REVIEW

CURRENT
OPINION Implants in facial skeletal augmentation
Michael G. Brandt a and Corey C. Moore b

Purpose of review
Alloplastic implants have demonstrated longstanding utility in the augmentation of the facial skeleton.
Although their popularity may have waned in recent years, their established efficacy endures. This review
summarizes the techniques, limitations, and complications associated with the use of facial implants.
Recent findings
Given the recognized utility of facial implants in the augmentation of the facial skeleton, they have received
little attention in the recent literature. Contemporary reports have focused on the refinement of techniques –
with renewed interest in the vertical transoral approach, and expanding the scope of facial implants – that
is, the utility of facial implants as alternatives and/or adjuncts to orthognathic surgery.
Summary
Facial augmentation using alloplastic implants remains a tried, tested, and true means of correcting skeletal
insufficiencies and abnormalities. Thus, what was once old will be new again, and a renaissance in the
use of facial implants will undoubtedly occur.
Keywords
genioplasty, implant, malar, mandible, mentoplasty, midface, submalar

INTRODUCTION prefabricated solutions. As such, prefabricated

Facial implants have demonstrated longstanding implants remain a reliable means of augmenting
efficacy in the reconstruction and esthetic augmen- the facial skeleton and their contemporary usage
tation of the facial skeleton. Both large craniofacial focuses on the mandibular and midfacial regions.
defects and minor esthetic concerns have been
successfully addressed through the application of
MANDIBULAR AUGMENTATION
alloplastic implantation.
A variety of alloplastic implantation materials Microgenia and a poorly defined mandibular angle
have been developed and are well reviewed in border are two of the most frequently augmented
previous reports within this journal [1] and other mandibular regions. Poor projection of the pogon-
sources [2]. Briefly, contemporary alloplastic ion, and/or soft-tissue inadequacy of the prejowl
implantation materials include: silicone (Silastic, sulcus can both be corrected with the use of chin,
Dow Corning, Midland, Michigan, USA), expanded extended chin, chin-jowl, or prejowl implants. The
polytetrafluoroethylene (Gore-Tex, W.L. Gore & mandibular angle region can also be augmented to
Associates, Inc., Flagstaff, Arizona, USA), polyethy-
lene (Medpor, W.L. Gore & Associates, Inc.), and a
Division of Facial Plastic and Reconstructive Surgery, Department of
combination materials such as polymethyl metha- Otolaryngology – Head and Neck Surgery, Faculty of Medicine, Univer-
crylate, hydroxyapatite cement, and bioactive glass. sity of Toronto, Toronto and bDivision of Facial Plastic and Reconstructive
Although each of these materials has its individual Surgery, Department of Otolaryngology – Head and Neck Surgery,
benefits and limitations, most have been used suc- Schulich School of Medicine and Dentistry, Western University, London,
Ontario, Canada
cessfully in augmenting the facial skeleton with very
few adverse sequelae. Correspondence to Dr Corey C. Moore, MD, MSc, FRCSC, Associate
Professor, Division of Facial Plastic and Reconstructive Surgery, Depart-
Implants have been used for the augmentation ment of Otolaryngology – Head and Neck Surgery, Schulich School of
and reconstruction of various facial regions. In spite Medicine & Dentistry, University of Western Ontario, St. Joseph’s Health-
of recent interest in personalized custom-fabricated care London, 268 Grosvenor Street, London, ON N6A 4V2, Canada. Tel:
implants for facial augmentation [3–5], their use has +1 519 646 6383; fax: +1 519 646 6173; e-mail: [email protected]
been largely limited to complex craniofacial defects Curr Opin Otolaryngol Head Neck Surg 2013, 21:396–399
for a number of reasons including the efficacy of DOI:10.1097/MOO.0b013e32836385d1

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 Implants in facial skeletal augmentation Brandt and Moore

