Bilateral implant-retained auricular prosthesis for a patient with fire-related missing ears: A case report

Abstract

Replacing missing ears with implant-retained prostheses, particularly when using a surgical guide, can yield highly satisfactory prosthetic outcomes. This case report describes the prosthetic rehabilitation of a 28-year-old man with severe facial burns, which resulted in significant cosmetic and psychological challenges. Bilateral implant-retained auricular prostheses were fabricated, and a surgical guide was employed to ensure predictable implant placement and accurate prosthesis positioning. This approach not only addressed the physical deformities but also alleviated the associated psychological distress. The use of osseointegrated implants for auricular prosthesis retention proved to be a predictable and effective treatment modality, enabling the patient to reintegrate into society. This case highlights the clinical significance of combining reconstructive techniques with prosthetic solutions to improve both physical appearance and self-perception, ultimately enhancing the patient’s quality of life.

INTRODUCTION

A facial deformity, whether from congenital anomalies, trauma, or tumors, significantly impacts self-confidence and social interactions.[1] Auricular defects, due to the ear’s complexity, are particularly challenging. Historically, surgical reconstruction using autogenous grafts was preferred but often required multiple revisions and could fail in complex cases. Prosthetic rehabilitation, especially with implant-supported auricular prostheses, has emerged as a reliable alternative, offering superior retention, stability, and aesthetic results.[2,3,4]

Advances in craniofacial implants (CIs) have revolutionized rehabilitation.[5] CIs, placed in the mastoid region and secured via attachments like clip bars or magnets, eliminate adhesives, reduce skin reactions, and enhance durability and comfort.[4,6] Preoperative imaging (Computed tomography (CT), cone beam computed tomography (CBCT), magnetic resonance imaging (MRI)) ensures precise planning and placement, while modern techniques create natural looking prostheses.[4,7] Recent advancements in 3D computer-aided design/computer-aided manufacturing (CAD/CAM), artificial intelligence (AI), and digital printing are set to transform auricular prosthetics. These technologies can enable precise, patient-specific designs based on digital scans or 3D models, ensuring a better fit and appearance.[8,9]

Etiological factors, such as congenital malformations (e.g., microtia), trauma, or tumor resection, necessitate tailored approaches. Prosthetic rehabilitation, supported by these advancements, restores appearance, addresses social stigma, and improves the quality of life, making it a vital option alongside surgical reconstruction.[10,11]

The external ear plays an aesthetic role in facial beauty. Ear deformities, whether congenital or acquired, can lead to psychological challenges like reduced self-esteem and social isolation.[12]

Ear rehabilitation, particularly through prosthetic reconstruction, plays a crucial role in restoring both the physical appearance and psychological well-being of individuals with ear defects.[13]

The concept of function in this context is intriguing because it can be argued that if a patient uses a prosthesis for cosmetic reasons, it serves a purpose. Therefore, the psychological and functional effects of the prosthesis greatly contribute to the rehabilitation process by helping patients adapt to their loss and facilitating a more normal professional and social life. The objective of this case report is to demonstrate the utilization of a surgical guide and implants for auricular rehabilitation, specifically chosen to ensure precise implant placement and optimal retention in a patient with significant facial trauma due to burn injuries, where digital approaches were not employed.

CASE REPORT

Patient history

A 28-year-old man presented with bilateral ear loss due to fire-related trauma eight years prior [Figure 1]. He was in good general health with no systemic diseases. The burn injuries had caused extensive damage to his facial structures, resulting in significant aesthetic and functional challenges. The trauma led to the complete loss of both external ears, as well as damage to surrounding tissues, including the eyebrows and facial skin. The code of ethics for this study (IR.MUK.REC.1404.049).

Figure 1.

Preprosthetic images of the patient

To address these issues, the patient had undergone multiple reconstructive surgeries, including hair and eyebrow replantation and skin grafts. Despite these interventions, the absence of ears remained a prominent aesthetic concern, contributing to psychological distress and social isolation. Additionally, the burn injuries had left him with heightened sensitivity to severe light, necessitating the use of anti-UV sunglasses. However, the lack of ears made it impossible for him to wear sunglasses comfortably, further exacerbating his functional difficulties.

The patient sought prosthetic rehabilitation to address both the physical and psychological sequelae of his condition, with the goal of restoring his facial appearance and improving his quality of life.

Treatment plan

With the patient’s consent, the proposed treatment plan included bilateral implant-retained auricular prostheses.

Diagnostic workup

First, a CT scan was obtained from the mastoid area of the ears, which revealed sufficient bone thickness for implant placement. Initial molding of both ears was then performed, followed by the preparation of casts. A transparent acrylic base plate, with sufficient expansion and a thickness of 1.5 mm, was made on the cast. The ear wax pattern was then prepared on the acrylic base and placed on the patient’s face for evaluation in three planes: horizontal, vertical, and frontal (using a face bow). Necessary changes were made to the wax pattern based on the evaluation.

Next, the wax pattern was converted into a surgical template. The surgical guide was placed on the patient’s face to determine the location of two implants, with a distance of 15 mm between them [Figure 2].

Figure 2.

The acrylic surgical guide

Surgical procedure

In the mastoid area, two implants were placed in the temporal bone, at 1 and 3 o’clock for the left ear and at 9 and 11 o’clock for the right ear. Both implants were placed at a distance of 15–18 mm from the outer ear canal. Generally, for deep and large acquired facial lesions [Figure 3], CT scans and 3D imaging are used to obtain information about the size and thickness of the mastoid bone and the condition of the air cells.

