Abstract
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.
Introduction
Facial defects may occur as a result of malignant disease, trauma or congenital deformity . Loss of facial continuity can inhibit speech, eating, swallowing, oral competence, aesthetics, and social interaction . Damaged facial and oral structures can cause post-treatment psychological and social problems .
Surgery is a common approach to the treatment of facial defects. When surgical treatment is not indicated or not considered as an option, prosthetic management of facial defects is carried out by means of maxillofacial prostheses . Factors influencing the success or failure of a facial prosthesis are numerous. For a facial prosthesis to be successful, it must meet criteria of aesthetic acceptability, functional performance, biocompatibility, and desired retention .
Providing adequate retention has been a constant challenge with many facial prostheses . Inherent mechanical retention within the defect or the use of adhesive systems has frequently proved to be problematic or unacceptable . With the introduction of osseointegration to the extra-oral craniofacial complex, predictable mechanical retention of facial prostheses has been established.
Osseointegration has been in clinical use in extraoral craniofacial sites since the 1970s . Endosseous osseointegrated implants have greatly improved the potential for rehabilitating patients with extensive soft and hard tissue craniofacial defects . Although it is minor surgery, implant treatment may be contraindicated in some cases , so some patients may refuse implant treatment . Therefore, conventional facial defect prostheses are still of great value. As experience increases, it is important that the long-term outcomes of various treatment alternatives are documented and reported .
The purpose of this study was to evaluate retrospectively extraoral prostheses and the use of extraoral implants for patients referred to the Department of Prosthodontics, Hacettepe University, for the restorative treatment of facial defects between 2001 and 2006.
Materials and methods
This study includes the prosthetic rehabilitation of 10 patients with facial defects referred between September 2001 and March 2006 ( Table 1 ). Five patients were treated with extraoral prostheses using 16 extraoral implants and the other five cases were rehabilitated without using extraoral implants. The patients’ mean age was 37 years (range 13–62 years). Five males and five females were included in the study. Three females and 2 males were treated with implants.
| Patient no. | Age (years) | Date of referral | Gender | Primary disease | Defect size and extent of tumour ablation | Radiation (Gy) | Time between last operation or irradiation to implantation (months) | Time between implantation or last operation to prosthetic treatment (months) |
|---|---|---|---|---|---|---|---|---|
| 1 | 62 | December 2001 | M | Congenitally missing ear | Total absence of right ear | – | – | >120 |
| 2 | 46 | November 2002 | F | Basal cell carcinoma | Partial absence of left ear | – | – | >36 |
| 3 | 48 | June 2003 | F | Adenoid cystic carcinoma | Right orbital exenteration | – | – | 6 |
| 4 | 50 | December 2003 | M | Squamous cell carcinoma | Right maxillectomy and orbital exenteration | > 60 | – | 15 |
| 5 | 40 | November 2004 | M | Adenoid cystic carcinoma | Right orbital exenteration | 50 | 6 | 5 |
| 6 | 13 | December 2004 | F | Congenitally malformed ear | Total absence of right ear | – | 4 | 4 |
| 7 | 14 | May 2005 | F | Hemifacial dysostosis and microtia | Total absence of right ear | – | 6 | 4 |
| 8 | 23 | October 2005 | M | Traffic accident | Total absence of left ear | – | 3 | 4 |
| 9 | 60 | October 2005 | F | Squamous cell carcinoma | Right maxilla, orbita, nasal vestibule, cheek and upper lip resected | 60 | 18 | 5 |
| 10 | 14 | February 2006 | M | Goldenhar Syndrome | Partial absence of right ear | – | – | 9 |
Figure 1 shows patient no. 7, who had undergone numerous surgical revisions over the years and was dissatisfied with the result. She had right-sided hemifacial dysostosis and an associated microtia. She was treated with an extra-oral implant retained auricular prosthesis. Figure 2 a shows patient no. 9, who was edentulous and had a large midfacial defect. Seven extraoral implants were inserted in her right orbital rim and zygoma regions. Two of them failed during the healing period. She was treated with an implant supported midfacial prosthesis ( Fig. 2 b and c). Patient no. 10 with Goldenhar syndrome had a partial ear defect ( Fig. 3 a) . Plastic and reconstructive surgical operations were unsuccessful in restoring the defect area. He was rehabilitated with a partial auricular prosthesis ( Fig. 3 b).
