Osseointegrated craniofacial implants in the rehabilitation of orbital defects: an update of a retrospective experience in the United States

Dental implant considerations in patients with systemic diseases: An updated comprehensive review

BACKGROUND

Various medical conditions and the drugs used to treat them have been shown to impede or complicate dental implant surgery. It is crucial to carefully monitor the medical status and potential post-operative complications of patients with systemic diseases, particularly elderly patients, to minimize the risk of health complications that may arise.

AIM

The purpose of this study was to review the existing evidence on the viability of dental implants in patients with systemic diseases and to provide practical recommendations to achieve the best possible results in the corresponding patient population.

METHODS

The information for our study was compiled using data from PubMed, Scopus, Web of Science and Google Scholar databases and searched separately for each systemic disease included in our work until October 2023. An additional manual search was also performed to increase the search sensitivity. Only English-language publications were included and assessed according to titles, abstracts and full texts.

RESULTS

In total, 6784 studies were found. After checking for duplicates and full-text availability, screening for the inclusion criteria and manually searching reference lists, 570 articles remained to be considered in this study.

CONCLUSION

In treating patients with systemic conditions, the cost-benefit analysis should consider the patient's quality of life and expected lifespan. The success of dental implants depends heavily on ensuring appropriate maintenance therapy, ideal oral hygiene standards, no smoking and avoiding other risk factors. Indications and contraindications for dental implants in cases of systemic diseases are yet to be more understood; broader and hardcore research needs to be done for a guideline foundation.

A Case Series of Prosthetic Rehabilitation of Post-COVID Rhinorbitocerebral Mucormycosis Ocular Defects: A Digital and Analog Experience

Removal of a part of or the entire orbit results in facial defect, causing psychological trauma to the patient, apart from anatomic loss. This case series presents 6 clinical cases of prosthetic rehabilitation of ocular defects related to post-COVID-19 ROCM by both analog and digital workflow. The basic objective of this case series was to achieve a well retained, user-friendly, maxillofacial ocular prosthesis with esthetic accuracy. Unique size and shape of the ocular defect in each case, variety of skin tones, age range of patients and compromised neuromuscular control made each of the six cases challenging. This clinical series apart from proposing a digital & analog algorithm for rehabilitating ocular defects also illustrates analog workflow for 4 cases and digital workflow for 2 cases for fabrication of ocular prosthesis.

Outcome of implants placed to retain craniofacial prostheses - A retrospective cohort study with a follow-up of up to 30 years

OBJECTIVES

To retrospectively assess the treatment outcomes of endosseous implants placed to retain craniofacial prostheses.

MATERIAL AND METHODS

Patients with craniofacial defects resulting from congenital disease, trauma, or oncologic treatment had implant retained prostheses placed in the mastoid, orbital, or nasal region and then assessed over a period of up to 30 years. Implant survival rates were calculated with the Kaplan-Meier method. Clinical assessments consisted of scoring skin reactions under the prosthesis and the peri-implant skin reactions. Possible risk factors for implant loss were identified. Patient satisfaction was evaluated using a 10-point VAS-scale.

RESULTS

A total of 525 implants placed in 201 patients were included. The median follow up was 71 months (IQR 28-174 months). Implants placed in the mastoid and nasal region showed the highest overall implant survival rates (10-year implant survival rates of 93.7% and 92.5%, respectively), while the orbital implants had the lowest overall survival rate (84.2%). Radiotherapy was a significant risk factor for implant loss (HR 3.14, p < 0.001). No differences in implant loss were found between pre- and post-operative radiotherapy (p = 0.89). Soft tissue problems were not frequently encountered, and the patients were highly satisfied with their implant-retained prosthesis.

CONCLUSION

Implants used to retain craniofacial prostheses have high survival and patient satisfaction rates and can thus be considered as a predictable treatment option. Radiation is the most important risk factor for implant loss.

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.

