**2. Our experience**

From May 2002 to December 2010, 415 facial prosthesis (1117 implants) have been positioned in our Ephitesy Center. Defects were congenital (N = 142), consequent to trauma (N = 95) and to demolitive surgery for malignant tumors (N = 95), and infection (N = 83). In 40 patients, implants were placed in previously irradiated areas. A total of 1117 titanium implants were placed to support 187 auricular prostheses (bilateral in 29 cases), 126 orbital prostheses, 89 nasal prostheses, and 13 complex midfacial prostheses.

Clinical Case 1U.G., 57-year-old patient, came to our observation with ethmoidalsphenoidal-orbital-hemimaxillary resection and reconstruction with pectoral flap complicated in the same year by cerebral abscess of Eikenella. The patient was presenting the absence of the skeleton structures and the soft tissues of the third middle of the right emi-face with involvement of the nose and of the hard palate. The pectoral flap was causing deficit in the movements of extent and left rotation of the head. As a consequence of a cerebral ictus and for the detachment of septic carotid plaque embolus, the patient presented with hemiplegy. Heavy deficits were furthermore present to deglutition and masticatory function. The patient was arriving to our observation in order to restore the symmetry of the face and the integrity of the hard palate and to recover the motility of the cervical stroke. A surgical intervention of positioning of epithesis to rebuild the third middle and superior of the face and of the revision of the pectoral flap was therefore planned. Four fixtures with related abutments were placed to support anchoration for the midfacial prosthesis (Figs 3 and 4). In addition, a dental implant was placed in the right tuber maxillae to support a palatal obturator (Fig 5). Finally, a surgical revision of the pectoral flap was performed. Ten months after surgery, a palatal obturator was placed so that it was possible to remove percutaneous endoscopicgastrectomy (PEG).

Clinical Case 2, R.A., a 40-year-old man affected by the Goldenhar syndrome, underwent different reconstructive surgical treatments to restore the normal symmetry of the face soft tissues. The patient came to our center presenting a facial asymmetry characterized by atrophy of the right hemifacial soft tissues, associated to auricular agenesy and to esterior uditive conduct and ''anteroposizione'' of the left auricular (Figs 6 and 7). Clinical and radiologic examinations with computer tomography dental scan and Telecranium x-ray in 2 projections with cefalometric study were performed to evaluate the bone and the soft tissues. After 1 month, a surgery has been performed to remove the residual cartilage planted in the site corresponding to porous polyethylene prosthesis, positioned during the previous surgical treatment. In addition, 2 fixtures with abutment have been positioned in the right mastoid bone. Then the left auricular was positioned to reestablish the normal structures of the face. In the same surgical time, 2 porous polyethylene prostheses were implanted in the malar region to restore the sagittal diameter of the middle third of the face; then 2 porous polyethylene prostheses were implanted in the mandibular angle, and 1 prosthesis was implanted on the mandibulae, to restore the transversal and sagittal diameter of the third inferior of the face. After 3 months, an auricular prosthesis associated to polyacrylamide implant was positioned in bilateral preauricular area (Figs 8 and 9). Clinical and radiologic follow-up demonstrated a good integration of implants and the biomaterial Clinical Case 3 A.S., a 51-year-old man affected with posttraumatic anophthalmia, sequelae of left orbit exenteration and reconstruction of the eye socket with a titanium mesh covered by dermo-adipose flap, came to our observation with anophthalmia O.S. and fibrotic scars. Clinical and radiologic examinations with three-dimensional computed tomography were

From May 2002 to December 2010, 415 facial prosthesis (1117 implants) have been positioned in our Ephitesy Center. Defects were congenital (N = 142), consequent to trauma (N = 95) and to demolitive surgery for malignant tumors (N = 95), and infection (N = 83). In 40 patients, implants were placed in previously irradiated areas. A total of 1117 titanium implants were placed to support 187 auricular prostheses (bilateral in 29 cases), 126 orbital

Clinical Case 1U.G., 57-year-old patient, came to our observation with ethmoidalsphenoidal-orbital-hemimaxillary resection and reconstruction with pectoral flap complicated in the same year by cerebral abscess of Eikenella. The patient was presenting the absence of the skeleton structures and the soft tissues of the third middle of the right emi-face with involvement of the nose and of the hard palate. The pectoral flap was causing deficit in the movements of extent and left rotation of the head. As a consequence of a cerebral ictus and for the detachment of septic carotid plaque embolus, the patient presented with hemiplegy. Heavy deficits were furthermore present to deglutition and masticatory function. The patient was arriving to our observation in order to restore the symmetry of the face and the integrity of the hard palate and to recover the motility of the cervical stroke. A surgical intervention of positioning of epithesis to rebuild the third middle and superior of the face and of the revision of the pectoral flap was therefore planned. Four fixtures with related abutments were placed to support anchoration for the midfacial prosthesis (Figs 3 and 4). In addition, a dental implant was placed in the right tuber maxillae to support a palatal obturator (Fig 5). Finally, a surgical revision of the pectoral flap was performed. Ten months after surgery, a palatal obturator was placed so that it was possible to remove

