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Table of Contents   
CASE REPORT  
Year : 2011  |  Volume : 22  |  Issue : 1  |  Page : 152-156
Implant-supported auricular prosthesis


1 Senior Resident, MAIDS, New Delhi, India
2 Associate Proffessor, CDER, AIIMS, New Delhi, India
3 Assistant Professor, ENT, AIIMS, New Delhi, India
4 Ex Senior Resident, CDER, AIIMS, New Delhi, India

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Date of Submission12-Jul-2009
Date of Decision24-Apr-2010
Date of Acceptance14-May-2010
Date of Web Publication25-Apr-2011
 

   Abstract 

Differences in the balance of shape, size, and position of body organs are immediately perceived as "looking wrong" and this perception can subject the individual to significant peer ridicule and social ostracism, often expressing as intense shame and anguish in the attitude of the afflicted. Rehabilitation of such patients can be remarkably beneficial on the individual's self-esteem and body image. The onus of the deed lies in the hands of a team that combines artistic excellence with surgical expertise, by combining the skills of anaplastologists, surgeons, and prosthodontists. This is a review of a few surgical and prosthetic considerations in the management of auricular defect and a case description of management of a patient of microtia following similar guidelines in fabrication of the epithesis.

Keywords: Auricle, implants, microtia

How to cite this article:
Nanda A, Jain V, Kumar R, Kabra K. Implant-supported auricular prosthesis. Indian J Dent Res 2011;22:152-6

How to cite this URL:
Nanda A, Jain V, Kumar R, Kabra K. Implant-supported auricular prosthesis. Indian J Dent Res [serial online] 2011 [cited 2019 Nov 15];22:152-6. Available from: http://www.ijdr.in/text.asp?2011/22/1/152/79983
Auricular defects ranging from minor deformities to complete anotia can be due to various causes, such as congenital defects, tumor resection, inflammation of cartilage, and trauma. [1],[2],[3],[4] Treatment options comprise autogenous reconstruction [2],[3],[5] or prosthetic rehabilitation. [3]

The requirements of prosthesis are esthetics, retention and stability, [6],[7] alignment and positioning, biocompatibility, and longevity. [5]

Retentive aids for prosthesis can be by either anatomic or mechanical methods. [3],[6] The mechanical methods comprise straps and head bands anchored behind head, eyeglass frame, and adhesives. Disadvantages of adhesives are, decrease in efficacy with continual use, possibility of an allergic response, poor dexterity hampering proper application and positioning of epithesis, disturbance of the adhesive bond by facial movement and perspiration, daily removal and reapplication for hygiene, and poor maintenance affects the prognosis. [6],[8] A recent exclusive mechanical method with promising results [2],[7],[8],[9] consists of implants with accessory retention features after the pioneering works of Branemark Per Ingvar and Tjellström at Sahlgrenska Hospital, Göteborg, Sweden, in 1979.

Advantages of implants include [2],[5] a short and straight forward surgery, which can be performed either as a two-stage or a single-stage procedure under local anesthesia or general anesthesia, esthetics being much similar to normal, a remake is possible, implants enables early detection of recurrence in cancer patients. [8]

Disadvantages of the implant supported prosthesis are that patient does not perceive it as self. [5] Also, inability to maintain peri-implant hygiene leads to peri-implantitis and other soft tissue changes, which may result in misfit of the prosthesis if ignored or even failure of implants. Complete soft tissue removal is required for the procedure, which leads to anotia with scar formation, making subsequent autogenous reconstruction impossible. The treatment has an extended duration as compared with other types of prosthetic rehabilitation methods and the prosthesis has a reduced longevity (the average being 2-3 years, with the most common cause for remake being discoloration and fracture of clips with time, making repair difficult). [3]


   Case Report Top


An 18-year-old male patient [Figure 1]a and b with bilateral congenital microtia (treated with canaluloplasty on right side) was referred to the Department of Prosthodontics from Ear Nose and Throat (ENT) department. The presence of rudimentary cartilage was seen on both sides with scar tissue on the right side. The patient was in his postgrowth spurt period, so surgical intervention was not contraindicated. The patient's expectations were for a flexible and relatively life-like fixed prosthesis.
Figure 1: (a) Preoperative right lateral view; (b) preoperative left lateral view