Systematic Review of Clinical Applications of CAD/CAM Technology for Craniofacial Implants Placement and Manufacturing of Orbital Prostheses

This systematic review was aimed at gathering technical and clinical applications of CAD/CAM technology for the preoperative planning of craniofacial implants placement, designing of molds and substructures and fabrication of orbital prostheses. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, an electronic search was executed. Human studies that utilized digital planning systems for the prosthetic rehabilitation of orbital defects were included. A total of 16 studies of 30 clinical cases, which were virtually planned through various digital planning and designing software, were included. The most common preoperative data required for digital planning were CT scans in 15 cases, the 3DSS-STD-II scanning system in 5 cases, an Artec Color 3D scanner in 3 cases and a NextEngine Desktop 3D laser scanner in 2 cases. Meanwhile, the digital designing software were Ease Orbital Implant Planning EOIPlan software in eight cases, Geomagic software in eight cases, Simplant software in four cases and Artec Studio 12 Professional in three cases. Surgical templates were fabricated for 12 cases to place 41 craniofacial implants in the orbital defect area. An image-guided surgical navigation system was utilized for the placement of five orbital implants in two cases. Digital designing and printing systems were reported for the preoperative planning of craniofacial implants placement, designing of molds and substructures and fabrication of orbital prostheses. The studies concluded that the digital planning, designing and fabrication of orbital prostheses reduce the clinical and laboratory times, reduces patient visits and provide a satisfactory outcome; however, technical skills and equipment costs are posing limitations on the use of these digital systems.

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.

Palatomaxillary Obturation and Facial Prosthetics in Head and Neck Reconstruction

Rehabilitation of head and neck defects following trauma, oncologic resection, or congenital malformation is a challenging task. Not only is the restoration of three-dimensional form necessary for acceptable cosmesis, but simultaneous restoration of functional speech and swallow is also essential for optimal reconstruction outcomes. While advances in free tissue transfer have allowed surgical reconstruction of head and neck defects once considered inoperable and associated with poor quality of life, not all patients are ideal surgical candidates. As such, nonsurgical solutions to both functional and cosmetic restoration remain a necessary alternative option. Facial prostheses and palatomaxillary obturators have evolved with increasingly biocompatible materials as well as retention systems to address significant defects that challenge the limits of surgical reconstruction.

Prosthetic Facial Reconstruction in a Blast Injury Case

The management of blast and burn injuries to the facial soft tissue and craniomaxillofacial skeleton has been a challenge since the inception of reconstructive plastic surgery. These injuries continue to present complex reconstructive challenges today. While there have been advancements in free tissue transfer and vascularized composite allotransplantation, prosthetics have been used successfully since antiquity until the present day. Prosthetics may achieve acceptable coverage without complex surgery or as an adjunct to reconstructive surgery. Here, we report a case of devastating blast injury to the face that has been managed successfully with orbital prosthetics anchored with osseointegrated implants.

[Prosthetic rehabilitation in the head and neck region]

Implant-retained craniofacial prostheses (or epitheses) made of silicone are state of the art for prosthetic rehabilitation of facial defects. With the modern extraoral implant systems, prostheses may be securely anchored to the bone regardless of size and location of the defect. Prerequisite for successful implantation is the classical atraumatic surgical technique with avoidance of any thermal trauma to the bone. The treatment intention may be a temporary measure, a rescue procedure after failed (re)construction, or a definitive treatment option. This article gives an overview of the strategies in various facial regions stratified according to the age of the patient and the etiology of the defect. Moreover, prosthetic rehabilitation offers additional options for septal perforations, distorted and leaky tracheostomies, and treatment-resistant tracheoesophageal fistula.

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.

Prosthetic Reconstruction of Orbital Defects

Orbital and craniomaxillofacial defects, in general, are best approached preoperatively by a multidisciplinary team with a clear reconstructive plan in place. Orbital defects result from a myriad of underlying diseases and injuries, and reconstruction after orbital evisceration, enucleation, or exenteration can pose a challenge to the reconstructive team. Reconstruction of orbital injuries with orbital implants and prostheses can lead to acceptable aesthetic outcomes, and the reconstructive surgeon should be familiar with current orbital implants and prostheses. Herein, the authors review terminology and classifications of orbital defects, different types of orbital implants, advantages and disadvantages of different orbital implant reconstructive options, types of orbital prostheses, and pros and cons of different prosthetic options.

