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A New Implant for Nasal Reconstruction

Andrew Dawood, MRD RCS, MSc, BDS1/Susan Tanner, MRD RCS, MSc, BDS2
Iain Hutchison, FFDRCSI, FRCS (Eng and Edin), FDSRCS, MBBS, BDS3/
Extraoral implants have been used for many years to anchor silicone nasal prostheses. This report describes
the design and use of a specially engineered bifunctional implant, which is placed via an intraoral approach,
to simultaneously anchor nasal and oral prostheses for an edentulous patient who has undergone a
complete rhinectomy. The bifunctional implant was designed and milled from commercially pure titanium
using computer-aided design/computer-assisted manufacturing (CAD/CAM) technology. The nasal part of
the implant was designed to fit through the prepared site and protrude into the piriform aperture. A hex
attachment was orientated perpendicular to the axis of the implant on this extension. The intraoral head
of the implant was provided with a standard Brnemark hex configuration. Implants were placed using the
guide and associated instrumentation. This case demonstrates the potential for CAD/CAM technology to
produce bespoke implantable components at low cost. In this report, the implant greatly facilitated the
surgical and prosthetic management for the simultaneous provision of nasal and oral prostheses. Int J Oral
Maxillofac Implants 2012;27:e90e92
Key words: bifunctional implant, nasal implant, nasal reconstruction

blative surgery or trauma to the nose can result in


extensive mutilation or destruction. Surgical reconstruction can accommodate young and fit individuals, but can be complex and challenging for elderly
patients or those with complex defects.1
Extraoral implants have been used for many years2 to
provide anchorage for silicone nasal prostheses, as an alternative to surgical reconstruction.3 Conventional dental implants are generally used in nasal reconstruction.
However, access to the prosthetic platform for prosthetic
reconstruction can be difficult because of the positioning of the implant head within the piriform aperture.
This case report describes the design and use of a
specially engineered bifunctional implant with improved surgical and prosthetic handling characteristics that may be placed via an intraoral approach. The
implant is able to provide anchorage at both of its
ends, making it possible to simultaneously stabilize
nasal and dental prostheses.

1Specialist

in Periodontics and Prosthodontics, Private


practice, London, United Kingdom; Honorary clinical fellow,
St Bartholomews and The Royal London Hospitals.
2Specialist in Prosthodontics, Private practice, London, United
Kingdom.
3Professor in Oral and Maxillofacial Surgery, St Bartholomews
and The Royal London Hospitals.
Correspondence to: Dr Andrew Dawood, 45 Wimpole Street,
London, W1G 8SB, United Kingdom. Fax: +4420 7935 1181.
Email: andrewdawood@hotmail.com

Case Report
This report describes the design and use of a bifunctional implant to treat an edentulous patient who had
undergone a complete rhinectomy. The objective was
to design an implant capable of retaining a nasal prosthesis inserted into the nasal cavity from an intraoral
approach. The intention was to utilize standard surgical
instruments and prosthetic components. The implant
was designed in computer-aided design/computer-assisted manufacturing (CAD/CAM) software with a nasal
extension that could fit through the prepared site. This
nasal extension incorporated a standard hex connection. The implant (Fig 1) was machined from a type IV
titanium rod using a computer controlled lathe and
multiaxis mill.
To facilitate access to the nasal prosthetic platform,
the hex was orientated perpendicular to the axis of
the implant, on a flattened extension of the implant.
To fit this portion through the prepared site, the hex
was given a narrow platform (NP) configuration, and
the diameter of the body of the implant was slightly
increased from that of a standard Brnemark regular
platform implant to 4.3 mm.
The aim was to surface treat the portion of the implant that was in contact with the bone. Those portions
of the implant that traveled into the nasal aperture, or
were in contact with the nasal mucosa or gingivae,
were left with a machined surface. The intraoral head
of the implant was provided with a standard regular
platform (RP) Brnemark hex configuration.

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Dawood et al

Fig 1 (Above)The bifunctional implant. The


nasal extension is provided with a NP hex connection, oriented perpendicularly to the axis
of the implant. A conventional RP hex is at the
head of the implant.
Fig 2 (Right)The implants have been installed, and the nasal connections positioned
ideally for prosthetic access. The heads of
the implants are available intraorally for conventional prosthodontic reconstruction. Implant mounts have been repositioned after
removal of the surgical guide.

