Endosseous implants in maxillofacial prosthesis.pptx

Ammar G. Salem
4th year KBMS- restorative department

 Introduction.
 Primary factors affecting prosthesis
success.
 Contraindications.
 Auricular prosthesis.
 Nasal prosthesis.
 Orbital prosthesis.
 Mandibular defects.
 Hard and soft palate defects.
 Zygomatic implants.
 Soft tissue complications.
 Hygiene instructions.
 Surgical templates.
 Retention systems.
 Implant-retained vs. adhesive-retained.
 Conclusion.

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, aesthetic, and social interaction.
As defect increases in size or as the number of involved structures increases in number, the task of the
prosthodontist increases in complexity.
Prosthesis should provide function, esthetic, and comfort for the patient.
Adequate retention of maxillofacial prostheses is regarded as the primary factor affecting patient satisfaction and
acceptance.
Taylor T. Clinical Maxillofacial Prosthetics; 2000 Quintessence Publishing Co, Inc
Dings JPJ, Merkx MAW, de Clonie Maclennan-Naphausen MTP, van de Pol P, Maal TJJ, Meijer GJ. Maxillofacial prosthetic
rehabilitation: A survey on the quality of life. J Prosthet Dent. 2018 Nov;120(5):780-786.
Beumer III JB, Curtis TA, Marunick MT. Maxillofacial Rehabilitation: Prosthodontic and Surgical Considerations. 2nd ed. St.
Louis: Ishiyaku Euromerica 1996: 377–449.
Lemon JC, Chambers MS, Wesley PJ, Reece GP, Martin JW. Rehabilitation of a midface defect with reconstructive surgery and
facial prosthetics: a case report. Int J Oral Maxillofac Implants 1996: 11: 101–105.

Must resist variant forces which can be directed toward, away, or at an angle to the
supporting structure.
Retention need:
- Optimal degree achieved of remaining teeth, soft and hard tissues.
- Close adaptation to underlying tissue.

Support need:
- Supporting structures are remaining teeth, edentulous area, and the postsurgical
defect.
- Need maximum peripheral extension with accurate adaptation to remaining
structures.

Stability need:
- Provided by the remaining teeth, residual ridges, and the surgical site.
Majority of forces are at an angle, stability frequently encountered during function.

Compensation for unfavorable anatomy generally requires surgical alteration of
defect area, alternative methods of external fixation, mechanical engagement of
tissue undercuts, or the use of adhesives.
Endosseous implants maybe used to address the concerns of diminished support,
retention, and stability.
Complications may occur in cases of gross bone resection or need of therapeutic
modalities (i.e. radiation).

Prosthetic design and strategic implant placement must anticipate the functional
demands of the prosthesis while also recognizing the dislodging forces applied to it.
In extraoral defects, support and stability are unlikely to overstress the implants. Thus,
they require reduced number of implants relative to prosthesis size if compared to
intraoral prosthesis.

 Systemic diseases which impair bone metabolism:
 Osteoporosis.
 Paget’s disease.
 Fibrous dysplasia.
 Multiple myeloma.
 Inability to preserve implant hygiene.
 Selective radiation therapy patient depending on:
 Radiation intensity (dose).
 Ability to locally control the doses (type of radiation).
 Hyperbaric oxygenation sessions before and after implant placement.
Borgia SG, Asociación Brasilera de Enseñanza Odontológica (ABENO). Prótesis buco-maxilo-facial sobre implantes extraorales, San Pablo
2007. 2007
Arcuri MR, LaVelle WE, Fyler A, Funk G. Effects of implant anchorage on midface prostheses. J Prosthet Dent. 1997; 78 (5): 496-
500.
Sosa et al. Prótesis Faciales Retenidas con Implantes e Imanes: Presentación de Tres Casos Clínicos en Pacientes Oncológicos de Prótesis
Maxilofacial del Instituto Nacional de Cancerología. Cancerología. 2008; 3: 71-76.

Implants are placed in the temporal bone to permit positive retention.
They are favored to adhesive due to presence of hair and absence of anatomic
irregularities and also for the easiness of seating the prosthesis.
Main complication is difficulty to maintain adequate hygiene around the skin.

