Extraoral implants in the rehabilitation of craniofacial defects: implant and prosthesis survival rates and peri-implant soft tissue evaluation

Exploring digital technologies used in the design and manufacture of craniofacial implant surgical guides: A scoping review

STATEMENT OF PROBLEM

Unlike intraoral implants, digitally planned surgical templates used for guiding the ideal position of the craniofacial implants are not well established, and clear methods and guidelines for their design and construction are lacking.

PURPOSE

The purpose of this scoping review was to identify the publications that used a full or partial computer-aided design and computer-aided manufacture (CAD-CAM) protocol to create a surgical guide that achieves the correct positioning of craniofacial implants to retain a silicone facial prosthesis.

MATERIAL AND METHODS

A systematic search was conducted in MEDLINE/PubMed, Web of Science, Embase, and Scopus for articles published before November 2021 in the English language. Articles needed to satisfy the eligibility criterion of in vivo articles that created a surgical guide with digital technology for inserting titanium craniofacial implants to hold a silicone facial prosthesis. Articles that inserted implants in the oral cavity or upper alveolus only and articles that did not describe the structure and retention of the surgical guide were excluded.

RESULTS

Ten articles were included in the review; all were clinical reports. Two of the articles used a CAD-only approach alongside a conventionally constructed surgical guide. Eight articles described applying a complete CAD-CAM protocol for the implant guides. The digital workflow varied considerably depending on the software program, design, and retention of guides. Only 1 report described a follow-up scanning protocol to verify the accuracy of the final implant positions compared with the planned positions.

CONCLUSIONS

Digitally designed surgical guides can be an excellent adjunct to accurately place titanium implants in the craniofacial skeleton for support of silicone prostheses. A sound protocol for the design and retention of the surgical guides will enhance the use and accuracy of craniofacial implants in prosthetic facial rehabilitation.

Prosthetic Nasal Reconstruction

Prosthetic nasal reconstruction provides a restorative option for patients with nasal defects, and these can be retained with a variety of methods including adhesives and implants. These prostheses can significantly improve appearance, self-esteem, and quality of life for patients and they restore many functions of the external nose. Traditional fabrication methods are often used by the skilled professionals who make these custom prostheses, but digital technology is improving the workflow for design and fabrication of silicone nasal prostheses. Nasal prosthetic reconstruction requires multidisciplinary coordination between surgeons, maxillofacial prosthodontists, anaplastologists, and other members of the healthcare team. Prosthetic treatment can be considered as an alternative to, or an addition to treatment with surgical reconstruction.

Fabrication of orbital prosthesis by two different methods in patients with post-COVID-19 rhino-orbital maxillary mucormycosis: A case series

Neoplasms, congenital disorders, fungal infections, and traumatic injuries are the predominant causes of orbital defects. Various retentive mechanisms such as application of adhesive, utilization of mechanical undercuts, and implant-supported attachments are generally used in the maxillofacial prosthesis. In the orbital region, the result of magnet-retained attachments is favorable compared with other mechanisms. Different advantages of the magnet-retained prosthesis are less manual dexterity needed during insertion or removal and better maintenance of hygiene. The skin-implant interface and thick tissues in the maxillofacial region are the critically important points that should be given importance during the planning and placement of implants. Ideally, implant sites for orbital prosthesis are the lateral, infra-, and supraorbital rims of the orbital region. The following case series describes two different methods to rehabilitate patients with an exenterated eye due to mucormycosis by individually designed implant with magnetic attachment and mechanical undercut-retained orbital prosthesis.

Accuracy of implant placement using CAD-CAM tooth-supported surgical guides for an auricular prosthesis in vitro

PURPOSE

To evaluate the accuracy of tooth-supported surgical guides used to place implants in auricular prostheses. The accuracy (trueness and precision) of the implant positions was evaluated, and the difference between the surgical guide with and without retention of the external auditory canal (EAC) was compared.

MATERIALS AND METHODS

This study simulated implant placement in vitro for the treatment of right auricle malformation. Surgical guides and other casts were fabricated using additive manufacturing technology. The casts were divided into 2 groups according to the surgical guide, with 10 bone blocks in each group (with or without the EAC plug (Guides 1 and 2)). Three implant positions (Implants 1-3) were prepared for each bone block using surgical guides. Implant positions were registered using light-body silicone impressions combined with optical surface scans to measure the coronal, apical, depth, and angular deviations. Four deviations of trueness and precision were reported as the mean ± standard deviation, which was analyzed by Student's t-test.

RESULTS

Each group of 10 bone blocks with 30 implant positions was successfully prepared and digitally reproduced as implants. The accuracies of implant position with surgical guides were acceptable when compared with the preoperatively planned implant positions. Compared with the Guide 2 group, there was a significant difference in the apical, depth, and angular deviations of Guide 1 group in terms of precision (p = 0.001). There was a significant difference in the depth deviation of Implant 1 (p = 0.028) and apical deviation of Implant 2 (p < 0.001) compared two groups in terms of trueness. In terms of precision, there was a significant difference in the coronal (p = 0.002), apical (p = 0.001), and depth (p < 0.001) deviation of Implant 1; apical (p = 0.036) and angular (p < 0.001) deviation of Implant 2 also existed significant difference; the coronal deviation of Implant 3 (p = 0.018) also existed significant difference. Moreover, the group with the EAC plug showed lower deviation in precision and a smaller volume in the 95% confidence ellipsoid.

CONCLUSION

Both types of tooth-supported surgical guides can provide acceptable accuracy. A surgical guide with an EAC plug was considered to be more precise.

A novel design for prosthetic ear guiding device: A technical note

This article describes a newly designed Prosthetic Auricular Guide (PAG) that allows for accurate planning and positioning of both the auricular implants and the prosthetic auricle. The design aims to provide a cost-effective guiding device for more esthetic ear prostheses which is the patient's main concern. Along with determining the best clinically accepted position of the ear, the device can be used while taking CBCT which allows for the integration of the clinically approved position with the remaining bone for accurate planning of implant positions. Furthermore, the device can be fixed during surgery for accurate transmission of the planned position. The device is also adjustable making it suitable for all patterns of auricular defects, different ages, and even for patients with asymmetric faces.

A Contemporary Review of the Role of Facial Prostheses in Complex Facial Reconstruction

BACKGROUND

Maxillofacial prostheses provide effective rehabilitation of complex facial defects as alternatives to surgical reconstruction. Although facial prostheses provide aesthetically pleasing reconstructions, multiple barriers exist that prevent their routine clinical use. The accessibility of facial prostheses is limited by the scarce supply of maxillofacial prosthodontists, significant time commitment and number of clinic appointments required of patients during prosthesis fabrication, short lifespan of prostheses, and limited outcomes data.

