Fig. 36.13 (a) Aterio–venous (A/V) malformation right auricle (upper left). (b) Status post resection implant placement and retaining bar with two resilient attachments (Locator, Zest

Anchors LLC, Escondido, CA). (c) Lateral view with silicone implant retained prosthesis in place. (d) Full face frontal view with silicone implant retained prosthesis in place

36.10Implant Retained Orbital Prosthesis

Orbital implant placement considerations vary depending on the remaining boney architecture following orbital exenteration. If the floor of the orbit/infraorbital rim is left intact, then the goal for implant placement is to try to achieve a “milk stool” distribution of the implants that being an implant in the supraorbital rim, one in the lateral orbital rim and one in the infraorbital rim (see Fig. 36.14a–d). This distribution results in a tripod base of support for the orbital prosthesis. Given the lateral aspect of the frontal sinus frequently extends midway across the superior aspect of the orbit placement of an implant in the supraorbital rim is limited to where bone volume is and that does not encroach on invading the sinus.

From a prosthodontic perspective, the options for splinting vs. using independent retainers each offer

their distinct challenges. Independent magnet retention using console abutments of varying angulations of the pod for placement of the magnet keeper not infrequently can create a problem with soft tissue management (Fig. 36.15a–d). With that said, a splinted bar construction can offer challenges as regards access for hygiene as well. It is difficult to achieve a firm tissue base in the peri-abutment region with either independent or splinted retention approaches. The path of placement for an orbital prosthesis unlike that for a nasal or auricular prosthesis is at 90° to the long axis of implants. While craniofacial prostheses do not have to contend with occlusal loading, their path of placement and removal might influence impact on the bone/ implant interface. One can only speculate as to whether this difference, i.e., the nonaxial path of placement for an orbital prosthesis compared to auricular or nasal implant retained prostheses has an influence on the poorer success/survival rate [19–21].

Fig. 36.14 Orbital exenteration to treat a melanoma. (a) Orbital defect status post-craniofacial implant placement in supraorbital, infraorbital, and lateral orbital rims with healing caps in place. (b) Implant with console abutments (Cochlear, Centennial,

Summary: Multisite Implant Retained Craniofacial

Prosthesis

•Clearly this treatment modality requires an extensive level of experience and expertise.

36.11Multisite Implant Retained Craniofacial Prosthesis

As regards multisite implant supported craniofacial prostheses, each case is so unique that it is not easy to identify specific recommendations as to implant

CO) with notable accumulation of secretions about the abutments. (c) Silicone orbital prosthesis. (d) Implant retained orbital prosthesis in place, full face view

sites, distribution, framework design, retention elements, etc. Clearly, this treatment modality is very challenging and requires an extensive level of experience and expertise. The lack of large numbers of patients requiring this type of treatment lends itself to representing uncharted territory. It is unlikely that this will change going forward as surgical interventions of this kind typically are deferred and relegated to patient’s disease management with radiotherapy with or without chemotherapy largely to accommodate local control without intent for cure. The fact that large anatomical defects associated with the head and neck region give one pause to consider extensive surgical management and rehabilitation

Fig. 36.15 Right orbital exenteration status post radiation treatment, preand post-craniofacial implant placement with adjunctive hyperbaric oxygen treatment. (a) Orbital craniofacial implants with console abutments in place on the implants. (b)

with implant supported prostheses in that the overriding concern about recurrence and need for further management can create significant challenges for patient management, yet alone allow one to focus on their rehabilitation needs [22, 23].

Upper left, example of console abutment (Cochlear, Centennial, CO). (c) Tissue surface of the silicone orbital magnet retained prosthesis. (d) Full face view of the right silicone orbital prosthesis in place

Summary: Conclusion

•The best prosthetic results occur when the Surgeon Patient and Maxillofacial Prosthodontist meet prior to surgery.

36.12 Conclusion

Providing life like appearing craniofacial prostheses for head and neck cancer patients requires a team approach between the Surgeon, the Patient, and the Maxillofacial Prosthodontist. The patient should be referred to the Prosthodontist prior to surgery so that preop impressions can be made. The patient can be shown examples of similar prostheses available. The Surgeon and the Prosthodontist should meet prior to surgery to discuss creating a surgical base that can appropriately support the prosthesis.

Acknowledgements Appreciation and acknowledgement of the following individual whose efforts are associated with the fabrication of the prostheses in Figs. 36.1–36.9.

Robert Mann CDT CCA

University of Florida College of Dentistry, Maxillofacial

Prosthetics.

Appreciation and acknowledgement of following individuals

whose efforts are associated with the fabrication of the prosthe-

ses in Figs. 36.10–36.15. They are as follows:

Ruth Bourke CDT

Bud Perry CDT

William Desantis CDT

Calvin Cowan CDT

Sharron Haggerty MAMS CCA

University of Washington School of Dentistry, Maxillofacial

Prosthetic Service

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