vertical intraoral approach among a series of 105

KEY POINTS patients. This approach preserves the attachment of
 Alloplastic facial implants are a reliable and efficacious the mentalis muscle while achieving augmentation
means of augmenting the facial skeleton. results and complication rates equivalent to other
approaches [8]. Irrespective of the chosen surgical
 Correct diagnosis of bony inadequacy leads to approach, a tightly dissected tissue pocket is critical
appropriate alloplastic implant seletion.
in ensuring implant fixation. Whether or not this
 The prudent use of facial implants can augment aging- pocket should be subperiosteal or supraperiosteal
face procedures and improve patient satisfaction. is still a matter of debate in the literature [9] –
anecdotally, surgeons who perform the technique
regularly tend to choose a subperiosteal approach.
Irrespective of the approach chosen, the implant
become more sharply defined and/or laterally should be placed along the dense cortical bone of
augmented (i.e. increase the lateral projection of the anterior inferior mandible and not the alveolar
the masseter) using posterior mandibular angle or bone. Once placed, the wound is then closed in
lateral mandibular angle implants. When consider- layers. Some surgeons elect to place a single self-
ing chin or angle implants, careful evaluation of tapping screw to ensure rigid fixation [7].
bony and/or soft-tissue inadequacy facilitates the Mandibular angle augmentation involves
correct diagnosis and right choice of implant. the placement of a posterior angle or lateral angle
In evaluating a patient’s suitability for chin implant. These implants strive to improve the
implantation, it is important to recognize that definition of the mandibular ramus and angle.
micrognathia, retrognathia, and/or vertical lower- The lateral angle implant also augments the lateral
facial height inadequacy are not ‘corrected’ using width of the lower facial third by laterally displacing
implants [6]. These conditions frequently require the masseter muscle. Placement is carried out via an
the employment of carefully planned osteotomies intraoral approach. An incision is made over the
(i.e., sliding sagittal-split osteotomies and/or lateral mandibular ramus and a subperiosteal pocket
osseous genioplasty), to comprehensively correct is then elevated – extending from the sigmoid notch
both the occlusal and skeletal problems. Thus, an superiorly to the inferior mandibular border and
important step in patient evaluation is the examin- around the posterior border of the ramus. It is
ation of maxillomandibular occlusion and facial important to keep the pterygomasseteric sling
proportions. Once these features have been estab- intact, as a disruption of this sling will result in both
lished, all options can then be presented to the functional and esthetic complications (i.e., high
patient with the goal of achieving both an esthetic riding masseteric bulge when chewing) [10]. Once
and functional outcome. In weighing these options, the appropriate pocket is created, the implant is
many patients elect to undergo implantation in lieu placed and then secured to the mandible with a
of more invasive (but comprehensively corrective) fixation screw (either placed in the thin bone under-
orthognathic and orthodontic procedures. In some lying the coronoid process or along the lateral
circumstances, implantation can also be used as an ramus – recognizing the position of the inferior
adjunct to orthognathic procedures [7]. There are of alveolar nerve). Screw fixation is important when
course limits to implantation, and an understanding placing a mandibular angle implant as these
of these limits should guide the prudent surgeon implants are subject to rotational, vertical, and
in efforts to mask mandibular inadequacies with horizontal displacement.
alloplastic implantation. On the whole, complications of mandibular
Of the implant shapes available for chin aug- implantation are rare and generally preventable.
mentation, the extended anatomical chin implant Of those that occur, the most frequently encoun-
provides a smooth transition from the central men- tered include: inadequate correction or overcorrec-
tum to the lateral mandible, and is thus a favored tion, asymmetry, malposition, bone resorption,
choice for chin augmentation. When effacement of infection, extrusion, and nerve hypesthesia/anes-
the prejowl sulcus is necessary in addition to chin thesia [9,11]. Inadequate correction, overcorrection,
augmentation (i.e. rhytidectomy), a prejowl-chin asymmetry, and malposition typically extend from
implant is utilized. Finally, a prejowl implant is used improper implant selection and/or improper place-
when prejowl sulcus effacement is necessary and no ment. Appropriate preoperative planning, a tight
chin augmentation is required. Both external and subperiosteal pocket, rigid fixation of the implant,
intraoral placements are efficacious and well estab- and immediately recognizing implant buckling will
lished. A recent investigation by Aynehchi et al. [8] avoid many of these issues. Bone resorption is a well
demonstrated efficacy in chin augmentation using a documented consequence of chin augmentation,