At the beginning of the prosthetic treatment, 6 auricular prostheses were made for six patients: 2 were partial and 4 were total. Three patients were rehabilitated with total auricular prostheses installing 2 extraoral implants that were 3.3 mm/5.5 mm in diameter with an insertion depth of 4 mm (EO implants with shoulder, Straumann AG, Waldenburg, Switzerland) for each patient.
Three orbital prostheses were fabricated for three patients after orbital exenteration. An orbital prosthesis was made for a midfacial defect patient who had been treated with maxillary obturator previously. For one irradiated orbital defect patient, three extraoral implants were installed that were 3.3 mm/3.5 mm in diameter with an insertion depth of 3.5 mm (EO implants with conical neck, Straumann AG).
An irradiated midfacial defect patient was rehabilitated with an acrylic and silicone midfacial prosthesis using 5 extraoral implants ( Fig. 2 b). Four were 3.3 mm/3.5 mm in diameter with an insertion depth of 3.5 mm, and one was 3.3 mm/3.5 mm in diameter with an insertion depth of 5 mm. Two implants, one with an insertion depth of 3.5 mm in the supraorbital rim and the other with an insertion depth of 5 mm in the zygoma region, failed before initial integration was achieved.
Subsequent to implant placement, clinical examinations were conducted monthly. After prosthetic reconstruction, clinical follow-up was carried out every 6 months. The assessed clinical outcome parameters included health of the peri-implant tissue, implant hygiene, and loss of implants. Health of the peri-implant tissue was classified according to the clinical scoring system of H olgers et al. and G ranstrom et al. . Prosthetic complications and the patients’ prosthetic complaints were noted at follow-up.
Materials and methods
This study includes the prosthetic rehabilitation of 10 patients with facial defects referred between September 2001 and March 2006 ( Table 1 ). Five patients were treated with extraoral prostheses using 16 extraoral implants and the other five cases were rehabilitated without using extraoral implants. The patients’ mean age was 37 years (range 13–62 years). Five males and five females were included in the study. Three females and 2 males were treated with implants.
| Patient no. | Age (years) | Date of referral | Gender | Primary disease | Defect size and extent of tumour ablation | Radiation (Gy) | Time between last operation or irradiation to implantation (months) | Time between implantation or last operation to prosthetic treatment (months) |
|---|---|---|---|---|---|---|---|---|
| 1 | 62 | December 2001 | M | Congenitally missing ear | Total absence of right ear | – | – | >120 |
| 2 | 46 | November 2002 | F | Basal cell carcinoma | Partial absence of left ear | – | – | >36 |
| 3 | 48 | June 2003 | F | Adenoid cystic carcinoma | Right orbital exenteration | – | – | 6 |
| 4 | 50 | December 2003 | M | Squamous cell carcinoma | Right maxillectomy and orbital exenteration | > 60 | – | 15 |
| 5 | 40 | November 2004 | M | Adenoid cystic carcinoma | Right orbital exenteration | 50 | 6 | 5 |
| 6 | 13 | December 2004 | F | Congenitally malformed ear | Total absence of right ear | – | 4 | 4 |
| 7 | 14 | May 2005 | F | Hemifacial dysostosis and microtia | Total absence of right ear | – | 6 | 4 |
| 8 | 23 | October 2005 | M | Traffic accident | Total absence of left ear | – | 3 | 4 |
| 9 | 60 | October 2005 | F | Squamous cell carcinoma | Right maxilla, orbita, nasal vestibule, cheek and upper lip resected | 60 | 18 | 5 |
| 10 | 14 | February 2006 | M | Goldenhar Syndrome | Partial absence of right ear | – | – | 9 |
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