HASSON ET AL
J Oral Maxillofac Surg
Late Infections Associated With
Alloplastic Facial Implants
Oscar Hasson, DDS,* Gideon Levi, DMD, MD,† and
Roy Conley, DMD‡
Different surgical techniques have been developed in
recent years to improve facial appearance. Oral and
maxillofacial surgeons have traditionally performed sur-
gical procedures based on osteotomies and local bone
movement, and fewer using alloplastic implants to ob-
tain the desirable facial changes; however, this has been
changing lately.1,2 Although alloplastic implant proce-
dures have been reported as safe and predictable, late
complications seem to occur.3-5 Alloplastic implants are
usually inserted in the chin and malar bone areas, which
are close to dental bearing regions. Because of this
proximity, surgeons must certify the good status of re-
gional teeth to prevent possible contamination of the
implant’s site by a future dental infection.
The purpose of this article is to report late infection
related to alloplastic implants inserted in the chin and
malar bone region, clarifying the need for good oral
hygiene to prevent late infections when implants are
close to dental-bearing areas.
Report of Cases
Both cases reported were treated at the department of
Oral and Maxillofacial Surgery at the Kaplan Medical Center,
Rehovot, Israel.
CASE 1
A 46-year-old woman was referred for examination of
swelling and a depression on the skin in the left portion of
her chin. She was otherwise healthy and reported having
plastic surgery for her nose bridge and receiving a chin
implant 20 years prior.
Received from the Department of Oral and Maxillofacial Surgery,
Kaplan Medical Center, Rehovot, Israel.
*Senior Surgeon.
†Chairman.
‡Senior Surgeon.
Address correspondence and reprint requests to Dr Hasson:
Department of Oral and Maxillofacial Surgery, Kaplan Medical Cen-
ter, POB 1, Rehovot, Israel; e-mail:oshasson@yahoo.com
© 2007 American Association of Oral and Maxillofacial Surgeons
0278-2391/07/6502-0028$32.00/0
doi:10.1016/j.joms.2005.11.066
321
65:321-323, 2007
She reported a swelling on her chin and a secretion
coming out of the depression area that was present for a
few weeks. The oral examination showed poor oral hy-
giene. The inferior vestibule was swollen; however, no
liquid material was felt within the tissue. The extraoral
examination showed a fistula located in the left portion of
her chin (Fig 1). The x-ray examination showed a periapical
lesion in the left lower lateral incisor that was supporting a
fixed bridge. An ultrasound examination was performed,
showing the presence of the chin implant and no collection
inside the tissues. The computed tomography (CT) scan
showed the presence of the chin implant and mandibular
resorption in the symphysis area (Fig 2).
Although it was clear that infection was present, the cause
was not obvious. It was decided to perform exploration of the
area, clarifying to the patient that she would possibly end up
without the chin implant or her left lower fixed bridge, or
without both. Exploration of the area was performed under
general anesthesia. After a periodontal flap was raised, a totally
mobile chin implant was discovered. A free piece of a blue
synthetic material was also seen (Fig 3). The skin fistula was
approached extraorally and direct communication to the chin
implant was found, confirming that the implant was causing
the infection. The chin implant was removed and curettage
was performed of granulation tissue encountered in the im-
plant’s bed. Apicectomy and curettage of the periapical lesion
involving the left lower lateral incisor was also carried out, yet
this was not the cause of the chin infection. After closure of
the intraoral flap, repair of the facial fistula by an extraoral
approach was performed. At 1-year follow-up, there was good
facial appearance without the presence of any pathology.
CASE 2
A 41-year-old man was referred for evaluation of a persistent
fistula in his upper left vestibule and for evaluation of a recent
fistula in the external portion of his left cheek. He reported
receiving a Proplast implant (Vitek Inc, Houston, TX) for aug-
mentation of his left and right cheek bones 10 years prior to
our consultation. He reported having pain in his left cheek
before the appearance of the fistula. The intraoral fistula was
present for 3 years and it opened just above the roots of the
first left upper molar, which had a root canal treatment. The
x-ray study showed no pathology involving this tooth. He was
treated with antibiotics, with some relief of symptoms but no
cure. The extraoral fistula appeared 1 year later with pus
discharge. A CT scan performed in another institution showed
continuity between the sinus tract and the implant in the left
cheek. Under general anesthesia a gingival flap was raised and
the Proplast implant of the left cheek region was removed.
