Extraoral prostheses using extraoral implants

The aim of this study was to evaluate extraoral prostheses and the use of extraoral implants in patients with facial defects. 10 cases were treated utilizing maxillofacial prostheses employing extraoral implants in five cases. 16 extraoral implants were installed. Seven implants were placed in irradiated sites in the orbital regions. Six implants were placed in mastoid regions and three in a zygoma region that was irradiated. Two implants failed before initial integration was achieved in irradiated areas. Using 14 extraoral implants as anchors, five extraoral prostheses were set. The other five cases were treated with extraoral prostheses without using extraoral implants due to cost and patient-related factors. The data included age, sex, primary disease, implant length, implant failure, prosthetic attachment, radiation therapy, and peri-implant skin reactions. The use of extraoral implants for the retention of extraoral prostheses has simplified the placement, removal, and cleaning of the prosthesis by the patient. The stability of the prostheses was improved by anchors. Clinical and technical problems are presented with the techniques used for their resolution. Using extraoral implants resulted in a high rate of success in retaining facial prostheses and gave good stability and aesthetic satisfaction.     

Experimental and postexperimental response to anteriorly directed extraoral force in young Macaca nemestrina.

An anteriorly directed extraoral force was applied to the maxillas of four healthy young M. nemestrina monkeys. Experimental, retention, and postretention alterations were evaluated through a combination of cephalometric, histologic, and gross techniques. In view of the results of the present study, the following conclusions can be made: 1. Skeletal remodeling occurs in all circummaxillary sutures following the application of an anteriorly directed extraoral force to the maxilla. The amount of remodeling appears to be proportional to a suture's distance from and orientation to the applied force system. 2. The maxillary complex exhibited a marked anterior positioning with a small amount of counterclockwise rotation during the experimental period. 3. The application of an extraoral force to the maxilia produces compensatory deposition and resorption of bone, not only at the sutural margins but also at the external surface of the bones themselves. 4. It is possible that the experimental appliance transmits its effect to the facial bones adjacent to the maxilla through an alteration in the skull's periosteal envelope. 5. A substantial reorientation of the maxillary complex occurs following the termination of active force, and the degree of relapse or reorientation is directly proportional to the length of stabilization. 6. The dentition, through the periodontal ligament, undergoes approximately four times as much relapse as do the facial bones through their sutural articulations, following a minimal period of stabilization. 7. Extraoral forces applied to the craniofacial complex are transmitted through the maxilla and related midfacial bones, resulting in changes in such deep cranial structures as the cartilaginous synchondroses of the sphenoid bone. 8. Anterior displacement of the maxilla by extraoral traction appears to have a minimal effect on the mandible and the temporomandibular joint. 9. The number of sinusoidal vessels in the sutural ligament tends to increase in those sutures subjected to a tensional force.     

腭裂引起反的前牵引与下颌髁突位置关系的初步研究

目的　评价应用口外弓加面具对唇腭裂继发骨性反牙合畸形进行早期阻断性治疗后 ,下颌骨髁突位置的变化。方法　对 8例患者治疗前和治疗 6个月的薛氏位片进行分析 ,比较颞下颌关节 (TMJ)前、上、后间隙的宽度。结果　治疗前后双侧TMJ的 3个间隙均无明显改变 (P >0 .0 5 )。结论　应用口外弓加面具作上颌骨前牵引后 ,未发现髁突位置的明显改变。     

Indications and methods of care for aspects of extraoral osseointegration

The introduction of percutaneous osseointegration biotechnology in 1979 to head and neck reconstruction permanently revised the long held view that a facial prosthesis was a last resort for the patient and surgeon alike. Since that time, the use of extraoral osseointegration has expanded considerably. The present review of the literature considers indications and methods of care for aspects of extraoral osseointegration as it relates to facial prosthetics. The clinical literature reviewed was graded for hierarchy of strength of evidence according to the Bandolier system. Almost all literature reviewed was of the lowest level of strength of evidence. Consequently, clinicians are advised to be cautious in applying the evidence to patients.     

Skeletal changes associated with extraoral appliance therapy: an evaluation of 200 consecutively treated cases

Questions exist concerning the degree to which orthodontic treatment alters facial form. This study has attempted to discern changes in several measures of vertical facial form which might be influenced by varying vectors and amounts of extraoral force. The data were collected from pre- and posttreatment lateral cephalograms of 200 children treated consecutively with full edgewise orthodontic appliances. The sample was divided into three pretreatment groups based on the type of extraoral force delivered; cervical, "combi," and no-headgear. All groups showed a wide range of variation in treatment response, but did not demonstrate significant differences. While the extraoral forces predictably improved horizontal maxillo-mandibular discrepancies, there was too much variation in response to predict vertical changes.     