To compensate for the natural inclination of the


premaxilla, specially engineered, 5-mm long, 17-degree angled NP abutments were manufactured for the
connection of a gold substructure, which would retain
a silicone prosthesis produced using entirely standard
prosthetic and laboratory components and materials.
Surgical planning software (Nobel Guide, Nobel
Biocare) was used. Because the implant was not available in the implant library, a similarly sized, long cylindric implant was planned in a position that would
extend through the nasal floor, so that the intraoral
head of the implant would be conveniently positioned
for prosthesis retention, and the tips of the implants
would penetrate the nasal floor in close proximity to
the nasal aperture. Measurements of the available
bone determined that the threaded portion of each
anterior implant should be 12 mm long, ensuring that
the threaded portion of the implant would be entirely
within the bone.
A surgical guide was ordered from within the software. The special implants were ordered. Surgery took
place using a standard guided protocol for the two
bifunctional implants (Fig 2) and two further tapered
implants (Replace Select, Nobel Biocare).
Connection of multiunit abutments left the prosthetic platforms ideally located for prosthetic access,
both extra- and intraorally (Figs 3a and 3b). A conventional impression technique was used for both the oral
and nasal prostheses which were fitted after a 12-week
healing period (Fig 4) that allowed for tissue healing
and osseointegration before loading the implants with
a fixed resin prosthesis. Had the stability of the implants been better at time of insertion, an immediate
loading protocol may have been considered.
Implant-retained reconstruction remains the most
straightforward approach to nasal reconstruction, particularly in elderly patients or in those in whom access to
the nasal cavity for inspection of the region is important.

Access for surgery and prosthetics to implants


placed from a nasal approach is relatively less straightforward compared with an intraoral approach. Alternatives include the placement of zygoma implants,4
where access for surgery and the course of the implant
can be challenging, or placing conventional dental implants horizontally.5
Many patients requiring nasal reconstruction are
also edentulous (eg, five of nine patients had edentulous maxillae in the study by Karakoca et al6) and
would benefit from oral reconstruction. Partially dentate patients might also benefit from simultaneous
oral rehabilitation if anterior teeth are missing.
The bifunctional implant has also found application
in cases requiring extensive surgery in both the nasal
and maxillary regions, where there may be only one
suitable site for an implant, enabling simultaneous oral
and nasal or orbital reconstruction, where it might not
otherwise be possible to restore both cavities (Fig 5).
CAD/CAM technology offers the opportunity to
produce small numbers of bespoke components at a
low cost. The bifunctional implant facilitated surgical
and prosthetic management in this unique case.
The provision of a fixed implant-retained denture
avoided the need for a removable prosthesis, which in
this case may have led to a disturbance in the seating
of the nasal prosthesis if a labial flange had been provided. It may have also been difficult to wear following
surgery. Regardless, the patient experienced the great
benefit of a fixed oral rehabilitation.
Complete rhinectomy is not a particularly common
procedure, but it is highly mutilating. Surgical reconstruction is difficult and not always possible in the
older or infirm patient or when tissues have been extensively irradiated.
The situation of the implant may possibly be compared with that of a conventional dental implant that
has engaged the nasal or sinus floor, achieving bicortiThe International Journal of Oral & Maxillofacial Implants e91

2012 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
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Dawood et al

Fig 3a Conventional multiunit abutments are ideally presented


for connection of the nasal prosthesis.

Fig 3bIntraoral abutment ready for fixation of the maxillary


prosthesis.

Fig 4 (Left)The nasal and oral prostheses in place.


Fig 5 (Right)With only a few sites available for implant placement, the bifunctional implant (arrow) is able to provide simultaneous anchorage for a facial and intraoral prosthesis.

cal stabilization. In this particular elderly patient, it was


felt that anchorage would be sufficient to provide support for the oral prosthesis; however, a shorter implant,
with bone loss at both ends, may offer less predictable
anchorage.
Static mechanical loading of the nasal portion of
the implant is minimal; the potential for harmful forces
to be transmitted through the retaining superstructure
as the nasal prosthesis is removed might be worthy of
further study.
The tissue response of the nasal mucosa to titanium
implants or abutments does not appear to have been
adequately studied or reported. Clinical trials are needed to explore this new approach to simultaneous oral
and nasal rehabilitation with the bifunctional implant.
It is hoped and anticipated that this modified dental
implant will offer a more straightforward surgery and
improved prosthetic management for patients requiring nasal prostheses.

Acknowledgment
The authors thank Lars Jorneus and Fredrick Stromberg of Nobel Biocare for the provision and prompt delivery of the bifunctional implants for the treatment carried out for this patient.

References
1. Singh G, Withey S, Butler P, Kelly M. Forehead flap method for total
nasal reconstruction. Asian J Surg 2006;29:101103.
2. Lundgren S, Moy P, Beumer J III, Lewis S. Surgical considerations for
endosseous implants in the craniofacial region: A 3-year report Int J
Oral Maxillofac Surg 1993;22:272277.
3. Roumanas E, Freymiller E, Chang T, Aghaloo T, Beumer J III. Implantretained prostheses for facial defects: An up to 14-year follow-up
report on the survival rates of implants at UCLA. Int J Prosthodont
2002;15:325332.
4. Bowdena J, Flood T, Downie IP. Zygomaticus implants for retention
of nasal prostheses after rhinectomy. Br J Oral Maxillofac Surg
2006;44:5456.
5. Dimitroulis G. Nasal implants following nasectomy. Int J Oral Maxillofac Surg 2007;36:447449.
6. 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;100:458464.

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2012 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.

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