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

Correspondence to: Dr Muaiyed Mahmoud Buzayan,


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

The International Journal of Oral & Maxillofacial Implants e255

© 2017 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
Buzayan et al

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-
Fig 2  Two virtual implants of 3.6-mm diameter and 8-mm posed photographs (Figs 3 and 4), and from this, the im-
length were inserted, and the image was demonstrated in the plants were verified to emerge within the contour of the
coronal, transverse, sagittal, and three-dimensional views. alar and margin of the prosthesis, with no interference
with the margins of the nasal prosthesis.
nasal prosthesis. The patient was previously diagnosed Using the template as a guide to the implant posi-
with basal cell carcinoma affecting the nose. Examina- tion, surgery was performed under infraorbital local
tion revealed that the defect margins were regular and anesthesia, and two implants (Bone Level, Superline,
completely healed. A split skin graft had been placed Implantium) were placed using the intraoral approach.
at the base of the defect. Further investigation was re- Healing screws were connected, and the implants
quired to assess availability of bone around the defect were left to osseointegrate for 3 months before stage
region for implant placement (Fig 1). 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
PROCEDURE packed with Vaseline-coated gauze to prevent flow of
impression material into the nasal cavity. Impression
The preliminary impression of the nasal defect and copings were screwed to the implants, and the final
surrounding area was made in irreversible hydrocol- impression was made using polyvinyl siloxane im-
loid impression material (Kromopan, Lascod). From the pression materials (GC Exaflex light, GC America) after
preliminary cast obtained, a diagnostic template cov- the defect area was boxed using boxing wax. Plaster
ering the defect area was constructed using vacuum of Paris was packed on the top of the impression ma-
form thermoplastic resin material (Erkodur, Erkodent). terial to add support. Implant analogs were attached,
Gutta percha was inserted at a few strategic locations and the impression was poured in type IV stone (Elite
along the margin in the template as a marker. Three- stone, Zhermak).
dimensional scanning was performed using CBCT, and Using the master cast, the nasal pattern was sculp-
the data set generated was used to determine the bone tured using Bredent modelling wax (Epithetic Bredent)
volume for determination of the implant position. Two (Fig 5) and tried on. The metal framework consisted of
virtual implants of 3.6-mm diameter and 8-mm length double bars splinting the implants horizontally, and
(Superline, Implantium) were inserted, and their posi- a cantilever portion that extended vertically upward
tions were verified to be parallel to each other (Fig 2). along the nasal septum was cast. This bar orientation

e256 Volume 32, Number 6, 2017

© 2017 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
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 prior to processing. Extrinsic color was added to final-
prosthesis around the horizontal axis. The framework ize the color of the prosthesis to match the patient’s
was tried for fit (Fig 6), and in the laboratory, it was re- skin color at the delivery visit (Fig 7).
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. DISCUSSION
The silicone part of the nasal prosthesis was pro-
cessed using heat curing silicone material (Multisil Epi- Because of insufficient bone observed lateral to the
thetic, Bredent) with the intrinsic color added chairside nasal defect and the high failure rate associated with

The International Journal of Oral & Maxillofacial Implants e257

© 2017 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
Buzayan et al

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.

a b

Fig 7  The definitive prosthesis in place


with different views.

implants in the glabella,10 it was decided to position ACKNOWLEDGMENTS


the implants in the base of the maxillary bone. Virtual
surgical planning software enhances the surgical out- The authors reported no conflicts of interest related to this study.
come and prediction of future facial prosthesis interfer-
ences. In this case, prior to implant surgical placement,
the virtual surgical planning Materialise software was REFERENCES
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e258 Volume 32, Number 6, 2017

© 2017 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.