Int. J. Oral Maxillofac. Surg.

2011; 40: 378383

doi:10.1016/j.ijom.2010.12.001, available online at http://www.sciencedirect.com

Clinical Paper
Implants

Extraoral prostheses using

extraoral implants

G. Pekkan1, S. H. Tuna2,
F. Oghan3
1
Department of Dentistry, Dumlupinar
University, Kutahya, Turkey; 2Department of
Prosthodontics, Faculty of Dentistry,
Suleyman Demirel University, Isparta, Turkey;
3
Department of Otolaryngology, Dumlupinar
University, Medical School, Kutahya, Turkey

G. Pekkan, S.H. Tuna, F. Oghan: Extraoral prostheses using extraoral implants. Int. J.
Oral Maxillofac. Surg. 2011; 40: 378383. # 2010 International Association of Oral
and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Abstract. The aim of this study was to evaluate extraoral prostheses and the use of
extraoral implants in patients with facial defects. 10 cases were treated utilizing
maxillofacial prostheses employing extraoral implants in five cases. 16 extraoral
implants were installed. Seven implants were placed in irradiated sites in the orbital
regions. Six implants were placed in mastoid regions and three in a zygoma region
that was irradiated. Two implants failed before initial integration was achieved in
irradiated areas. Using 14 extraoral implants as anchors, five extraoral prostheses
were set. The other five cases were treated with extraoral prostheses without using
extraoral implants due to cost and patient-related factors. The data included age,
sex, primary disease, implant length, implant failure, prosthetic attachment,
radiation therapy, and peri-implant skin reactions. The use of extraoral implants for
the retention of extraoral prostheses has simplified the placement, removal, and
cleaning of the prosthesis by the patient. The stability of the prostheses was
improved by anchors. Clinical and technical problems are presented with the
techniques used for their resolution. Using extraoral implants resulted in a high rate
of success in retaining facial prostheses and gave good stability and aesthetic
satisfaction.

Introduction

Facial defects may occur as a result of

malignant disease, trauma or congenital
deformity4. Loss of facial continuity can
inhibit speech, eating, swallowing, oral
competence, aesthetics, and social interaction14. Damaged facial and oral structures
can cause post-treatment psychological and
social problems12.
Surgery is a common approach to the
treatment of facial defects. When surgical

This study was presented as an oral presentation, European Prosthodontic Association Congress 2007, 1113 October, Athens,
Greece.

0901-5027/040378 + 06 $36.00/0

treatment is not indicated or not considered as an option, prosthetic management

of facial defects is carried out by means of
maxillofacial prostheses4. Factors influencing the success or failure of a facial
prosthesis are numerous. For a facial prosthesis to be successful, it must meet criteria of aesthetic acceptability, functional
performance,
biocompatibility,
and
desired retention15.
Providing adequate retention has been
a constant challenge with many facial
prostheses5. Inherent mechanical retention within the defect or the use of
adhesive systems has frequently proved
to be problematic or unacceptable7,11.
With the introduction of osseointegra-

Keywords: extraoral implants; extraoral prostheses; facial defects; irradiation; peri-implant

infection; retention.
Accepted for publication 13 December 2010
Available online 20 January 2011

tion to the extra-oral craniofacial

complex, predictable mechanical retention of facial prostheses has been established.
Osseointegration has been in clinical use
in extraoral craniofacial sites since the
1970s2123. Endosseous osseointegrated
implants have greatly improved the potential for rehabilitating patients with extensive soft and hard tissue craniofacial
defects1. Although it is minor surgery,
implant treatment may be contraindicated
in some cases1,15, so some patients may
refuse implant treatment20. Therefore, conventional facial defect prostheses are still of
great value. As experience increases, it is
important that the long-term outcomes of

# 2010 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Extraoral prostheses using extraoral implants

various treatment alternatives are documented and reported2,10,16,17,23,25.
The purpose of this study was to evaluate retrospectively extraoral prostheses
and the use of extraoral implants for
patients referred to the Department of
Prosthodontics, Hacettepe University, for
the restorative treatment of facial defects
between 2001 and 2006.
Materials and methods