METHODS

A literature review was completed using PubMed and Embase databases, with search phrases including face and maxillofacial prostheses. Patient cases are included to illustrate the use of facial prostheses to reconstruct complex facial defects.

RESULTS

The clinical use of facial prostheses requires a multidisciplinary team including a reconstructive surgeon, a maxillofacial prosthodontist, and an anaplastologist, if available, to provide patients with aesthetically appropriate facial prostheses. Developing technology including computer-aided design and three-dimensional printing may improve the availability of facial prostheses by eliminating multiple steps during prosthesis fabrication, ultimately decreasing the time required to fabricate a prosthesis. In addition, enhanced materials may improve prosthesis durability. Long-term outcomes data using validated measures is needed to support the continued use of facial prostheses.

CONCLUSIONS

Facial prostheses can be used to reconstruct complex facial defects, and bone-anchored prostheses are associated with high patient satisfaction. Multiple barriers prevent prostheses from being used for facial reconstruction. New technologies to assist the design and fabrication of prostheses, and cost reduction measures, may allow their use in the appropriately selected patient.

Patient satisfaction with different types of craniofacial prostheses

STATEMENT OF PROBLEM

A maxillofacial prosthesis represents an effective method of giving maxillofacial defects a positive esthetic appearance with minimal risk. However, studies of complications among prosthesis wearers are lacking.

PURPOSE

The purpose of this cross-sectional study was to determine levels of patient satisfaction with various maxillofacial prostheses and retention types, as measured through a survey questionnaire package.

MATERIAL AND METHODS

Patients treated at the Sunnybrook Health Sciences Center Craniofacial Prosthetics Unit (CPU) since 2015 were included. They had been treated according to a standardized protocol and answered a survey questionnaire package with the following sections: demographics, frequency of prosthesis usage, and the Toronto Outcome Measure for Craniofacial Prosthetics (TOMCP-27) survey addressing patient satisfaction. To be eligible for this study, patients must have been more than 18 years of age, in possession of a maxillofacial prosthesis, and received treatment at the Sunnybrook Health Sciences Center CPU since 2015.

RESULTS

A total of 157 patients were eligible and contacted, of whom 51 agreed to participate in the survey. The study population was overall extremely satisfied with their maxillofacial prostheses. In 77.8% of the TOMCP-27 questions, the largest group of patients chose the answer demonstrating the highest level of satisfaction. Of all prosthesis types surveyed, patients with auricular prostheses reported the greatest rates of satisfaction, with the entire group having selected answers corresponding to the highest levels of overall satisfaction. However, patients with orbital prostheses were more likely to experience varying degrees of dissatisfaction, with 72% of the highest reported levels of dissatisfaction being from this prosthesis group. In addition, patients with osseointegrated implant-retained prostheses reported higher satisfaction levels with other retention methods, with the bar clasp group outperforming the magnetic coupling retention group.

CONCLUSIONS

Patients experienced an excellent overall rate of satisfaction with their maxillofacial prostheses. Future development should focus on the continued development of osseointegrated methods, improved magnetic coupling, and improved prosthesis technology, especially for orbital prostheses.

Preparation of hybrid samples for scanning electron microscopy (SEM) coupled to focused ion beam (FIB) analysis: A new way to study cell adhesion to titanium implant surfaces

The study of the intimate connection occurring at the interface between cells and titanium implant surfaces is a major challenge for dental materials scientists. Indeed, several imaging techniques have been developed and optimized in the last decades, but an optimal method has not been described yet. The combination of the scanning electron microscopy (SEM) with a focused ion beam (FIB), represents a pioneering and interesting tool to allow the investigation of the relationship occurring at the interface between cells and biomaterials, including titanium. However, major caveats concerning the nature of the biological structures, which are not conductive materials, and the physico-chemical properties of titanium (i.e. color, surface topography), require a fine and accurate preparation of the sample before its imaging. Hence, the aim of the present work is to provide a suitable protocol for cell-titanium sample preparation before imaging by SEM-FIB. The concepts presented in this paper are also transferrable to other fields of biomaterials research.

Carboxymethyl Dextran-Based Nanomicelle Coatings on Microarc Oxidized Titanium Surface for Percutaneous Implants: Drug Release, Antibacterial Properties, and Biocompatibility

Bacterial contamination and biofilm formation onpercutaneous implants can lead to device failure and be life-threatening. To solve this issue, we constructed a carboxymethyl dextran- (CMD-) based nanomicelle antibacterial coating on the microarc-oxidized titanium (MAO-Ti) surface (described in the supplementary file). The self-assembled CMD-based nanomicelles and octadecylamine (ODA) were developed as a drug carrier and loaded with minocycline (MC). The characterization and stability of the MC-loaded nanomicelles were determined. The surface roughness, hydrophilicity, and drug release property of the coatings were also investigated. Our findings showed that the cross-linked MC-loaded nanomicelles (MC@(ODA-CMD)CL) were more stable than the uncross-linked nanomicelles. Moreover, MC@(ODA-CMD)CL was successfully incorporated into the pores of MAO-Ti, which significantly increased the surface hydrophilicity of the coatings without influencing their surface roughness. In addition, the coatings demonstrated a sustained release time of 360 h, with a cumulative release rate reaching 86.6%. Staphylococcus aureus (S. aureus) was used to determine the antibacterial properties of the coatings, and human skin fibroblasts were seeded on them to investigate their biocompatibility. The results showed that the coatings significantly reduced the number of adhesive S. aureus and promoted the viability, adhesion, and morphology of the human skin fibroblasts compared to smooth titanium (S-Ti) sheets. In conclusion, MC-loaded CMD-based nanomicelles coated on MAO-Ti surface (MC@(ODA-CMD)CL-Ti) demonstrated sustained-release properties, excellent antibacterial properties and biocompatibility, and promising potential as coatings for percutaneous implants.

