Virtual Treatment Planning for Implant-Retained

Nasal Prosthesis: A Clinical Report

Muaiyed Mahmoud Buzayan, BDS, MClinDent1/Norsiah Binti Yunus, BDS, MSc2/
Ha Kien Oon, BDS, MBBS, FDSRCS3/Omar Tawfiq, BDS, MSc4

Osseointegrated craniofacial implants have improved retention and patients’ perceptions of implant-retained
nasal prostheses; however, the determination of the available bone sites for implant placement post-rhinectomy is
difficult. This case report describes the use of cone beam computed tomography scanning and computer-assisted
virtual planning in conjunction with digital photographs for rehabilitation of a facial defect with an implant-retained
silicon nasal prosthesis. Two implants were planned in the anatomical area with adequate bone volume to achieve
favorable cosmetic outcomes and accessibility for hygiene maintenance. The implant-retained nasal prosthesis
resulted in a meaningful improvement in the esthetics without the need for plastic surgery. In such cases,
the post-rhinectomy reconstruction surgery should be limited to preparation of the surgical defect area for an
implant-retained prosthesis. Silicone prostheses are reliable alternatives to surgery and should be considered in
selected cases. Int J Oral Maxillofac Implants 2017;32:e255–e258. doi: 10.11607/jomi.4302

Keywords: bar attachment, implant retained, maxillofacial prosthesis, nasal prosthesis

S urgical management of basal cell carcinoma in the

facial region could lead to a partial- or full-thickness
facial defect. A partial-thickness defect can be managed
satisfactorily with plastic surgery, while surgical recon-
struction in a full-thickness defect, such as in cases of to-
tal rhinectomy, can be more challenging.1 The necessity
to restore the complex three-dimensional anatomy of
the nose with satisfactory cover lining and appropriate
support requires multistage procedures and availability
of healthy surrounding soft tissue. The risk of flap fail-
ure and tumor recurrence and the side effect of radio-
therapy make reconstruction even more challenging.1
1Senior
Lecturer, Department of Prosthodontic Dentistry,
Faculty of Dentistry, SEGi University, Malaysia.
2Professor, Department of Prosthetic Dentistry, Faculty of
Dentistry, University of Malaya, Kuala Lumpur, Malaysia.
3Senior Lecturer, Department of Oral and Maxillofacial Surgery,
Faculty of Dentistry, University of Malaya, Kuala Lumpur,
Malaysia.
4Lecturer, Department of Prosthodontic Dentistry, Faculty of
Dentistry, SEGi University, Malaysia.
All authors contributed equally in the preparation of this case
report.
On the other hand, the prosthetic management of such
defects would be less demanding.2
Methods to establish the retention of maxillofacial
prostheses include the use of adhesives, undercuts,
eyeglasses, and implants.3 Adhesive usage requires the
patient to regularly apply it to the periphery of the pros-
thesis, and some patients could develop allergic reactions.
Patients who do not wear eyeglasses may not prefer that
option. On the other hand, extraoral implants have been
shown to be successful at anchoring hearing aids and au-
ricular prostheses since 1977, and their application has
been extended to retain other maxillofacial prostheses.4–6
To get the best result for the prosthesis, proper treat-
ment planning is necessary, especially in the fabrication
of maxillofacial prostheses. Routine application of cone
beam computed tomography (CBCT) for dental implant
planning has been suggested7 since the accuracy is ad-
equate with the data acquired.8 Its popularity is based
on known advantages, such as low radiation dose, short
scanning times, and low acquisition cost compared
with conventional multislice computed tomography.9
The aim of this case report is to report on the use
of virtual treatment planning for an implant-retained
nasal prosthesis.

Correspondence to: Dr Muaiyed Mahmoud Buzayan,

Department of Prosthodontic Dentistry, Faculty of Dentistry,
SEGi University, 9 Jalan Teknologi, Kota Damansara, 47810
Petaling Jaya, Selangor, Malaysia.
Email: muaiyed_zyan@hotmail.com
©2017 by Quintessence Publishing Co Inc.
CLINICAL CASE
A woman 71 years of age who had undergone a total rhi-
nectomy was referred to the Department of Prosthetic
Dentistry for rehabilitation with an implant-retained

