The Cleft Palate-Craniofacial Journal 52(2) pp. 229–233 March 2015 Ó Copyright 2015 American Cleft Palate-Craniofacial Association
CASE REPORT Prosthodontic Rehabilitation of Congenital Auricular Defect: A Clinical Report Binit Shrestha, B.D.S., M.Sc., Fahima Fatmasari, D.D.S., M.Sc., Sita Thaworanunta, D.D.S., M.S., M.Sc., Theerathavaj Srithavaj, D.D.S., M.S. This clinical report presents the prosthetic rehabilitation of a congenital auricular defect. The rehabilitation was initially performed with an adhesive retained silicone prosthesis. After careful evaluation of the patient’s retentive needs, two endo-osseous craniofacial implants were placed in the mastoid region. After integration, an implant-retained silicone prosthesis was fabricated using a Hader bar with two ERA attachments, which restored the defect with good aesthetic and functional outcome. Prosthetic rehabilitation is a viable treatment option for restoring auricular defects and can be indicated in situations where surgical reconstruction may not be feasible. KEY WORDS:
auricular rehabilitation, craniofacial implants, silicone prosthesis
INTRODUCTION
OBJECTIVE
Congenital malformation of the ear can be associated with such syndromes as hemifacial microsomia and Treacher Collins syndrome. These defects can be restored surgically or prosthetically. Various surgical techniques have been mentioned in the literature for surgical reconstruction of the ear (Kobus et al., 2002). Although these techniques differ in the number and timing of the procedures, they are based on creating a framework of the ear from the costal-arch rib cartilage. The aesthetic outcomes of surgical reconstruction have varied results due to the high degree of skills involved during tissue manipulation or due to absence of adequate soft tissue (Thorne et al., 2001). In turn, prosthetic rehabilitation with silicone prosthesis is considered a less invasive, less timeconsuming treatment option with a high predictability. Furthermore, various retentive means, such as frameworks, adhesives, magnets, and bar and clip attachments, can be used to suit the patient’s retentive needs.
This clinical report aims to present the prosthetic rehabilitation of a patient who had a congenital defect of the left ear. MATERIALS
AND
METHODS
The 16-year-old Thai boy presented with a chief complaint of a missing left ear. Clinical examination revealed congenital atresia of the left external auditory canal and presence of a small, peanut-sized remnant at the tragus (Fig. 1A and B). No other forms of facial asymmetry were observed. The initial treatment was to fabricate an adhesive-retained auricular prosthesis. The impression of the defect side was made using irreversible hydrocolloid impression material (Jelrate Fast Set; Dentsply, York, PA). A wax (Cavex TT Soft; Cavex, Haarlem, Netherlands) mock-up of the auricular prosthesis was made and tried on the patient. The patient was instructed to perform functional movements to check the marginal adaptation of the prosthesis, after which a threepiece mold of the waxed ear was fabricated with Type IV dental stone (Nok Stone; LeFarge, Petchaburi, Thailand). Room-temperature, vulcanizing, medical-grade silicone (MDX-4-4210; Factor II Inc., Lakeside, AZ) was mixed with intrinsic staining (KT-699 functional intrinsic staining kit; Factor II Inc.), according to the manufacturer’s recommendations, and packed into the de-waxed mold. After vulcanization, the auricular prosthesis was extrinsically stained (Dry Earth Pigments; Factor II Inc.) and fixed with silicone adhesive (Silastic Medical Adhesive Type-A; Dow Corning Corp, Midland, MI) and delivered to the patient (Fig. 2A and B). The patient was prescribed with water-based silicone adhesive (Daro Adhesive; Factor II Inc.). However, after a
Dr. Shrestha is Instructor, Dr. Fatmasari is Instructor, Dr. Thaworanunta is Assistant Professor, and Dr. Srithavaj is Assistant Professor, Maxillofacial Prosthetic Service, Faculty of Dentistry, Mahidol University, Bangkok, Thailand. Presented as a poster presentation at the 2nd Annual Bangkok Implant Symposium, Bangkok, Thailand, November 28–30, 2012. Submitted March 2013; Revised August 2013; Accepted September 2013. Address correspondence to: Dr. Srithavaj, Maxillofacial Prosthetic Service, Faculty of Dentistry, Mahidol University, 6th Yothi Street, Rajthevee, Phayathai, Bangkok, Thailand. E-mail theerathavaj.sri@ mahidol.ac.th. DOI: 10.1597/13-074 229
230
Cleft Palate-Craniofacial Journal, March 2015, Vol. 52 No. 2
FIGURE 1 A: Patient with the congenital auricular defect. B: Close up view of the defect.