Clinical Case 2, R.A., a 40-year-old man affected by the Goldenhar syndrome, underwent different reconstructive surgical treatments to restore the normal symmetry of the face soft tissues. The patient came to our center presenting a facial asymmetry characterized by atrophy of the right hemifacial soft tissues, associated to auricular agenesy and to esterior uditive conduct and ''anteroposizione'' of the left auricular (Figs 6 and 7). Clinical and radiologic examinations with computer tomography dental scan and Telecranium x-ray in 2 projections with cefalometric study were performed to evaluate the bone and the soft tissues. After 1 month, a surgery has been performed to remove the residual cartilage planted in the site corresponding to porous polyethylene prosthesis, positioned during the previous surgical treatment. In addition, 2 fixtures with abutment have been positioned in the right mastoid bone. Then the left auricular was positioned to reestablish the normal structures of the face. In the same surgical time, 2 porous polyethylene prostheses were implanted in the malar region to restore the sagittal diameter of the middle third of the face; then 2 porous polyethylene prostheses were implanted in the mandibular angle, and 1 prosthesis was implanted on the mandibulae, to restore the transversal and sagittal diameter of the third inferior of the face. After 3 months, an auricular prosthesis associated to polyacrylamide implant was positioned in bilateral preauricular area (Figs 8 and 9). Clinical and radiologic follow-up demonstrated a good integration of implants and the biomaterial Clinical Case 3 A.S., a 51-year-old man affected with posttraumatic anophthalmia, sequelae of left orbit exenteration and reconstruction of the eye socket with a titanium mesh covered by dermo-adipose flap, came to our observation with anophthalmia O.S. and fibrotic scars. Clinical and radiologic examinations with three-dimensional computed tomography were

prostheses, 89 nasal prostheses, and 13 complex midfacial prostheses.

percutaneous endoscopicgastrectomy (PEG).

**2. Our experience** 

performed to evaluate the bone and the soft tissues (Figs 10 and 11). After the clinical and radiologic evaluation and the patient's agreement, 4 fixtures with corresponding abutments were placed to support the anchor of the orbital epithesis. Nasal and orbital scars were corrected by little flaps (Figs 12 and 13).

Clinical Case 4 F.M., a 61-year-old man, was referred with a nose extirpation for a squamocellular cancer on the nasal tip, involving all nasal structure, 7 years before (Fig 14).The patient and his family declined any kind of reconstructive operative interventions, so the patient underwent nasal movable prosthesis resting. Based on this situation,wehad proposed tohimnasal removable prosthesis fixed with bone paranasal implants. For this reason, the patient had undergone computed tomography scan of the head and neck to study bone density and then 2 implants (4 mm) were placed. Follow-up at 3, 6, and 12 months with clinical visits and computed tomography scan revealed correct implant bone integration (Fig 15).

Clinical Case 5 P.D., a 25-year-old woman, underwent surgical exenteration orbitae because of retinoblastoma. The orbital cavity was restored by temporal muscle flap and dermal-free flap. The patient underwent many reconstructive surgical treatments through the use of fillers of biomaterials in frontal-temporal-cheek side, to reconstitute the anatomic structure. She arrived in our observation with a moving orbital prosthesis (Fig 16). Clinical and radiologic examinations with three-dimensional computed tomography were performed to evaluate the bone and the soft tissues. In accordance with the patient's desire, 3 titanium fixtures with abutments were implanted to position the orbital prosthesis (Fig 17).

Clinical Case 6 M.N., a 56-year-oldwoman,was referred with a partial auricular extirpation for a basocellular cancer on the auricular left elice. The 2/3 superiors of the auricular pavilion have been removed, with a partial deficit of the pavilion itself, which has caused psychologic problems to the patient. In agreement with the patient, a second surgical treatment was performed, modeling porous polyethylene peace with Nagata technique and covered by temporoparietal fascia and dermo-epidermic flap to fill the auricular fault. The biomaterial is not osteointegrated, so it has been removed. For such reason, in agreement with the patient justified strongly to an immediate and no invasive aesthetic rehabilitation, 2 fixtures with abutments have been positioned that support auricular epithesis (Figs 18Y20). The clinical and radiologic follow-up has shown a correct osteointegration of the implants reaching psychologic stability of the patient.

Clinical Case 7 G.B., a 68-year-old woman, with epatotrasplanting and hepatitis C virus has arrived in our observation with a necrotic lesion of the nasal tip resulting to immunosuppressive therapy. She was referring to have noticed the appearance of the necrosy and his progressive growth soon after the end of the therapy. The patient was presenting exposure of the cartilaginous septum with erosion and cutaneous necrosy to the nasal base (Fig 21). Because of the clinical conditions of the patient, a fixture's implant has been made for the positioning of an epithesis in order to obtain an effective reconstruction. Three fixtures with abutments have been applied. A fixture was removed approximately 2 months after the installing because it is not integrated. The other 2 implants seemed to be well supplemented to allow the positioning of the bar that supports the epithesis, but after 2months, 1 fixture has been removed because of missed osteointegration. Therefore, it was decided to position some magnets to anchorage the epithesis (Fig 22).

