• This clinical report shows the use of extraoral implants
to rehabilitate an ocular defect.

• The patient, a 57-year-old man had squamous cell
. carcinoma that is completely resected.
• After surgery, the peri-orbital region was kept intact.

• A custom-made artificial acrylic resin eye was selected
according to the color, contour, and size of the
patient’s healthy left eye.
• Over the stone cast, a layer of warm wax was placed
on the defect area.
• This wax sheet was tried on the patient’s face to serve
as the basis for correctly positioning the artificial eye,
based on referential face lines .

• This was an important procedure, because inadequate
eye positioning frequently leads to a poor esthetic result.
• the remaining tissues surrounding the artificial eye were
carved in wax, observing the anatomic details of the left
side, especially the upper and lower eyelids.
• A natural and esthetic wax-up was completed.

Surgical template based on the diagnostic wax-up.

Prosthesis margin reference lines to guide
correct implant placement.

Titanium cylinder dental implants placed in the
zygomatic bone. The healing abutments were installed at
the same time.
• A reduction in skin thickness and a compressive suture
were performed in the one-stage implant surgery

• A framework pattern was planned after verifying there
was adequate space for the skin (1 mm) and the
external contour.
The patient experienced a great deal of difficulty in
maintaining a clean defect area after casting procedures
and the use of this framework for a week
The framework of the metal structure was designed with a
volume too large to hold an orbital prosthesis.

Initial clip bar framework design.

• Therefore, another framework design was planned
with a retention method consisting of two cylinder
magnets positioned on a bar segment .

• After final casting procedures, the magnet cap
bases were fixed on an acrylic base behind the
iris

and the prosthesis silicone pattern was invested and
processed in an RTV platinum silicone elastomer

Frontal aspect of the silicone
prosthesis.

Lateral aspect of the silicone
prosthesis.

Extraoral applications of osseointegrated implants. J Oral Maxillofac Surg.
1991;49:33–45

• The indications for autogenous auricular reconstruction versus
prosthetic reconstruction with osseointegrated
implantretained prostheses
were outlined
in
Plastic
and Reconstructive Surgery in 1994.
• The choice between the two remaining techniques,
autogenously reconstruction and prosthetic reconstruction,
depends more on the surgeon’s training and tradition than on an
analysis of which procedure is preferable in a given clinical
situation.
• For example, most children with microtia in the United States are
treated with autogenous techniques.In contrast, the same
deformities in Sweden are more commonly treated with
prosthetics.

• The etiology of the loss of an auricle can be either
acquired or congenital.
• Among acquired cases, gun shot injuries, traffic
accidents ,burns, ablative cancer surgeries are the
reasons.
• Patients with post traumatic or post ablative auricular
defects are more often in adults, and their defects
differ from those of children with congenital
deformities in several ways.
1) The skin loss and scarring resulting
from trauma
or previous surgery may make standard autogenous
reconstruction difficult.

2) The tragus is frequently preserved in the
trauma/ablative patient, making the aesthetics
of prosthetic reconstruction much more favorable.

• The presence of a tragus allows the anterior border of
the prosthesis to be hidden, a major aesthetic benefit.

• The diagnostic step is an important point that must be
clearly deﬁned in construction of an auricular
prosthesis.
• CT of the temporal bone and clinical photographs of the
patient should be obtained preoperatively to plan the
placement and appropriate size of the implants .

• To evaluate the thickness and spaces of mastoid cortical
bone in order to preserve the duramater.

The axial CT scan of the cranium.
the distances from the masoid region to the adjacent anatomical
structures such as external auditory canal, duramater and the
orbit.

• It has been suggested that the mastoid region as a
recipient site could offer the best results in implant
retained auricular prosthesis.
• Wright et al have stated that, the mastoid region
provided a high degree of predictable individual
implant survival.

• auricular implants enhance retention and stability of
prostheses, improving the patient’s confidence and
sense of security.
• In addition, attachment systems aid in the proper
positioning of prostheses, facilitating insertion by the
individuals with auricular defects.

• The implants should be placed at least 20 mm away
from the external acustic meatus and 15 mm from
each other.
• In addition, in cases with two implants, 9 and 11
o’clock positions are recommended.

• Implant surgery may be performed in single or two
stages.
• because the operation area get covered with a
previous scar tissue formation because of compromise
the vascular supply of the area, the two-stage
procedure is not recommended.