腭裂引起反He的前牵引与下颌髁突位置关系的初步研究

目的：评价应用口外弓加面具对唇腭裂继发骨性反He畸形进行早期阻断性治疗后,下颌骨髁突位置的变化。方法：对8例患者治疗前和治疗6个月的薛氏位片进行分析,比较颞下颌关节（TMJ）前,上,后间隙的宽度,结论：治疗前后双侧TMJ的3个间隙均无明显改变（P＞0．05）。结论：应用口外弓外面具作上颌骨前牵引后,未发现髁突位置的明显改变。     

Auricular rehabilitation by means of bone grafting from the iliac crest in combination with porous extraoral implants: a case report

Background: Maxillofacial defects caused by cancer treatment are a huge problem affecting the quality of life of patients. Some of these deformities are minimized using facial epitheses, which need some additional retention devices like glasses or skin adhesives. The use of extraoral fixtures as bone anchorage was introduced many years ago and since then many patients were rehabilitated with better results. Purpose: Because of poor bone conditions, for example, irradiated bone, the success rate of extraoral implants is less than in the oral cavity, causing difficulties to rehabilitation. One possible cause of fixture failure could be the poor primary stability achieved in some cases, hence, with an increased bone contact implant stability and survival could be improved. The present report discusses possibilities to use extraoral fixtures with a modified surface structure. Materials and Methods: A new porous surfaced Brazilian extraoral implant (MasterExtra®, Conexão, Sistema de Próteses, São Paulo, Brazil) was used. A bone transplant from the iliac crest was taken to make it possible to insert at least three extraoral implants for an auricle epithesis. Clinical evaluation and resonance frequency analysis (RFA) measurements were performed during the course of the treatment. Results: Eight months after grafting, four fixtures were inserted. Three fixtures were used for connection of an auricular epithesis. RFA measurements did show high initial values and the values remained stable during the course of the treatment and at later checkups. Conclusion: Porous fixture is a good option in areas where the bone is compromised. RFA is a good tool also in the clinical setting to evaluate immediate and long‐term stability of extraoral fixtures.     

Facial nerve injuries associated with orthognathic surgery: a review of incidence and management

While facial nerve injuries associated with both extraoral and intraoral orthognathic surgery are rare, the results of such an injury can be devastating to the patient. A review of the literature shows that the majority of such injuries fall into the first-, second-, and third-degree injury categories. Prevention cannot be stressed enough; however, early recognition of an injury with prompt electrodiagnostic testing can assist with determining prognosis and treatment planning. When close observation is indicated, a variety of medical therapies have been suggested. For more severe injuries, nerve repair and facial reanimation have been reported.     

Complex midfacial reconstruction with an implant-supported framework

This clinical report describes the treatment of a patient with osseointegrated extraoral implants supporting a framework retainer and acrylic resin mesostructures and a large silicone midfacial prosthesis. A metal framework was used to splint the implants together and provided satisfactory retention for the facial prosthesis. A 2-piece prosthesis that composed of an obturator and facial prosthesis was fabricated. Cosmetic improvements as well as the ability to speak, swallow, and, to a lesser degree, chew, were achieved for this patient.     

Effectiveness of barrier devices,high-volume evacuators,and extraoral suction devices on reducing dental aerosols for the dental operator: A pilot study

BackgroundThe COVID-19 pandemic has increased the importance of minimizing exposure to aerosols generated during dental procedures. The authors’ objective was to measure the aerosolized particles in the breathing zone of operators using several facial protection and filtration methods.MethodsTwenty-one dentists performed maxillary anterior incisor veneer preparations using a microscope and drape and loupes with or without a face shield. In each test condition, the following 3 levels of filtration were tested: no filtration, a high-volume evacuator [HVE], and an HVE with an extraoral suction device. Measurements were made using a mass monitor attached to the operator’s chest with inlet within 10 inches of the operator’s face.ResultsThe authors found that the microscope and drape provided the lowest levels of aerosolized particles compared with loupes with or without a face shield (P < .001). There was no detectable difference in the concentration of particles between operators wearing a face shield and wearing loupes alone (P = .47). The particles in each test condition were lowered when an HVE was used (P < .001) and further lowered with an extraoral suction device.ConclusionsThe findings of this study suggest that the use of a surgical microscope and bag barrier drape, HVE, and extraoral suction device result in the lowest concentration of aerosolized particles. The face shield did not appear to offer any protection from aerosolized particles. HVE and extraoral suction were effective in decreasing aerosols regardless of the type of facial protection used.Practical ImplicationsDentists can reduce exposure to aerosols with a drape, HVE, and extraoral suction.     