month of usage, the patient complained that the prosthesis was frequently dislodged. This occurred primarily because of the febrile and compressible nature of the remnant, which prevented proper seating of the prosthesis. Oily skin secretions also lead to breaks in the adhesive seal.
A new treatment plan was proposed to the patient to fabricate an implant-retained prosthesis. The prosthesis was duplicated with autopolymerizing polymethyl methacrylate (PMMA) resin (Orthojet; Lang Dental Mfg Co. Inc., Wheeling, IL) to fabricate a radiographic stent, and a
FIGURE 2 A: Adhesive retained auricular prosthesis. B: Rehabilitation with adhesive retained auricular prosthesis.
Shrestha et al., PROSTHODONTIC REHABILITATION OF AURICULAR DEFECT
231
FIGURE 3 First stage: Craniofacial implant placement in mastoid region.
FIGURE 4
computed tomographic scan of the temporal and mastoid areas was made. After careful discussions with the treatment team, the patient’s consent was obtained to proceed with the treatment. A full-thickness skin flap was raised under general anesthesia, and two 4-mm endoosseous craniofacial implants (Flanged fixture SEC 002-0; Entific Medical Systems, Goteborg, Sweden) were placed at the mastoid region (Fig. 3). After 6 months of healing, the surgical site was uncovered under general anesthesia and straight abutments (Abutment Complete 5.5 mm, SEC 007-0; Entific Medical Systems) were connected to the implant fixtures. The ear remnant was removed, and a split-thickness skin graft obtained from the thigh region was placed at the surgical site (Fig. 4). Healing caps (Healing Caps Ø 14 mm Unigrip 90251; Entific Medical Systems) were attached to the prosthetic abutment, and a surgical dressing dipped in povidone-iodine was wrapped in a figure-8 technique to apply adequate pressure to seat the graft. The pressure dressing was maintained for 48 hours, and the nonresorbable sutures were removed after 7 days. After a healing period of 5 weeks and satisfactory graft integration, as assessed by the absence of any signs of inflammation and infection, impression copings (Impression Coping Squared DCA 040-0, Entific Medical Systems) were attached to the prosthetic abutments and an impression was made with light- and medium-bodied vinyl polysiloxane impression material (Multisil Epithetik soft and hard form; Bredent, Senden, Germany). Laboratory analogs (Abutment Replica DCB 175-0; Entific Medical Systems) were then attached to the impression copings, and the impression was poured with Type IV dental stone (Nok Stone; LeFarge). A semi-precision bar (Hader Bar; Sterngold Dental, Attleboro, MA) with two semi-precision resilient attachments (ERA Overdenture; Sterngold Dental) was fabricated on the model, which was casted with semi-precious metal (palladium mixed with 2% gold) and tried on for passive fit (Fig. 5).
A PMMA resin housing was fabricated using the corresponding retentive attachments, after which an implant-retained silicone prosthesis was fabricated and delivered (Fig. 6A through C). The patient was instructed on daily hygiene procedures with normal saline solution
FIGURE 5
Second stage: Split-thickness skin graft placement.
Hader bar and ERA attachment in place.
232
Cleft Palate-Craniofacial Journal, March 2015, Vol. 52 No. 2
FIGURE 6 A: Implant retained auricular prosthesis. B: Tissue surface of the prosthesis with PMMA resin housing. C: Rehabilitation with implant retained auricular prosthesis.
