Changing faces, changing lives: Correction of facial defects using patient-matched subperiosteal implants

BY PROFESSOR JOHAN REYNEKE

Blog

The advances in reconstructive facial surgery and how patient-matched subperiosteal implants deliver outcomes over the past decades could be described ‘unbelievable’. Historically, surgical analysis was entirely visual, with surgeons relying on their eyes to examine defects and plan the surgical approach. Over time and with many exciting advances in surgical tools and techniques, the approach evolved to measuring the defect and planning the reconstruction of a specific area of the face with precision.

Today, facial implants are numerous, and any area of the face can be augmented or reconstructed by means of implants. Surgeons have a variety of options. If there’s a defect in the face or a deformity, orthognathic surgery can reposition the jaw, part of the jaw, or the chin. If there is sufficient tissue, surgeons may opt for distraction, using the tissue and distracting it into a certain position or to augment a part. Many years ago, distraction was very popular, and it certainly has its place for specific reconstructions. Then there is grafting: replacing a missing structure either with tissues from the patient, or with an artificial, synthetic, or natural material.

This article is concerned with alloplastic implants—when to use them, how to use them, and the cases where they have transformed a patient’s quality of life.


Watch the recording of the expert presentation by Johan Reyneke on “Correction of Facial Defects by Means of Patient Matched Subperiosteal Implants” in the AO Video Hub (members only):


Considerations for selecting subperiosteal implants

Types of subperiosteal facial implants:

*Autogenous grafts (homograft)

  • Bone
  • Cartilage
     

*Human donor grafts

  • Freeze dried bone (lyophilized bone)
     

Xenografts (heterograft)

Alloplastic materials

  • Acrylic bone cement
  • Chemically cured methyl methacrylate
  • Porous polyethylene (HDPE) – Medpor
  • Silasti
  • Titanium
  • Porous hydroxyapatite block implant

*Fibula, metatarsal, cranium, clavicle, Iliac crest, costo chondral

Checklist for ideal implants:

Implants for facial reconstruction should be:

  • readily available (and affordable)
  • sterilizable
  • strong
  • inert
  • non-allergic
  • durable
  • non-carcinogenic
  • easily manipulated and shaped
  • suitable for single stage reconstruction 

Contra-indications to consider:

  • infection
  • soft tissue deficiency
  • load bearing areas?
  • large exposure to maxillary sinus
  • mobility
  • lack of soft tissue cover

Case study: 3D technologies assist implant placement in ameloblastoma patient

This case with Professor Carlo Ferretti involved a patient with ameloblastoma, which required resection and reconstruction. Virtual treatment planning was very beneficial in this case, allowing us to bend the plate on a 3D model and develop cutting guides for the patient-matched plate. We removed the tumor intraorally—so no incision on the outside—and inserted the plate, followed by a silastic spacer.

The spacer was placed in very much the same anatomy as the resected jaw, obviously without the tumor, and held in position with wire.

After closing the defect, the spacer remained in place for three months, after which time it was removed via an extraoral incision. The nice thing about silastic is that it’s like rubber, so when you have to remove it, it slips out beautifully. We removed the soft tissue from the proximal and distal stumps then in the pocket left behind we were able to inject compressed particulate cortico-cancellous iliac crest bone.

The final reconstruction involved placing implants in the graft, a procedure that was executed very effectively and accurately with assistance from virtual treatment planning.

Three trauma cases highlight innovations in patient-matched implants

Patient-matched implants have applications in a diverse number of craniomaxillofacial cases, as demonstrated in these three cases involving a gunshot wound, a bike accident, and a young girl’s fall from a swing.

Double reconstruction of malocclusion and zygoma

The patient presented with a class two malocclusion and was referred for orthognathic surgery. Unfortunately, the patient was subsequently attacked and shot in the zygomatic area, resulting in a big defect. The patient was not satisfied with the hospital’s reconstruction of the cheekbone, and still had his malocclusion.

My approach was to undertake a sagittal split osteotomy, advancing the mandible, and at the same time augmenting the defect of the left zygoma. The reconstructive surgeon had installed 17 bone plates, which certainly increased the patient’s weight but blocked the path for osteotomy. We removed two or three of the plates and designed a large three-piece patient-matched implant, approached from the coronal, intraoral and infraorbital sides.

The implants fitted beautifully and advancing the mandible resulted in a much-improved profile for the patient. I was fortunate to see the patient 10 years later. His occlusion was stable and functional, and he was quite happy with the zygoma.

Dentist vs bike case ends with a smile

In this case, a dentist on holiday in Germany took part in a cycling competition and had a nasty fall, resulting in the loss of the outer table of his skull. After the accident he had to wear a cap to work, because his patients couldn’t take their eyes off his head injury—worried that he had lost the part of his brain that had to do with dentistry.