Oculofacial Prosthetic Rehabilitation Complemented With Temporary Fillers and Neurotoxin

ABSTRACT

Surgical treatment of head and neck cancer causes severe tissue loss, therefore, deformities and psychosocial consequences. In cases involving orbit exenteration, satisfactory reconstruction can only be achieved with prosthetic replacement, despite successful reconstructive plastic surgery. Extraoral implants, 3D scanning, and prototyping technologies have contributed to increase satisfactory aesthetic results of oculofacial prosthesis. However, to achieve prosthetic rehabilitation refinement, patients' biological tissues have been treated with injectable cosmetic adjuncts methods as complements to results. This study aimed to describe the use of botulinum toxin type A, hyaluronic acid, and calcium hydroxyapatite previously to oculofacial prostheses manufacturing, in 5 oncologic patients of a rehabilitation unit. Outcomes produced by additional cosmetic methods on tissues, prostheses planning, and overall facial rehabilitation were observed and registered by photographs. Botulinum toxin type A, hyaluronic acid, and calcium hydroxyapatite has shown to be useful in improving asymmetries, volumizing surgical depressions and dissembling atrophic scars. Presenting an additional resource to improve overall results, enabling the manufacturing of smaller, thinner, and better-fitting oculofacial prostheses. Limitations as chronic infection and necrosis episodes, related to filler injection into previously irradiated sites, were described. The temporary effect of the materials used generates a need for reapplications but increases the safety of such procedures and enables patients' cancer treatment follow-up.

9-year follow up on maxillofacial implant-supported framework designed to accommodate childhood growth

This clinical report focuses on the challenges and solutions for a child subjected to craniofacial trauma from a wild hyena biting off his nose and anterior maxilla. Unique considerations in prosthodontics and biomedical engineering were required based on future craniofacial growth and development of the child. The physical requirement of a maximum retentive prosthesis for an active, athletic child required unique engineering designs and executions. The sequence of treatment and prosthesis fabrication are detailed. The patient has been followed for nine years without physiologic complications and only minor prosthodontic complications. This article is protected by copyright. All rights reserved.

Outcome measures in facial prosthesis research: A systematic review

STATEMENT OF PROBLEM

Facial prosthesis research uses a wide variety of outcome measures, which results in challenges when comparing the effectiveness of interventions among studies. Consensus is lacking regarding the most appropriate and meaningful outcome measures to use in facial prosthesis research to capture important perspectives.

PURPOSE

The purpose of the systematic review was to identify and synthesize outcome measures used in facial prosthesis research.

MATERIAL AND METHODS

Electronic searches were performed in 11 databases (including nonpeer-reviewed literature). The citations were searched, and expert societies were contacted to identify additional studies. Inclusion criteria comprised studies of participants with facial defects who required or had received prosthetic rehabilitation with an external facial prosthesis. Exclusion criteria comprised participants with ocular prostheses, case reports, case series with fewer than 5 participants, laboratory-based studies, and studies published before 1980. Study selection was performed independently by 2 reviewers. Discrepancies were resolved through discussion or by a third reviewer. Outcome measures were synthesized with a categorization approach based on the perspective, theme, and subtheme of the outcome measures. Quality assessment was performed with an appraisal tool that enabled evaluation of studies with diverse designs.

RESULTS

Database searching identified 13 058 records, and 7406 remained after duplications were removed. After initial screening, 189 potentially relevant records remained, and 186 full texts were located (98% retrieval rate). After full-text screening, 124 records were excluded. Citation searches and contact with expert societies identified 4 further records. In total, 69 articles (grouped into 65 studies) were included. Studies were categorized as per the perspective of their outcome measures, with the following findings: patient-reported (74% of studies), clinical indicators (34%), clinician-reported (8%), multiple viewpoints (6%), and independent observer-reported (3%). Patient-reported outcome measures included tools to assess satisfaction, quality of life, and psychologic health. Variability in the choice of outcome measures was evident among the studies, with many self-designed, unvalidated, condition-specific questionnaires reported. A greater number of outcome measure themes emerged over time; themes such as service delivery and health state utility have recently been evaluated.

CONCLUSIONS

Over the past 40 years, facial prosthesis research has focused on patient-reported outcome measures. Outcome measures relating to other perspectives have been used less frequently, although new themes appear to be emerging in the literature. Future research should use outcome measures with appropriate measurement properties for use with facial prosthetics.

Osseointegrated Implants for Orbito-Facial Prostheses: Common Complications and Solutions

PURPOSE

To evaluate anatomical and functional results of osseointegration with magnetic coupling for oculofacial prosthetic rehabilitation after exenteration.

METHODS

This retrospective study included 11 consecutive patients who received orbital reconstruction and oculofacial prosthetic rehabilitation between September 2015 and October 2019. Patient demographics, surgical indications, previous treatment procedures, histopathologic features, and reconstructive procedures were recorded.

RESULTS

The mean age was 37.81 ± 23 years (range 5-78 years). The mean follow-up was 23.81 ± 12 months (range 10-48 months). The principal diagnoses were squamous cell carcinoma of the eyelids (n = 2/11), mucoepidermoid carcinoma of the maxillary sinus (n = 2/11), rhabdomyosarcoma (n = 1/11), mucormycosis (n = 1/11), neurofibromatosis (n = 1/11), basosquamous carcinoma (n = 1/11), malign melanoma (n = 1/11), primitive neuroectodermal tumor (n = 1/11), and retinoblastoma (n = 1/11). Six of the patients were repaired by primary closure. Procedures performed to reconstruct the orbital cavity included split-thickness skin graft (n = 2/11), temporalis muscle flap (n = 2/11), and frontalis muscle flap (n = 1/11). Nine of the 11 patients who received orbital implants were successfully rehabilitated by epithesis. Postoperative complications included implant loss (n = 4/11), periprosthetic local infection (n = 3/11), and soft tissue overgrowth around the orbital prosthesis (n = 2/11). All patients had Straumann bone level implant (Basel, Switzerland) osseointegrated titanium implants (3.5 mm) placed in a 2-stage procedure over a span of 3 to 4 months with subsequent successful prosthesis fitting.

CONCLUSION

The reconstructive methods following orbital exenteration, should be customized according to the patients' characteristics such as extension of the orbital defect, bone quality, and expectations to achieve satisfactory results.

Biomaterials in Craniomaxillofacial Reconstruction: Past, Present, and Future

ABSTRACT

Deformity and tissue loss involving the craniomaxillofacial region occurs frequently as a result of trauma, oncologic resection, or a congenital malformation. In order to maximize the patient's quality of life, reconstruction of the craniomaxillofacial skeleton must seek to restore aesthetics as well as function. Advances in diagnostic technology, surgical technique, instrumentation, and innovative biomaterials used have transformed the way reconstructive surgeons approach their patients' needs. From the advent of alloplastic reconstruction, surgeons have sought the ideal material for use in craniomaxillofacial surgery. Substances such as metals, ceramics, glasses, and more recently resorbable polymers and bioactive materials have all been utilized.While autologous bone has remained widely-favored and the gold standard, synthetic alternatives remain a necessity when autologous reconstruction is not readily available. Today, alloplastic material, autografting via microvascular tissue transfer, hormone and growth factor-induced bone formation, and computer-aided design and manufacturing of biocompatible implants represent only a fraction of a wide range of options used in the reconstruction of the craniomaxillofacial skeleton. We present a brief review of the materials used in the repair of deformities of the craniomaxillofacial skeleton as well as a look into the potential future direction of the field.