This study includes the prosthetic rehabilitation of 10 patients with facial defects
referred between September 2001 and
March 2006 (Table 1). Five patients were
treated with extraoral prostheses using 16
extraoral implants and the other five cases
were rehabilitated without using extraoral
implants. The patients mean age was 37
years (range 1362 years). Five males and
five females were included in the study.
Three females and 2 males were treated
with implants.
Figure 1 shows patient no. 7, who had
undergone numerous surgical revisions
over the years and was dissatisfied with
the result. She had right-sided hemifacial
dysostosis and an associated microtia. She
was treated with an extra-oral implant
retained auricular prosthesis. Figure 2a
shows patient no. 9, who was edentulous

and had a large midfacial defect. Seven

extraoral implants were inserted in her right
orbital rim and zygoma regions. Two of
them failed during the healing period. She
was treated with an implant supported midfacial prosthesis (Fig. 2b and c). Patient no.
10 with Goldenhar syndrome had a partial
ear defect (Fig. 3a). Plastic and reconstructive surgical operations were unsuccessful
in restoring the defect area. He was rehabilitated with a partial auricular prosthesis
(Fig. 3b).
At the beginning of the prosthetic treatment, 6 auricular prostheses were made
for six patients: 2 were partial and 4 were
total. Three patients were rehabilitated
with total auricular prostheses installing
2 extraoral implants that were 3.3 mm/
5.5 mm in diameter with an insertion
depth of 4 mm (EO implants with
shoulder, Straumann AG, Waldenburg,
Switzerland) for each patient.
Three orbital prostheses were fabricated
for three patients after orbital exenteration.
An orbital prosthesis was made for a midfacial defect patient who had been treated
with maxillary obturator previously. For
one irradiated orbital defect patient, three
extraoral implants were installed that were
3.3 mm/3.5 mm in diameter with an insertion depth of 3.5 mm (EO implants with
conical neck, Straumann AG).

379

An irradiated midfacial defect patient

was rehabilitated with an acrylic and silicone midfacial prosthesis using 5 extraoral
implants (Fig. 2b). Four were 3.3 mm/
3.5 mm in diameter with an insertion
depth of 3.5 mm, and one was 3.3 mm/
3.5 mm in diameter with an insertion
depth of 5 mm. Two implants, one with
an insertion depth of 3.5 mm in the
supraorbital rim and the other with an
insertion depth of 5 mm in the zygoma
region, failed before initial integration was
achieved.
Subsequent to implant placement, clinical examinations were conducted
monthly. After prosthetic reconstruction,
clinical follow-up was carried out every 6
months. The assessed clinical outcome
parameters included health of the periimplant tissue, implant hygiene, and loss
of implants. Health of the peri-implant
tissue was classified according to the clinical scoring system of HOLGERS et al. and
GRANSTROM et al.9,13. Prosthetic complications and the patients prosthetic complaints were noted at follow-up.
Results

The mean follow-up time for the extraoral

implants and the extraoral prostheses were
19 and 26 months, respectively. All the

Table 1. Patient data, date of referral, primary disease, defect size, radiation and treatment time.

Patient
no.

Age
(years)

Date of
referral

Gender

Primary disease

62

December 2001

46

November 2002

48

June 2003

50

December 2003

Congenitally
missing ear
Basal cell
carcinoma
Adenoid cystic
carcinoma
Squamous cell
carcinoma

40

November 2004

13

December 2004

14

May 2005

23

October 2005

60

October 2005

Squamous cell
carcinoma

10

14

February 2006

Goldenhar
Syndrome

Adenoid cystic
carcinoma
Congenitally
malformed ear
Hemifacial
dysostosis
and microtia
Traffic accident

Defect size and

extent of
tumour ablation
Total absence of
right ear
Partial absence of
left ear
Right orbital
exenteration
Right maxillectomy
and orbital
exenteration
Right orbital
exenteration
Total absence of
right ear
Total absence of
right ear
Total absence of
left ear
Right maxilla, orbita,
nasal vestibule,
cheek and upper
lip resected
Partial absence of
right ear

Radiation
(Gy)

Time between
last operation or
irradiation to
implantation
(months)

Time between
implantation or
last operation
to prosthetic
treatment
(months)

>120

>36

> 60

15

50

60

18

380
[()TD$FIG]

Pekkan et al.

Fig. 1. (a) Close up of the defect area in patient no. 7, showing soldered Dolder bars and bar abutments screwed in implant abutments; (b) lateral
and (c) frontal view of the patient with auricular prosthesis in place.

implants were 3.3 mm in diameter; in

length 8 were 3.5 mm, 6 were 4 mm and
2 were 5 mm. Three of the patients were
irradiated, during which two of them were
treated with extraoral implants. No
implants were lost in patients who had
not undergone irradiation (100%), but 2
implants (diameter 3.3 mm/3.5 mm,
3.3 mm/5 mm) were lost in the irradiated
group (80%). The overall implant survival
rate was 88%. No patient reported foreignbody sensation, dysaesthesia coming from

the implants or pain on implant percussion.