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 Maxillofacial surgery

yet its clinical consequences have yet to be deter- well reviewed by Constantinides et al. [17]. Irrespec-
mined [8]. Surgical principles dictate that an tive of the technique utilized, once the ‘ideal’ posi-
immobile implant is less likely to cause bone resorp- tion of the malar mound is identified, one can
tion, but this has yet to be empirically evaluated in determine if malar repositioning or augmentation
the literature. Infection and extrusion can be pre- is required. Once this is established, the soft tissues
vented through meticulous attention to implant of the midface are evaluated. These considerations
and wound sterilization. Placement of the implant determine whether a malar implant, submalar
in an antibiotic bath (i.e., 50000 U/l Bacitracin implant, or combined malar-submalar (midface)
saline solution), along with the irrigation of the implant are required.
implant pocket with antibiotic solution assists in Once the correct diagnosis is made and region of
preventing infection. Finally, temporary and or per- augmentation is selected, the technical placement
manent hypesthesia of the mental nerve (in the case of the implant is relatively straightforward. The
of chin augmentation), or the inferior alveolar nerve transoral placement technique is the approach of
as a whole (in the case of mandibular angle choice. An upper gingivobuccal sulcus incision is
augmentation) can occur, and knowledge of their made taking care to preserve a cuff of alveolar
anatomic location is critical to avoiding this com- mucosa to allow for ease of wound closure. Peri-
plication. To review, the mental nerve exits the osteum is then elevated to create a subperiosteal
mental foramen located immediately below the sec- pocket overlying the region for implantation –
ond premolar tooth (51% of the time), and is located typically extending to the inferior orbital rim supe-
approximately 15 mm from the inferior border of riorly and to the masteric tendon laterally. A more
the mandible [12]. The inferior alveolar nerve enters limited subperiosteal dissection is carried out in
the mandible on its medial surface via the mandib- circumstances wherein a submalar implant is placed
ular foramen and then travels along the mandibular to avoid the upward displacement of the implant
body via the mandibular canal. The mandibular during wound contracture [16]. Dissection over the
foramen is located in the midramus region, immedi- zygomatic arch and malar eminence should remain
ately posterior to the lingula and just superior to the in the subperiosteal plane and should proceed with
mandibular occlusal plane – the placement of caution to avoid injury to the buccal and frontal
screws above the mandibular foramen or along branches of the facial nerve [16]. Great care must
the most posterior aspect of the ramus avoids the also be taken to avoid the infraorbital nerve –
inferior alveolar nerve during mandibular angle located approximately 7 mm inferior to the inferior
augmentation. orbital rim in the same vertical plane as the second
premolar tooth [12]. Once the subperiosteal pocket
has been elevated, the pocket is irrigated with Baci-
MIDFACIAL AUGMENTATION tracin solution (50000 U/l) and the implant is placed
The midfacial complex is composed of a skeletal and positioned. Bolster sutures can then be passed
framework and a soft-tissue covering. As with other through the skin, the underlying implant, and back
facial regions, both the skeletal and soft-tissue com- through the skin in a horizontal mattress fashion to
ponents synergistically establish the position and ensure implant positioning during surgical conva-
esthetics of the cheek. Consequently, inadequacy lescence (typically tied over a dental roll or fabric
and/or malposition of the skeletal and/or soft-tissue bolster) [16,18]. Others prefer to rigidly secure the
components can lead to undesirable midfacial fea- implant in place via titanium screws [7].
tures. Numerous tools and techniques have been Potential complications of midface implan-
described as methods of augmenting the midface tation are analogous to those of mandibular implan-
[13]. As with mandibular augmentation, correct tation – inadequate correction or overcorrection,
diagnosis yields the most efficacious solution malposition, implant migration, infection, extru-
&
[14 ]. Accordingly, volumetric deficiencies of the sion, nerve hypesthesia/anesthesia, and facial nerve
soft tissues or skeletal framework can be improved injury [11]. Careful preoperative analysis can be
through augmentation, whereas soft-tissue descent preventive in avoiding over/under correction
&
typically requires resuspension (i.e., midface lifting [14 ,17]. Meticulous surgical technique, knowledge
or rhytidectomy). Malar hypoplasia, submalar soft- of anatomy, and implant fixation can minimize
tissue insufficiency, and combined malar and sub- problems of malposition, migration, and nerve
malar deficiency can be addressed through midfacial injury. Finally, careful sterilization procedures,
implant augmentation [15–17]. The ideal position perioperative antibiotics, intraoperative wound irri-
of the malar mound can be identified using the gation, and postoperative 0.12% chlorhexidine gluc-
techniques of Mladick, Wilkinson, Silver, Prender- onate mouth rinses, can reduce the incidence of
gast and Schoenrock, Whitaker, or Powell, and is infection and extrusion.

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 Implants in facial skeletal augmentation Brandt and Moore

Although appropriately selected midfacial Conflicts of interest

implants succeed in permanently improving the Both authors have no direct nor indirect conflicts of
contour of the midface, they are not the only interest to declare.
solution. Skeletal deficiencies can also be
addressed through a more invasive Le Fort III
osteotomy with advancement. This technique REFERENCES AND RECOMMENDED
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