Orbital exenteration: an updated review with perspectives

Orbital exenteration is a radical and disfiguring surgery mainly performed in specialized tertiary care centers. Orbital exenteration has long been considered the treatment of choice for managing periocular tumors invading the orbit or primary orbital malignancies. Over the past decades, attention has been directed toward reducing the perioperative morbidity by developing new surgical devices and new strategies and promoting cosmetic rehabilitation by providing adequate facial prostheses. Despite these advances, several studies have questioned the role of orbital exenteration in improving overall survival. The last decade has been marked by the emergence of a new paradigm: the "eye-sparing" strategies based on conservative surgery with or without adjuvant radiotherapy and/or targeted therapies and immunotherapies. We summarize the data on orbital exenteration, including epidemiology, etiologies, use of surgical ablative and reconstructive techniques, complications, outcomes, and the related controversies.

Digital surgical planning and placement of osseointegrated implants to retain an auricular prosthesis using implant software with cone-beam computed tomography and 3D-printed surgical guides: A case report

Integration of CBCT imaging with dental implant treatment planning software and 3D-printed surgical guides can facilitate surgical planning for extraoral implant placement. In the current case, this combined planning strategy enabled navigation of challenging osseous anatomy, avoided critical structures, and optimized osseointegration for prosthesis retention.

The challenge of managing oral maxillofacial rehabilitation with quality and cost-benefit

Although orofacial cancer leads to substantial functional, esthetic, and psychosocial deficits for patients, reconstructive plastic surgeries may not be indicated for large facial defects. The high costs of prosthetic oral maxillofacial rehabilitation may hamper such treatment, which commonly involves virtual planning, craniofacial implants, and computer-aided design and computer-aided manufactured prostheses. This report shows the treatment of 2 patients with large facial defects from surgical resection of cancerous tissue who were rehabilitated with implant-supported bar-clip overdentures and facial prostheses fabricated by using low-cost straightforward methods.

Implant prognosis in irradiated versus non-irradiated nasal, orbital and auricular sites

The purpose of this systematic review was to evaluate implant survival in irradiated nasal, auricular, orbital sites and to compare them with non-irradiated respective sites. Four electronic databases and seven related journals were searched until December and March 2018, respectively. A total of 7892 articles were identified, 18 of which were included in this review; one non-randomized clinical trial, two prospective cohort, eight retrospective cohort and seven cross-sectional studies. Using the ROBIN-I Cochrane tool for risk assessment, 13 studies were judged at serious, one at moderate and four at critical risk of bias. Thirteen were included in 18 meta-analyses, the results of which showed a significant difference between irradiated and non-irradiated sites, favouring non-irradiated with risk ratio (RR) = 0.93, 95% confidence interval (CI) 0.89-0.97, P=0.001. Comparisons among nasal, auricular and orbital sites revealed no significant differences, whether in irradiated or non-irradiated patients at P<0.05. Hence, it was concluded that, within the limitations of this review, survival of craniofacial implants is negatively affected by radiotherapy, especially in orbital sites. Level of evidence is moderate. Therefore, further prospective cohort studies with calculated sample sizes, restricted or properly managed confounders and no deviations from intended interventions might produce different results.

Maxillofacial prosthetic rehabilitation: A survey on the quality of life

STATEMENT OF PROBLEM

Maxillofacial prostheses, especially those supported by endosseous implants, are regarded as a viable, secure treatment for the reconstruction of facial defects to restore quality of life. The long-term quality of life of patients treated with facial prostheses with different retentive systems is unclear.

PURPOSE

The purpose of this clinical study was to assess the long-term quality of life of patients treated with facial prostheses with different retentive systems over a 14-year period at a Dutch oral and maxillofacial surgery unit.

MATERIAL AND METHODS

A total of 66 patients with facial prostheses were inventoried and categorized based on anatomic location and type of retention. A 62-item questionnaire was designed to survey the daily prosthetic use, care, quality, durability, longevity, and reliability of retention. Furthermore, issues relating to general satisfaction, self-image, and socialization frequency were addressed.

RESULTS

Completed validated questionnaires were returned by 52 patients. Of the prosthetic replacements, 23% (n=12) were orbital, 33% (n=17) nasal, and 44% (n=23) auricular prostheses. The survey showed that a prosthetic reconstruction led to high satisfaction scores with regard to wearing comfort, anatomic fit, color, and anatomic form. A significant difference was shown for implant-retained facial prostheses, which provided enhanced retention and increased ease of placement and removal (Fisher exact test P=.01 and P=.04). Patients with nasal prostheses were less satisfied with the junction of their prostheses to the surrounding soft tissue and more aware of others noticing their prosthetic rehabilitation. Patients with auricular defects were less embarrassed (P=.01) by their prostheses. Although auricular prostheses were less frequently cleaned (P=.01), no significant difference was found in minor soft tissue complications between different anatomic locations and the various retentive systems.

CONCLUSIONS

Implant-retained prostheses have advantages over adhesive-retained prostheses in terms of ease of handling. However, improvements in prosthetic material properties, including color stability and durability, are needed to increase the longevity of facial prostheses.

Advancements in craniofacial prosthesis fabrication: A narrative review of holistic treatment

The treatment of craniofacial anomalies has been challenging as a result of technological shortcomings that could not provide a consistent protocol to perfectly restore patient-specific anatomy. In the past, wax-up and impression-based maneuvers were implemented to achieve this clinical end. However, with the advent of computer-aided design and computer-aided manufacturing (CAD/CAM) technology, a rapid and cost-effective workflow in prosthetic rehabilitation has taken the place of the outdated procedures. Because the use of implants is so profound in different facets of restorative dentistry, their placement for craniofacial prosthesis retention has also been widely popular and advantageous in a variety of clinical settings. This review aims to effectively describe the well-rounded and interdisciplinary practice of craniofacial prosthesis fabrication and retention by outlining fabrication, osseointegrated implant placement for prosthesis retention, a myriad of clinical examples in the craniofacial complex, and a glimpse of the future of bioengineering principles to restore bioactivity and physiology to the previously defected tissue.