Endoscope-assisted conservative condylectomy in the treatment of condylar osteochondroma through an intraoral approach

Mandibular condylar osteochondroma (OC) can result in morphological and functional disturbances, including facial asymmetry and temporomandibular joint (TMJ) dysfunction. The aim of this study was to explore the feasibility of endoscope-assisted tumour resection and conservative condylectomy via an intraoral approach. Seven patients with condylar OC were enrolled in this study. Endoscope-assisted tumour resection and conservative condylectomy were achieved intraorally, and no conventional extraoral incision was needed. Direct vision of the magnified and illuminated operative field was realized with the assistance of an endoscope. No facial nerve injury or salivary fistula occurred in any patient. Stable occlusion was realized through postoperative orthodontic treatment. The patients showed no signs of tumour recurrence or TMJ ankylosis during follow-up (range 18–43 months). Endoscope-assisted condylar OC resection and conservative condylectomy via intraoral approach offers great advantages with no significant complications compared with conventional extraoral incisions. The endoscope provides us with a valuable treatment option for this potentially complicated procedure     

经口内入路切除下颌骨良性肿瘤及同期血管化腓骨肌瓣精确重建下颌骨

目的： 首次介绍口内入路行下颌骨良性肿瘤切除和显微血管吻合的腓骨肌瓣即刻精确重建的经验。方法： 2018年1月—3月,对我科收治的4例下颌骨良性肿瘤患者行经口内入路的下颌骨节断性切除及显微血管吻合的腓骨肌瓣即刻重建术。3例术前行虚拟手术计划设计,并行钛板数字化压模成型。术中先在口内颊部显露面动、静脉并保护,按截骨导板完成下颌骨节断性切除和腓骨瓣塑形、钛板固定后,用导航验证重建下颌骨的位置。显微镜下将腓动脉与面动脉作端-端吻合,腓静脉与面静脉用微血管吻合器Coupler吻合。术后常规采用手提超声多普勒监测血管血流信号;术后1周复查全景片,检查重建下颌骨的位置。结果： 4例患者均顺利完成经口内入路的下颌骨节断性切除、腓骨重建,其中3例顺利完成口内显微血管吻合,1例因术区瘢痕、面静脉不理想而引至下颌下吻合。术后超声多普勒监测显示血流信号正常,口内及供区伤口均一期愈合。术中导航及术后全景片显示重建的下颌骨位置理想,咬合关系正常,面部外形对称,无面瘫及开口受限。结论： 经口内入路行下颌骨良性肿瘤的节断性切除及腓骨肌瓣精确重建和口内显微血管吻合是完全可行的,能够达到口外入路同样的效果,同时口外无瘢痕。     

Intraoral open reduction with rigid internal fixation of mandibular subcondylar fractures

Open reduction of subcondylar fractures achieves precise anatomic alignment of bony fragments and may prevent the postoperative sequelae seen with some closed reductions. Using an extraoral approach, a fracture can be easily seen and manipulated. An intraoral approach avoids large facial scars, facial nerve injury, and allows visualization of the occlusion during the procedure. Cases for this technique should be carefully selected.     

A multicenter interracial study of facial appearance. Part 1: A comparison of extraoral parameters

PURPOSE: This study was undertaken to compare the facial appearance of patients from six racial groups (African American, Caucasian, Chinese, Hispanic, Japanese, and Korean) for interracial and/or gender differences and to determine if "norms" existed. MATERIALS AND METHODS: A total of 253 subjects (144 men and 109 women) ranging in age from 18 to 41 years (mean age 26.5 years) were evaluated using a standardized protocol. The data were collected and analyzed to establish reference ranges for seven frontal and six profile extraoral parameters. Mean scores were compared by race and gender using a one-way analysis of variance, followed by the Tukey-Kramer test for honestly significant difference when statistically significant differences were found (P < .05). RESULTS: There were no significant differences for any of the seven frontal or six profile extraoral parameters between men and women. No significant differences were found between racial groups for five of the seven frontal and one of the six profile extraoral parameters. CONCLUSION: Most of the frontal facial parameters and one profile extraoral parameter might be considered norms for male and female patients of different ethnic origins. Additional research with larger patient populations would be needed to confirm or refute these trends.     

Orthodontic treatment of a Class II division 1 malocclusion exhibiting significant maxillary arch length deficiency: a case report.