Frontal sinus augmentation: Preliminary results of a new approach in prosthetic orbital reconstruction

PURPOSE

Reliable application of endosseous implants for prosthetic facial reconstruction depends on the bone volume available at the defect site. Regarding the orbit, sufficient bone presentation in the medial superior orbital rim is limited due to the frontal sinus. The aim of this article is to report for the first time on the augmentation of the frontal sinus for gaining bone volume for supraorbital implant placement.

MATERIALS AND METHODS

Between 2007 and 2014, five patients with orbital exenteration were treated by frontal sinus augmentation using autogenous cancellous bone graft from the ilium. Extraoral implants for prosthetic orbit reconstruction were placed 4-7 months later. In advance, cadaver surgery was performed to prove the feasibility of the method. Surgical technique is described, and intraoperative images are provided.

RESULTS

The frontal sinus was successfully augmented in all five patients. No major complications related to the procedure were observed. A total of nine orbital implants were inserted in the augmented bone, thereof one sleeping implant. Six implants were restored prosthetically, two implants were lost at exposure. The observation period ranged from 6 to 97 months (mean: 52.8 months). Mean time for patient rehabilitation was 13 months. High patient satisfaction was achieved with the implant-retained orbital prosthesis.

CONCLUSION

The augmentation of the frontal sinus allows implant placement by providing sufficient bone volume in the medial supraorbital rim. Considering the surgical success of this method and patient satisfaction, this new approach is concluded to be a viable option in a unique subset of patients.

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.

Self-retaining magnetic implant: A novel design of orbital prosthesis for the exenterated orbit

Orbital exenteration can lead to significant disfigurement causing considerable functional, cosmetic and psychological disturbances to the patient. Orbital prosthesis is important for the patient's cosmetic and psychological rehabilitation. A 49-year-old man received orbital exenteration and postoperative radiotherapy for malignant orbital carcinoma. In view of uncertain suitability and survival of osseointegrated implant in his case, a novel design of ocular implant consisting of a self-retaining magnetic spring retainer and a coupling silicone prosthesis was used. This novel design was shown to provide the patient with ease of use, good cosmetic outcome and better quality of life.

Auricular Prostheses in Microtia

The progress made in the development of the silicones and percutaneous titanium implants allow for rehabilitation of patients with microtia with an inconspicuous auricular prosthesis. The art of making the prosthesis by the dedicated anaplastologist is the key for the success of this approach. Most patients with microtia desire camouflage. The greatest advantage of the auricular prosthesis is that it can be manufactured as a mirrored replica of the opposite side. The outcome is predictable. Computer science with virtual planning and rapid prototyping is about to revolutionize the process of prosthetic auricular rehabilitation.

Prosthetics in Facial Reconstruction

Reconstruction of the head and neck can be a challenging undertaking owing to numerous considerations for successful rehabilitation. Although head and neck defects were once considered irretrievably morbid and associated with a poor quality of life, advances in surgical technique has immensely contributed to the well-being of these patients. However, all patients are not suitable surgical candidates and many have sought nonsurgical options for functional and cosmetic restoration. As such, the advent of prostheses has ameliorated those concerns and provided a viable alternative for select patient populations. Prosthetic reconstruction has evolved significantly over the past decade. Advances in biocompatible materials and imaging adjuncts have spurred further discovery and forward progress. A multidisciplinary approach to head and neck reconstruction focused on appropriate expectations and patient-centered goals is most successfully coordinated by a team of head and neck surgeons, maxillofacial surgeons, and prosthetic specialists. The aim of this article is to provide a comprehensive review of the current trends for prosthetic rehabilitation of head and neck defects, and further elaborate on the limitations and advancements in the field.

Influence of Orbital Implant Length and Diameter on Stress Distribution: A Finite Element Analysis

Purpose:

A mathematical simulation of stress distribution around orbital implants was used to determine which length and diameter of implants would be best to dissipate stress.

