Oral and Maxillofacial Surgery Cases 6 (2020) 100141

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Oral and Maxillofacial Surgery Cases

journal homepage: www.oralandmaxillofacialsurgerycases.com

Reconstruction of a total rhinectomy defect by implant-retained

nasal prosthesis: A clinical report
Afrooz Javanmard a, Farnoosh Mohammadi b, Hamid Mojtahedi c, *
a
Postgraduate Prosthodontics resident, Department of Prosthodontics and Dental Research Center, Faculty of Dentistry, Tehran University of Medical
Sciences, Tehran, Iran
b
Craniomaxillofacial Research Center, Oral and Maxillofacial Surgery Department, Shariati Hospital, Tehran University of Medical Sciences,
Tehran, Iran
c
Postgraduate Oral and Maxillofacial Surgery resident, Craniomaxillofacial Research Center, Oral and Maxillofacial Surgery Department, Shariati
Hospital, Tehran University of Medical Sciences, Tehran, Iran

A R T I C L E I N F O A B S T R A C T

Keywords: Since the Nasal unit is the prominent part of the face and subjected to ultraviolet radiation, it’s a
Maxillofacial prostheses frequent site of skin tumors such as squamous cell carcinoma and basal cell carcinoma. Tumor
Total rhinectomy ablation surgeries can leave a patient with a severe deformity, which results in psychosocial and
Prosthetic implant
functional impairment. Nose consists of three layered, anatomically complex sculpture and
Precision attachment
Replacement of total rhinectomy lesion may not be satisfactorily accomplished by means of
autogenous and microvascular grafts. Nowadays nasal prosthesis rehabilitation proved to be a
predictable option for reconstruction of craniofacial defects. This case report describes a safe and
economical method for the rehabilitation of a patient with absent nasal unit using an implant
supported silicone prosthesis. Two implants were placed in the nasal floor of the maxillary bone.
Reconstruction of the nose was done with nasal silicone prosthesis, retained using bar and clip
attachments to increase the stability and retention of the prosthesis.

1. Introduction

Squamous cell carcinoma (SCC) is one of the most common lesions involving nasal skin area [1]. Tumors larger than 1 cm, which
invade the cartilage and deeper structures, are among the aggressive groups of lesions and require total or subtotal rhinectomy [2].
Since nasal defects after tumor ablative surgery produce a severe cosmetic deformity, reconstruction of such defects could markedly
improve the quality of life of patients [3]. Rehabilitation of large nasal defects remains a challenge and frequently requires staged
approaches. Although Traditionally, Restoring the complex anatomy of the nose by means of local and distant flaps is considered
satisfactory, this would withstand many drawbacks. Technically, reconstruction of nasal unit with all its support and internal linings is
difficult and the final outcome, especially in total rhinectomy cases, is not esthetically pleasant [4]. On the other hand, skin flaps could
obscure malignant lesion recurrence which occurs mostly within 3 years of initial treatment [5].
Nowadays prosthesis rehabilitation gained much attention in reconstruction of craniofacial defects. In the past, mostly the nasal
prosthesis was retained by strings, intraoral or extraoral extension of other prostheses or spectacle frames [6]. Likewise, the choice of

* Corresponding author.
E-mail addresses: Afroozjavanmard.69@gmail.com (A. Javanmard), Farnooshmohammadi2003@yahoo.com (F. Mohammadi), Hamid.
mojtahedi91@yahoo.com (H. Mojtahedi).

https://doi.org/10.1016/j.omsc.2020.100141
Received 30 December 2019; Accepted 13 February 2020
Available online 19 February 2020
2214-5419/© 2020 Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
A. Javanmard et al. Oral and Maxillofacial Surgery Cases 6 (2020) 100141

tissue adhesives as a retentive method can be associated with local skin reactions, prosthesis discoloration and frequent dislodgments
[7].
Currently, with the introduction of osseointegration concept, more predictable modes of retention are provided for nasal implant
prostheses [8]. Implant-retained nasal prosthesis does not have the limitations of conventional retentive methods, providing a stable
prosthesis with desirable aesthetic outcome [9,10]. Mostly, the patients who undergo resective surgeries due to malignant lesions are
given post-surgical radiotherapy regimens. Osseointegration in irradiated patients can be affected by many factors, including the
amount of radiation dose, dose fractionation, time from radiotherapy and the quality of bone [11]. Lundgren reported that successful
osseointegration in post-radiation patients is feasible and the lack of adequate cortical bone to provide initial fixture stability is the
main culprit in craniofacial implant failure [12].
The purpose of this study was to present a case with the history of nasal skin SCC who underwent total rhinectomy, followed by
reconstruction with implant-retained nasal prosthesis.