The implant came out in a few large pieces, and granulation
tissue in the region was removed. The anterior portion of the
malar bone did not show bone resorption. There was no
322 INFECTIONS ASSOCIATED WITH ALLOPLASTIC FACIAL IMPLANTS
FIGURE 1. Fistula on the left portion of the chin.
Hasson et al. Infections Associated With Alloplastic Facial Im-
plants. J Oral Maxillofac Surg 2007.
granulation tissue surrounding the roots of the first upper
molar. The patient did well, and at 1-year follow-up there was
no sign of the intra- and the extraoral fistulas.
Discussion
The chin and malar bone regions are important ele-
ments for facial balance, and for that reason, they are
normally assessed. Traditionally, the surgical procedures
for enhancement of these regions are divided between
using alloplastic materials or performing osteotomies
and bone movement. Choosing one technique over the
other depends mostly on surgeons’ preference and
background. Reviewing the literature, we found that
both approaches are accepted and that advantages and
disadvantages are related to both procedures.1,3 Allo-
plastic implants for facial improvement are advocated to
FIGURE 2. Axial CT scan showing the presence of the silicone
implant and resorption of bone in the chin area.
Hasson et al. Infections Associated With Alloplastic Facial Im-
plants. J Oral Maxillofac Surg 2007.
FIGURE 3. Transoperative view of the mobile silicone implant. Note
the presence of a synthetic blue material within the wound.
Hasson et al. Infections Associated With Alloplastic Facial Im-
plants. J Oral Maxillofac Surg 2007.
be safe, easy to use, to lack donor site morbidity, and to
normally have good postoperative tolerance.1 However,
bone resorption, because of lack of stability, is still one
of its pitfalls. This lack of stability seems to be related to
early or even late implant infection. Niamtu3 has indi-
cated the need for fixation of the implant in the chin
area by screws. Ivy et al6 reported that for the malar
implant, precise pocket creation is important and
enough to permit implant fixation without the need of
sutures or screws.
Osteotomies and bone movement permit better fixa-
tion of segments, however, they require demanding
surgical skills to precisely fixate fragments without caus-
ing nerve injury. Osteotomies are performed more in
the chin and less in the malar area. The anatomic chin
location permits clear visualization of the surgical field,
better-controlled osteotomy, and bone movement and
segment fixation.7 Although reported in the litera-
ture,8-10 it seems that osteotomy and bone movement of
the malar bone are more complicated, and visualization
is poor. Because of that, a consensus exists about using
alloplastic implants for malar enhancement.
The literature reports infection related to placement
of alloplastic implants. Strauss and Abubaker3 reported
infection rates for alloplastic chin implants to be from
5% to 7%, depending on what type of implant is used.
Rubin and Yaremchuk5 reported an infection rate of
only 0.7% for silicone in the chin area and 7.6% for
Proplast implant in the same area. They reported infec-
tion of a chin implant as late as 47 years after its inser-
tion. They also reported a 14.6% infection rate for Pro-
plast implants used in the facial region; however,
Whitaker11 reported an infection rate of 2.3% for these
implants in the same area.
Our 2 cases show the presence of late infection (after
10 and 20 years) of alloplastic implants that appears to
DIMITRAKOPOULOS ET AL
be related to poor oral hygiene of adjacent teeth. In both
patients, alloplastic implants were not fixated, and teeth
in the area already had chronic dental infection or had
dental treatment performed. Although cannulation of
the fistula during surgery (in the chin case) and preop-
eratively (in the malar implant case) hinted about the
possible implant infection, assurance was only possible
with exploratory surgery. We believe that preoperative
clinical and radiograph screening are important to diag-
nose and treat any dental pathology, especially of those
teeth close to surgical areas. Also, it is important for oral
and maxillofacial surgeons who have a strong dental
background to properly consider surgical options for
facial enhancement in the presence of poor or unpre-
dictable adjacent teeth.