Methods:

An integrated system for computed tomography data was utilized to create a 3-dimensional model of craniofacial structures. The model simulated implants placed in the 7, 11, and 12 o’clock positions of the orbital rim. A load of 2 N was applied to the model along the long axis of the implant (model 1) and an angle of 45° with the long axis of the implant (model 2). A model simulating an implant with a diameter of 3.75 mm and lengths of 3, 4, 6, 8, and 10 mm was developed to investigate the influence of the length factor. The influence of different diameters was modeled using implants with a length of 6 mm and diameters of 3.0, 3.75, 4.2, 5.0, and 6.0 mm. Values of von Mises equivalent stress at the implant–bone interface were computed using the finite element analysis for all variations.

Results:

The elements exposed to the maximum stress were located around the root of the orbital implant in model 1 or between the neck and the first thread of the orbital implant in model 2. An increase in the orbital implant diameter led to a decrease in the maximum von Mises equivalent stress values. In model 1, the reductions were 45.2% (diameter of 3.0–3.75 mm), 25.3% (diameter of 3.75–4.2 mm), 17.2% (diameter of 4.2–5.0 mm), and 5.4% (diameter of 5.0–6.0 mm). In model 2, the reductions of the maximum stress values were 51.9%, 35.4%, 19.7%, and 8.1% respectively. However, the influence of orbital implant length was not as pronounced as that of diameter. In model 1, the reductions were 28.8% (length of 3–4 mm), 19.2% (length of 4–6 mm), 9.6% (length of 6–8 mm), and 4.3% (length of 8–10 mm). In model 2, the reductions of the maximum stress values were 35.5%, 21.1%, 10.9%, and 5.4% respectively.

Conclusions:

An increase in the implant diameter decreased the maximum von Mises equivalent stress around the orbital implant more than an increase in the implant length. From a biomechanical perspective, the optimum choice was an orbital implant with no less than 4.2 mm diameter allowed by the anatomy.

Virtual surgical planning and 3D printing in prosthetic orbital reconstruction with percutaneous implants: a technical case report

Osseointegrated titanium implants to the cranial skeleton for retention of facial prostheses have proven to be a reliable replacement for adhesive systems. However, improper placement of the implants can jeopardize prosthetic outcomes, and long-term success of an implant-retained prosthesis. Three-dimensional (3D) computer imaging, virtual planning, and 3D printing have become accepted components of the preoperative planning and design phase of treatment. Computer-aided design and computer-assisted manufacture that employ cone-beam computed tomography data offer benefits to patient treatment by contributing to greater predictability and improved treatment efficiencies with more reliable outcomes in surgical and prosthetic reconstruction. 3D printing enables transfer of the virtual surgical plan to the operating room by fabrication of surgical guides. Previous studies have shown that accuracy improves considerably with guided implantation when compared to conventional template or freehand implant placement. This clinical case report demonstrates the use of a 3D technological pathway for preoperative virtual planning through prosthesis fabrication, utilizing 3D printing, for a patient with an acquired orbital defect that was restored with an implant-retained silicone orbital prosthesis.

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.

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.

Image-Guided Placement of Osseointegrated Implants for Challenging Auricular, Orbital, and Rhinectomy Defects

OBJECTIVES

Prosthetic reconstruction can restore the preoperative form and function after surgery for head and neck malignancies. We demonstrate the use of preoperative planning and intraoperative image guidance for placement of osseointegrated implants to restore craniofacial defects.

METHODS

A retrospective review of patients with craniofacial defects treated with image-guided placement of osseointegrated prosthetic implants was performed.

RESULTS

Case 1: 55-year-old male who underwent total auriculectomy with anterolateral thigh reconstruction. Case 2: 64-year-old male who required orbital exenteration and total auriculectomy with latissimus dorsi reconstruction. Case 3: 74-year-old male presented after a total rhinectomy. Cases 1 and 3 received adjuvant radiation prior to implantation. Case 2 underwent simultaneous placement of osseointegrated hearing and prosthetic implants. Computed tomography scans were used to perform preoperative planning to determine the optimal implant trajectories and sites. Complications included tissue overgrowth, delayed nonunion of implant, wound infection, and dehiscence.