[The interdisciplinary approach to the rehabilitation of the patients presenting with congenital atresia of the external auditory canal and the concomitant microtia]

The objective of the present study was to develop and introduce into the clinical practice the method for the combined aesthetic and functional rehabilitation of the patients presenting with congenital atresia of the external auditory canal (CAEAC) and the concomitant microtia. A total of 8 patients at the age from 6 to 21 years with unilateral CAEAC and microtia were given the surgical treatment. During the intervention, atresia was resolved using the trans-mastoid approach, tympanoplasty of autofasciae and ossiculoplasty making use of the partial titanium prosthesis and the placement of cranial osteointegratable titanium implants. At the second stage of the surgical intervention the 3D silicone prosthesis of the auricle shaped on an individual basis were used. The long-term follow-up observations have demonstrated the stable formation of the tube of the external auditory canal, with the bone-air interval amounting to 15-20 dB. The auricular prosthesis was the mirror image of the natural ear and completely concealed the congenital defect.

Quality of life assessment of patients utilizing orbital implant-supported prostheses

STATEMENT OF PROBLEM

Evaluate the effect of orbital prosthesis retained by implants through a specific quality of life (QOL) questionnaire provides important information on patients QOL, great incentive for the multidisciplinary team and public health support to continue work in this area.

PURPOSE

The objective of the study was to evaluate patient satisfaction with orbital implant-supported prostheses using an adapted quality of life questionnaire.

MATERIALS AND METHODS

Forty five patients using orbital implant-supported prostheses for a period ranging from six to 120 months. The subjects answered a questionnaire that consisted of 10 questions covering appearance, retention, conspicuousness, self-confidence, difficulty of placement, difficulty of removal, cleaning, limitation of activities, discomfort of tissues, and recommendation of the method to other patients. Answers were expressed using a visual 100-mm scale. The arithmetic mean of the responses was converted into a percentage to represent the satisfaction index.

RESULTS

Patients demonstrated a high level of satisfaction on all items, with the lowest rate being for aesthetics and the highest being for recommending the method to other patients. High satisfaction rates regarding the placement and removal of the prosthesis, discomfort to the tissues, and cleaning suggest the ease of handling of the prosthesis. High satisfaction with retention, self-confidence, conspicuousness of the prosthesis, and limitation of activities indicated an association with a better social life.

CONCLUSIONS

The results showed that use of bone anchorage technique of extraoral prostheses provided a high level of satisfaction among patients, confirming that osseointegrated implants are a very important resource for the rehabilitation of orbital deformities.

Complex functional and epithetic rehabilitation after ablation of recurrent retroauricular basal cell carcinoma - a case study

The reconstruction of extended defects of the concha poses a complex challenge for plastic surgeons. In cases of subtotal ablation, an alternative method designed especially for elderly oncological patients consists of epithetic rehabilitation. However, inserting an implant-retained concha epithesis proves challenging in patients with antecedents of deep resections involving the mastoid process. In the present case study, we report on the long-term treatment course (2009-2017) of a 79-year-old male patient suffering from a recurrent basal cell carcinoma of the retroauricular region. Following tumor resection, along with lateral mastoidectomy, reconstruction, and adjuvant radiotherapy, functional and esthetic deficits primarily due to peripheral facial nerve palsy were successfully managed using a multistep procedure. The procedure was completed by inserting an implant-retained concha epithesis, resulting in improved quality of life. Due to prior lateral mastoidectomy, ultra-short implants (4 mm) were inserted, partially at atypical positions. For maintaining healthy periimplant soft tissue, aftercare comprised cold plasma treatment. This oncologic case demonstrates the therapeutic necessity of using a broad spectrum of reconstructive procedures, along with their limitations, in a critical anatomic region. Specific features include the presentation of a workflow using ultra-short implants in a compromised mastoid region. Surgeons should consider alternative implant positions in the event of any compromised mastoid process. A particular emphasis has been put on meticulous aftercare to preserve healthy periimplant soft tissues.

Prosthetic supply of facial defects: long-term experience and retrospective analysis on 99 patients

INTRODUCTION

Defects in the head region may be caused by tumour treatments, injuries, as well as congenital malformations. The restoration of these defects that can be performed through reconstructive plastic surgery and/or prosthetic surgery occupies a high priority in the physical and psychological rehabilitation of the patient. The present study reports on long-term experience in supply of facial prosthesis.

MATERIALS AND METHODS

The medical records of 99 patients, who had been supplied with custom-made facial prostheses between 2001 and 2011, were evaluated retrospectively.

RESULTS

There were 59 male (60%) and 40 (40%) female patients. The reason for prosthetic supplement was a tumour disease in 50 patients, congenital malformation in 39 patients, and trauma in 10 patients. Fifty-three patients were treated with ear prosthesis, twenty-seven patients were treated with eye prosthesis, and nineteen patients with nasal prosthesis. 82.8% of prosthetic supplies were designed as magnetic support prostheses. The most common complication was skin redness around the implants. 10% of patients suffered the loss of the osseointegrated implants.

CONCLUSION

The osseointegrated titanium implants with magnet support provide a reliable attachment for prosthesis and constitute a promising alternative to surgical reconstruction of complex facial defects.

Management of Peri-Implant Hypertrophic Scarring for an Ear Prosthesis

The clinical report describes a case of a 14-year-old patient with a traumatic amputation of the left auricle and severe hypertrophic scarring. The management of peri-implant soft tissue was challenging, but successful in the rehabilitation of a patient with auricular prosthesis retained by implants. The prosthesis restored the patient's facial aesthetics and contributed not only to function, but also to psychosocial well-being.

Using Osseointegrated Implants Concomitant With Onlay Bone Grafting for Auricular Reconstruction

Conventional dental implants have been reported for nasal and orbital regions but due to limited thickness of calvarium they are not used in mastoid region. Onlay bone grafting in skull concomitant with implants is a predictable method and experimental animal studies confirm it. Parietal bone and lateral mandibular ramus are suggested source of bone grafts and dental implants with 7 mm length can be used safely. Increased fixture length may lead to increase survival in long term.

Retention systems for extraoral maxillofacial prosthetic implants: a critical review

We describe the techniques available for retention of implant-supported prostheses: bar-clips, O-rings, and magnets. We present reported preferences and, although this is limited by the heterogeneity of methods used and patients studied, we hope we have identified the best retention systems for maxillofacial prosthetic implants. If practitioners know the advantages and disadvantages of each system, they can choose the most natural and comfortable prosthesis. We searched the PubMed and Scopus databases, and restricted our search to papers published 2001-13. MeSH terms used were Maxillofacial prosthesis and Craniofacial prosthesis OR Craniofacial prostheses. We found a total of 2630 papers, and after duplicates had been removed we analysed the rest and found 25 papers for review. Of these, 12 were excluded because they were case reports or non-systematic reviews. Of the remaining 13, 10 described group analyses and seemed appropriate to find practitioner's choices, as cited in the abstract (n=1611 prostheses). Three papers did not mention the type of prosthetic connection used, so were excluded. The most popular choices for different conditions were analysed, though the sites and retention systems were not specified in all 10 papers. The bar-clip system was the most used in auricular (6/10 papers) and nasal prostheses (4/10). For the orbital region, 6/10 favoured magnets. Non-osseointegrated mechanical or adhesive retention techniques are the least expensive and have no contraindications. When osseointegrated implants are possible, each facial region has a favoured system. The choice of system is influenced by two factors: standard practice and the abilities of the maxillofacial surgeon and maxillofacial prosthetist.