One-Stage Surgical Technique for Auricular
Implant Placement
• Implant Site Selection: This must be done before the patient
is taken to surgery. The external ear canal is a good landmark.
The ideal placement is 18 to 22 mm from the center of the
external auditory meatus, and on the left-hand side it is between
the 1-0’ and 2-0'clock positions for the upper cranial implant and
between the 3:30 and 4:30 positions for the caudal implant.

• The reason for this is that the implants and the bar
construction will be located underneath the antihelix
ridge. This is important to achieve an adequate depth and
contour of the prosthesis.

• Marks are made with surgical ink where the implants should
be placed, and the area is cleaned and patient is draped in the
usual way. The incision line, usually 7 to 10 mm behind the
intended implant sites is marked. 10ml of 2 % lidocaine with
epinephrine is injected, and the incision is made down to the
periosteum. That flap is folded anterior and kept in place with
two self-retaining retractors.

Implant Placement:
The positions of the implant sites are checked and marked in the
periosteum.
A 6 mm wide incision is made in the periosteum and the drilling
with a guide drill is started. During all drilling procedures,
generous cooling with saline solution is important.

• When the lower implant is in place, the position of the upper
implant is selected. The distance between the two implants
should be at least 15 to 20 mm. The position of the cranial
implant often will be in the temporal bone where the bone in
most cases is dense and thicker. The drilling in the cranial site is
started with a 3 mm guide drill. If bone is still found in the
bottom, a drill that will provide space for a 4mm implant is used

• It is important to make sure that the whole length of the guide
drill has gone down. The reason is that the next drill, which is
the spiral drill with a countersink edge, does not cut at the tip.
The drills are made of stainless steel and 1,500 to 3,000 rpm is
used. The next steps are made at slow speed, 8 to 15 rpm, and
with titanium tap

The titanium tap is picked up, with the connector placed in
the low speed hand piece. The tap is kept over the
entrance and the direction is checked carefully. Adequate
cooling is used when the tap is removed.

• The implant mount is picked up with the fork shaped
instrument and the screwdriver. The implant mount is
screwed on top of the implant. The implant site is
cleaned of soft tissue and bone fragments by flushing
with saline and using a blunt dissecting instrument.

• The implant mount with the implant is picked up with
the adapter on the hand piece of the drill and kept over
the hole. The direction is checked with the drill at low
speed, the implant is allowed to find its way into the
threaded hole using slight pressure

• When the implant is all the way down, the hand piece is
turned slightly counterclockwise to release the implant
mount from the connector. It is Important not to tilt the
implant mount when disconnecting it from the hand
piece. The implant mount is then removed from the
implant. It is then covered with the thin skin and
sutured is placed.

Soft Tissue Management :
1) The immobility of the skin close to the implants relative to the

underlying bone and the abutment is very important. This is
achieved by making a subcutaneous tissue reduction at the
implant site.

2) There should be no hair follicles present in the skin at
the Implant site.

These two goals can be achieved by reducing the
thickness of the flap or by using a split-thickness skin
graft

Abutment Connection :
With a 4mm disposable skin punch, a hole is made immediately

over the implant and the abutment is secured to the implant
with an internal screw.

When the fit is established, the abutment screw is tightened firmly.

Healing caps are then attached to the abutments to keep
ointment soaked gauze down toward the skin to avoid
postoperative hematoma and swelling.

The surgical procedure is finished by applying a firm mastoid
dressing for 1 day. After this, only a light dressing is needed.

Postoperative Care :
After 5 to 7 days, the packing and the healing caps are removed
and the surgical field is left open.

A mild antibiotic ointment is prescribed and the patient is told to
use that for a week or two and then just occasionally.
Three weeks after operation the patient may start to clean the
area with soap and water.
implants are left without any load for 3 months.

• The choices of retentive mechanisms to be applied on
the implants depend on the patient, the number of the
implants and the ﬂexibility of the episthesis.

Locking retentive attachment for an implant-retained auricular prosthesis. J Prosthet Dent.
2002;87:336–338

The conventional retention techniques involve magnetic or
clip retention provided by golden bars and ball clip or
magnet retentive cap systems.

• For the use of a golden bar, at least two bone-ﬁtting
implants and a moderately hand-skilled patient are
needed.
Magnets can be used with at least 3 bone- connected
implants.