Pekkan G, Tuna SH, Oghan F. Extraoral prostheses using extraoral implants. Int J Oral Maxillofac
Surg. 2011 Apr;40(4):378-83

A study conducted on 33 patients with 85 implants, the functioning fixture success rate was
100%, where most of implants were in the temporal area.
Jacobsson et al reported 98.7% success rate in temporal area, and Sweden et al found
nearly similar results 98.3%.
Most adverse reactions found in those studies were peri-implant soft tissue complications.
Abu-Serriah MM, McGowan DA, Moos KF, Bagg J. Outcome of extra-oral craniofacial endosseous implants. Br J Oral Maxillofac
Surg. 2001 Aug;39(4):269-75.
Jacobsson M, Tjellstrom A, Fine L, Andersson H. A retrospective study of osseointegrated skin-penetrating titanium fixtures
used for retaining facial prostheses. Int J Oral Maxillofac Implants 1992; 7: 523–528.
Parel SM, Tjellstrom A. The United States and Swedish experience with osseointegration and facial prostheses. Int J Oral
Maxillofac Implants 1991; 6: 75–79.

Bar clips retention system are the most indicated for retention of auricular prostheses.
Although they require follow-up for revision and repair of acrylic resin substructure.
Katz MR, Irish JC, Devins GM, Rodin GM, Gullane PJ. Reliability and validity of an observer-
rated disfigurement scale for head and neck cancer patients. Head Neck 2000;22:132-41.
Arcuri MR, LaVelle WE, Fyler A, Funk G. Effects of implant anchorage on midface prostheses. J
Prosthet Dent 1997;78:496-500.

In clinical study on 10 patients with auricular defects, 40 implants were placed in the
temporal bone and the results are as follow:
- 31 were placed on pre-existing skin, and 9 in STSG.
- All achieved osseointegration 100% success rate 40/40.
- They suggested placing 3 implant rather than 2 in auricular area.
Nishimura RD, Roumanas E, Sugai T, Moy P. Auricular prostheses and osseointegrated implants:
UCLA experience. J Prosthet Dent 1995;73:553-8.

2 or 3 implants ??
- Old studies suggest 2 implants for each prosthesis, this needed a long cantilever of
metal suprastructure to ensure good adaptation of the margins of the prosthesis
distant from the implants.
- But this will allow lateral/bending loads of those long cantilevers to be detrimental to bone-
implant interface.
- Thus placement of 3 implants in a (non-linear) alignment will create an offset that
reduces the bending loads.

Implant success is highest when are placed into the superior surface of the maxilla
and used to retain the inferior aspect of the nasal prosthesis.
The bone quality and quantity in the glabellar region of frontal bone is limited, and
implants at superior aspect of nasal defect usually cannot be placed.
The design of retentive elements of the prosthesis should incorporates two planes of
retention.

A U-shaped retentive bar connected to the implants at the base of the U will provide
3 points for retention.
Two vertical struts and the horizontal crossbar.
Retentive clips or magnets are used to secure the prosthesis.

 In a study conducted on 11 patients, two implant sites where chosen:
 17 implants in ANF.
 4 implant in glabellar bone.
 Success rate in ANF was 88.1% 15/17, while it was 0% 0/4 in glabellar bone.
placement of implant in ANF need caution with traumatizing the roots apices of
maxillary anterior or premolar teeth, and providing a more anterior position to aid
hygiene access.
Severe soft tissue reaction around implants in ANF is rare.
Nishimura RD, Roumanas E, Moy PK, Sugai T. Nasal defects and osseointegrated implants: UCLA
experience. J Prosthet Dent. 1996 Dec;76(6):597-602.

Nishimura RD, Roumanas E, Moy PK, Sugai T. Nasal defects and osseointegrated implants: UCLA experience. J
Prosthet Dent. 1996 Dec;76(6):597-602

Saint LR, Torres TJF, González CV. Implant-supported nasal prosthesis. Clinical case report. Rev Odont
Mex. 2016;20(1):44-49.

In small defects the adhesive retention maybe satisfactory.
The location of the implants generally in the supraorbital rim or in the lateral rim
of the residual orbit.

Functional success rate of implant fixtures was 74% in orbital implant retained
prosthesis.
Nishimura reported only 35% success rate for orbital implant retained prostheses.
Reports shows that superior rim has less successful rate than lateral rim and buttress
area.
Abu-Serriah MM, McGowan DA, Moos KF, Bagg J. Outcome of extra-oral craniofacial endosseous implants. Br J Oral Maxillofac
Surg. 2001 Aug;39(4):269-75.
Nishimura RD, Roumanas E, Moy PK, Sugai T, Freymiller EG. Osseointegrated implants and orbital defects: UCLA.
experience. J Prosthet Dent 1998; 79: 304–309.
Jacobsson M, Tjellstrom A, Fine L, Andersson H. A retrospective study of osseointegrated skin-penetrating titanium fixtures
used for retaining facial prostheses. Int J Oral Maxillofac Implants 1992; 7: 523–528.