CONCLUSIONS

Defects following oncologic resection of head and neck malignancies can be difficult to achieve with native tissue alone. Osseointegrated implants offer an excellent means for reconstruction but can be challenging due to limited bone stock and anatomic landmarks. This can be overcome using intraoperative image guidance techniques for prosthetic reconstruction.

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.

Bone and Skin-Supported Stereolithographic Surgical Guides for Cranio-Facial Implant Placement

PURPOSE

Osseointegrated skin-penetrating implants enhance the retention and stability of the craniofacial prostheses and provide the long-term comfort. However, to determine the implant locations is a great challenge facing the surgeon. Implants may either be located in conventional manner or by STL generated surgical guides.

MATERIALS AND METHODS

Present study reports the CT based 3D virtual modeling, preoperative virtual planning and the implant placement by using a STL surgical guide, in an anotia case.

RESULTS

Employed materials and the methods facilitated the implant surgery while improving the operational security.

CONCLUSIONS

CT based 3D virtual modeling of the surgical site, determining the implant locations virtually and the STL guided placement of the craniofacial implants, were found useful applications in order to facilitating the surgical intervention and providing prevention from complications.

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.

Prosthetic rehabilitation after orbital exenteration: a case series

Orbital exenteration is executed by the ophthalmic surgeon to treat various neoplasms or non-malignant diseases. But it leads to several functional, esthetic and psychological problems for the patients. Orbital prosthesis is a good alternative for cosmetic and psychological rehabilitation, if reconstructive surgery is not possible or not desired by the patient. In the following article, different materials and retentive aids for fabrication of an orbital prosthesis given in the literature along with few novel methods have been discussed for four patients who underwent orbital exenteration. Factors that an ophthalmic surgeon should consider during surgery, which may later on help the prosthodontist to obtain good cosmetic results, are also discussed briefly. Remarkable results can be obtained if both work as a team for one common goal i.e. improvement of quality of life of the patient after orbital exenteration.

Single-stage osseointegrated implants for nasal prosthodontic rehabilitation: A clinical report

Malignant tumors in the nasal region may be treated by means of invasive surgical procedures, with large facial losses. Nasal prostheses, retained by osseointegrated facial implants, instead of plastic surgery, will, in most patients, offer good biomechanical and cosmetic results. This clinical report describes the prosthetic rehabilitation of a patient with nasal cancer who had the entire nasal vestibule removed in a single-stage surgical procedure in order to shorten the rehabilitation time. The nasal prosthesis was built on a 3-magnet bar and was made of platinum silicone with intrinsic pigmentation, thereby restoring the patient's appearance and self-esteem. The authors concluded that single-stage implants may reduce the rehabilitation time to as little as 1 month, and the correct use of materials and techniques may significantly improve the nasal prosthesis.

Use of Orbital Conformer to Improve Speech in Patients with Confluent Maxillectomy and Orbital Defects

The basic objective in prosthetic restoration of confluent maxillary and orbital defects is to achieve a comfortable, cosmetically acceptable prosthesis that restores speech, deglutition, and mastication. It is a challenging task complicated by the size and shape of the defects. The maxillary obturator prosthesis often satisfies the objective of adequate deglutition; however, orbital defects that are not obturated in the medial, septal, or posterior walls allow air to escape, negatively impacting phonation. This article describes a technique to achieve favorable prosthetic rehabilitation in a patient with a maxillectomy and ipsilateral orbital exenteration. The prosthetic components include maxillary obturator, orbital conformer, and orbital prosthesis connected using rigid magnetic attachments.

Quality of life of patients with implant-retained maxillofacial prostheses: a prospective and retrospective study

STATEMENT OF PROBLEM

Clinical studies on implant-retained maxillofacial prostheses have focused on biological outcomes. An assessment of the effect of prostheses on patients' quality of life (QOL) by using specific questionnaires developed for this patient population provides important information on treatment outcomes from the patients' perspectives.