• In cases with three implants, a cantilever extension of
the bars could be planned.

• If four bone connected implants were used,
there is no need for a cantilever extension of
the bars.

• Episthesis connected on bars between four
implants by ball shaped caps are also used.

• An impression and cast construction technique for
implant-retained auricular prostheses(J PROSTHET DENT
1996:75:45-9.)

• Implant-retained auricular prostheses provide a
challenge with regard to adaptation of visible margins
that may adversely influence the esthetic result of the
prosthesis.
• Movement of the mandibular condyle and soft tissues
associated with changes in head position can result in
the loss of contact of the anterior margin of the silicone
prosthesis with the underlying skin.

• The exposed anterior margin of the implant retained
auricular prosthesis must maintain skin contact at all
times if the esthetic value of the prosthesis is to be
preserved.

• The design of the fitting surface should only allow for
prosthesis-skin contact at the anterior and conchal
margins and the posterior conchal margin must include
an aeration channel.

• The goals of the technique are
(1) to make an impression that allows continuous skin
contact by the anterior silicone margin.
(2) to construct a master cast that provides adequate
planned spacing under the completed prosthesis, and
(3) to construct a master cast that does not require the
retentive bar to be returned to the mold for prosthesis
processing.

• Make a preliminary impression that incorporates the
implant impression copings.
• Fabricate the retentive bar and clip retained resin
substructure
• Space the acrylic resin substructure to provide 1 to 3
• mm of clearance from the skin.

• The custom tray must provide for clear visualization of the
retentive bar through the resin substructure through a window in
the tray

• Assess the movement of the condyle of the mandible under the
preauricular skin to determine the point of maximum skin
depression.
• Also assess head movement for maximum skin depression and
record the impression in these positions. Mark the desired
position of the prosthesis on the skin.
• The mandible can be held open in the desired position with a
mouth prop.
Mark the desired position of the prosthesis on the skin.

• Load uncatalyzed silicone putty into a disposable syringe
• Place the acrylic resin substructure in position on the
retentive bar and syringe the silicone putty around the
margin of the acrylic resin substructure.
• Use a plastic instrument to remove the excess silicone
putty.

• Paint the custom impression tray with adhesive and load the tray
with polyether impression material. Select the viscosity according
to skin mobility.
• Recording of impression with mouth prop holding jaw open and
head in predetermined position. Confirmation of relationship
between custom tray, acrylic resin substructure, and retentive
bar through cut out in custom tray.

Recover the impression and mark the area of soft tissue
that is not to have tissue contact anterior to the acrylic
resin substructure on the impression surface.

use a photocopy (on transparent sheet) of normal ear to help
demarcate anterior margin, internal spacing, and aeration
channel.

• Reduce the impression surface in the marked with
tungsten carbide rotary instrument.
• Assess the depth of spacing with a periodontal probe.

• To provide a define margin, trim the impression
material margin around the resin substructure.
• The impression surface posterior to the resin
substructure can be reduced to create the opening for
the aeration chamber under the ear prosthesis.

• Bend a stainless steel wire of diameter that
matches the retentive bar to replicate the bar.
• This is introduced into the clips in the resin
substructure.
• Box and pour the impression.

• Incorporate the replica of the bar, soft tissue spacing,
and anterior soft tissue recording for anterior margin
of silicone prosthesis into the completed cast to
provide an esthetic margin.

Fitting surface of two prostheses processed out of
same mold.

Completed prosthesis shows contact of silicone margin along
anterior border.

Anterior esthetic margin of prosthesis
maintain skin contact during extreme
mandibular movements.

• An implant-retained auricular impression technique to minimize
soft tissue distortion(J Prosthet Dent 2003;89:97-101.)

Auricular defect site with indelible ink orientation lines used for
positioning diagnostic wax pattern. Small circle indicates position of
temporomandibular joint.

• Connect the impression copings with prefabricated acrylic resin
bars .Lute the ends of the resin bars to the impression copings
with acrylic pattern resin.
• The use of prefabricated acrylic resin bars will minimize the
amount of error that would occur as a result of polymerization
shrinkage.

• light-body vinyl polysiloxane impression material over the tissue
site and impression copings.
• Apply only enough material to cover the skin with approximately 3
mm of polyvinyl siloxane

Apply a thin layer of tray adhesive over the vinyl
polysiloxane and allow it to dry.