and an end-tufted brush. Maintenance and recall visits were made every 3 months, during which the implant-abutment interface was irrigated with 2% chlorhexidine and normal saline solution to remove any adherent debris. Hygiene education was also repeated during these visits. The overall follow-up period was 2 years. The patient reported that he could perform such activities as chewing and yawning without dislodging the prosthesis. He had no complaints with the overall treatment other than the discoloration of the silicone prosthesis after approximately a year of use. Chair-side restaining of the prosthesis was done with extrinsic colors and delivered to the patient. DISCUSSION Surgical reconstruction of an auricular defect is a timeconsuming procedure that needs to be planned and requires the expertise and experience of the anaplastologist. It is considered as the treatment of choice in children when the reconstructive surgery can be performed in several steps to give the most ideal results (Kobus at al., 2002; Thorne et al., 2001). Prosthodontic rehabilitation can be considered a predictable treatment alternative to surgery. An adhesiveretained prosthesis can be initially fabricated to evaluate the patient’s acceptance of the treatment. It can also be used to determine the patient’s retentive needs. In our experience, we proceed with the implant-retained prosthesis when the patient is 16–18 years old to prevent any disruptions in facial growth. In addition, at this age the patient is aware of the maintenance needs associated with the implant-retained prosthesis. Nonetheless, this technique offers several key advantages over an adhesive-retained prosthesis. (1) Implant-retained prostheses offer higher retention and are easy to place.
(2) Implant-retained prostheses eliminate the use of adhesives that might be difficult and time consuming for patients with limited dexterity. (3) Because no adhesives are used, marginal tear associated with the application and removal of adhesives are also eliminated, extending the life of the prosthesis (Reisberg and Habakuk, 1995). On the other hand, an implant-retained prosthesis require lifelong maintenance of the surrounding skin around the implant. Peri-implantitis has been reported at an incidence of 5% to 75% (Mylanus et al., 1994; Visuttiwattanakorn et al., 2006), which is mainly attributed to an incomplete seal of the peri-abutment skin interface, which increases the chances that microflora will penetrate into the deeper tissues. Histologic studies have shown that the seal comprises chronically inflammatory cells, which suggests that the interface has a dynamic nature (Holgers et al., 1995). Microbiological cultures of the interface have shown Staphylococcus aureus as the most commonly isolated pathogen (Abu-Serriah et al., 2001), and it was also the most commonly found microorganism in infected surgical sites (Owens and Stoessel, 2008). Constant movement of the skin around the abutment may act as an irritant, increasing the chances of debris and epithelial crusting to be trapped between the abutment and the skin, which can then act as foreign bodies. Thus, placement of a hair-follicle–free, split-thickness skin graft or thinning of the subcutaneous tissues at the implant site have been suggested to immobilize the tissues and to reduce the incidence of peri-implantitis (Karakoca et al., 2008). The thigh region serves as a suitable donor site for the splitthickness skin graft because there is no need to change the position of the patient during the surgery, as would be the case when harvesting from regions such as the scapula and latissimus dorsi. Furthermore, variable thickness of the graft can be obtained from the thigh, and it causes less aesthetic morbidity compared with harvesting from the
Shrestha et al., PROSTHODONTIC REHABILITATION OF AURICULAR DEFECT
forearm (Nnene et al., 2000). However, because of the fibrosis and contraction that follows graft integration, it may be difficult to perform surgical reconstruction of the ear if the patient decides to do so in the future. Prosthetic component design should also consider the ease of hygiene maintenance. The Hader bar with ERA attachments was used in lieu of a conventional bar-and-clip design so as to reduce the size of the overall components. The ERA overdenture attachment is held in a metal jacket and permits the retentive nylon counterparts to be changed according to the retentive requirement or when the components have worn out. The use of magnetic attachments can also be considered when there is a lack of clearance space (,2 mm) between the bar and the tissues or when the patient lacks adequate manual dexterity. However, the most important factor for