Combination prosthetic design providing a superior retention for mid-facial defect rehabilitation: A Case Report

Large maxillofacial defects from malignant tumor treatment are rarely rehabilitated by surgical reconstruction alone. Ameloblastic carcinoma, a rare aggressive odontogenic malignant tumor, requires wide surgical excision to gain a tumor-free margin. In the post-surgical defect, prosthetic rehabilitation is the treatment of choice to restore function and esthetics. Moreover, an intra-oral prosthesis such as an obturator restores speech, mastication and deglutition. Retention of the obturator is a major problem while rehabilitating large defects. The existing anatomical structures from the defect with the help of magnet attachments are suitable to enhance retention, stability and support of the prostheses. This case report presents a patient with an intraoral and extra-oral combination defect following surgical resection of ameloblastic carcinoma and describes the prosthetic techniques and design considerations for a magnet-retained obturator and mid-facial prosthesis. An implant-retained mid-facial prosthesis was fabricated. The retention of combined prostheses was obtained from the remaining right posterior teeth only. The patient had an unfavorable defect due to the large size and presence of scar contracture that vertically tends to dislodge the obturator. Magnet attachments were used to combine the facial and oral prosthesis, minimize the vertical dislodging forces and enhance retention. In addition, the retention was also gained from the scar band at lower border of mid-facial defect that avoided the need for more implants surgery. Magnet attachment with anatomical structure of the mid-facial defect provides an acceptable means of retention in large extraoral-intraoral combinations defects, improving the function, esthetic and the patients' quality of life. Key words:Mid-facial prosthesis, obturator, magnet attachment, maxillectomy.

A decomposable silica-based antibacterial coating for percutaneous titanium implant

Although percutaneous titanium implants have become one of the best choices as retainers in the facial defects, peri-implantitis still occurs at a significant rate. This unwanted complication occurs due to adhesion of bacteria and subsequent biofilm formation. To solve this problem, we have developed a novel antibiotic nanodelivery system based on self-decomposable silica nanoparticles. In this study, silica-gentamycin (SG) nanoparticles were successfully fabricated using an innovative one-pot solution. The nanoparticles were incorporated within a gelatin matrix and cross-linked on microarc-oxidized titanium. To characterize the SG nanoparticles, their particle size, zeta potential, surface morphology, in vitro drug release, and decomposition process were sequentially evaluated. The antibacterial properties against the gram-positive Staphylococcus aureus, including bacterial viability, antibacterial rate, and bacteria morphology, were analyzed using SG-loaded titanium specimens. Any possible influence of released gentamycin on the viability of human fibroblasts, which are the main component of soft tissues, was investigated. SG nanoparticles from the antibacterial titanium coating continuously released gentamycin and inhibited S. aureus growth. In vitro investigation showed that the obtained nanodelivery system has good biocompatibility. Therefore, this design can be further investigated as a method to prevent infection around percutaneous implants.

Osseointegration and implant stability of extraoral implants in Göttingen minipigs after irradiation

OBJECTIVES

The aim of this study was to compare the influence of implant surface treatment and irradiation dose on implant stability and osseointegration of 144 extraoral implants in irradiated frontal bone of minipigs.

MATERIAL AND METHODS

144 implants with 3 different surface treatments (machined, etched and HAVD-coated) were implanted in the frontal bone of 16 Göttingen minipigs. Three groups of four pigs received radiation with equivalent doses of 25, 50 and 70 Gy, and one group served as control. Resonance frequency analysis (RFA) was performed recording Implant Stability Quotients (ISQ) at implant placement and 3 months thereafter. Removal torque was measured whilst removing specific implants after 3 months. In addition, the bone-to-implant contact (BIC) was analyzed.

RESULTS

Evaluation of ISQ, BIC-values showed no significant difference between the different surface treatments in irradiated and non-irradiated bone. Removal torque revealed statistically significant differences between machined and HAVD-coated implants in the irradiated bone.

CONCLUSIONS

Implant stability and osseointegration, based on Removal Torque showed significant higher results for the HAVD-coated implants. No significant difference was observed between the irradiated and non-irradiated animals. This study shows that HAVD-coated extraoral implants can potentially be used for craniofacial rehabilitation in non-irradiated and irradiated bone.

A systematic comparison of bar-clips versus magnets

STATEMENT OF PROBLEM

Currently, which type of suprastructure is preferred when fabricating implant-retained craniofacial prostheses is unknown.

PURPOSE

The purpose of this systematic review was to identify the best retention system (bar-clips versus magnets) for implant-retained craniofacial prostheses.

MATERIAL AND METHODS

This systematic review was conducted and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. A systematic search of Medline/PubMed and Web of Science databases for clinical trials was conducted on implant-retained craniofacial prostheses published between 2005 and 2015. English-language studies that directly compared different types of retention systems or presented information on implant survival, periimplant soft tissue reactions, and prosthetic complications were included. Nonclinical studies were excluded to eliminate bias.

RESULTS

A total to 173 studies were identified, of which 10 satisfied the inclusion criteria. In total, 492 participants were included in these studies. Four selected studies displayed detailed information with regard to the number of implant failures according to the retention system. As reported, 29 (18.2%) of 159 implants with magnets failed, whereas 25 (31.6%) of 79 implants with bars failed. Overall auricular superstructures showed the highest survival (99.08%). In addition, 55.4% of all participants in the selected studies showed grade 0 of periimplant soft tissue reactions.

CONCLUSIONS

A systematic search for clinical studies resulted in few studies with a short-term follow-up and small number of participants. The limited data collected indicated that magnets show fewer complications than bar superstructures; however, no hard conclusions could be drawn. Further research, preferably in the form of clinical trials, is needed to validate these findings.