• Thin layer of tray material applied over vinyl polysiloxane
impression material to provide rigidity.
• Apply a continuous stream of compressed air with occasional
water spray to keep the material cool.
• The polymerization of the acrylic tray resin can create a
considerable amount of exothermic heat if a thick layer of tray
acrylic is applied.

• Remove the impression from the skin with a minimum
amount of leverage.
• Connect abutment replicas to the impression copings and
tighten the guide pins .

• Box and pour the impression in dental stone. Use just enough
dental stone to cover the abutment replicas. Excess dental
stone will only increase the amount of expansion and
subsequent error.
• Allow the stone to set for a minimum of 45 minutes.
• Recover the cast for use

Master cast with transferred indelible ink
orientation lines used for positioning
diagnostic wax pattern. Small circle
indicates position of temporomandibular
joint.

Fabricate the prosthesis, The anterior dam will help to
compensate for natural postural positions and soft tissue
movements associated with eating and conversing

Clinical evaluation of a newly designed single- stage craniofacial implant: a
pilot study. J Prosthet Dent. Vol. 100, No. 5, (Nov 2008), pp. 375-383,

Khamis et al described a new technique with modified
abutments in implant-retained auricular prostheses, using a
single- stage surgical procedure.

• They have screwed the modified O-ring
abutments directly onto the implants at the time
of surgery.

• Plastic washers were attached to the O-ring
heads of the exposed abutments to avoid skin
over growth to allow a single-stage surgical
procedure.

• After a osseointegration period of 4 months, a
silicone prosthetic ear was fabricated and
retained using clips over the O-ring abutments

Complications
•

Retrospective study of treatment outcomes with implant-retained extraoral prostheses:
Survival rates and prosthetic complications. ( J Prosthet Dent 2010;103:118-126)

• Complications related to auricular prosthesis are the
1)loosening of abutment
2)broken bar or extensions
3)loosening of prosthetic bar screws,
4) broken or lost clips, loss of clip retention, loss of
magnet retention,
5) fractured acrylic resin substructure
6)loss of bonding between substructure and silicone,
deposits on tissue surface of the prosthesis,

7) and tear or rupture of the prosthesis
8)Loosening of bar screws is another relatively frequent
complication noted in auricular prosthesis.
Therefore, the screws should be placed with proper
torque control, ensuring complete seating of the driver
into the screw head.
The most frequent complications are
mechanical failures of the substructure and retentive
attachments, including acrylic resin substructure fracture,
clip fracture, and loss of attachment between the silicone
and substructure.

• According to the literature survey of Gumieiro et al,
auricular osseointegrated implants have presented
survival rates varying according to the length of followup, ranging from 92% after 8 years to 100% with
shorter follow-up. However, there have been limited
clinical studies on the life span of extraoral prostheses.

Nasal prosthesis

• Throughout the history the nose has been described as
the object of beauty and symbol of strength. The
amputation of nose has been the bitter price of social
dishonor and even the reason for military conflict in
the history.

In the total nasal defect, there is usually sufficient amount
maxillary bone that creates the inferior border of the piriform
aperture.

If the nasal defect involves only the lower portion of the nose, only
two Osseointegrated implants inferiorly in the maxilla are enough
or further resection of the remaining nose in the upper area is
done to expose the nasal bones.

.

• For aesthetic reasons, glabella and lateral
maxillary sites are poor choices for
implants, because framework will interfere
with the aesthetic formation of the nose

The state of the maxillary dentition and presence or absence
of anterior teeth can be important diagnostic factors in
selecting fixture type, length, and location.
Ventilation requirements for nasal prostheses are facilitated
via perforations within the artificial nares.

Fixture sites for large midfacial defects are dictated by the
residual anatomy. The residual zygomatic arches can also
be used for the horizontal placement of long fixtures which
offer excellent anchorage points.

Stage I
An incision is made and the periosteum and skin are
elevated together. The location of the implants is marked,
and a 4 mm implant is usually placed in the lower piriform
aperture and 4 mm or 3 mm implants in the nasoethmoidal
area. It is extremely important to use minimally traumatic
technique, low speed drilling, and copious irrigation

Stage II
Approximately 3 months after the first stage, It is preferred to
open the old incision and the flaps are thinned and the wound is
approximated with a few sutures.
The holes for the penetration of the abutments are created with
a punch or a scalpel. The cover screws are removed, abutments
are placed such that the abutment extends approximately 3 mm
above the skin.
Healing caps are applied, and a moderately compressive dressing
is used to facilitate adherence of the flaps and to limit edema
formation. The wound is allowed for 2 weeks to heal before the
prosthetic work is started.

