1. Restoration of Ear Defects
John Beumer III DDS, MS
Don Pedroche DDS, CDT
Division of Advanced Prosthodontics
UCLA School of Dentistry
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2. Table of Contents
l Alterations at surgery to enhance the prosthetic
prognosis
l Etiology
l Presurgical Consultation
l Master impressions
l Sculpting and margin placement
l Processing the silicone prosthesis
l Coloration
l Partial ear defects
l Craniofacial Implants

3. Alterations at surgery to enhance the
prosthetic prognosis
Ear defects
v Total auriculectomy defects are easier to
restore than partial auriculectomy defects
v Retain the tragus
v Line the defect with a split thickness skin
graft
v Avoid the use of flaps with hair follicles
v When appropriate, place osseointegrated
implants

4. a
Alterations at surgery to enhance the
prosthetic prognosis
Unfavorable ear defects
Large displaced ear fragments. Bilateral symmetry with
opposite ear cannot be achieved with the prosthesis

5. Alterations at surgery to enhance the
prosthetic prognosis
Unfavorable ear defects
Partial ear defects are more difficult to restore because:
v Blending margins is more difficult
v Bilateral symmetry may be impossible to restore

6. Alterations at surgery to enhance
the prosthetic prognosis
v Retain the tragus.
v Line site with split thickness skin graft. Why?
The tragus helps hide the anterior margin of the prosthesis

7. Alterations at surgery to enhance the
prosthetic prognosis
Unfavorable ear defects
This defect has been lined with a hair bearing scalp flap.
Problems that result:
v Difficult to use skin adhesives
v We are unable to place osseointegrated implants through skin with
hair follicles. Why?

8. Alterations at surgery to enhance the
prosthetic prognosis
Unfavorable ear defects
Sebaceous secretions from the hair follicles adhere to the
surface of the implant abutments and the implant connecting
bar. These secretions become contaminated with bacteria
resulting in constant tissue irritation of the peri-implant tissues.

9. Alterations at surgery to enhance the
prosthetic prognosis
v Whenappropriate, place
osseointegrated implants
v Treatment time is reduced
v Caution
v Ifthe patient is scheduled to
receive postoperative radiation
one may wish to reconsider,
particularly if the dose will be
above 65 Gy. The backscatter
will enhance the dose delivered
to the bone anchoring the
implant 15-18 percent (see
lecture entitled “Implants in
irradiated tissues.”

10. Restoration of Ear Defects
A difficult challenge. Both surgical
reconstruction and prosthetic
rehabilitation have distinct limitations
v The surgeon is limited by the complexity of the
structures to be reconstructed, the availability of
tissue, compromise of the local vascular bed by
radiation in tumor patients and the need for
visual inspection of oncologic defects
v The prosthodontist is limited by the properties of
the available materials , mobility of the tissues
Surgically
adjacent to the defects.
reconstructed ear

11. Etiology
v Facial neoplasms
v Basal cell carcinoma
v Squamous carcinoma
v Malignant melanoma
v Craniofacial anomalies
v Microtia
v Trauma
v Burns

12. Ear prosthesis
Preop consultation and impression

13. Presurgical Consultation
Issues
v Psychosocial
v Impressions
v Photographs
v Explain the limits of the prosthetic rehabilitation
v Brief review of prosthetic care procedures

14. Presurgical Consultation
Psychosocial issues
v Challenges confronting tumor patients
v Mortality
v Morbidity
v Functional impairments
v Esthetics
v Quality of life - Social function
v Challenges confronting the provider
v Establish lines of communication
v Maintain empathy and compassion while at the same time maintaining the
ability to motivate the patient to perform needed home care procedures

15. Presurgical Consultation
Tasks to be accomplished
a) Impressions and
photographs
b) Patient education
regards nature of the
defect and the purpose
of the prosthesis
c) Patient expectations
need to tempered

16. Master impressions
v Irreversiblehydrocolloid
v Light body polysulfide
v Light body polysiloxane
v Digital impression techniques
The objective is to obtain an impression without
displacing tissues

17. CAD-CAM Techniques
a b c d
Wax patterns can be developed with CAD-CAM
techniques
a: Normal ear opposite the defect.
b: 3D image of normal ear.
c: Mirror image of normal ear.
d: Wax pattern developed from mirror image data.

18. Sculpting and margin placement
A selection of wax ears
can be accumulated by
making an extra
casting from every
impression.
Dividing normal ear into equal compartments will aid sculpting.
Note how anterior margin is feathered.