PURPOSE

The purpose of this study was to report patient-based outcomes of implant-retained maxillofacial prostheses and to evaluate the effect of implant-retained maxillofacial prostheses on QOL of participants in a prospective study.

MATERIAL AND METHODS

Eighty-two participants were treated with implant-retained maxillofacial prostheses. Participants were divided into 2 groups: a retrospective group (participants treated and under care) and a prospective group (participants willing to be treated). The posttreatment patient satisfaction scores for each question were statistically analyzed by 2-way ANOVA with variables of defect type and retention type. The Student-Newman-Keuls test was used to determine any significant differences among the groups. In the prospective group, mean scores before and after prosthetic treatment were compared with the paired t test (α=.05).

RESULTS

The details of 54 retrospective and 28 prospective participants were reviewed. The posttreatment results of 82 patients showed that patient satisfaction with implant-retained maxillofacial prostheses was significantly different for cleaning the prostheses and recommending treatment to other people, depending on the defect and retention type. In the prospective group, participants reported significant increases in satisfaction for all questions.

CONCLUSIONS

Implant-retained prostheses were considered highly satisfactory, indicating good QOL for patients with maxillofacial defects. A comparison of pretreatment and posttreatment assessments revealed that implant-retained maxillofacial prostheses increased patient QOL.

Prosthetic rehabilitation of defects of the head and neck

Patients afflicted with head and neck cancer, traumatic injuries to the head and neck, or those with congenital or developmental defects benefit from multidisciplinary team management. The head and neck region participates in complex physiologic processes that can often be impeded by these circumstances. Evaluation of the patient by the maxillofacial prosthodontist can assist the other members of the team in providing treatment planning options for the patients. Intraoral defects arising from these circumstances can be treated with prosthodontics that serve to assist with speech, swallowing, and to some degree mastication. If chemotherapeutic or radiation modalities are also used to treat the head and neck, assessment of the patient by the maxillofacial prosthodontist may prove to identify factors that may predispose to undesirable sequelae. Preventive treatment by elective tooth extraction, prosthodontic assessment, and patient education prove to assist in predictable management of these oftentimes complex presenting conditions. Facial defects arising from similar circumstances can be an alternative or adjunct to plastic surgical reconstruction and offer the added advantage of tumor surveillance in susceptible patients.

Simplified technique for orbital prosthesis fabrication: a clinical report

Loss of orbital content can cause functional impairment, disfigurement of the face, and psychological distress. Rehabilitation of an orbital defect is a complex task, and if reconstruction by plastic surgery is not possible or not desired by the patient, the defect can be rehabilitated by an orbital prosthesis. The prosthetic rehabilitation in such cases depends on the precisely retained, user-friendly removable maxillofacial prosthesis. Many times, making an impression of the orbital area with an accurate record of surface details can be a difficult procedure. The critical areas are making a facial moulage, mold preparation, and attaching the retention device, particularly when eyeglass frames are used. This case focuses on these hindrance factors. A simple basket was used for the impression tray to obtain the facial moulage. A putty mold was used, and attachment of the prosthesis to a retention device was accomplished with positional distance. This method proves to be an economical and simple way of making an orbital prosthesis.

Analysis of the periimplant tissue of craniofacial implants by sulcus fluid flow rate (SFFR)

STATEMENT OF PROBLEM

The tissue surrounding craniofacial implants is prone to inflammation; however, no adequate instrument is currently available to measure this objectively.

PURPOSE

The purpose of this study was to describe the parameters influencing the sulcus fluid flow rate in the extraoral periimplant tissue environment.

MATERIAL AND METHODS

Thirty-four patients with 112 craniofacial implants participated. The sulcus fluid flow rate (SFFR) was measured with standardized paper strips. The influence of cleansing liquids, implant location, presence of purulent exudates, smoking habits, depth of crevice, and previous irradiation on the sulcus fluid flow rate were evaluated with covariate adjusted finite mixture models.