References
1. Reed EH, Smith G: Genioplasty: A case for alloplastic chin
augmentation. J Oral Maxillofac Surg 58:788, 2000
Inflammatory Myofibroblastic Tumor
of the Maxillary Sinus: A Case Report
Ioannis Dimitrakopoulos, DDS, MD, PhD,*
Konstantinos Psomaderis, DDS,† Fotios Iordanidis, MD,‡
and Dimitrios Karakasis, DDS, MD, PhD§
Inflammatory myofibroblastic tumor (IMT) is a rare
lesion composed of myofibroblasts, fibroblasts, and
inflammatory cells of uncertain etiology and disputed
nosology. Because of these unknown factors, IMT was
referred to by several different terms until the World
*Oral and Maxillofacial Surgeon, Associate Professor in Oral and
Maxillofacial Surgery, Clinic of Aristotle University of Thessaloniki,
Thessaloniki, Greece.
†Oral and Maxillofacial Surgeon, Oral and Maxillofacial Surgery
Clinic of Aristotle University of Thessaloniki, Thessaloniki, Greece.
‡Pathologist, General Hospital “G. Papanikolaou,” Thessaloniki,
Greece.
§Oral and Maxillofacial Surgeon, Head Professor in Oral and
Maxillofacial Surgery, Clinic of Aristotle University of Thessaloniki,
Thessaloniki, Greece.
Address correspondence and reprint requests to Dr Dimitrako-
poulos: 28 Pavlou Mela St, 54622, Thessaloniki, Greece; e-mail:
kostpsom@hotmail.com
© 2007 American Association of Oral and Maxillofacial Surgeons
0278-2391/07/6502-0029$32.00/0
doi:10.1016/j.joms.2005.11.068
323
2. Niamtu J: Alloplastic chin augmentation. Oral Maxillofac Surg
Clin North Am 12:765, 2000
3. Strauss RA, Abubaker OA: Genioplasty: A case for advancement
osteotomy. J Oral Maxillofac Surg 58:783, 2000
4. Constantinides MS, Galli SKD, Miller PJ, et al: Malar, submalar,
and midfacial implants. Facial Plast Surg 16:35, 2000
5. Rubin JP, Yaremchuk MJ: Complications and toxicities of im-
plantable biomaterials used in facial reconstructive and aes-
thetic surgery: A comprehensive review of the literature. Plast
Reconstr Surg 100:1336, 1997
6. Ivy JE, Lorenc PZ, Aston SJ: Malar augmentation with silicone
implants. Plast Reconstr Surg 96:63,1995
7. Lee RN: Genioplasty techniques. Oral Maxillofac Surg Clin
North Am 12:755, 2000
8. Van Sickles JE, Tinner BD: A combined Le Fort I and bilateral
zygomatic osteotomy for management of midface and maxillary
deficiency. J Oral Maxillofac Surg 52:327, 1994
9. Acebal-Bianco F, Vuylsteke PLPJ, Mommaerts MY, et al: Peri-
operative complications in corrective facial orthopedic sur-
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754, 2000
10. Jones RHB, Ching M: Intraoral zygomatic osteotomy for cor-
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J Oral Maxillofac Surg
65:323-326, 2007
Health Organization (WHO) classified IMT as a dis-
tinct entity in 1994. The tumor occurs most com-
monly in the lungs where it presents a genuine be-
nign behavior. Its extrapulmonary location, although
rare, has also been reported and is characterized by a
different, more aggressive behavior. Cases of ex-
trapulmonary sites primarily appear during child-
hood. To the best of our knowledge only 2 cases of
IMT affecting the maxillary sinus have been previ-
ously reported in the international medical litera-
ture.1,2 In this article we present an interesting case of
a 70-year-old patient suffering from IMT of the maxil-
lary sinus.
Report of a Case
A 70-year-old man presented with complaints of head-
aches, nasal obstruction, and low but constant fever. Both
extraoral and intraoral clinical examinations revealed no
pathologic signs. Anterior nasoscopy was also negative for
any pathology. Computed tomography examination of the
patient revealed a compact soft tissue mass occupying the
left maxillary sinus, without erosion of the bony walls