We planned a patient-matched implant for him to correct the defect and undertook what was quite a nerve-wracking surgery. The inner table of the patient’s skull was intact, but mobile; if you pressed on the bone, it would bounce up and down onto the brain. We dissected it off and fixed the implant with two or three small bone plates.

We achieved a nice result, and he now practices in his surgery every day.

Correcting diplopia in a young patient

Our young patient had a little accident on a swing in the park, resulting in injury to her right zygoma which developed into enophthalmos with a slight facial defect. She also developed diplopia, which is very difficult to correct in the long term. The CT scan revealed that the right orbit was lower down than the left side and deeper, causing the diplopia.

Our treatment plan was to reposition the globe of the eye, 1.5 mm superior medially, and 2.3 anteriorly. We then placed an implant intraorally into the orbit to augment the zygoma.

Five years later, the diplopia was corrected, and we had a nice aesthetic result.

Problem-shooting: when implant is not an option

To return to an earlier point, there are several options for correcting facial deformity and certain contra-indicators for patient-matched implants. For instance, I treated a young patient that had a retinoblastoma of her eye. Because she had had radiation on that side, the zygoma and maxilla did not develop so we could not think of an implant. We did a zygomatic osteotomy and also added a small bone graft close to close the bony defect. That is a case where an implant is not indicated.

I would also like to share a tip based on a mistake I once made. I saw a patient who had a cranial procedure by a neurosurgeon when she was a young child, and she was unhappy about a defect in the frontal area. I took a CT scan and designed a beautiful implant to augment the cranial defect. However, I was in for a big surprise when we exposed the area: there was a big blob of acrylic where the neurosurgeon had placed the implant. That tells you how much the neurosurgeon considered aesthetics. Our patient-matched implant then did not fit this case. Fortunately, I was able to correct her open bite with a three-piece Le Fort I osteotomy and placed a modified patient-matched implant on the frontal area, achieving a very acceptable result.

The challenges and rewards of treating patients as they grow

For patients with hemifacial microsomia, it can feel like they have become part of your family. You see these patients from the age of two or three right through to adulthood. The important thing for these cases in my mind is that the timing of each procedure should be correct, keeping in mind the patient’s psychology and development.

One particularly interesting case was a young boy with cleft palate, who we treated with an alveolar bone graft at the age of six. At the age of eight, I did a costochondral graft to construct his left condyle and ramus of his mandible. Unfortunately, that rib graft did not grow. As a result, I have become very critical of the costochondral graft because it is so unpredictable: it can grow too much, or not at all, get infected or re-ankylosed. If you’re lucky, you may get one that grows exactly the amount required from that mandible. In these cases, I would consider reconstruction by means of a patient-matched implant.

By the age of 17 the patient’s deformity had grown so much worse, and he had a severe class three malocclusion. From a psychological point of view, he was very unhappy. Our final treatment plan involved the placement of a patient-matched temporomandibular joint with fossa, setback of his mandible on the right-hand side, and final facial correction by use of Le Fort I osteotomy with the correction of the cantor occlusal plane. The final result was very acceptable. We certainly helped the patient—not from the first costochondral graft I placed many years ago, but over time. We have come a long way.

Summing up the advantages and disadvantages of patient-matched subperiosteal implants

Given these cases that I have worked on throughout my career, the main advantages to this treatment option are clear. Patient-matched implants allow immediate post-op physio, especially in a patient with ankylosis. There’s no donor site morbidity. The surgery has decreased the time of treatment. We can design the anatomy, and mimic the normal, with our patient-matched implant. We maintain a stable occlusion, correct antrum posterior problems, and allow for fossa reconstruction.

The main disadvantage may be the cost of the device, but keep in mind if we use another material, such as a bone graft, that adds to the cost of the procedure, the time that we operate. There is the risk of heterotopic bone formation that you get with any other material, and the possible need for revision.

In terms of wear and tear, there is very little. The first implant I placed 24 years ago is still working perfectly. With a patient-matched implant, it’s so much more accurate and easier for the patient… in Afrikaans we have a phrase saying, ‘it fits like a fist on an eye’.

So, there are all kinds of advantages, and we have the privilege of seeing those in our patients many years later. It makes me think sometimes: we don’t just change faces, we change lives.

About the author:

Professor Johan P. Reyneke has served as professor in the department of maxillofacial and oral surgery at the university of the Witwatersrand in Johannesburg since 1991 and was appointed extraordinary professor of the University of the Western Cape in South Africa in 2014. Internationally, he holds professorships at the university of Oklahoma and Florida in the USA as well as the university of Nacional Autònoma de Mexico, San Salvador, Mexico.

Prof Reyneke has a passion for Orthognathic and Reconstructive facial surgery and has published more than 93 papers in refereed journals and delivered numerous courses and lectures.

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