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Buzayan et al
Fig 2  Two virtual implants of 3.6-mm diameter and 8-mm
length were inserted, and the image was demonstrated in the
coronal, transverse, sagittal, and three-dimensional views.
nasal prosthesis. The patient was previously diagnosed
with basal cell carcinoma affecting the nose. Examina-
tion revealed that the defect margins were regular and
completely healed. A split skin graft had been placed
at the base of the defect. Further investigation was re-
quired to assess availability of bone around the defect
region for implant placement (Fig 1).
PROCEDURE
The preliminary impression of the nasal defect and
surrounding area was made in irreversible hydrocol-
loid impression material (Kromopan, Lascod). From the
preliminary cast obtained, a diagnostic template cov-
ering the defect area was constructed using vacuum
form thermoplastic resin material (Erkodur, Erkodent).
Gutta percha was inserted at a few strategic locations
along the margin in the template as a marker. Three-
dimensional scanning was performed using CBCT, and
the data set generated was used to determine the bone
volume for determination of the implant position. Two
virtual implants of 3.6-mm diameter and 8-mm length
(Superline, Implantium) were inserted, and their posi-
tions were verified to be parallel to each other (Fig 2).
e256 Volume 32, Number 6, 2017
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Fig 1  Frontal and lateral view of the
defect.
The rendered facial image obtained from the CBCT
scanning was utilized to ensure that the proposed
implant position would not interfere with the nasal
openings of the prosthesis and would be within the
anatomical contour of the nasal prosthesis. For this, a
preoperative photograph (prior to the total rhinectomy)
and another photograph taken in the current state were
scanned. The digital images were edited and superim-
posed using photo managing software (Corel PaintShop
Pro X4 version 14.0.0.322). The rendered facial image
obtained from the CBCT scanning (utilizing Simplant
software) was further superimposed on these superim-
posed photographs (Figs 3 and 4), and from this, the im-
plants were verified to emerge within the contour of the
alar and margin of the prosthesis, with no interference
with the margins of the nasal prosthesis.
Using the template as a guide to the implant posi-
tion, surgery was performed under infraorbital local
anesthesia, and two implants (Bone Level, Superline,
Implantium) were placed using the intraoral approach.
Healing screws were connected, and the implants
were left to osseointegrate for 3 months before stage
two of implant surgery and the prosthetic stage.
At the prosthetic stage, prior to secondary impres-
sion taking, the nasal apertures at the defect area were
packed with Vaseline-coated gauze to prevent flow of
impression material into the nasal cavity. Impression
copings were screwed to the implants, and the final
impression was made using polyvinyl siloxane im-
pression materials (GC Exaflex light, GC America) after
the defect area was boxed using boxing wax. Plaster
of Paris was packed on the top of the impression ma-
terial to add support. Implant analogs were attached,
and the impression was poured in type IV stone (Elite
stone, Zhermak).
Using the master cast, the nasal pattern was sculp-
tured using Bredent modelling wax (Epithetic Bredent)
(Fig 5) and tried on. The metal framework consisted of
double bars splinting the implants horizontally, and
a cantilever portion that extended vertically upward
along the nasal septum was cast. This bar orientation
 Buzayan et al

Fig 3  The (a) preoperative patient pho-

tograph was superimposed on (b) the
current patient photograph to show the
boundaries of the nose.

a b

a b
Fig 4   The (a) three-dimensional rendered image and (b) final superimposed picture showing the location of emerging implants (yel-
low dots) within alar border (blue arches).

Fig 5   Master cast showing the (a) implant

analog and (b) waxed nasal prosthesis.

a b

was selected to resist the rotation tendency of the
prosthesis around the horizontal axis. The framework
was tried for fit (Fig 6), and in the laboratory, it was re-
screwed and the nasal wax pattern was replaced on
the cast for investing. The acrylic frame was processed
to house two clip attachments for retention.
The silicone part of the nasal prosthesis was pro-
cessed using heat curing silicone material (Multisil Epi-
thetic, Bredent) with the intrinsic color added chairside
prior to processing. Extrinsic color was added to final-
ize the color of the prosthesis to match the patient’s
skin color at the delivery visit (Fig 7).
DISCUSSION
Because of insufficient bone observed lateral to the
nasal defect and the high failure rate associated with

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Buzayan et al
a b
implants in the glabella,10 it was decided to position
the implants in the base of the maxillary bone. Virtual
surgical planning software enhances the surgical out-
come and prediction of future facial prosthesis interfer-
ences. In this case, prior to implant surgical placement,
the virtual surgical planning Materialise software was
used to confirm that the proposed implant positions
would not interfere with the future nasal prosthesis
margins. That provided the ability to visualize the fu-
ture prosthetic boundaries and form. As a result, the
implants were planned in the anatomical area with the
best cosmetic outcome.
The bar clip attachment has higher retention than
magnets; however, it needs sufficient space inside the
prosthesis to accommodate the acrylic resin clip car-
rier and bar. With adequate implant planning, it was
possible to utilize this type of attachment without
compromising the outcome. The bar can also be useful
for cases involving nonparallel implants.
CONCLUSIONS
The implant-retained facial prosthesis is a reliable
alternative for prosthetic reconstructing of large
full-thickness rhinectomy defects. However, preop-
erative virtual planning for the surgical placement of
the implants considering the facial prosthesis’ future
shape, boundaries, and anatomy is critical to avoid pros-
thetic problems and to get the best cosmetic result.
e258 Volume 32, Number 6, 2017
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Fig 6  (a) Cast metal bars at trial stage
and (b) the inner surface of processed sili-
con nasal prosthesis showing plastic clips
attached to the acrylic frame.
Fig 7  The definitive prosthesis in place
with different views.
ACKNOWLEDGMENTS
The authors reported no conflicts of interest related to this study.
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