Biomaterials and Epithesis, Our Experience in Maxillo Facial Surgery 33

Fig. 3. Intraoperative point of view.

Fig. 4. Anchoration for the midfacial prosthesis.

Fig. 1. Preoperative frontal view of the patient.

Fig. 2. Preoperative three-dimensional computed. TomographyVfrontal view of the patient.

Fig. 2. Preoperative three-dimensional computed. TomographyVfrontal view of the patient.

Fig. 1. Preoperative frontal view of the patient.

Fig. 3. Intraoperative point of view.

Fig. 4. Anchoration for the midfacial prosthesis.

Biomaterials and Epithesis, Our Experience in Maxillo Facial Surgery 35

Fig. 7. Preoperative lateral view of the patient.

Fig. 8. Postoperative frontal view of the patient.

Fig. 5. The palatal obturator.

Fig. 6. Preoperative frontal view of the patient.

Fig. 5. The palatal obturator.

Fig. 6. Preoperative frontal view of the patient.

Fig. 7. Preoperative lateral view of the patient.

Fig. 8. Postoperative frontal view of the patient.

Biomaterials and Epithesis, Our Experience in Maxillo Facial Surgery 37

Fig. 11. Preoperative computer tomographyVfrontal view.

Fig. 9. Postoperative lateral view of the patient.

Fig. 10. Preoperative frontal view of the patient.

Fig. 9. Postoperative lateral view of the patient.

Fig. 10. Preoperative frontal view of the patient.

Fig. 11. Preoperative computer tomographyVfrontal view.

Biomaterials and Epithesis, Our Experience in Maxillo Facial Surgery 39

Fig. 14. Preoperative frontal view of the patient.

Fig. 15. Postoperative frontal view of the patient.

Fig. 12. Postoperative frontal view of the patient.

Fig. 13. Postoperative computer tomographyVfrontal view.

Fig. 12. Postoperative frontal view of the patient.

Fig. 13. Postoperative computer tomographyVfrontal view.

Fig. 14. Preoperative frontal view of the patient.

Fig. 15. Postoperative frontal view of the patient.

Biomaterials and Epithesis, Our Experience in Maxillo Facial Surgery 41

Fig. 18. Fixtures positioning.

Fig. 19. Patient with auricular epithesis.

Fig. 16. Preoperative frontal view of the patient.

Fig. 17. Postoperative frontal view of the patient.

Fig. 18. Fixtures positioning.

Fig. 16. Preoperative frontal view of the patient.

Fig. 17. Postoperative frontal view of the patient.

Fig. 19. Patient with auricular epithesis.

Biomaterials and Epithesis, Our Experience in Maxillo Facial Surgery 43

The facial prosthetic rehabilitation is a valid alternative when the conventional reconstructive surgical techniques cannot be applied either because of the psychophysical conditions of the patient or because of an excessive substance loss. The surgical technique with prosthesis has several applications: malformative, infective, traumatic pathology, results of oncologic surgery and radiant therapy, and particular clinical conditions such as diabetes, leukemia, and others. The position of epithesis, as described in the literature5,6

and confirmed by the experience of our epithesis Center, is suitable in selected cases: reconstruction with patient's own tissue, which is uneventful or impossible;

The described technique presents absolute limits such as osteolitic process, leukemialymphoma, and terminal cirrhosis and relative limits such as ending life, hygienic deficiency, and psychological refuse. Another important limit is the radiotherapy treatment; the skeletal structure of persons who undergone radiotherapy react to the osteointegration process with a lower success percent. It goes, in fact, to consider that if the combined application of the chemotherapy and radiotherapy treatments with demolitive surgery increases the life on average, the survival of the subject with surgical cancerYablation increases, compromising the quality of life.7 The results of the osteointegration in patients who have underwent chemotherapy are very variable, approximately 60% and 100%.8 In accordance with the literature, we can affirm that the radiotherapy compromises the human tissues, hindering the osteointegration process, when the irradiation is around 5000 Gy. Besides the site and the radiation dose, the time existing between the radiant treatment and the positioning of the implant is another determinant factor for the success of osteointegration process. In particular, 6 months should exist between the term of the radiant treatment and the positioning of the implant period in which the tissue alteration produced by the radiations are in regression. According to the oncologic guideline, it would

Advanced age or poor health; and poor tissues quality patient's choice

Fig. 22. Postoperative frontal view of the patient.

''Reversible'' intervention to operate clinically;

Surveillance in oncologic patients;

**3. Conclusion** 

Fig. 20. Auricular epithesis.

Fig. 21. Preoperative frontal view of the patient.

Fig. 22. Postoperative frontal view of the patient.