Epithetic nasal reconstruction for nasal carcinoma: retrospective analysis on 22 patients

Advanced nasal cancers usually demand partial or total rhinectomy followed by radiotherapy. Reconstruction of the resulting defects can be achieved by means of reconstructive plastic surgery and/or epithetic surgery. The data of 22 patients who had been treated after nasal ablation by means of custom-made silicone nasal epithesis fixed by bone-anchored magnets between 2003 and 2014 were evaluated retrospectively. There were 15 male (68.2 %) and 7 (31.8 %) female patients. The most common etiology that led to epithetic rehabilitation was a squamous cell carcinoma in 16 patients. An operative revision was necessary in two patients due to screw loss. Twenty patients were still alive with no evidence of disease after minimum follow-up of 2 years (90.9 %). Epithetic rehabilitation after nasal ablation to treat nasal malignancies is an interesting alternative to plastic and reconstructive surgery. Bone-anchored fixation using magnets can achieve a stable epithetic fixation after nasal ablation necessitating, in numerous cases, additional adjuvant therapy like radiation.

Survival and complications of implants to support craniofacial prosthesis: A systematic review

OBJECTIVE

To assess the survival rate of craniofacial implants (CIs) to support facial prosthesis/epithesis and the prevalence of surgical/biological complications based on previously published studies.

METHODS

An electronic search was undertaken in March/2016. Only studies with a minimum of 5 patients were included. Untransformed proportions of implant failures for different regions were calculated. A meta-analysis evaluated the influence of radiotherapy on the failure rates. A meta-regression was performed considering the follow-up period as covariate.

RESULTS

Seventy publications included 2355 patients and 8184 CIs (545 failures). The probability of a failure was 5.5% for all CIs (95%CI 4.5-6.5, P < 0.001), 1.2% for CIs in the auricular region (95%CI 0.8-1.5, P < 0.001), 12.2% for the nasal region (95%CI 9.0-15.5, P = 0.017), and 12.1% for the orbital region (95%CI 9.3-15.0, P < 0.001). Radiotherapy statistically affected the CIs rates (OR 5.80, 95%CI 3.77-8.92, P < 0.00001). There was no statistically significant influence of the follow-up time on the proportion of implant failures (P = 0.814). Soft tissue adverse reactions were the most common complications.

CONCLUSIONS

Implants placed in the auricular region have a lower probability of failure than those in the nasal and orbital regions. Soft tissue adverse reactions were the most common complications. Radiotherapy significantly affected the CIs failure rates.

Treatment Outcome of the Transfacial Titanium Epiplating System for Total Nasal Defects

BACKGROUND

Malignant tumors are the most frequent reason for acquired defects of the nose. Bone-anchored craniofacial prostheses represent a secure, uncomplicated, and cosmetically acceptable rehabilitative alternative to surgical reconstruction. The aim of this study was to determine a potential benefit of the Titanium Epiplating System (Fa. Medicon, Tuttlingen, Germany) as a grouped implant system in the anatomically difficult nasal region with limited bone supply.

METHODS

Patients with complete nasal defects who received a transfacial Titanium Epiplating System between January of 2009 and December of 2013 for nasal prostheses were included. The Epiplating titanium plates are specially adapted to the nasal region and were modified individually. Implant survival, periimplantitis, clinical course, and risk factors for implant survival were assessed retrospectively, including univariate statistics.

RESULTS

Fifty-three patients were included in this study. At the time of last follow-up, 51 of 53 Epiplating systems (96.2 percent) were stable in situ. One titanium plate had to be renewed because of a traumatic accident and one plate had to be removed because of disease recurrence. Periimplantitis occurred in 7.5 percent and could be treated successfully by either local or systemic antibiotic therapy without any loss of stability in bone anchorage. Only smoking significantly increased the risk of periimplantitis (p = 0.013), whereas age, irradiation, chemotherapy, and immunosuppression did not influence the outcome of therapy. The median healing time with use of the Titanium Epiplating System was 3.6 ± 2.7 months.

CONCLUSIONS

The Titanium Epiplating System is a safe and uncomplicated system for bone-anchored retention of nasal prostheses. Good aesthetic results can be achieved.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Monoscopic photogrammetry to obtain 3D models by a mobile device: a method for making facial prostheses

Purpose

The aim of this study is to present the development of a new technique to obtain 3D models using photogrammetry by a mobile device and free software, as a method for making digital facial impressions of patients with maxillofacial defects for the final purpose of 3D printing of facial prostheses.

Methods

With the use of a mobile device, free software and a photo capture protocol, 2D captures of the anatomy of a patient with a facial defect were transformed into a 3D model. The resultant digital models were evaluated for visual and technical integrity. The technical process and resultant models were described and analyzed for technical and clinical usability.

Results

Generating 3D models to make digital face impressions was possible by the use of photogrammetry with photos taken by a mobile device. The facial anatomy of the patient was reproduced by a *.3dp and a *.stl file with no major irregularities. 3D printing was possible.

Conclusions

An alternative method for capturing facial anatomy is possible using a mobile device for the purpose of obtaining and designing 3D models for facial rehabilitation. Further studies must be realized to compare 3D modeling among different techniques and systems.

Clinical implication

Free software and low cost equipment could be a feasible solution to obtain 3D models for making digital face impressions for maxillofacial prostheses, improving access for clinical centers that do not have high cost technology considered as a prior acquisition.

Soft Tissue Response and Survival of Extraoral Implants: A Long-Term Follow-up

Maxillofacial defects may be reconstructed by plastic surgery or treated by prosthetic mean rehabilitation. In case of large defects, prosthetic rehabilitation rather than surgical reconstruction is preferred due to the insufficient esthetic results of surgical interventions. However, retention of the craniofacial prosthesis is a great problem despite the satisfactory esthetic results. With the presentation of extraoral implants, the retention of maxillofacial prostheses was improved, and osseointegrated craniofacial implants have become indispensable for retention and stability. However, there are conflicting results regarding the success rates of osseointegrated implants used at the craniofacial region. A total of 24 patients with 64 implants (30 in auricular region of 13 patients, 24 in nasal region of 8 patients, and 10 in orbital region of 3 patients) ranging in age from 16 to 83 years (mean age = 45.45 years) were evaluated. One patient among 13 patients (1/13) has lost his implants in the auricular area, 1 patient among 8 patients (1/8) lost his implants, and 1 patient among 3 patients (1/3) has lost all of her implants. Peri-implant soft tissue response was evaluated for a 60-month period and a total of 654 visits/sites recorded. Grade 0 (no irritation) was present in 72.8% (476/654) of the visits/sites. Grade 1 (slight redness) was observed for 18.8% (123/654). Grade 2 (red and slightly moist tissue) was scored in 6.9% (45/654). Grade 3 (red and slightly moist tissue with granulation) was noted in 1.5% (10/654) and grade 4 (infection) could not be found. Ossseointegrated implants provide reasonable support and show successful results when used with maxillofacial prostheses.

