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CASE REPORT
Year : 2017  |  Volume : 6  |  Issue : 4  |  Page : 262-266

Implant retained auricular prosthesis: A clinical report


Department of Prosthodontics, Meghna Institute of Dental Sciences, Nizamabad, Telangana, India

Date of Web Publication26-Dec-2017

Correspondence Address:
Dr. Khaja Yousuf Sharif
Department of Prosthodontics, Meghna Institute of Dental Sciences, Nizamabad, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2277-8632.221526

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  Abstract 


Prosthetic ears are created for patients with microtia, a congenital defect that affects 1 in 10,000 births, as well as patients that have ears removed due to cancer and trauma. The current standard for ear prostheses is osseointegrated abutments and either magnets or bar clip prosthetic attachments. Osseointegration is a technology that grew out of the dental industry and was effectively translated to other prosthetic applications. Defects of the external ear could be corrected using prosthetic reconstructions retained by implants. Implant retained auricular prosthesis eliminates the need for the adhesives and provides better retention compared to the conventional prosthesis. Bar and clip design is currently followed for retaining the ear prosthesis. Bars are fixed onto osseointegrated craniofacial implants through a surgery. Clips embedded in an acrylic housing are used to retain the prosthesis on the bars. The major problems in this method are the bulk of prosthesis that compromises the final cosmetic outcome and the loosening of the clips. Although several reconstructive techniques exist for the auricular defect, the use of implants to anchor auricular prosthesis presents a suitable alternative. This article presents a case of a right auricular defect, which was congenital for which two bone-anchored implants were placed. Hader bar with ERA attachments was used for retention of the silicone auricular prosthesis.

Keywords: Auricular prosthesis, extra oral implants, Hader bar attachments, silicone prosthesis


How to cite this article:
Chakravarthy AK, Sharif KY, Mallikarjun M, Babu KM, Gautham P, Prasad BV. Implant retained auricular prosthesis: A clinical report. J NTR Univ Health Sci 2017;6:262-6

How to cite this URL:
Chakravarthy AK, Sharif KY, Mallikarjun M, Babu KM, Gautham P, Prasad BV. Implant retained auricular prosthesis: A clinical report. J NTR Univ Health Sci [serial online] 2017 [cited 2020 Mar 29];6:262-6. Available from: http://www.jdrntruhs.org/text.asp?2017/6/4/262/221526




  Introduction Top


The term of “microtia” is a combination of the words of the “micro” and “otia” literally; the micro indicates small, and the otia indicates ear. Microtia is a congenital deformation with the incompletely formed ear.[1] Due to the auricle developing from tissues of the branchial arches, the facial deficiency is common for the microtia patient. The photo of the abnormal ear of the microtia patient is shown in [Figure 1].
Figure 1: Preoperative straight and lateral profile view

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Since the introduction of endosseous implants for use with bone conduction hearing aids in 1970s, the use of osseointegrated implants to retain facial prostheses has acquired an important role in the prosthetic rehabilitation of patients with craniofacial defects and became an integral part of treatment planning for facial reconstruction.[2],[3],[4]

Implant retention is currently considered as the gold standard in the prosthetic reconstruction of these structures. The success of bone-anchored auricular prostheses could base upon the patients' acceptance, contribution to the quality of life and use of the prostheses as replacement prosthesis for either a developmental defect or acquired defect.[5],[6]

The use of cranial implants has also provided an alternative approach towards rehabilitating patients with severe auricular defects since 1977[7] and has become a viable option that can offer several advantages over traditional reconstructive techniques.[8] It has been suggested that, auricular implants enhance retention and stability of prostheses, improving the patient's confidence and sense of security.[5] In addition, attachment systems aid in the proper positioning of prostheses, facilitating insertion by the individuals with auricular defects. The etiology of the loss of an auricle can be either acquired or congenital. Among acquired cases, gunshot injuries, traffic accidents etc., burns, ablative cancer surgeries are the reasons.