Attachments :
In general, metal bars work better in the area of the nose.
The bar has the additional advantage that it limits rotational forces
on the implants. once the metal bars or magnets have been
placed, the work of attaching the prosthesis can be started.

For nasal prostheses, a midline clip and framework retention is
best in most cases.
The framework is designed to be cast in metal and is an inverted Y
shape that has a cross brace between the widest part of the Y
near the abutments.

The advantages of this design are that it:
1) Allows maximum bilateral air flow.
2) Provides for vertical and horizontal clip orientation,
preventing the misapplication of the facial prosthesis; and
3) Provides adequate access to the nasal cavity and peri abutment

tissues for hygiene maintenance.

Triangular segments of the Y should be as far away from the walls
of the nasal cavity as possible, so cleaning of septal surfaces of the
internal nose can be accomplished.

Restoration of nasal defect with implant-retained nose
prosthesis.The Journal of Indian Prosthodontic Society | October 2007 |
Vol 7 | Issue 4

• This case report presents a patient with the excision
of nose due to xeroderma pigmentosa rehabilitated
with implant retained silicone nose prosthesis.
• Two cylindrical implants with a diameter and length
of 3 mm and 10 mm were surgically inserted in the
floor of the anterior maxilla.

• After a healing period of six months the implants were surgically
exposed ,cover screws removed, and universally modified
abutments (UMA) and healing caps attached
Healing caps were removed after 1 month and this was followed by
the prosthetic phase

• Prosthetic phase
• Impression posts were attached to the UMA for transferring the
position of the implants onto a stone cast .
• Impressions of the nasal tissues were taken in a rubber base
impression without distorting the surrounding tissues.
• Implant analogs were fixed to the impression post and master cast
was obtained .
• Wax pattern of the retention bar (superstructure) was fabricated on
the master cast.

• The trial of the wax pattern on the face was taken.
Subsequently, retention bar was casted in metal.
• After assessing the fitting of the retention bar, it was
fixed on the UMA attached to the implants.
• The impression of the tissues was taken again .
• The stone model for sculpting was obtained

• The sculpting of the prosthetic nose in wax to achieve appropriate
size, contour, surface texture, and margins was done.
• Superior and superio-lateral portions of the lateral margin were
positioned beneath the glass frame.
• The lower portion of the lateral margin was blended with the skin
• The sculpted prosthetic nose was adapted on an acrylic
substructure.

• Acrylic resin substructure was adapted on the retentive bar.
• It contains the retentive element – bar clip, which must fit within
the confines of the nasal prosthesis.
• Sufficient surface area was ensured so that the bond between
the resin and silicone did not fail.

• The processing and flasking of the sculpted wax nose
was performed for the fabrication of a silicone nose
prosthesis with an acrylic substructure containing the
bar clips.

• Implant-retained nasal prosthesis for reconstruction of large
rhinectomy defects. International Journal of Oral and Maxillofacial Surgery April
2010, Pages 343–349

• Their technique of modifying post-rhinectomy defects is
described and factors influencing implant success are evaluated.

• The overall success rate was 89% (99/111); 94% in patients
who did not receive radiotherapy and 86% in those who did.

Areas of defect modification.

Elephant’ shaped skin graft.

• The prosthesis was in place in all patients (100%) at the time of last
follow up. Post-rhinectomy defect modification enables adequate
access for safe placement of long implants with good primary
stability and helps the maintenance of good hygiene (further
enhanced by the use of skin grafts).

• The implant-retained prosthesis is a reliable option for
reconstructing large full thickness rhinectomy defects.
They suggest their technique of modifying the defect,
use of long implants and magnets for retention is
responsible for the high success rate of implants used
to retain a nasal prosthesis.

• Zygomaticus implants were originally developed for
dental reconstruction of the edentulous maxilla with
severe bone resorption.

• The recent development of the zygomaticus implants
has made nasal reconstruction more flexible as these
implants can be placed horizontally from the middle of
the nasal defect through the maxillary sinus under the
eye, engaging the cortical bone of the zygoma.