long-term success of the treatment is patient compliance; thus, it is critical that the patient is properly instructed to carry out additional hygiene procedures to maintain the prosthesis, implants, along with the retentive elements, and to keep the periimplant skin healthy (Reisberg and Habakuk, 1995). In this study, the patient was followed up for 2 years, during which time he was satisfied with the implantretained auricular prosthesis. Under the limitations of this clinical report, the Hader bar with ERA attachments also met the patient’s retentive needs and permitted maintenance of the skin around the craniofacial implants. However, a long-term study in a larger patient group is suggested to validate the outcomes. CONCLUSION An auricular defect was successfully restored by an implant-retained auricular prosthesis with good aesthetic
233
and functional outcome. Prosthetic rehabilitation of auricular defects serves as a successful alternative treatment option to surgical reconstruction. However, emphases on additional hygiene procedures are required for long-term success of the treatment. REFERENCES Abu-Serriah MM, Bagg J, McGowan DA, Moos KF. A clinical outcome study of extra-oral craniofacial endosseous implantretained prostheses. Br J Oral Maxillofac Surg. 2001;39:269–275. Holgers KM, Thomsen P, Tjellstrom A, Ericson LE. Electronic microscopic observation on the soft tissue around clinical long-term percutaneous titanium implants. Biomaterials. 1995;16:83–90. Karakoca S, Aydin C, Yilmaz H, Bal BT. Survival rates and periimplant soft tissue evaluation of extraoral implants over a mean follow-up period of three years. J Prosthet Dent. 2008;100:458–464 ´ Kobus K, Szczyt M, Łatkowski I, Wojcicki P. Reconstruction of the auricle. Br J Plast Surg. 2002;55:645–651. Mylanus EAM, Cremers WRJ, Snik FM, van der Berge NW. Clinical results of percutaneous implants in the temporal bone. Arch Otolaryngol Head Neck Surg. 1994;120:81–85. Nnene CO, Abu-Seido H, Isbister ES. Harvesting split skin grafts of appropriate thickness using the hand-held knife. Ann R Coll Surg Engl. 2000;82: 339–340. Owens CD, Stoessel K. Surgical site infections: epidemiology, microbiology and prevention. J Hosp Infect. 2008;70:3–10. Reisberg DJ, Habakuk SW. Hygiene procedures for implant-retained facial prostheses. J Prosthet Dent. 1995;74:499–502. Thorne CH, Brecht LE, Bradley JP, Levine JP, Hammerschlag P, Longaker MT. Auricular reconstruction: indications for autogenous and prosthetic techniques. Plast Reconstr Surg. 2001;107:1241–1252. Visuttiwattanakorn S, Srithavaj T, Thaweeboon S. Evaluation of microflora around extraoral per-implant percutnaeous tissues in a group of Thai patients. Mahidol Dent J. 2006;26:281–288.
CASE REPORT Prosthodontic Rehabilitation of Congenital Auricular Defect: A Clinical Report Binit Shrestha, B.D.S., M.Sc., Fahima Fatmasari, D.D.S., M.Sc., Sita Thaworanunta, D.D.S., M.S., M.Sc., Theerathavaj Srithavaj, D.D.S., M.S. This clinical report presents the prosthetic rehabilitation of a congenital auricular defect. The rehabilitation was initially performed with an adhesive retained silicone prosthesis. After careful evaluation of the patient’s retentive needs, two endo-osseous craniofacial implants were placed in the mastoid region. After integration, an implant-retained silicone prosthesis was fabricated using a Hader bar with two ERA attachments, which restored the defect with good aesthetic and functional outcome. Prosthetic rehabilitation is a viable treatment option for restoring auricular defects and can be indicated in situations where surgical reconstruction may not be feasible. KEY WORDS:
auricular rehabilitation, craniofacial implants, silicone prosthesis
INTRODUCTION
OBJECTIVE
Congenital malformation of the ear can be associated with such syndromes as hemifacial microsomia and Treacher Collins syndrome. These defects can be restored surgically or prosthetically. Various surgical techniques have been mentioned in the literature for surgical reconstruction of the ear (Kobus et al., 2002). Although these techniques differ in the number and timing of the procedures, they are based on creating a framework of the ear from the costal-arch rib cartilage. The aesthetic outcomes of surgical reconstruction have varied results due to the high degree of skills involved during tissue manipulation or due to absence of adequate soft tissue (Thorne et al., 2001). In turn, prosthetic rehabilitation with silicone prosthesis is considered a less invasive, less timeconsuming treatment option with a high predictability. Furthermore, various retentive means, such as frameworks, adhesives, magnets, and bar and clip attachments, can be used to suit the patient’s retentive needs.