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Diagnostic aids for implant placement comprised of preliminary impressions, fabrication of a wax prototype, an acrylic diagnostic template, and a computed tomographic (CT) scan of middle third face. Tentative sites for implants were marked on the patient's face and transferred to diagnostic impressions. On the left side, the prospective position of implants were at 2 and 4 o'clock positions from a horizontal line joining the location of external auditory meatus (EAM) and outer canthus of the eye, whereas on the right side the positions were at 8 and 11 o'clock positions similarly. (EAM is located approximately 10 mm from the condyle head at rest position.) All the implants were within 15-20 mm radius from the location of the EAM and the distance between 2 consecutive implants was 12-15 mm. Preliminary diagnostic impressions in alginate backed by impression compound were then made [Figure 2].
Figure 2: Diagnostic impressions

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Wax prototype was fabricated using the diagnostic model and clinical landmarks. The landmarks used were superior horizontal line through superior tarsal plate and nasion, inferior horizontal line through base of nose, anterior vertical line through outer rim of orbit and perpendicular to horizontal lines, and posterior vertical line through angle of mandible and perpendicular to horizontal lines [Figure 3]a and b. The wax prototype enabled to ascertain that the implants were positioned well concealed by its thickest portion (antihelix and antitragus) and also provided an estimate of the amount of removal of rudimentary cartilage, which impaired the design of the prosthesis [Figure 4].
Figure 3: (a) Landmarks for diagnostic wax up; (b) lateral view

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Figure 4: Wax prototype

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After blocking soft tissue undercuts on diagnostic model, an acrylic diagnostic template was fabricated over the diagnostic model in clear self-curing resin. The prospective site of implants was transferred to the acrylic diagnostic template by indelible pencil marks on the diagnostic casts. The radioopaque markers were placed at the prospective positions by adhesive tape on the acrylic diagnostic template. CT scan was done in coronal (to assess the adjacent anatomic structures) and saggital views (to assess the amount of bone and vicinity of vital structures) after placement of acrylic diagnostic template carrying the radioopaque lead foils at the prospective implant sites [Figure 5]a and b. Bilaterally it was found that 5×5 mm implants could be placed safely.

Correlating the clinical findings, the CT diagnosis and patient expectations, it was decided to place 5 mm diameter and 5 mm length, external hex implants with sintered porous surface at the 4 sites, respectively.
Figure 5: (a) CT in coronal view; (b) CT in sagittal view

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The surgery was done in two stages by the Ear, Nose and Throat surgeons. In the 1 st stage the implants were placed. Acrylic diagnostic templates were converted to surgical templates by drilling holes in the prospective implant site location (transferred from diagnostic cast at the time of diagnosis and carrying radioopaque markers at the time of CT scan) [Figure 6]. This surgical template assisted in transferring the prospective site of implant as decided during diagnosis into actual placement of implant. Rudimentary cartilage was removed and thinning of subcutaneous tissue was done (to enable easy palpation, reduce hairless zone, and limit mobility of skin over implants).
Figure 6: Diagnostic template modified as surgical template

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In the 2 nd stage uncovering of implants by removal of soft tissue and placement of secondary healing caps 3 months from the date of 1 st stage surgery (subsequent to osseointegration) was carried out.

Prosthetic ear fabrication comprised fabrication of bar framework and actual ear prosthesis fabrication. The first step for this was connecting UMA (Universally Modified Abutments) transmucosal abutments to implants [Figure 7], which was done 3 weeks after second stage surgery. The next step was making impression of implant positions and soft tissues together. For this, the guidelines to assist in wax up of prosthesis were drawn on face (similar to during diagnosis) and impression was made after splinting of transfer copings with resin and backing light body polyvinyl siloxane with acrylic resin [Figure 8]. It has been recommended that impression materials must cause minimum soft tissue distortion, for which irreversible hydrocolloid, polyvinyl siloxane, and polyether have been suggested. Backing of impression material must not distort soft tissue under its weight, so acrylic resin in dough stage is recommended instead of impression plaster or prefabricated acrylic trays. Splinting of transfer copings by polyether, impression plaster, floss, or prefabricated resin bars is required for correct recording of orientation of implant. [10],[11] After the impression, the UMA laboratory analogs were connected to transfer coping and model was poured.
Figure 7: UMA transmucosal abutments

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Figure 8: Splinting of transfer copings

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Bar framework designing and fabrication was done on the model obtained in the previous step. Placement of plastic sleeve on UMA analog was done. Hader bar framework design included the following features: less than 10 mm cantilever, 2 mm distance from skin surface, and bar in between center of one implant to center of the other implant design [Figure 9]. From biomechanical point of view, bar must reduce loads and also optimize hygiene, hence offset design is not recommended. The bar is made to follow center-to-center design, that is, each section of the bar should be attached to the guide sleeve on the UMA analog in such a way that the imaginary longitudinal bisector of the bar extends through the center of the implant.
Figure 9: Cast bar trial on the patient