• These implants are useful where the anterior maxilla has
been lost and pyriform rim implants are not possible.
Care is taken to avoid the infra-orbital nerve and injury
to the eye.
• Malignant tumours of the nose occasionally require
rhinectomy. Implant retained prostheses can give good
aesthetic results.

Zygomaticus implants for retention of nasal
prostheses after rhinectomy
British Journal of Oral and Maxillofacial Surgery 44 (2006) 54–5
• After rhinectomy zygomaticus implants orientated horizontally
from the piriform aperture into the zygoma to retain the nasal
prosthesis.

• Postoperative appearance with two zygomaticus implants
orientated horizontally across the maxillary sinus and one
intraoral implant in the glabella, all with Magna-Cap
attachments.

• COMPLICATIONS
• Soft tissue complications include inflammation,
bleeding, tissue overgrowth, granulation tissue
and infection.
• Inflammation and excessive loading can cause
bone resorption.
• Overloading, even after several years, can cause
microfractures in the bone that heal into scar
tissue and cause the implant to become loose.

• common problem with the nasal prosthesis is the
contamination of the fitting surface with bacteria. This is
due to the combination of warmth, moisture and normal
nasal secretions.

• If bacteria are allowed to penetrate the silicone,
difficulty is experienced in its removal. This particular
problem can be avoided by ensuring that the patient is
made aware of the cleaning regime for the prosthesis
and the defect area.

Reconstruction of the maxilla and midface: Oncol. 2010 Oct,
Vol. 11, No. 10, pp. 1001-8.
• Reconstruction of midfacial defects with implant insertion

• Mid-facial defect is one of the most disfiguring and
impairing defects.
• A design of prosthesis that is aesthetic and stable can be
precious to a patient who has lost part of his face due to
surgical excision.
• Prosthesis can restore the patient’s self-esteem and
confidence, which affects the patients and their life style.

• The maxilla can be described as a geometrical structure with six
walls (hexahedrium).
• Each wall is part of another anatomical structure in the face.
The roof of the maxilla is the floor of the orbit and supports
the ocular globe.
• The medial wall of the maxilla is the lateral wall of the nasal
cavity and is part of the lacrimal system.

• Combining bone grafts with skin/soft tissue flaps
simplifies reconstruction of the highly complicated
three dimensional nature of the maxillary defect.

• Osseointegrated implants may be used in several
different prosthesis designs.

• Craniofacial Site Classification.
• The dry skull study suggests a gross site
classification based on anatomic location and
bone volume for appropriately placed fixtures.
• Given these limitations, craniofacial implant sites
can be classified into three groups:

• Alpha sites are 6 mm or greater in axial bone volume, permitting
the use of dental implants. These locations can be used to
partially retain denture or complex facial prostheses.
• The most common areas of the facial skeleton having that much
bone available are the anterior maxilla through the nasal fossa
and the zygoma and/or zygomatic arch when using a bicortical
engagement technique with long implants traversing the inner
face of the zygomatic arch

• Beta sites have 4 to 5 mm of bone volume available,
permitting the use of a 4-mm craniofacial implant or 5-mm
fixture. Beta sites encompass the superior, lateral, and
inferolateral orbital rims as well as much of the temporal
bone and zygoma.

• 3. Delta sites are marginal sites with 3 mm or less of bone
volume available.
• Locations in the temporal bone, pyriform rim, infraorbital
rim, nasal bone, zygomatic buttress, and zygomatic arch
require the use of 3-mm craniofacial implants in series.

• A 58-year-old male had a 10-year history of adenocystic carcinoma
of the midface with early metastasis to the right lung. The patient
was markedly disfigured in the nasofacial area.
• He could not open his mouth, had difficulty in speaking, and could
not breathe through the nose.
• Definitive excision of the midfacial lesion included radical
rhinectomy, 90% total maxillectomy, complete upper labialectomy,
and bilateral partial malarectomies.

• The left zygoma was reduced by about 50% and the right by
25%. The right side also retained a small section of the zygomatic
buttress.
• The maxilla was almost completely removed; only the second
molar on each side and a 4-mm-wide interconnecting portion of
the most posterior hard palate remained.
• The soft plate was not disturbed. The upper lip, both cheeks up
to the orbits, and all nasal soft tissues were removed

• At the time of ablative surgery, two 18-mm implants
were placed into the malar bones bilaterally using the
curve of the zygomatic arch to allow for bicortical
engagement.