2. Case presentation

A 78-year-old man with the history of previous nasal skin SCC was referred to oral and maxillofacial surgery department of Shariati
hospital (Tehran university of medical sciences, Tehran, Iran). The patient had undergone total rhinectomy 1 year before the referral
visit. Post-surgical radiotherapy was initiated for him at the dosage of 45 Gy almost after surgical ablation for 6 sessions. Clinical
evaluation revealed absence of total nasal unit skin and cartilages. Bony nasal septum and pyriform apertures were intact and were
covered by skin advancement flaps after nasal resection (Fig. 1).
As an elder member of the family, the patient concerned about his facial malformation and its leading disturbances in his social
activities. Therefore, all the rehabilitation modalities and their retentive means were introduced and discussed with the patient and his
companions. After explaining the cosmetic and stability features of nasal prosthesis, The Patient accepted implant-retained nasal
prosthesis made of medical-grade silicon and casting bar attachments.
Cone beam computed tomography and plain radiographies were obtained to evaluate the amount of available bone and appropriate
locations for implant insertion. Two implants with 4.5 mm in diameter and 8 mm in length (Simple line II, Dentium, Seol, korea) were
chosen according to the available bone height in anterior maxilla.
Under general anesthesia, separate skin incisions were made on either side of nasal septum. Full thickness mucoperiosteal flaps
were then elevated and the anterior maxillary bone was exposed. A surgical guide was provided for optimal implant positioning with
respect to sculpture of the prosthesis. After preparation of the implant hole, two fixtures, with the aforementioned dimensions, were
inserted and the ideal primary stability was achieved (Figs. 2 and 3). At the end, healing abutments were placed and mucoperiosteal
flaps were repositioned and closed with 5–0 nylon sutures (Hamiteb, Tehran, I.R. IRAN). Patient received instructions on skin and
wound management during healing time. Wound dressing was performed by direct delivery of 3% tetracycline antibiotic ointment
(Razak, Karaj, I.R. IRAN) to the skin part and Periokin gel (Laboratorios KIN S.A., Barcelona, Spain) to the mucosal side of the nasal
wound.
After four months, the patient was requested to attend pre-prosthetic visit and the healing of nasal defect was evaluated. Clinical
assessment revealed complete prei-implant mucosal and skin healing and absence of any edema and inflammation. Therefore, the

Fig. 1. Patient with total nasal defect after tumor ablation surgery.

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Fig. 2. Implant hole preparation.

Fig. 3. Posterior-anterior radiographic view of two osseointergrated implants located in nasal floor.

patient was referred to maxillofacial prosthesis department (dentistry faculty, Tehran university of medical sciences, Tehran, Iran) to
carry on prosthesis rehabilitation stage.
In order to obtaining impression, the periphery of nasal defect was moistened with petroleum jelly (Vaseline, Firooz, Tehran, I.R.

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A. Javanmard et al. Oral and Maxillofacial Surgery Cases 6 (2020) 100141

IRAN) and encircled with a roll of putty condensation silicone (Colten speedex, Langenau, Germany). Additionally, moist gauze was
packed in nasal cavity to prevent the flow of undesired impression material. Impression pins were placed and were connected to each
other using an auto polymerizing acrylic resin (GC America, Alsip, Illinois, united states) and a discarded fissure bure, to decrease the
amount of polymerization shrinkage. After that, the light consistency poly vinyle siloxane (Panasil, Kettenbachdental, Eschenburg,
Germany) was injected around splinted impression pins followed by medium body poly vinyle siloxane surrounding that to fill the
nasal defect (Fig. 4). At the end, plaster of paris (Well mix G30, Asia shimi teb, Tehran, I.R. IRAN) and salt mixture, used to accelerate
the plaster setting, was used to cover the impression material. In order to obtain open tray technique, obscuring of the head of splinted
pins were prevented during the impression stage. By then, Analogous pins were placed and The impression was poured with type IV
dental stone (Well mix G30, Asia shimi teb, Tehran, I.R. IRAN) and the working model was provided.
Before the framework design stage, verification jig was provided by means of auto polymerizing acrylic resin (GC America, Alsip,
Illinois, united states) in order to verify the accuracy of master cast and three-dimensional relationship of implants. Splinted
impression copings were threaded on implants clinically and trial verification of future prosthesis fitness was performed.
Castable abutments (metal casting abutment, Simple line II, Dentium, Seol, korea) were placed and framework designed by two
horizontal elements through nasal septum and a vertical extension on posterior component. Framework Wax up was performed by
forming inlay wax (Cavex, Haarlem, Netherlands) on abutments separately. Prefabricated castable bars, compatible with clip at­
tachments, were used to connect the castable bars. The framework casting was performed with cobalt-chromium metal alloy (Bredent,
Weissenhorner, Germany). On trial session, after finishing and polishing, the framework fitness and passivity was verified by screw
resistance test (Fig. 5) and by means of posterior-anterior plain radiography.
Framework was located on master cast and two attachment clips were placed on horizontal and vertical bars concerning a 1 cm gap
in between. Attachments were imbedded in auto polymerizing acrylic resin (Ivoclar\vivadent, Schaan, Liechtenstein). Acrylic sub­
structure was incorporated into the nasal wax pattern. Taking into account the patients’ former photos and duplication model of his
sons’ nose, a nose shaped wax pattern was designed on master cast. After final refinement and providing the anatomic details, the
patient was called and the wax pattern was tried in. Adaptation of borders has paramount importance and should be precisely achieved
before final prosthesis provision. After Final adjustments, the wax nose was flasked conventionally. At the presence of the patient, the
intrinsic characterization of prosthesis was performed by packing the silicone (Cosmosil, Kyoto, Japan) in layers into the mold, ac­
cording to the patients’ skin texture. Just before packing, care should be taken to apply the primer (A-330-Gold, Factor II, Lakeside, AZ,
United States) on acrylic substructure to enhance bonding to silicone. The mold was cured at 100 � C for 1 hour and was allowed to cool