Another advantage of the implant retained auricular prostheses is that the skin and mucosa are less subject to mechanical and chemical irritation from mechanical retention or adhesives.[5] Cosmetically, a fine feathered margin in implant-retained prostheses allows the creation and maintenance of more esthetic results and patient satisfaction. The elimination of the marginal degradation due to daily application and removal of adhesives improves extension in the functional life of the prostheses.[5],[6]

The use of osseointegrated implants in extraoral prosthetic rehabilitation has resulted in several studies, which are primarily focused on implant osseointegration success and soft tissue complication rates.[5],[6],[9]

Extraoral prostheses are usually made of silicone elastomers, acrylic resin, or of both of these. According to the literature survey of Karakoca et al., the use of silicones have been used for over 50 years in the field of craniofacial prosthetics, with desirable material properties including flexibility, biocompatibility, ability to accept intrinsic and extrinsic colorants, translucency, chemical and physical inertness, moldability, and ease of cleaning.

Gumieiro et al. have reviewed the literature and stated the indications for implant retained auricular prosthesis in adult patients. According to their results, among patients, autogenous reconstruction is the procedure of choice.[10]

  • The presence of an acquired total or subtotal auricular defect, most often traumatic or ablative in origin.
  • When plastic surgery is impossible or when the final cosmetic result is unsatisfactory.
  • Lack of adequate tissue for reconstruction.
  • Absence of the lower half of the ear.
  • Failed attempts at reconstruction.
  • Major cancer excision.
  • Poor operative risks.
  • Selection of the technique by the patient.


This article presents a case report of implant retained medical grade room temperature vulcanizing (RTV) silicone auricular prosthesis.


  Case Report Top


A 40-year-old male patient was referred to the Department of Prosthodontics for the prosthetic rehabilitation of her right auricular defect [Figure 1]. On examination, the partial antihelix was remaining. The treatment plan consisted of fabrication of implant retained right auricular prosthesis using Hader bar with ERA attachments in order to obtain a good retention.

After evaluating of the computerized tomography scan, the first stage surgery was performed with the placement of two (3.7 mm × 4 mm) craniofacial implants (Entific, Gothenburg, Sweden) in the temporal bone. After 7 months, second stage surgery was performed with a partial thickness skin graft and placement of 5.5 mm abutments [Figure 2]. After 3 weeks, an impression of the defect was made with impression copings [Figure 3] using polyvinyl siloxane impression material (3M ESPE, Express, 3M, USA). The impression was removed, and the cast was poured in type IV die stone (Lafarge Prestia, Meriel, France). Then, Hader bar was fabricated [Figure 4] and [Figure 5] and 2 ERAs and lip were chosen for retention of the auricular prosthesis and try-in done [Figure 6]. Subsequently, heat resin night guard was fabricated where 1 clip and ERA male parts were attached to it [Figure 7]. The wax pattern was sculptured and tried on the patient [Figure 8]. It was checked for the fit and esthetic. Then, the mold was made from die stone. On next visit after 1-week, the RTV silicon elastomer (MDX 4-4210, Dow Corning, USA) was mixed chairside and intrinsic coloration was done to simulate the patient's normal skin color. Afterward, the mixed silicone was packed at room temperature and allowed to set for 3 days according to the manufacturer's instructions. After 3 days, the silicone prosthesis was secured, the excess materials were trimmed, and the prosthesis was tried on the patient [Figure 9]. Extrinsic coloration was done to match the patient's left ear. The final auricular prosthesis was delivered [Figure 10] to the patient, and the home care instructions were given.
Figure 2: Impression capping placement

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Figure 3: Making of Impression

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Figure 4: Try-in of wax pattern of Hader bar

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Figure 5: Completed casting

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Figure 6: Try-in of casting

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Figure 7: Acrylic frame work

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Figure 8: Try-in of wax ear

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Figure 9: Completed ear prosthesis

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Figure 10: Patient with final prosthesis

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  Discussion Top


The surgical technique for auricular prostheses retained on osseointegrated implants seems to be simple and is associated with a low rate of perioperative and long-term complications. The major advantages of this technique are that it puts less strain on the patient and has superior esthetics, compared with traditional surgical reconstructive techniques. The disadvantages of the method are the lifelong daily skin care and dependence on the health services that are required.