19. Sculpting and margin placement
The wax sculpting of
the ear is positioned
on the patient. The
sculpture is checked
for contour, symmetry
with opposite ear and
margin placement.

20. Margin placement
a b
v The anterior margin is thinned and placed
behind the tragus if this structure is present (a)
v If the tragus is absent the anterior margin is
thinned and blended into the skin (b)

21. Surface texture
A moderate stipple is used to reproduce the surface
texture of the adjacent skin and opposite ear.

22. Processing the silicone prosthesis
Investing and flasking
A three piece mold is made to facilitate removal of the
silicone casting from the mold after processing

23. Intrinsic coloration
Base Shade
Lightest skin shade is selected favoring the yellow tones

24. Coloration
Surface Detail - Intrinsic vs Extrinsic
We prefer extrinsic coloration to create and highlight the
surface detail because:
v It is easier as opposed to intrinsic coloration methods
v More consistent esthetic results can be obtained with this method
v This method is more time efficient. Multiple prostheses can be
efficiently fabricated with this technique

25. Processing
The silicone is mixed, vacuumed to eliminate air
bubbles, and injected into the mold. Following
polymerization, the ear casting is removed.

26. Extrinsic coloration

27. Coloration - Extrinsic
v Shade guides will ensure consistency in
color and translucence of base.
v Coloration is accomplished under
corrected light conditions.

28. Deglossing
.
a b c
Adding small amounts of fumed silicone dioxide (Cabo-O-Sil) to the RTV
silicone used for sealing will moderate some of the shine. Care should be
taken to avoid applying excessive thickness of sealant. Excessive shine
can also be avoided by using a dry brush as a blotter as the silicone
begins to cure after applying the initial layer of sealant. This process is
repeated twice at 5 minute intervals upon application of the silicone
sealant. The purpose of this technique is to maintain the original surface
texture and avoid excessive shine.

29. Deglossing
.
a b c
a : Before deglossing and after sealant applied.
b : After deglossing.
c : Prosthesis in position.

30. Coloration - Extrinsic
Finished ear prostheses. Note excellent color
matching, surface texture reproduction and marginal
adaptation.
v Tragus hides some of the anterior margin
v Without a tragus the margin anteriorly is carefully thinned
v Ear lobe margins represented by a line in the skin

31. Partial ear defects
v Small ear defect.
v Prosthesis engages undercuts behind ear and in concha to
enhance retention.
v Margins are strategically placed and carefully thinned and
adapted

32. Partial ear defects
v Small ear defect.
v Prosthesis is implant retained.
v Exposed margins are carefully thinned and adapted
Note: Partial ear prostheses are only effective
when the remaining ear fragment is not displaced.

33. Use of Craniofacial Implants to Restore
Auricular Defects
For many years we have been able to produce exceptional
esthetic results
Challenges:
v Patient acceptance
v Retention

34. Use of Craniofacial
Implants to Restore Auricular Defects
Benefits
(1) Improved retention and stability of the prosthesis
(2) Elimination of occasional skin reaction to adhesives
(3) Ease and enhanced accuracy of prosthesis placement
(4) Improved skin hygiene and patient comfort
(5) Decreased daily maintenance associated with removal and reapplication
of skin adhesives
(6) Increased life span of the facial restoration (when skin adhesives are
used for retention, they must be removed and reapplied each day,
leading to loss of colorants at the margin of the prosthesis and eventually
rendering the prosthesis unacceptable)
(7) Enhanced esthetics of the lines of juncture between the prosthesis and
skin. When an implant-borne prosthesis is fabricated its margins can be
made thinner and positive pressure can be developed by the margins of
the prosthesis with the movable peripheral tissues.

35. Facial Prostheses - Retention During Daily
Activities
Adhesive Implant
100 95
* 89
84 * 85
79 *
80
63
% 'Excellent'
57
60
44 44
38
40
20
0
Home Eating Exercise Perspire Sneeze/Cough
Chang et al, 2005

36. Frequency of Wear Facial Prostheses
Adhesive Implant Chang et al, 2005
120
95 100
100 89 88
% Wearing
80
63
*
60
44
40
20
3 0
0
Home Work Social Never

37. Ear Implants-Treatment Planning
CT Scan-Bone quantity
Markers
Two to three implants are
Radiographic Stent placed posterior and superior
to the ear canal

38. Congenital ear defects
In patients with congenital ear defects the major issue is the fate of tissue
remnants. With microtia ear remnants will vary in size, shape and position
and may need to be removed. Before these remnants are resected all
possible options for habilitation must be presented, explored and
discussed with the patient and their family. In some patients it may be
desirable to reconstruct the ear canal. If so, this procedure can be
performed during the same surgery as implant placement.