Figure 3.

First stage surgery using surgical guide followed by second surgery and placement of the healing cap four months after first surgery

The location of the implants was chosen so that the upper cantilever attached to the implants was placed in the Crura, the lower cantilever was placed under the anti-tragus, and the middle bar was placed in the antihelix of the ear.

Implants with a length of 4 mm and a diameter of 5 mm in the flange area, and a diameter of 3.75 mm in the twisted area, were selected. The flange provides initial stability to the implant and prevents it from penetrating deeper tissues.[14] The surgery was performed in two stages, similar to intraoral surgery.[15] After four months, the second surgery was performed, and healing caps with a diameter of 4 mm were placed on the fixtures. After four weeks, the patient returned to continue the treatment.

Prosthesis fabrication

Final impressions and castings were made, and the metal structure was adjusted to fit the patient’s ear. Universal castable long abutment (UCLA) extraoral abutments were used, which provided the capability for wax-up and shaping, similar to bars, to serve as the retentive component of the ear prosthesis. These abutments were designed to ensure optimal retention and stability of the prosthesis while allowing for precise placement and removal by the patient.

An acrylic base was prepared on the metal structure, and the final model of the ears was created on the acrylic base. The model was evaluated in three planes (horizontal, vertical, and frontal), and any necessary corrections were made to ensure a precise fit and natural appearance.

After removing the muffling and wax, silicone preparation and color determination for different parts of the ear were performed. The silicone was carefully matched to the patient’s skin tone to achieve a lifelike appearance. Once the silicone had hardened, the prosthesis was polished, and color pigments dissolved in xylenol were applied to enhance the realism of the ear’s anatomical features, such as the helix, antihelix, and tragus.

To improve comfort and functionality, grooves were created on the back of the silicone prosthesis to allow for air ventilation, reducing the risk of skin irritation. The metal structure was then placed on the mastoid fixtures and secured with a torque of 10 N/cm. The prosthesis was delivered to the patient, ensuring a secure fit and natural appearance [Figure 4].

Figure 4.

Ear prosthesis after polishing and delivering to the patient

Follow-up

The patient underwent periodic examinations and follow-up sessions for one year and no problems were found.

DISCUSSION

Maxillofacial rehabilitation using osseointegrated implants for auricular prostheses has proven to be efficient and predictable, offering benefits, such as convenience, improved retention, stability, and longevity.[10,11] The most common technique involves implant insertion in the mastoid process, followed by the prosthetic phase with bars and clips.[11] However, silicone ear prostheses may require reconstruction due to color change, and 33% of them experience screw loosening.[16] The study’s success rate was comparable to Nishimura et al., emphasizing the importance of considering surgical technique, patient selection, and maintenance for long-term success.[13,17] Furthermore, this approach significantly impacts patients’ psychological well-being and quality of life.[13] Trauma-related ear loss presents unique challenges, often causing mental trauma and broader tissue damage compared to congenital defects.[13] This study stands out by addressing mental shock and post-traumatic syndrome alongside prosthetic treatment.

The successful use of implant-retained auricular prostheses has been demonstrated in several studies, highlighting the critical role of retention and attachment choice in achieving optimal outcomes. Gupta et al. (2023)[11] emphasized the effectiveness of magnetic attachments over traditional bar and clip systems, which, while popular for their retention, can lead to complications, such as deformation over time. Their findings align with our own, where meticulous preoperative planning and the use of surgical guides were essential for precise implant placement in a patient with significant facial trauma. Similarly, Malick et al. (2023)[10] reported on three patients with microtia and anotia who were rehabilitated using titanium implants, followed by bar and clip retained prostheses, achieving high patient satisfaction and retention over an 18-month follow-up period. Both studies underscore the importance of considering patient-specific factors, such as the cause of ear loss, when selecting the appropriate rehabilitation method.

The advantages of implant-retained prostheses over traditional tissue-supported options are further supported by Jafarian et al. (2023),[3] who described a comprehensive surgical and prosthetic workflow for a patient rehabilitated after basal cell carcinoma resection. Their approach involved meticulous presurgical planning and the use of digital technology to mirror the contralateral ear, enhancing the accuracy of prosthesis design. This aligns with our findings, where the integration of osseointegrated implants alleviated complications associated with adhesive use, thereby improving the patient’s psychosocial well-being. The emphasis on individualized treatment and thorough surgical workflows in their study reinforces the principles that guided our approach to auricular rehabilitation. Innovative techniques in prosthetic rehabilitation are also highlighted in the work of Song et al. (2024),[18] which discusses the use of ultrashort dental implants and prefabricated surgical guides for auricular reconstruction in a trauma patient. This study illustrates that implant-retained prostheses can yield reliable outcomes, particularly when traditional osseointegrated implants are unavailable. While our case did not utilize digital technologies, the principles of careful planning and individualized treatment remain central to successful auricular rehabilitation. Additionally, the case report by Viswanathan and Chidambaranathan (2024)[19] emphasizes the importance of immediate restoration in improving the quality of life for patients with auricular defects, showcasing the versatility of prosthetic options, including silicone and acrylic materials. Their findings highlight the necessity of tailoring treatment plans to address both aesthetic and functional outcomes, particularly in light of economic constraints and the specific nature of each defect.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. The patient has provided written consent for their images and other clinical information to be reported in the journal. The patient understands that their name and initials will not be published, and due efforts will be made to conceal their identity; however, anonymity cannot be guaranteed.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.