Fig. 4. Final impression of nasal defect.

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Fig. 5. The frame work that consists of vertical and horizontal components, was threaded to implants.

down at room temperature. The margins were finished and the nostrils were cut open for air passage.
Extrinsic characterization (Cosmosil, Kyoto, Japan) was undertaken by the stimulation of pigmentation and telangiectasia patterns
of patients’ nasal skin details (Fig. 6). The final fitness of prosthesis was verified and the home-care instructions were given to the
patient. At the 4-week follow up evaluation, during which the patient exhibits no complaints, he expressed satisfaction with the final
prosthesis.

3. Discussion

Reconstruction of the craniofacial defects, including nose, and other structures, has remained a challenge for the reconstructive
surgeons. Since Psychosocial and functional impairments are significant in post-rhinectomy patients, it is important to provide
appropriate rehabilitation to improve their quality of life [13]. Traditional methods, including microvascular free flaps and autogenous
reconstructions, can be used to restore the defects, but require multiple-staged procedures, which are more technically demanding and
increase the risk of surgical complications [14]. Nowadays, prosthetic reconstructions offer an excellent treatment option, which is
well suited for total loss of complex structures of the face. By the advent of osseointegrated implants, the need for adhesives, spectacle
frames and other conventional fixation methods has been eliminated, and Optimal stability of Implant-retained nasal prosthesis
enhanced the patient’s self-esteem and social activity level.
Among the craniofacial prosthesis implant sites, nasal region is the most challenging to treat [12]. The poor quality of nasal floor in
premaxillary region, which is mostly consisted of cancellous bone, with the fragile post-radiated covering nasal skin and mucosa, make
the cranial implantation more difficult. It was reported that the inadequacy of cortical bone for primary stability was the major culprit
of fixture failure in craniofacial regions [15]. It is suggested to place two implants in nasal floor in edentulous patients, considering the
amount of bone and vital structures, including nasopalatine canals. Unlike glabellar implants, emergence profile of nasal floor implants
mostly do not interfere with prosthesis sculpture. Another unique feature of nasal defects reconstruction is the accessibility for im­
plants instrumentation. Mostly, as in the present patient, Bony septum and narrow opening of nasal cavities imped the osteotomy of
nasal floor. It is better to slightly diverge the angulation of implants anteriorly so that the osteotomy and prosthetic instrumentations
become accessible.
The mechanical connection between the implant and prosthesis could be bar and clip versus magnetic retention options [14]. We
designed a frame work that consisted of vertical and horizontal components to increase the surface area for stability and retention of
prosthesis. In the way that the clip attachments were positioned in two right angled alignments to decrease the chance of accidental
prosthesis dislodgment. This method is preferred over magnetic systems.
In the present report, we decided to use implant-retained nasal prosthesis as a permanent treatment in a patient who had undergone
nasal resection due to skin carcinoma. Regarding the disadvantages of complex surgical reconstruction of the nasal unit, including
donor site morbidity and lengthy staged procedures, implant surgery can be restricted to single surgical procedures without any
significant complications. During the follow up appointments, the patient was satisfied with the results and had no complaints.

4. Conclusion

Since nasal defects after tumor ablative surgery produce severe cosmetic deformities, reconstruction of such defects could markedly
improve the quality of life of the patients. Nowadays nasal prosthesis rehabilitation has gained much attention in reconstruction of
craniofacial defects. In this clinical report, nasal prosthesis, which had supported by two implants located in nasal floor and stabilized
with bar and clip attachments, was used to reconstruct post-rhinectomy defect.

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A. Javanmard et al. Oral and Maxillofacial Surgery Cases 6 (2020) 100141

Fig. 6. Definitive prosthesis insertion appointment.

Ethical approval

Not required.

Declaration of competing interest

The authors declare that they have no conflicts of interest.

Acknowledgments

None.

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