This clinical report aims to present the prosthetic rehabilitation of a patient who had a congenital defect of the left ear. MATERIALS
AND
METHODS
The 16-year-old Thai boy presented with a chief complaint of a missing left ear. Clinical examination revealed congenital atresia of the left external auditory canal and presence of a small, peanut-sized remnant at the tragus (Fig. 1A and B). No other forms of facial asymmetry were observed. The initial treatment was to fabricate an adhesive-retained auricular prosthesis. The impression of the defect side was made using irreversible hydrocolloid impression material (Jelrate Fast Set; Dentsply, York, PA). A wax (Cavex TT Soft; Cavex, Haarlem, Netherlands) mock-up of the auricular prosthesis was made and tried on the patient. The patient was instructed to perform functional movements to check the marginal adaptation of the prosthesis, after which a threepiece mold of the waxed ear was fabricated with Type IV dental stone (Nok Stone; LeFarge, Petchaburi, Thailand). Room-temperature, vulcanizing, medical-grade silicone (MDX-4-4210; Factor II Inc., Lakeside, AZ) was mixed with intrinsic staining (KT-699 functional intrinsic staining kit; Factor II Inc.), according to the manufacturer’s recommendations, and packed into the de-waxed mold. After vulcanization, the auricular prosthesis was extrinsically stained (Dry Earth Pigments; Factor II Inc.) and fixed with silicone adhesive (Silastic Medical Adhesive Type-A; Dow Corning Corp, Midland, MI) and delivered to the patient (Fig. 2A and B). The patient was prescribed with water-based silicone adhesive (Daro Adhesive; Factor II Inc.). However, after a
Dr. Shrestha is Instructor, Dr. Fatmasari is Instructor, Dr. Thaworanunta is Assistant Professor, and Dr. Srithavaj is Assistant Professor, Maxillofacial Prosthetic Service, Faculty of Dentistry, Mahidol University, Bangkok, Thailand. Presented as a poster presentation at the 2nd Annual Bangkok Implant Symposium, Bangkok, Thailand, November 28–30, 2012. Submitted March 2013; Revised August 2013; Accepted September 2013. Address correspondence to: Dr. Srithavaj, Maxillofacial Prosthetic Service, Faculty of Dentistry, Mahidol University, 6th Yothi Street, Rajthevee, Phayathai, Bangkok, Thailand. E-mail theerathavaj.sri@ mahidol.ac.th. DOI: 10.1597/13-074 229
230
Cleft Palate-Craniofacial Journal, March 2015, Vol. 52 No. 2
FIGURE 1 A: Patient with the congenital auricular defect. B: Close up view of the defect.
month of usage, the patient complained that the prosthesis was frequently dislodged. This occurred primarily because of the febrile and compressible nature of the remnant, which prevented proper seating of the prosthesis. Oily skin secretions also lead to breaks in the adhesive seal.
A new treatment plan was proposed to the patient to fabricate an implant-retained prosthesis. The prosthesis was duplicated with autopolymerizing polymethyl methacrylate (PMMA) resin (Orthojet; Lang Dental Mfg Co. Inc., Wheeling, IL) to fabricate a radiographic stent, and a
FIGURE 2 A: Adhesive retained auricular prosthesis. B: Rehabilitation with adhesive retained auricular prosthesis.
Shrestha et al., PROSTHODONTIC REHABILITATION OF AURICULAR DEFECT
231
FIGURE 3 First stage: Craniofacial implant placement in mastoid region.