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The next prosthetic step was fabrication of an acrylic resin substructure. The acrylic resin substructure is an acrylic plate fabricated in clear resin that provides a backing for silicone and carries retentive clips in its tissue surface. These clips help to snap fit the prosthesis on the bar during placement. Its superior surface priming was done to create adhesion of acrylic with silicone. Wax up of prosthesis was then done followed by trial on the patient. This was followed by three-part flasking of the wax up with formation of the channels for silicone escape Shade matching for Cosmosil RTV silicone was done according to various anatomic regions followed by curing at room temperature overnight. Final prosthesis was retrieved and then placed on patient's face [Figure 10] a and b.
Figure 10: (a) Final prosthesis right lateral view; (b) final prosthesis left lateral view

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Maintenance was emphasized to the patient as it is imperative for the long-term success of prosthesis. [3],[4],[12] Mechanical cleaning with interdental brush around abutments and with gauze soaked in peroxide 3% solution and saline in (1:1) ratio or soap and water is advised. Sharp instruments should be avoided as trauma to skin, scratching titanium surface make future cleaning more difficult.


   Discussion Top


Implant survival rate in mastoid region of 100%-95.7% [3],[4] has been reported, which has been attributed to dense cortical bone in mastoid region [1],[3],[4] and vasculature, which ensures maintenance of a bone implant interface adequate to support functional loads. [1] However, meticulous management and care can prolong the life and success of prosthesis. Thus, it can be concluded that implant supported auricular prosthesis is another avenue worth trying while rehabilitating patients with auricular defects.

 
   References Top

1.Nishimura RD, Roumanas E, Sugai T, Moy PK. Auricular prostheses and osseointegrated implants: UCLA experience. J Prosthet Dent1995;73:553-8.  Back to cited text no. 1
[PUBMED]    
2.Wang RR, Andres CJ. Hemifacial microstomia and treatment options for auricular replacement: A review of literature. J Prosthet Dent1999;82:197-204.  Back to cited text no. 2
[PUBMED]  [FULLTEXT]  
3.Visser A, Raghoebar GM, Van Oort RP, Vissink A. Fate of implant - retained craniofacial prosthesis: Lifespan and aftercare. Int J Oral Maxillofac Implants 2008;23:89-98.  Back to cited text no. 3
[PUBMED]    
4.Aydin C, Karakoca S, Yilmaz H, Yilmaz C. Implant-retained auricular prosthesis: An assessment of implant success and prosthetic complications. Int J Prosthodont 2008;21:241-4.  Back to cited text no. 4
[PUBMED]    
5.Wilkes GH, Wolfaardt JF. Osseointegrated alloplastic versus autogenous ear reconstruction: Criteria for treatment selection. Plast Reconstr Surg 1994;93:967-79.  Back to cited text no. 5
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6.Parel SM. Diminishing dependence on adhesives for retention of facial prosthesis. J Prosthet Dent 1980;43:552-60.  Back to cited text no. 6
[PUBMED]    
7.Guo G, Schwedtner O, Klein M. A retrospective study of implant - retained auricular prosthesis. Int J Oral Maxillofac Implants 2008;23:539-43.  Back to cited text no. 7
[PUBMED]    
8.Butler DF, Gion GG, Rapini RP. Silicone auricular prosthesis. J Am Acad Dermatol 2000;43:687-90.  Back to cited text no. 8
[PUBMED]  [FULLTEXT]  
9.Seals RR Jr, Cortes AL, Parel SM. Fabrication of facial prosthesis by applying osseointegration concept for retention. J Prosthet Dent 1989;61:712-6.  Back to cited text no. 9
[PUBMED]  [FULLTEXT]  
10.Dumbrigue HB, Gurun DC, Javid NS. Prefabricated acrylic resin bars for splinting implant transfer copings. J Prosthet Dent 2000;84:108-10.  Back to cited text no. 10
[PUBMED]  [FULLTEXT]  
11.Kubon TM, Anderson JD. An implant retained auricular impression technique to minimise soft tissue distortion. J Prosthet Dent 2003;89:97-101.  Back to cited text no. 11
[PUBMED]  [FULLTEXT]  
12.Holgers KM, Tjellstrom A, Bjursten LM, Erlandsson BE. Soft tissue reaction around percutaneous abutments: A clinical study on skin penetrating titanium implants used for bone anchored auricular prosthesis. Int J Oral Maxillofac Implants1987;2:35-9.  Back to cited text no. 12
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Correspondence Address:
Aditi Nanda
Senior Resident, MAIDS, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9290.79983

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]

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