• The implants were placed approximately parallel to the Frankfort
horizontal plane but angled sagittally and placed vertically to each
other about 5 mm apart.
• On the right side, the inferiorly placed implant was inserted in
the zygomatic buttress area, where 4 to 5 mm of bone width was
available. It went through the posterior aspect of the buttress and
engaged the zygomatic arch

• The implants were exposed 6 months after surgery and
5.5-mm abutments were placed.
• Elastomeric impressions were made immediately
following resection of the facial tumor. An immediate
surgical obturator was then fabricated and worn
provisionally during the healing period.

• Hadar clip retention is built into gold bars attached to two 18mm implants placed into the zygomatic arch bilaterally.
• Magnetic attachments were positioned on the facial surface of
the maxillary obturator and the inner surface of the acrylic resin
mesostructure to aid in stabilization of the obturator yet allow
for functional occlusal movements during mastication .

The bars provide retention through a mesostructure for a large
obturator prosthesis.

.
The mesostructure aligns with the denture via magnetic attachments
and secures it secondarily after attachment to the gold bars with four
Hader clips.

• A circumferential retentive undercut was formed in the acrylic resin
of the mesostructure to help the retain the composite facial
silicone prosthesis, which extended from the bridge of the nose
laterally to the zygomatic areas, inferiorly to the buccal
vestibule, then medially to the lower lip and across to the midline.
• This included total replacement of the upper lip with the silicone
facial prosthesis.
• The denture also attaches to the second molars present bilaterally.

• The composite facial prosthesis extends from glabella to
stomion, including the bridge of the nose, zygomatic
areas, buccal vestibule, and full upper lip.

• The patient is able to wear glasses, which in this instance had
to rest on the prosthesis itself. The patient can breathe through
the prosthetic nose, articulate normally, and masticate
satisfactorily.
• He is hampered by the lack of sensation in his upper lip but is
able to drink from a glass and suck through a straw.

• The patient has functioned with this prosthesis for 3
years and is able to eat a fairly normal diet.
• However, he continues to have problems retaining food
intraorally because of lack of sensation in the upper lip
and lack of maxillary buccal vestibule.
• Intraoral suction is achieved by pursing his lower lip
against the silicone facial prosthesis.
• Salivary control is slightly hampered because of the loss
of the left commissure and part of the lower lip to the
resection.

A 63 year old man, was exposed to repeated surgical
procedures over several years, because of a basal cell
carcinoma of his face. After 10 years, tumor histology changed
into a squamous cell carcinoma.

A decision was made to provide him with not only a facial
prosthesis but also an implant supported fixed bridge in the
maxilla using osseointegrated fixtures.
Preoperative examination revealed that the quantity of
maxillary bone was not sufficient for a standard procedure, so a
bone graft had to be used.

Framework:
• The purpose of a fixed framework or substructure is to
retain the facial prosthesis.
• Two conventional bar constructions were made, one on
the three upper and the other on the three lower
maxillary abutments

A third part of the framework connects the two bar
constructions. This part of the construction has an
exceptionally long span. Therefore, a Custom made three
dimensional framework was prepared.
The goal was to achieve stiffness with low weight. These fittings
were then soldered to the bar splints and enabled to connect
the three parts of the construction.
.

• The entire framework was made out of a pre machined
gold alloy clasp wire 2 mm in diameter, which was bent
and soldered to conventional 3 mm gold cylinders

SKIN RESPONSE AT ABUTMENT SITE
Skin response to Percutaneus

abutments has also been

considered as an indicator of success, by rating it on a five
point scale.
This five point scale is a result of the work of Holgers et al in
1987 and has been adopted widely.

Class

Description

0

No irritation: epithelial debris removed if present.

1

Slight redness: temporary local treatment.

2

Red and slightly moist tissue; no granuloma formation:
local treatment; extra controls.

3 Reddish and moist; sometimes granulation tissue:
revision surgery is indicated.
4 Removal of skin-penetrating implant necessary as a
result of infection.
R Removal of implant for reasons not related to skin
problems.

FALLOW UP AND MANAGEMENT
Once a patient is treated, the osseointegration team has to
undertake a lifelong responsibility for the maintenance of the
bone anchored prosthesis. Much time and effort are spent in the
fabrication of a bone anchored prosthesis that will provide a
lifelike facial restoration.