FIGURE 4
computed tomographic scan of the temporal and mastoid areas was made. After careful discussions with the treatment team, the patient’s consent was obtained to proceed with the treatment. A full-thickness skin flap was raised under general anesthesia, and two 4-mm endoosseous craniofacial implants (Flanged fixture SEC 002-0; Entific Medical Systems, Goteborg, Sweden) were placed at the mastoid region (Fig. 3). After 6 months of healing, the surgical site was uncovered under general anesthesia and straight abutments (Abutment Complete 5.5 mm, SEC 007-0; Entific Medical Systems) were connected to the implant fixtures. The ear remnant was removed, and a split-thickness skin graft obtained from the thigh region was placed at the surgical site (Fig. 4). Healing caps (Healing Caps Ø 14 mm Unigrip 90251; Entific Medical Systems) were attached to the prosthetic abutment, and a surgical dressing dipped in povidone-iodine was wrapped in a figure-8 technique to apply adequate pressure to seat the graft. The pressure dressing was maintained for 48 hours, and the nonresorbable sutures were removed after 7 days. After a healing period of 5 weeks and satisfactory graft integration, as assessed by the absence of any signs of inflammation and infection, impression copings (Impression Coping Squared DCA 040-0, Entific Medical Systems) were attached to the prosthetic abutments and an impression was made with light- and medium-bodied vinyl polysiloxane impression material (Multisil Epithetik soft and hard form; Bredent, Senden, Germany). Laboratory analogs (Abutment Replica DCB 175-0; Entific Medical Systems) were then attached to the impression copings, and the impression was poured with Type IV dental stone (Nok Stone; LeFarge). A semi-precision bar (Hader Bar; Sterngold Dental, Attleboro, MA) with two semi-precision resilient attachments (ERA Overdenture; Sterngold Dental) was fabricated on the model, which was casted with semi-precious metal (palladium mixed with 2% gold) and tried on for passive fit (Fig. 5).
A PMMA resin housing was fabricated using the corresponding retentive attachments, after which an implant-retained silicone prosthesis was fabricated and delivered (Fig. 6A through C). The patient was instructed on daily hygiene procedures with normal saline solution
FIGURE 5
Second stage: Split-thickness skin graft placement.
Hader bar and ERA attachment in place.
232
Cleft Palate-Craniofacial Journal, March 2015, Vol. 52 No. 2
FIGURE 6 A: Implant retained auricular prosthesis. B: Tissue surface of the prosthesis with PMMA resin housing. C: Rehabilitation with implant retained auricular prosthesis.
and an end-tufted brush. Maintenance and recall visits were made every 3 months, during which the implant-abutment interface was irrigated with 2% chlorhexidine and normal saline solution to remove any adherent debris. Hygiene education was also repeated during these visits. The overall follow-up period was 2 years. The patient reported that he could perform such activities as chewing and yawning without dislodging the prosthesis. He had no complaints with the overall treatment other than the discoloration of the silicone prosthesis after approximately a year of use. Chair-side restaining of the prosthesis was done with extrinsic colors and delivered to the patient. DISCUSSION Surgical reconstruction of an auricular defect is a timeconsuming procedure that needs to be planned and requires the expertise and experience of the anaplastologist. It is considered as the treatment of choice in children when the reconstructive surgery can be performed in several steps to give the most ideal results (Kobus at al., 2002; Thorne et al., 2001). Prosthodontic rehabilitation can be considered a predictable treatment alternative to surgery. An adhesiveretained prosthesis can be initially fabricated to evaluate the patient’s acceptance of the treatment. It can also be used to determine the patient’s retentive needs. In our experience, we proceed with the implant-retained prosthesis when the patient is 16–18 years old to prevent any disruptions in facial growth. In addition, at this age the patient is aware of the maintenance needs associated with the implant-retained prosthesis. Nonetheless, this technique offers several key advantages over an adhesive-retained prosthesis. (1) Implant-retained prostheses offer higher retention and are easy to place.