39. Congenital ear defects
a: Patient presented with microtia. Attempts were made to
reconstruct the auricle, but the results were unsatisfactory.
The reconstructed ear was removed and implants placed.
b and c: Surgical template was used to help properly position
implants.

40. Surgical templates
A preliminary wax sculpting is fitted to the patient, the
most desirable implant positions are identified and a
surgical template is designed to enable accurate
positioning of the implants.

41. Craniofacial implants
v Implants 4mm or 5mm in length are
used. Note the flange design.
v The flange prevents impaction of the
implant intra-cranially
v Two to three implants are placed
posterior and superior to the ear canal

42. Implant placement
a b c d e
f g h i
Implant placement in mastoid bone. a: Auricular defect. b: Wax
sculpting fitted to identify proper implant position. c: Surgical
template. d: Flap reflected. e and f: Template used to locate
proper implant positions. g: Mastoid exposed and sites prepared for
three implants. Note countersink. h: Implant fixtures placed into
prepared sites. i: Wound closed in three layers.

43. Ear Implants-Soft Tissue Considerations
At second stage surgery care is Purpose: Reduce the length
taken to thin the tissue flap of the peri-implant pockets
overlying the implant sites

44. Auricular Implants-Soft Tissue Considerations
The skin around these sites is almost completely
healed 4 weeks after second stage surgery.
These implants emerge through a split thickness skin graft that had been
placed previously. The granulation tissue (arrow) is secondary to keratin
buildup and accumulations of sebaceous secretions.
The implant surfaces must be kept clean if
peri-implant tissues are to remain healthy.

45. Prosthetic Techniques
Impressions
a b c d e
f
a: Impression copings are secured to implant fixtures.
b: Thin layer of rubber base impression material applied.
c: Thin layer of gauze imbedded in impression material.
d: Plaster backing.
e: Impression with abutment analogues attached.
f: Master cast.

46. Prosthetic Techniques
Fabrication of implant connecting bar
a b c d
a: Wax sculpture positioned on master cast.
b: Silicone template fabricated as an aid to fabricate tissue bar.
c: Pattern for tissue bar. In this case, implants were positioned
perfectly.
d: Completed implant connecting bar

47. Prosthetic Techniques
Acrylic resin substructure to be imbedded within
silicone prosthesis. It contains retentive elements.

48. Prosthetic Techniques
a b
a: Extrinsic coloration added to silicone prosthesis.
b: Clips placed into substructure.

49. Metal framework must fit passively
Both of these patients rely primarily on the Hader
bar and clip system for retention of their prostheses

50. Auricular Implants – Bar Designs
These patients rely primarily on the Hader bar
and clip system for retention of their prostheses

51. Completed Prosthesis in Position

52. Individual attachments
Zest anchors
Advantages
" Easier to use
" Quicker and less expensive
than an implant connecting bar

53. Individual Attachments
We no longer use them. Why?
Retention is adequate, but stability is suboptimal and we
have had a higher rate of failure with these systems
We recommend that craniofacial implants be splinted
together with a bar for best long term results.

54. Implants in the mastoid
(UCLA Data - Followup: 4 – 13 years)
Defects Patients #placed #failed #buried
Success rate
Tumor 13 35 1 3
93.3%
Congenital 12 47 4 2
87.2%
Trauma 11 35 0 9
100%
Totals 36 117 5* 9
91.5%
3 of the 5 failures were due to trauma (a blow to the head). Overall
success rate without the loss of these 3 implants would be 95%

55. Craniofacial Implants Placed in the Mastoid
to Retain Ear Prostheses
Soft Tissue Response
Grade #Visits/Site
0 60
1 32
2 5
3 3
4 1
Total 101

56. Soft Tissue Response
Moderate Erythema Erythema with
Grade 1 supporation Grade 4

57. Soft Tissue Response
Treatment – Improve hygiene

58. Soft Tissue Response
v Patient suffered from persistent soft tissue irritation. All
conservative measures failed including a course of
systemic antibiotics based on culture.
v Porcelain added to transcutaneous portion resolved tissue
irritation.

59. Irradiated sites
v Tissue bar with magnetic retention in irradiated patient.
Note flange exposures. Two of three implants were lost.
v In irradiated sites most implant failures are after loading.

60. Irradiated Sites
Irradiated sites
v An
osteoradionecrosis
associated with implants
v Patient was treated with 60
Gy
v Following
removal of the
implant the exposed bone
sequestrated followed by
complete healing

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