Magnetic retention system were favored because of the ease of positioning by the
patient, despite the predictable corrosion phenomenon.
It offers compensation for non-parallelism of implants and induce minimal lateral forces,
thus less stress on implants.
Clip retention is favored in large defects where more effective retention required.
Nishimura RD, Roumanas E, Moy PK, Sugai T, Freymiller EG. Osseointegrated implants and orbital
defects: U.C.L.A. experience. J Prosthet Dent. 1998 Mar;79(3):304-9.
Katz MR, Irish JC, Devins GM, Rodin GM, Gullane PJ. Reliability and validity of an observer-
rated disfigurement scale for head and neck cancer patients. Head Neck 2000;22:132-41.

- Monocular vision and reduced perception of depth hinder adequate hygiene control.
- Circular arrangement of implants make single bar fabrication difficult and doesn’t
allow axial loading of implants.
- Orbital rim doesn’t possess sufficient remodeling potential to support long-term
osseointegration due to its thin and atrophic periosteum and lack of bone marrow.
- Medial lateral and anterior posterior curvature of orbital rim often require an
aggressive countersink to completely seat the flange of implant (which may cause
excessive thermal damage)
Nishimura RD, Roumanas E, Moy PK, Sugai T, Freymiller EG. Osseointegrated implants and orbital
defects: U.C.L.A. experience. J Prosthet Dent. 1998 Mar;79(3):304-9.

Goh BT, Teoh KH. Orbital implant placement using a computer-aided design and manufacturing (CAD/CAM)
stereolithographic surgical template protocol. Int J Oral Maxillofac Surg. 2015 May;44(5):642-8.

Ablative tumor surgery in the mandible result in mandibular discontinuity that is
managed by immediate or delayed surgical reconstruction to re-establish continuity.
Implants placed in the grafted bone will allow the placement of prosthesis that does
not create deleterious compressive forces on the graft. Instead internal loading will
result in bone preservation.

If mandible continuity is not established, the mandible will deviate toward the side
of the resection because of cicatricial changes in the surgical site and absence of
musculature on that side.
The angle of mandibular closure will place forces on the implants that are not in
line with the long axis of the implants.

 Three most common bone flaps used for reconstruction:
 Fibula free flap FFF – it has the least resorption and most stable overtime.
 Iliac crest free flap ICFF
 Scapula free flap SFF
Maxillofacial Reconstruction Using Vascularized Fibula Free Flaps and
Endosseous Implants

Maxillofacial Reconstruction Using Vascularized Fibula Free Flaps and
Endosseous Implants

Maxillofacial Reconstruction Using Vascularized Fibula Free Flaps and Endosseous Implants

Loss of supporting teeth and the large obturator prosthesis compromise retention and
support.
The tendency of rotation into the defect area when occlusal loads applied on the defect
side while it will rotate out as gravity pull the prosthesis.
Endosseous implants in the residual maxilla must be sufficient number, length and
distribution to resist the anticipated complex forces of mastication and dislodgment.
Four implants in the intact maxilla are suggested as the minimum number for
overdenture prosthesis.

If the implants can be distributed bilaterally, more acceptable forces will be generated
to the implants and better retention and stability will be achieved.
Occlusion is not a consideration in the soft palate defect, the primary function of
implants here is to retain prosthesis and support the occlusion.
Soft palate defects are normally associated with bilateral maxillary support.