For all of its advantages, the bone anchored facial prosthesis
does require more care on the patient's part and closer
professional follow up than one retained with adhesive.

Follow up management actually begins once the abutments have
been placed.
After the initial healing period and once a surgical dressing is no
longer needed, the patient should be instructed to clean this area
on a daily basis. The purpose is to remove cellular material on the
skin or abutment, which can come from the interface of the
epithelium and abutment.

This is performed with a soft end nylon bristle toothbrush,
an interproximal dental brush, or a cotton swab. To facilitate
cleaning, the area should be moistened first with an even
mixture of hydrogen peroxide and water to soften any dried
debris.

End tuft tooth brush Interproximal tooth brush

Cotton swab

•

The prosthodontist should monitor the stability of the abutment
and the health of the soft tissue during the regularly scheduled
visits for prosthesis fabrication.

Abutment clamp provides counter torque for checking
abutment tightness.

• Abutment tightness can be checked using a abutment
clamp. If the abutment loosens, complete seating should
be verified before retightening. This is done with an
abutment holder.

Abutment holder ensures complete seating of loose abutment.

On the day that the prosthesis is given to the patient,
adequate time should be allotted for instructions on
placing and removing the prosthesis as well as proper
maintenance of the prosthesis, abutments, and
surrounding skin areas.
When placing the prosthesis, the patient should be
certain that the retentive elements are engaged
completely to ensure that the prosthesis is seated fully.
The retention elements (clips, magnets, or balls or
studs) within the acrylic resin plate ensure security of the
prosthesis.

The patient should be careful when removing the prosthesis so
that the thin margins do not tear and the silicone rubber does not
separate from the resin plate.
For an auricular or nasal prosthesis, proper removal by grasping a
thick portion of the prosthesis and slowly disengaging the
retentive elements should be demonstrated and performed
several times by the patient.
For an orbital prosthesis, an outer margin should be lifted
carefully until a thicker portion can be grasped to lift the
prosthesis.

George E. Anastassov and Eric S. Asher (JPD 2000;84:215-16)
stated that the soft tissues overlying the percutaneous implants
are

usually

thick

and

mobile,

which

requires

longer

transcutaneous attachments. However these attachments may

compromise the stability of the implants and lead to the implant
loss. To avoid these complications skin and subcutaneous
debulking and split thickness skin grafts should be performed.

Stephen M. Parel. P I Branemark et al states that the
application of osseointegrated fixtures to the cranial skeleton
for facial prostheses retention marks revolutionary step in
search for the perfect soft tissue replacement. They along
present Eastover technology to be used to its greatest
potential by protecting surface color and allowing long term
retention of fine but weak peripheral margins.

Albertson et al conducted 951 clinical observations of skin
response around 389 abutments for BAHA(243 observations)
and auricular prostheses (708 observations). Of these

observations 92.1% showed no skin response and 3.9%
showed slight redness, potentially serious skin responses
occurred in only 2.8% of observations.

Rubinstein reported that orbital prostheses were fabricated
with wider variety of attachments than any other type bone
anchored facial prostheses: bar clips, magnets, ball studs, or a
combination of these types.

In review of treatment centers Rubenstein found that
magnetic

retention

represented

nearly

half

of

the

attachments in united states and Canada compared with only
one third of those used in Sweden. Clips were used only 20%
of the time in united states, 33% of the time in Canada and
nearly 50% of the time in Sweden. Approximately 20% of the
orbital prostheses in the united states and Sweden used a
combination of magnets and clips.

References
• Osseointegration in Maxillofacial reconstruction :
Per-ingvar branemark, Dan E. Tolman.
• Advanced Osseointegration Surgery – application in
maxillofacial region:

Philip Worthington, Per-ingvar Branemark.
• Maxillofacial rehabilitation:
Keith F. Thomas.

1.

Craniofacial osseointegration .The canadian experience
– Int J Oral maxillofac Implants 1993;8:197-204.

2. Microflora associated with percutaneous craniofacial implants

used for the retention of facial prosthesis
-Int J Oral maxillofac Implants 1995;10:578-82
3. Console abutment loading in Craniofacial osseointegration

-Int J Oral maxillofac Implants 1998;13:245-52.
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