Osseointegrated implants for orbito-facial prostheses: Preoperative planning tips and intraoperative pearls

PURPOSE

Implant-retained facial prostheses are becoming increasingly sophisticated. We describe our experience with successful implant placement.

METHODS

Retrospective case series. Patients with severe unilateral orbital deformity who underwent socket reconstruction with placement of orbital implants were identified. Data on patient age, gender, mechanism of eye, soft tissue, and bone loss, prior reconstructive surgeries and radiation, and orbital imaging were collected and analyzed.

RESULTS

Four patients (9 implants) between 2010 and 2014, who had osseointegrated implants placed for orbito-facial prostheses were identified. Three were male, one female. Average age was 59 years (range 34-86). Reason for eye loss was trauma in two patients, exenteration for recurrent rhabdomyosarcoma in one patient, and enucleation for retinoblastoma in one patient. All patients had Vistafix® (Gothenburg, Sweden) osseointegrated titanium implants (4 mm) placed in a 2-stage procedure over a span of 3-6 months with subsequent successful prosthesis fitting.

CONCLUSION

Implant-retained orbito-facial prostheses are safe, easy, and reliable. The ideal socket has minimal dead space, robust bone, and soft tissue 4-5 mm in depth. Preoperative planning should consist of: 1) orbit CT; 2) careful clinical exam of the orbital deformity; and, 3) analysis of socket topography. Operative tips for successful implant placement include: 1) 2-3 points of fixation; 2) placement of implants in bone of adequate thickness; and 3) implant placement as a 2-stage rather than 1-stage procedure. There appears to be no difference in outcome in irradiated and non-irradiated sockets in this series, but should be a consideration and discussed with the patient.

Patients' satisfaction with facial prostheses

We assessed the "impact on wellbeing" and "satisfaction" of patients who had a facial prosthesis (of the ear, nose, or orbit) fitted in The Netherlands Cancer Institute. Patients had either an adhesive-retained or an implant-retained facial prosthesis between 1951 and 2011. We did a cross-sectional survey of 104 patients, then gave a questionnaire to the final study group of 71 (68%), a year or more later. All were satisfied with their prostheses (visual analogue scale (VAS): mean (SD) 8.1(1.5). The implant-retained group were the most satisfied (p=0.022), and the adhesive-retained group felt more self-conscious (p=0.013). Three-quarters of all patients said that the prosthesis was not painful and there were no problems with the way it functioned. A well-designed facial prosthesis has obvious benefits, but there were no appreciable differences between the two groups. Each patient must make a careful decision about which type of prosthesis to choose, taking into account the quality of their remaining tissue, the site of the defect, and their general health.

Recommendations for implant-retained nasal prostheses after ablative tumor surgery: Minimal surgical aftercare, high implant survival, and satisfied patients

BACKGROUND

Nasal defects resulting from tumor resection are preferably rehabilitated with implant-retained nasal prostheses. Aftercare, clinical outcome of the implants, and patients' satisfaction with implant-retained nasal prostheses were assessed.

METHODS

Twenty-eight consecutive patients needing total rhinectomy because of tumor resection between 1998 and 2013 were treated according to a standardized protocol with 2 implants in the nasal floor. Surgical and prosthetic aftercare was scored using patient records. Finally in 2014, skin reaction, peri-implant bone loss, and patients' satisfaction were assessed in all 13 still living patients.

RESULTS

In total, 56 implants were inserted (median follow-up, 35.1 months; interquartile range [IQR], 8.9-63.3). Implant survival was 96.4%. Implant survival was independent of radiotherapy. Peri-implant skin was healthy and patients' satisfaction high. Longevity of the prostheses was limited.

CONCLUSION

Rehabilitation of nasal defects resulting from total rhinectomy with implant-retained nasal prostheses, according to our protocol, resulted in high patient satisfaction and favorable treatment outcome. © 2015 Wiley Periodicals, Inc. Head Neck 38: E-E, 2016.

Total Auricular Rehabilitation: Combined Cosmetic and Functional Lateral Temporal Bone Reconstruction

OBJECTIVE

The aim of the study was to describe 3 cases of total auricular rehabilitation, including the novel use of iliac crest bone grafts to support bone-anchored auricular prostheses.

STUDY DESIGN

This study is a retrospective case series from a single institution.

RESULTS

Three cases with large lateral temporal bone and soft tissue defects were successfully treated with total auricular rehabilitation. Rehabilitation included the following: soft tissue coverage with an anterolateral thigh microvascular free flap, iliac crest-free bone graft with staged placement of a bone-anchored auricular prosthesis into the bone graft, and audiologic rehabilitation with a bone-anchored hearing aid (BAHA). All of the cases with grafts and flaps survived and were without significant donor site morbidity. Bone-anchored hearing aid abutment skin overgrowth was seen in 2 cases and was revised under local anesthesia. All of the patients had expected functional recovery on postoperative audiologic testing. Each patient continues to consistently wear his/her auricular prosthesis and BAHA during 3 years of follow-up.

CONCLUSIONS

Total auricular rehabilitation is a complex task involving reconstruction of extensive soft tissue defects, bony defects, and the hearing apparatus. Acceptable cosmetic and functional outcomes and high patient satisfaction is possible in committed patients.

Prosthetic reconstruction of a patient with an acquired nasal defect using extraoral implants and a CAD/CAM copy-milled bar

Traditionally, patients with maxillofacial defects have been challenging to treat. A multitude of challenges associated with maxillofacial prosthetic treatment are not typically seen with patients who need conventional prosthodontic treatment. These types of patients generally require replacement of significant amounts of hard and soft tissues than do conventional prosthodontic patients. Most maxillofacial patients also warrant more emotional support than do conventional prosthodontic patients. Successful maxillofacial prosthetics still need to embrace the traditional goals of prosthodontic treatment: stability, support, retention, and esthetics. It is unlikely that a maxillofacial prosthesis will exactly duplicate the anatomy and function of missing or damaged structures. Although craniofacial implants (CFI's) have lower cumulative survival rates (CSR's) than intraoral endosseous implants, osseointegrated CFI's have proven to be significant adjuncts to improving retention of maxillofacial prostheses. However, CSR's of CFI's have been reported to be lower than CSR's for intraoral endosseous implants. Lately, computer-assisted design and computer-assisted machining (CAD/CAM) has been used in dentistry to facilitate fabrication of implant-supported frameworks. CAD/CAM protocols have numerous advantages over conventional casting techniques, including improved accuracy and biocompatibility, and decreased costs. The purpose of this paper is to review the literature on cumulative survival rates (CSR's) reported for CFI's and to illustrate the treatment of a maxillofacial patient using CFI's and a CAD/CAM copy-milled framework for retention and support of a nasal prosthesis.