They originally designed by Branemark in
1988.
Have a length of 30 to 52.5mm.
Are inserted in the palatal aspect of
maxillary alveolar ridge and anchored in
the body of the malar bone.
Branemark P: Surgery Fixture Installation: Zygomaticus Fixture Clinical Procedures (1st ed).
Gotemburgo, Suecia, Nobel Biocare, AB, 1998

Severe maxillary atrophy.
Extensive maxillary sinus pneumatization.
Previous total or partial maxillectomy.
Failure of advanced pre-prosthetic procedures
(such as ridge augmentation or sinus lift
surgery)
Bedrossian E: Rescue implant concept: The expanded use of the zygoma implant in the graftless
solutions. Dent Clin North Am 55:745, 2011

 Maxillary sinusitis or congestive symptoms.
 Oroantral fistula.
 Infection.
 Peri-implantitis.
 Infraorbital nerve paresthesia.
 Loss of primary stability.
 Implant failure.
Chrcanovic BR, Albrektsson T, Wennerberg A: Survival and complications of zygomatic implants:
An updated systematic review. J Oral Maxillofac Surg 74:1949, 2016
D’Agostino A, Trevisiol L, Favero V, et al: Are zygomatic implants associated with maxillary
sinusitis? J Oral Maxillofac Surg 74: 1562, 2016

Gómez-Pedraza A, González-Cardín V, Díez-Suárez L, Herrera-Villalva M. Maxillofacial Rehabilitation
With Zygomatic Implants in an Oncologic Patient: A Case Report. J Oral Maxillofac Surg. 2020

 Scott et al. (2016) restored 28 patients with total of 56 zygomatic implants, only one
implant failed (15 year implant success rate 98%)
 Durate et al. (2007) showed that immediate loading of zygomatic implants resulted in
high levels of osseointegration with 96% efficacy.
 In 2014, Goiato et al. showed a success rate 97.86% during the follow up of 1541
zygomatic implants.
Scott N, Kittur MA, Evans PL, et al: The use of zygomatic implants for the retention of nasal
prosthesis following rhinectomy: The Morriston experience. Int J Oral Maxillofac Surg 45:1044,
2016
Duarte LR, Filho HN, Francischone CE, et al: The establishment of a protocol for the total
rehabilitation of atrophic maxillae employing four zygomatic fixtures in an immediate loading
system —A 30-month clinical and radiographic follow-up. Clin Implant Dent Relat Res 9:186,
2007
Goiato MC, Pellizzer EP, Moreno A, et al: Implants in the zygomatic bone for maxillary prosthetic
rehabilitation: A systematic review. Int J Oral Maxillofac Surg 43:748, 2014

Evaluation criteria of soft tissue around implant:
0/ no irritation
1/ slight redness
2/ red and moist tissue
3/ granulation red, and moist tissue
4/ infection (suppuration and purulence)
Beumer J, Moy P. Bone-anchored craniofacial prosthesis investigation. Protocol, 1988. Nobelpharma
USA, Inc.

- Mechanical debridement with soft toothbrush and proxybrush.
- Irrigation with warm water and soap and/or hydrogen peroxide.
- Stepwise procedure proposed by Allen et al showed effectiveness in a limited sample size, it
is as follows:
- Cotton buds moistened in 50:50 hydrogen peroxide and water were used to remove debris around the
transcutaneous abutment cylinder.
- An interproximal toothbrush with soft bristles was used to clean the superior aspects of the
transcutaneous abutment cylinders. Where a bar retainer was present, a tufted floss was used to
clean abutments and the inferior surface of the bar.
- The silicone or acrylic prosthesis was cleaned with a soft toothbrush and mild soap.
- Patient were encouraged to remove the prosthesis while asleep to expose the skin to open air. The
purpose of this was to decrease the risk of fungal or bacterial contamination of the skin covered by
the prosthesis.
Allen PF, Watson G, Stassen L, McMillan AS. Peri-implant soft tissue maintenance in patients with
craniofacial implant retained prostheses. Int J Oral Maxillofac Surg. 2000 Apr;29(2):99-103.

 Successful prosthetic-driven rehabilitation depends on:
 Accurate diagnosis.
 Accurate preoperative planning.
 Accurate placement of endosseous implants.
 The development of MDCT and CBCT provides graphic and detailed 3D information
regarding bone volume, quality, and anatomical limitations.
 Virtual planning software has enabled 3D CAD-CAM of surgical templates to allow
guided implant placement, facilitating intraoperative correct positioning at
predetermined depth and angle.
 Guide support can be: skeletal, dental, or mucosal.
Dings JPJ, Verhamme L, Maal TJJ, Merkx MAW, Meijer GJ. Reliability and accuracy of skin-supported surgical
templates for computer-planned craniofacial implant placement, a comparison between surgical templates: With
and without bony fixation. J Craniomaxillofac Surg. 2019 Jun;47(6):977-983.

