JOMI on CD-ROM, 1986 Jan (27-29 ): Osseointegration and Facial Prosthetics Stephen M.

Pa

Copyrights 1997 Quintes

Osseointegration and Facial Prosthetics

Stephen M. Parel, D.D.S./G. Richard Holt, M.D./Per-lngvar Brnemark, M.D./Anders Tjellstrm, M.D., Ph.D.

Utilization of osseointegrated fixtures to support skin penetrating abutments and facial prostheses offers significant advantages. Clinical experience at Gteborg, Sweden, and the University of Texas at San Antonio is reported. The introduction of the Swedish method of osseointegrated implantology to the North American dental profession in May 1982, has had a profound effect on our capacity for providing a previously unobtainable level of oral rehabilitation. This concept is based on a specific metallurgic response, an atraumatic surgical placement, and a passive stress-distributed prosthetic technique; all of which contribute to a predictably high degree of implant longevity and long-term continuous prosthesis use.1-4 The application of these procedures to patients suffering from the devastating effects of oral or facial cancer has been equally valuable in increasing the level of functional rehabilitation.5-8

The facial prosthesis

Perhaps the most significant advancement in the relatively short history of modern facial prostheses is the ability to diminish dependence on adhesives afforded by the extraoral placement of osseointegrated fixtures.9-10 Problems with margin integrity, skin reactions, placement misalignment or prosthesis camouflage are all minimized or eliminated when this type of external mechanical retention is provided.

Surgical considerations
Although the surgical placement technique is based on the same principles that apply to the installation of fixtures in the oral cavity, special considerations are required because of the proximity of vital organ structures to the bone penetration sites. Unique depth-limiting burs are used to prepare the host bone, and custom made 3- or 4-mm flat-flanged fixtures are utilized as the bone anchor units (Fig. 1). Following an extended integration period of five to six months, the fixtures are exposed and short transepithelial abutments are placed on them through the puncture sites. The skin surrounding the abutments is then very carefully compressed for ten days to allow tight postoperative adaptation of the epithelial cuff.

Prosthetic procedures
Following resolution of the edema resulting from phase II surgery, impressions are made to accurately record the position of the abutments for bar splint construction. A wax pattern is created with extensions into areas of the proposed prosthesis that are thick enough to allow the placement of paired magnetic retainers without compromising esthetics. A circular receptor is created in the wax pattern to house each of the cantilevered magnets. Following casting, the bar is soldered to the gold cylinders creating a splint assembly to support the prosthesis (Fig. 2).

JOMI on CD-ROM, 1986 Jan (27-29 ): Osseointegration and Facial Prosthetics Stephen M. Pa

Copyrights 1997 Quintes

Samarium-Cobalt magnets are processed into each cantilever with autopolymerizing resin for protection. A paired attracting magnet is also enclosed in resin with a wire rossette attached to the outside. The wire is subsequently processed into the silicone of the ear prosthesis providing retention between the silicone and the elastomer (Fig. 3). The facial prosthesis is processed in silicone rubber and delivered with extrinsic coloration to match the existing adjacent skin tones. On occasion it is necessary to utilize the abutments free-standing with a screwed-down keeper plate. This will allow the use of stronger magnetic units independently placed on each abutment without compromising the overall result.

Present experience
Since the ultimate prosthesis is essentially static when in position, no continuous stress is placed on these fixtures other than gravitational forces from either the bar splint or free-standing retainers. As a result, the Swedish experience over an eight-year period indicates that these extraoral fixtures exhibit a longevity pattern as good or better than that obtained in the oral cavity (Table 1). Although only three years of data are presently available, initial results in the University of Texas at San Antonio pilot study tend to confirm this trend. Experience with auricular, nasal, and orbital restorations has been extremely encouraging. Prostheses that are far superior in terms of convenience and wear (Figs. 4a and 4b) have been fabricated and remain in service for patients with defects involving these facial structures. The potential for a more lifelike appearance is also enhanced with the relative immobility and marginal translucency that is possible through this system of anchorage (Figs. 5a to 5c).

Summary
The successful use of osseointegrated titanium fixtures to support oral prosthetic restorations has been proven by international experience. Application of the osseointegration concept and technique to the fabrication of and support for prostheses replacing parts of the face has been described and preliminary results reported from treatment centers in Gteborg, Sweden, and the University of Texas at San Antonio.

JOMI on CD-ROM, 1986 Jan (27-29 ): Osseointegration and Facial Prosthetics Stephen M. Pa

Copyrights 1997 Quintes

1. Brnemark, P-I, et al. Intra-osseous anchorage of dental prostheses I. Experimental studies. Scand J Plast Reconstr Surg 3:81-100, 1969. 2. Adell, R., et al. A 15 year study of osseointegrated implants in the treatment of the edentulous jaw. Int J Oral Surg 10:387-416, 1981. 3. Brnemark, P-I. Osseointegration and its experimental background. J Prosthet Dent 50:399-410, 1983. 4. Adell, R. Clinical results of osseointegrated implants supporting fixed prostheses in edentulous jaws. J Prosthet Dent 50:251-254, 1983. 5. Parel, S.M., Brnemark, P-I, and Jansson, T. Osseointegration in maxillofacial prosthetics, Part I: Intraoral applications (in press). 6. Brnemark, P-I, et al. Reconstruction of the defective mandible. Scand J Plast Reconstr Surg 9:116-128, 1975. 7. Lindstrm, J., Brnemark, P-I, and Albrektsson, T. Mandibular reconstruction using the preformed autologous bone graft. Scand J Plast Reconstr Surg 15:29-38, 1981. 8. Brnemark, P-I, et al. Repair of defects in mandible. Scand J Plast Reconstr Surg 4:100-108, 1970. 9. Tjellstrm, A., et al. The bone anchored auricular episthesis. Laryngoscope 90(5):811-815, 1981. 10. Brnemark, P-I, and Albrektsson, T. Titanium implants permanent penetrating human skin. Scand J Plast Reconstr Surg 16:17-21, 1982.

JOMI on CD-ROM, 1986 Jan (27-29 ): Osseointegration and Facial Prosthetics Stephen M. Pa

Copyrights 1997 Quintes

JOMI on CD-ROM, 1986 Jan (27-29 ): Osseointegration and Facial Prosthetics Stephen M. Pa

Copyrights 1997 Quintes

Fig. 1 Four depth-limited implant fixtures placed in the temporal bone distal to the region of the patient's missing ear.

Fig. 2 Bar splint with cantilevered magnet retainers anchored to three osseointegrated fixtures over area where congenitally missing ear will be.

JOMI on CD-ROM, 1986 Jan (27-29 ): Osseointegration and Facial Prosthetics Stephen M. Pa

Copyrights 1997 Quintes

Fig. 3 Ear prosthesis held in place without adhesive and utilizing magnets imbedded in the silicone for retention.

Figs. 4a and 4b Tissue surface of a nasal prosthesis showing distribution of an embedded magnetic retainer (left). Completed prosthesis in place, camouflaged with artificial hair at nasal base to blend with mustache and g/asses to hide vertical margins (right).

JOMI on CD-ROM, 1986 Jan (27-29 ): Osseointegration and Facial Prosthetics Stephen M. Pa

Copyrights 1997 Quintes

Figs. 5a and 5b Orbital defect with five osseointegrated fixtures in the superior and lateral orbital rim (left). Close-up view of orbital prosthesis showing level of margin camouflage available with implant retention technique (right).

Fig. 5c Full-face view with glasses hiding margins of orbital prosthesis held in place without adhesives.