RESULTS

Two latent subgroups of SFFR were identified based on a mixed model. The majority (95.5%) had a mean value of 1.44 mm, and the smaller subgroup (4.5%) had a mean value of 10.4 mm. The SFFR values were increased when purulent exudates were present (regression coefficient 1.41), 95% CI (0.67, 2.16). The depth of the crevice influenced the SFFR per unit depth (regression coefficient 0.37), 95% CI (0.22, 0.53). Additional covariates, such as the implant location, history of smoking, and prior irradiation, had no statistical effect on SFFR.

CONCLUSIONS

SFFR can be measured objectively in the extraoral periimplant tissue.

Extra-oral implants: insertion per- or post-ablation?

Although the benefit of extra-oral implants in the reconstruction of maxillofacial oncological defects is undisputable, some relevant issues need to be clarified. The purpose of this retrospective study was to evaluate the relationship between implants placed during ablation (DA-implants) and after ablation (AA-implants) of the tumor with respect to implant survival. In total, 103 implants were assessed: 44 nasal implants (17 patients) and 59 orbital implants (18 patients). All patients received their implant-retained maxillofacial epithesis between 1997 and 2010, with a mean follow-up of 35 months (range 8-156 months). The survival rate of DA-implants was 90.0% for the orbital region and 93.5% for the nasal region. The survival rate of the AA-implants for the orbital and the nasal region was 82.8% and 61.5%, respectively. This study shows a significant higher survival rate of extra-oral implants placed during ablative surgery compared to implants in a later stage (p=0.044), thereby stressing the importance of installing extra-oral implants during the ablative surgical session.

Prosthetic rehabilitation

Patients with head and neck defects may undergo reconstruction surgically, prosthetically, or with a combined approach. In some situations, prosthetic rehabilitation may be the preferred treatment option. Presurgical treatment planning and evaluation of the patient is paramount to successful reconstruction and rehabilitation. Patient education and assessment of the patient's expectations are essential in the acceptance of a proposed treatment plan. Communication and joint treatment planning early in the process between the surgeon and maxillofacial prosthodontist will optimize results.

The potential of cohesive silicone for facial prosthetic use: a material property study and a clinical report

PURPOSE

Prosthetic reconstruction of a facial defect can help to reduce disfigurement and restore the social functioning of the patient. Several methods for holding a prosthesis in place exist, including the use of osseointegrated implants and medical adhesive agents; however, since the treatment options for some patients may be restricted by various health conditions and other limitations, including allergies to adhesive agents, a history of radiation therapy, and financial issues, other options that suit individual demands are required. The objectives of this study were to test the hypothesis that adhesive characteristics could be bestowed on silicone elastomers by altering their catalyst/base silicone ratios (CBR) and to examine the effect of the thickness of the cohesive silicone layer of a prosthesis on its initial adhesive strength.

MATERIALS AND METHODS

The adhesive strengths of specimens with CBRs ranking from 1/10 to 1/70 were examined by the rolling ball tack test. A tensile test was used to evaluate the tensile adhesive strengths of specimens made of layers of cohesive silicone (CBR 1/60) and normal silicone (CBR 1/10) with different thicknesses. Auricular prostheses containing cohesive silicone on the skin side were applied to a 50-year-old man with defects in both auricular regions and with reduced manual dexterity due to serious burns.

RESULTS

The rolling distance was reduced with a decrease in CBR, and a thinner cohesive silicone (CBR 1/60) layer demonstrated a higher peak load. On clinical application, the adhesion of the auricular prosthesis containing cohesive silicone was improved by expanding the adhesive area and altering the thickness of the cohesive silicone layer, resulting in sufficient adhesion and easier handling than that achieved using an adhesive agent 1 year post delivery.

CONCLUSION

These results suggest that cohesive silicone can be used as a glueless retentive material for facial prostheses.