 CBCT taken 
 converted to DICOM 
 3D models created from DICOM 
 virtually planning of implant platform 
 full surgical template 
 exported as STL-files 
 transfer to prototyping system 
 3D printed from biocompatible resin.

McHutchion L, Kincade C, Wolfaardt J. Integration of digital technology in the workflow for an osseointegrated
implant-retained nasal prosthesis: A clinical report. J Prosthet Dent. 2019 May;121(5):858-862.

Martínez Plaza A, Peréz de Perceval Tara M, Marín Fernández AB, Bullejos Martínez E, Román Ramos M,
Fernández Valadés R, España López A. Bilateral auricular reconstruction with osseointegrated implant-retained
prostheses. Optimization of aesthetic outcomes using virtual planning. J Stomatol Oral Maxillofac Surg. 2019

 For auricular prosthesis, the bar clip was the most common.
 In oculo-palpebral and nasal regions, either bar-clip or magnets maybe selected,
this choice governed by: indication and practitioner’s ability.
Cobein MV, Coto NP, Crivello Junior O, Lemos JBD, Vieira LM, Pimentel ML, Byrne HJ, Dias RB. Retention
systems for extraoral maxillofacial prosthetic implants: a critical review. Br J Oral Maxillofac Surg. 2017
Oct;55(8):763-769.

Ease of handling and retention by means of osseointegrated implants proved
advantageous over the adhesive retained facial prosthesis.
Several studies showed significant improve with implant retained facial prosthesis
in all domains of QOL.
Dings JPJ, Merkx MAW, de Clonie Maclennan-Naphausen MTP, van de Pol P, Maal TJJ, Meijer GJ.
Maxillofacial prosthetic rehabilitation: A survey on the quality of life. J Prosthet Dent. 2018
Nov;120(5):780-786.
Bonanno A, Esmaeli B, Fingeret MC, Nelson DV, Weber RS. Social challenges of cancer patients
with orbitofacial disfigurement. Ophthal Plast Reconstr Surg 2010;26:18-22.
Wondergem M, Lieben G, Bouman S, van den Brekel MW, Lohuis PJ. Patients’ satisfaction with
facial prostheses. Br J Oral MaxillofacSurg 2016;54:394-9.

In a study of 19 implants, 10 in maxilla, 6 in frontal bones, 2 in a scapula and 1 in
zygoma.
Success criteria was: immobility, no radiographic peri-implant radiolucency, no
persistent infection/pain.
14/17 implants (82%) remained osseointegrated.
Arcuri MR, LaVelle WE, Fyler A, Funk G. Effects of implant anchorage on midface prostheses. J

retentio
n
appearanc
e
Self
consciousness
Ease
of
placement
Arcuri
MR,
LaVelle
WE,
Fyler
A,
Funk
G.
Effects
of
implant
anchorage
on
midface
prostheses.
J
Prosthet
Dent
1997;78:496-500.

Ability
to
perform
hygiene
activities
Ease
of
removal
Arcuri MR, LaVelle WE, Fyler A, Funk G. Effects
of implant anchorage on midface prostheses. J

Outcome of implants placed to retain craniofacial prostheses - A
retrospective cohort study with a follow-up of up to 30 years
 Total of 525 implants in 201 patients with follow up 28-174 months.
 Implants placed in the mastoid and nasal region showed the highest overall implant
survival rates (10 years SR of 93.7% and 92.5%, respectively).
 The orbital implants had the lowest overall SR (84.2%).
 Radiotherapy was a significant risk factor for implant loss.
Alberga J, Eggels I, Visser A, van Minnen B, Korfage A, Vissink A, Raghoebar G. Outcome of implants placed to
retain craniofacial prostheses - A retrospective cohort study with a follow-up of up to 30 years. Clin Implant Dent
Relat Res. 2022 Oct;24(5):643-654.

Outcome of implants placed to retain craniofacial prostheses - A
retrospective cohort study with a follow-up of up to 30 years
Alberga J, Eggels I, Visser A, van Minnen B, Korfage A, Vissink A, Raghoebar G. Outcome of implants placed to
retain craniofacial prostheses - A retrospective cohort study with a follow-up of up to 30 years. Clin Implant Dent
Relat Res. 2022 Oct;24(5):643-654.

Endosseous implants can be used to provide retention, support, and stability for
maxillofacial prosthesis when residual anatomy is no longer capable of fulfilling
these functions.

Endosseous implants in maxillofacial prosthesis.pptx

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