(2) Implant-retained prostheses eliminate the use of adhesives that might be difficult and time consuming for patients with limited dexterity. (3) Because no adhesives are used, marginal tear associated with the application and removal of adhesives are also eliminated, extending the life of the prosthesis (Reisberg and Habakuk, 1995). On the other hand, an implant-retained prosthesis require lifelong maintenance of the surrounding skin around the implant. Peri-implantitis has been reported at an incidence of 5% to 75% (Mylanus et al., 1994; Visuttiwattanakorn et al., 2006), which is mainly attributed to an incomplete seal of the peri-abutment skin interface, which increases the chances that microflora will penetrate into the deeper tissues. Histologic studies have shown that the seal comprises chronically inflammatory cells, which suggests that the interface has a dynamic nature (Holgers et al., 1995). Microbiological cultures of the interface have shown Staphylococcus aureus as the most commonly isolated pathogen (Abu-Serriah et al., 2001), and it was also the most commonly found microorganism in infected surgical sites (Owens and Stoessel, 2008). Constant movement of the skin around the abutment may act as an irritant, increasing the chances of debris and epithelial crusting to be trapped between the abutment and the skin, which can then act as foreign bodies. Thus, placement of a hair-follicle–free, split-thickness skin graft or thinning of the subcutaneous tissues at the implant site have been suggested to immobilize the tissues and to reduce the incidence of peri-implantitis (Karakoca et al., 2008). The thigh region serves as a suitable donor site for the splitthickness skin graft because there is no need to change the position of the patient during the surgery, as would be the case when harvesting from regions such as the scapula and latissimus dorsi. Furthermore, variable thickness of the graft can be obtained from the thigh, and it causes less aesthetic morbidity compared with harvesting from the
Shrestha et al., PROSTHODONTIC REHABILITATION OF AURICULAR DEFECT
forearm (Nnene et al., 2000). However, because of the fibrosis and contraction that follows graft integration, it may be difficult to perform surgical reconstruction of the ear if the patient decides to do so in the future. Prosthetic component design should also consider the ease of hygiene maintenance. The Hader bar with ERA attachments was used in lieu of a conventional bar-and-clip design so as to reduce the size of the overall components. The ERA overdenture attachment is held in a metal jacket and permits the retentive nylon counterparts to be changed according to the retentive requirement or when the components have worn out. The use of magnetic attachments can also be considered when there is a lack of clearance space (,2 mm) between the bar and the tissues or when the patient lacks adequate manual dexterity. However, the most important factor for long-term success of the treatment is patient compliance; thus, it is critical that the patient is properly instructed to carry out additional hygiene procedures to maintain the prosthesis, implants, along with the retentive elements, and to keep the periimplant skin healthy (Reisberg and Habakuk, 1995). In this study, the patient was followed up for 2 years, during which time he was satisfied with the implantretained auricular prosthesis. Under the limitations of this clinical report, the Hader bar with ERA attachments also met the patient’s retentive needs and permitted maintenance of the skin around the craniofacial implants. However, a long-term study in a larger patient group is suggested to validate the outcomes. CONCLUSION An auricular defect was successfully restored by an implant-retained auricular prosthesis with good aesthetic
233
and functional outcome. Prosthetic rehabilitation of auricular defects serves as a successful alternative treatment option to surgical reconstruction. However, emphases on additional hygiene procedures are required for long-term success of the treatment. REFERENCES Abu-Serriah MM, Bagg J, McGowan DA, Moos KF. A clinical outcome study of extra-oral craniofacial endosseous implantretained prostheses. Br J Oral Maxillofac Surg. 2001;39:269–275. Holgers KM, Thomsen P, Tjellstrom A, Ericson LE. Electronic microscopic observation on the soft tissue around clinical long-term percutaneous titanium implants. Biomaterials. 1995;16:83–90. Karakoca S, Aydin C, Yilmaz H, Bal BT. Survival rates and periimplant soft tissue evaluation of extraoral implants over a mean follow-up period of three years. J Prosthet Dent. 2008;100:458–464 ´ Kobus K, Szczyt M, Łatkowski I, Wojcicki P. Reconstruction of the auricle. Br J Plast Surg. 2002;55:645–651. Mylanus EAM, Cremers WRJ, Snik FM, van der Berge NW. Clinical results of percutaneous implants in the temporal bone. Arch Otolaryngol Head Neck Surg. 1994;120:81–85. Nnene CO, Abu-Seido H, Isbister ES. Harvesting split skin grafts of appropriate thickness using the hand-held knife. Ann R Coll Surg Engl. 2000;82: 339–340. Owens CD, Stoessel K. Surgical site infections: epidemiology, microbiology and prevention. J Hosp Infect. 2008;70:3–10. Reisberg DJ, Habakuk SW. Hygiene procedures for implant-retained facial prostheses. J Prosthet Dent. 1995;74:499–502. Thorne CH, Brecht LE, Bradley JP, Levine JP, Hammerschlag P, Longaker MT. Auricular reconstruction: indications for autogenous and prosthetic techniques. Plast Reconstr Surg. 2001;107:1241–1252. Visuttiwattanakorn S, Srithavaj T, Thaweeboon S. Evaluation of microflora around extraoral per-implant percutnaeous tissues in a group of Thai patients. Mahidol Dent J. 2006;26:281–288.