The use of craniofacial implants for retention of extraoral prostheses not only offers excellent support and retention, but also improves the patient's appearance and the quality of life. Implant retained auricular prosthesis provides multiple advantages such as convenience, security, consistent retention and positioning, elimination of the need for adhesives, which may cause tissue irritation, and maintenance of marginal integrity and longevity.[11]

For an auricular prosthesis, two implants are sufficient to retain the prosthesis. Magnet and bar-clip retention are the two other forms of retention used in the auricular region. Use of magnet was not recommended in this case because though magnet may provide acceptable retention, it is less stable under the lateral force.[12]

The bar-clip system provides good retention for the prostheses. However, bars may limit access for performing hygiene procedures. Hence, in our case, implant retained auricular prosthesis was indicated.[13] Numerous attachments are available for the retention of the implant-retained prosthesis. Locator and O-ring are also used. In addition to the prosthetic ear, implant-retained auricular prosthesis usually requires a bar-clip with other retentive elements like ERA to offer better retention.[11]


  Conclusion Top


In contrast with a conventional craniofacial prosthesis, an implant-retained auricular prosthesis often is not experienced as a prominent foreign object and can improve the quality of life. Utilization of Hader bar attachments on implant in the craniofacial region is considered viable option than magnetic attachment system. Although adequate patient hygiene is a must, this clinical report indicates that type and fit of the attachment, to create an intimate seal around the peri-implant epithelial tissue is crucial to maintaining healthy tissues in the peri-implant abutment site.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.



 
  References Top

1.
Fearon J. A Guide to Understanding Microtia, Children's Craniofacial Association; 1993. Available from: http://www.ccakids.com. [Last accessed on 2014 Dec 25].  Back to cited text no. 1
    
2.
Granström G. Craniofacial osseointegration. Oral Dis 2007;13:261-9.  Back to cited text no. 2
    
3.
Brånemark PI, Albrektsson T. Titanium implants permanently penetrating human skin. Scand J Plast Reconstr Surg 1982;16:17-21.  Back to cited text no. 3
    
4.
Scolozzi P, Jaques B. Treatment of midfacial defects using prostheses supported by ITI dental implants. Plast Reconstr Surg 2004;114:1395-404.  Back to cited text no. 4
[PUBMED]    
5.
Karakoca S, Aydin C, Yilmaz H, Bal BT. Retrospective study of treatment outcomes with implant-retained extraoral prostheses: Survival rates and prosthetic complications. J Prosthet Dent 2010; 103:118-26.  Back to cited text no. 5
[PUBMED]    
6.
Karayazgan-Saracoglu B, Zulfikar H, Atay A, Gunay Y. Treatment outcome of extraoral implants in the craniofacial region. J Craniofac Surg 2010;21:751-8.  Back to cited text no. 6
[PUBMED]    
7.
Niparko JK, Langman AW, Cutler DS, Carroll WR. Tissue-integrated prostheses in the rehabilitation of auricular defects: Results with percutaneous mastoid implants. Am J Otol 1993;14:343-8.  Back to cited text no. 7
[PUBMED]    
8.
Miles BA, Sinn DP, Gion GG. Experience with cranial implant-based prosthetic reconstruction. J Craniofac Surg 2006;17:889-97.  Back to cited text no. 8
[PUBMED]    
9.
Tolman DE, Taylor PF. Bone-anchored craniofacial prosthesis study. Int J Oral Maxillofac Implants 1996;11:159-68.  Back to cited text no. 9
[PUBMED]    
10.
Gumieiro EH, Dib LL, Jahn RS, Santos Junior JF, Nannmark U, Granström G, et al. Bone-anchored titanium implants for auricular rehabilitation: Case report and review of literature. Sao Paulo Med J 2009;127:160-5.  Back to cited text no. 10
    
11.
Schaaf NG, Kielich M. Implant-retained facial prostheses. In: McKinstry RL, editor. Fundamentals of Facial Prosthetics. Arlington: ABI Professional Publications; 1995.  Back to cited text no. 11
    
12.
Del Valle V, Faulkner G, Wolfaardt J, Rangert B, Tan HK. Mechanical evaluation of craniofacial osseointegration retention systems. Int J Oral Maxillofac Implants 1995;10:491-8.  Back to cited text no. 12
[PUBMED]    
13.
Reisberg DJ, Habakuk SW. Hygiene procedures for implant-retained facial prostheses. J Prosthet Dent 1995;74:499-502.  Back to cited text no. 13
[PUBMED]    


    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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