Patients' satisfaction after surgical facial reconstruction or after rehabilitation with maxillofacial prosthesis

The matching of the aesthetic, functional, and psychosocial results of a facial deformity may produce devastating effects in its carriers, especially if the lesion is extensive or the treatment is aggressive. Because of this, the objective of the present article was to evaluate patient's satisfaction rating after surgical facial reconstruction or rehabilitation with oral and maxillofacial prosthesis, by means of reviewing the literature.

Implant-retained craniofacial prostheses for facial defects

Craniofacial prostheses, also known as epistheses, are artificial substitutes for facial defects. The breakthrough for rehabilitation of facial defects with implant-retained prostheses came with the development of the modern silicones and bone anchorage. Following the discovery of the osseointegration of titanium in the 1950s, dental implants have been made of titanium in the 1960s. In 1977, the first extraoral titanium implant was inserted in a patient. Later, various solitary extraoral implant systems were developed. Grouped implant systems have also been developed which may be placed more reliably in areas with low bone presentation, as in the nasal and orbital region, or the ideally pneumatised mastoid process. Today, even large facial prostheses may be securely retained. The classical atraumatic surgical technique has remained an unchanged prerequisite for successful implantation of any system. This review outlines the basic principles of osseointegration as well as the main features of extraoral implantology.

Extraoral prostheses using extraoral implants

The aim of this study was to evaluate extraoral prostheses and the use of extraoral implants in patients with facial defects. 10 cases were treated utilizing maxillofacial prostheses employing extraoral implants in five cases. 16 extraoral implants were installed. Seven implants were placed in irradiated sites in the orbital regions. Six implants were placed in mastoid regions and three in a zygoma region that was irradiated. Two implants failed before initial integration was achieved in irradiated areas. Using 14 extraoral implants as anchors, five extraoral prostheses were set. The other five cases were treated with extraoral prostheses without using extraoral implants due to cost and patient-related factors. The data included age, sex, primary disease, implant length, implant failure, prosthetic attachment, radiation therapy, and peri-implant skin reactions. The use of extraoral implants for the retention of extraoral prostheses has simplified the placement, removal, and cleaning of the prosthesis by the patient. The stability of the prostheses was improved by anchors. Clinical and technical problems are presented with the techniques used for their resolution. Using extraoral implants resulted in a high rate of success in retaining facial prostheses and gave good stability and aesthetic satisfaction.

[Craniofacial prostheses for facial defects]

Craniofacial prostheses (or epitheses) are artificial substitutes for facial defects. Today, prostheses made of silicone are state-of-the-art. They may be fixed anatomically (to already existing structures), mechanically (to spectacle frames), chemically (using adhesives), or surgically (to osseointegrated titanium implants). With the existing extraoral implant systems, prostheses may be securely anchored to the bone regardless of size and location of the defect. The classic atraumatic surgical technique has remained an unchanged prerequisite for successful implantation by avoidance of any heat trauma to the bone. This review outlines the indications and contra-indications as well as advantages and disadvantages of craniofacial prostheses and their retention methods in various facial regions. It summarizes the basic principles of extraoral implantology in respect to implant positioning and the management of children and radiated patients.

Treatment outcome of extraoral implants in the craniofacial region

Extraoral implants for the retention of facial prosthesis have been used for better support, stability, and retention. Other than the clinical experiences, treatment outcomes of these prostheses should be evaluated for predicting the long-term success. The aim of this study was to evaluate the survival rates and soft tissue responses of extraoral implants. In total, 52 patients were examined, including 16 with auricular defects, 16 with orbital defects, 13 with nasal defects, and 7 with midfacial defects. Data on implant length and location, radiation-treatment history, systemic diseases, and alcohol and cigarette use were collected and assessed, and data on the health of periimplant soft tissue were recorded for all of the defects. Statistical analyses were performed with t and chi2 tests and correlation and regression analyses for the determination of the survival rate. According to results, the defect area has a significant effect on success rate. The overall success rate was found highest in the auricular area and least in the midfacial area. The presence of diabetes, alcohol use, and age were found as significant factors for implant loss, whereas smoking and radiotherapy were found as insignificant.