facial prostheses is the need for a firm, thin, tissue interface in the peri-abutment region so as to minimize soft tissue complications [9, 10]. The need for good bone into which implants can be placed to obtain primary stability as with any implant intervention is critical to achieve successful osseointegration. The distribution and number of implants placed for retaining implantbased craniofacial prostheses has evolved over time. As well, the protocol for implant placement regarding oneversus two-stage surgery also presents the clinician with a choice on a case by case basis that needs to be factored into the treatment plan [11]. Success/survival rates of craniofacial implants suggest that in the auricular region (see Fig. 36.10a–c), one can expect implant success that is comparable to intraoral placement of implants in the anterior mandible [12]. The nasal region is the next site having implant integration being reasonably predictable. However, implant placement in the region of the orbit has the highest complication and failure rate. Controversy exists regarding the use of adjunctive preand post-craniofacial implant placement hyperbaric oxygen treatment. The data for success/survival rates for craniofacial implant placement does not clearly document for those data bases reported for implants placed in radiated treatment fields as to whether or not this adjunctive therapy was used [13–15].

so as not to amputate the root apices when preparing implant sites. Also, for the edentulous patient, consideration need be given to not encroach on the gingivobuccal sulcus which could impede the patient from being able to wear a maxillary complete denture. Reports of placing craniofacial implants in the region of the glabella have demonstrated 100% failure likely due to the fact that this region is a suture line between the cartilaginous make up of the vomer with that of the cranial bone of the forehead and adjacent frontal sinuses and cribriform plate [16, 17].

The peri-abutment region for implants placed in the nasal region is best managed with a split-thickness skin graft to afford the patient an ability to comfortably clean and maintain the peri-abutment tissue health. Despite the area being in the realm of ongoing mucous secretions and flow of particulate contaminants from the environment, anecdotally speaking, implants in the nasal region tend to do quite well over the long term.

Summary: Implant Retained Auricular Prosthesis

•Osseointegrated implants in the mastoid bone or temporal bones have the greatest long-term success.

For implant retained nasal prostheses, placement of two implants in the lateral ala rims generally provides adequate support (see Fig. 36.11a–d). Not infrequently, the bone volume is adequate for use of conventional dental implants rather than shorter 3–4-mm craniofacial implants. By engaging the palatal bone implant, lengths up to 18 mm can be accommodated in some patients. Should additional implant support be needed, the nasal base midline can be considered as an alternate site for placement (see Fig. 36.12a–d). Consideration need be given to the apices of the maxillary anterior teeth if the patient is dentate in the anterior sextant

implants. In the recent past using two implants offers an adequate base of support to retain an implant retained auricular prosthesis. The placement of these implants is suggested as being approximately 18-20 mm posterior to the ear canal (if present) at approximately 1:00 and 3:00 o’clock on the patient’s left side and 9:00 and 11:00 o’clock on the patient’s right side. The bony architecture of mastoid region is replete with air cells, and as a result, it is sometimes difficult to ideally place implants exactly where prescribed by the implant surgical guide. In such cases, it is better to err by placing the implants further posterior so as not to encroach on the concha region of

Fig. 36.10 Sixteen years status post right temporal bone resection and 6,000 CGy post-op radiation tx, preand post-craniofacial implant placement hyperbaric oxygen treatment. (a) Dolder Clip

bar splinted to three craniofacial implants. (b) Silicone clip retained auricular prosthesis, lateral view. (c) Full face view with right silicone auricular clip retained implant prosthesis in place

the auricle that could result in an aberrant anatomical compromise of the prosthesis. The key is to have the implants situated under the planned tallest and thickest portion of the prosthesis so as to allow enough room for placement of the transmucosal abutments, retaining bar, attachments, attachment housings, acrylic substructure, and the overlying tissue skin tone matched silicone (see Fig. 36.13a–d).

The peri-abutment tissue in the auricular region can be addressed by either placing a split-thickness skin graft or undermining the tissue in this area at the time the abutments are placed. For patients who have been radiated, a staged procedure is generally advised so as to maximize the circulatory capacity during the healing period following implant placement surgery.

Another consideration for the prosthetic design is taking into account the movement of the temporomandibular joint. In some patients, the range of motion of the tissue

overlying the temporomandibular joint is dramatic leading to the opening of a gap space between the anterior margins of the prosthesis during jaw movements [18]. This movement in the closing motion can sometimes dislodge the prosthesis from its retentive base. One approach to manage this for patients with an excess range of motion is to incorporate a magnet retainer on the inferior pole of the retaining bar allowing for disengagement and reengagement of the prosthesis so as to maintain a compatible retention mechanism for such situations.

Summary: Implant Retained Orbital Prosthesis

•Osseointegrated implants placed in the rim of an orbit have the least long term predictably.

Fig. 36.11 Implant magnet retained nasal prosthesis. (a) Implants with transmucosal abutments in lateral ala region left and right. (b) Implant retention framework with two magnet

keepers. (c) Tissue surface of silicone nasal prosthesis with two magnets (Technovent, Factor Two, Lakeside, AZ). (d) Magnet retained nasal prosthesis in place

Fig. 36.12 Implant supported nasal prosthesis: (a) Pre-total rhinectomy for SCCA (upper left). (b) One week post-op (upper right). (c) Implant cast retaining structure with three resilient

attachments (Locators, Zest Anchors LLC, Escondido, CA). (d) Implant retained silicone nasal prosthesis in place, full face view