The orthodontic correction of a Class II Division I malocclusion with significant maxillary arch length deficiency and a blocked-out maxillary cuspid is reported. The case was successfully completed on a non-extraction basis using extraoral cervical headgear anchorage and compressed coil springs to gain necessary maxillary arch length. No intermaxillary elastics or functional appliances were used. Favorable patient cooperation and facial growth were instrumental in achieving good results.     

An intraoral anastomosing technique for microvascular bone flaps in alveolar ridge reconstruction: First clinical results

The main indication for microvascular reconstruction of the face is to achieve the best possible functional and aesthetic outcome. In several cases of reconstruction of the alveolar ridges of the mandible or maxilla, extraoral scars might have been avoided if microvascular anastomoses had been performed without using the extraoral approach. In 9 patients with severe defects of the alveolar ridge of the mandible or maxilla caused by trauma, tumour resection, atrophy or partial loss of premaxilla, reconstruction was performed using six microvascular corticocancellous femur flaps, two iliac crest flaps and one osteoperiosteal fibula flap. In every case, an intraoral approach was used to prepare the transplant bed and the facial vessels. The anastomoses were carried out via this intraoral approach between the donor vessels and the facial vessels. The patients were followed up radiologically and clinically for 6–24 months postoperatively. There was no flap loss or severe complication postoperatively. All patients had good functional and aesthetic results, were treated successfully with dental implants 4–6 months after microvascular reconstruction, and were subsequently fitted with implant-retained prostheses. Intraoral anastomosing of microvascular bone flaps is a reliable technique for microvascular reconstruction of the alveolar ridge. Extraoral scars can be avoided.     

Compound splint for comminuted mandibular fracture

Maintenance of an adequate airway, control of bleeding, and neurologic evaluation should take precedence over treatment of facial injuries. Comminuted mandibular fractures are rare and require the use of complex splints. Severe lacerations and bone displacement accompany comminuted mandibular fractures. Extraoral facial splints constructed from donor facial moulages can be used along with intraoral splints for these patients. Preaccident photographs and radiographs are excellent aids to help realign the fractured segments. The use of an extraoral "donor" splint in conjunction with an intraoral splint to stabilize comminuted mandibular fracture helps to eliminate unnecessary gross removal of mandibular bone.     

Effects of cervical anchorage during and after treatment: an implant study.

Two groups of ten patients with postnormal molar relation, identical as regards facial morphology and dental stage, were treated for 8 months with cervical traction of the Kloehn type. The extraoral arch of the headgear was tilted upward in relation to the occlusal plane in one group and downward in the other. The local tooth movements were measured and related to metal implants inserted in the jaws. The movement of the implants in relation to the anterior cranial base expressed the amount and direction of the sutural and condylar growth. It was shown that a normal molar relationship was established in the shortest time with a downward tilt of the extraoral bow. A pronounced distal tipping of the molars was observed in these patients. The growth direction of the maxilla during cervical treatment was downward and backward and the mandible rotated posteriorly. The children were observed again 7 to 8 years after treatment, and it appeared that the influence of the headgear on the growth pattern of the facial skeleton was reversible, as a pronounced anterior direction of growth of the maxilla as well as of the mandible was observed in all but two subjects.     

Use of denture adhesive to retain an extraoral facial prosthetic wax pattern for trial placement

This article demonstrates the use of denture adhesive to retain a wax pattern during trial placement of an extraoral facial prosthesis. Using denture adhesive in this manner easily and temporarily retains the wax pattern in place without visual obstructions such as hands or instruments holding the pattern in place. With the wax pattern held securely in place, the clinician is able to assess it from all angles for position, esthetics, margin extension, and tissue movement before the wax pattern is finalized and processed.     

Lebensbedrohliche Mundbodenblutung nach Implantatinsertion im Unterkieferseitenzahnbereich

In dental practice, surgical implant procedures are frequently conducted for pre-prosthetic surgery. Intra-operative complications are rare and can mostly be prevented effectively with adequate preparatory measures. However, not all risks can be anticipated a priori. Anatomical variation, such as variation in the path of blood vessels, is often unpredictable. This paper describes a life-threatening hemorrhage that occurred in a 60-year-old male during the insertion of an implant in the distal right mandible. It was impossible to stop the bleeding using local measures. Only extraoral ligation of the facial artery proved effective in suppressing the hemorrhage. The submentalis artery, a branch of the facial artery, had an atypical path directly below the caudal ridge of the mandible. The possibility of similar complications should make us re-evaluate preoperative preventive measures, and places greater demands on intra-operative complication prophylaxis. The international literature on this topic is discussed.