During the follow-up examinations, the
peri-implant skin reactions surrounding
the implants were registered (Table 2).
Prosthetic challenges were mainly retention, particularly in auricular prostheses
without implants. In orbital prostheses,
accurate globe placement, symmetrical
lid contours, proper positioning of the prosthetic margins, appropriate surface texture
and colouration were all challenging.

Some acrylic parts from the silicone

prosthesis became detached although
acrylic-silicone primers were used. For
patient no. 10, the partial auricular prosthesis was fabricated in summer when he
had a tan following a summer holiday.
When he returned to his usual skin colour
in winter, he was unhappy with the colour
of his prosthesis so a second prosthesis
was fabricated for him. Patient nos. 6 and
7 were 13 and 14 years old, respectively, at
the time of prosthetic treatment. As they

[()TD$FIG]

Fig. 2. (a) Extraoral view of patient no. 9 before extraoral implant treatment; (b) Dolder bars soldered to the bar abutments were screwed in
implant abutments 6 months after implant surgery; (c) midfacial prosthesis in place.

[()TD$FIG]

Fig. 3. (a and b) Patient no. 10 with Goldenhar Syndrome and partial ear defect; (c) partial auricular prosthesis was attached to the frame of the
glasses.

Table 2. Data from the follow-up, including implantation site, implant size and failure, prosthetic treatment and challenges.
Retention and
prosthetic
attachment type

Length
of follow
up (month)

Implant number
and implantation
site

Implant size
(diameter/length)

Implant failure
diameter/length

58

46

22

18

32

3.3 mm/3.5 mm

24

3, supra and
infraorbital
rim
2, mastoid region

3.3 mm/4 mm

Dolder bar and

matrix mini

Grade 1
(one implant)

22

2, mastoid region

3.3 mm/4 mm

Dolder bar and

matrix mini

Grade 1
(one implant)

21

2, mastoid region

3.3 mm/4 mm

Dolder bar and

matrix mini

Grade 0

17

7, supraorbital
and zygoma
region

3.3 mm/3.5 mm,

3.3 mm/5 mm
(2 implants)

Dolder bar and

matrix mini

10

18

3.3 mm/3.5 mm
(5 implants)
3.3 mm/5 mm
(2 implants)

External auditory
canal and eyeglasses

Grade 1
(one implant),
excluding failed
implants)

External auditory
canal and
adhesives
External auditory
canal and
adhesives
Anatomical undercut
of orbital defect
Anatomical undercut
of orbital defect
Magnetic retention

Skin reactions*

Prosthetic challenges

Patients
prosthetic
complaints

Retention

Retention

Use of adhesives
and eyeglasses

Slight erythema
due to skin
adhesive
Orbital flour
secretion of
body fluids

Retention

Ocular positioning,
edge adaptation

Retention

0.2%
Nitrofurazone

Oral, nasal and orbital

communication
Making acrylic
retentive extensions
for the magnet
Attachment between
acrylic template and
silicone
Attachment between
acrylic template and
silicone
Attachment between
acrylic template and
silicone
Impression making of
angulated implants,
attachment between
acrylic and silicone
Retention and colour
match

Retention

Colour of
prosthesis

0.2%
Nitrofurazone

Marginal
adaptation

Relining

Marginal
adaptation

Relining

Difficulty in
seating the
prosthesis

Training

Colour
mismatch
in winter

Making second prosthesis

Grade 1
(one implant)

Troubleshooting

The skin reactions were graded as follows: grade 0, no reaction; grade 1, reddish discolouration of the skin around the implant; grade 2, moist surface of skin around the implant; grade 3, formation
of granulation tissue around the implant; and grade 4, extensive soft tissue reaction requiring implant removal9,13.

Extraoral prostheses using extraoral implants

Patient
no.

381

382

Pekkan et al.

grew up, their craniofacial structures also

grew. In the follow up meetings 6 months
after fabrication of their implant-retained
auricular prostheses, they complained
about the marginal opening of their prostheses. They were satisfied after relining
the margins of their prostheses with room
temperature vulcanizing silicones. The
patient with the midfacial defect had difficulty in seating her prosthesis. She was
given training and her daughter assisted
her in learning.
Discussion

Craniofacial osseointegrated implants

offer patients who wear facial prostheses
a significantly improved quality of
life1,7,2123,25. The advantages of extraoral
implants are numerous, they provide consistent retention and positioning of the
facial prosthesis and can be placed during
the primary reconstruction procedure or
anytime postoperatively when the patient
can tolerate the procedure4,7,21,22. In addition to providing predictable retention,
several other important advantages were
achieved7. The aesthetics and durability of
prostheses have been enhanced because
fine feathered margins are maintainable
and not liable to damage by adhesives
and solvents7,12,15.
In this study, not all the patients benefited from extraoral implants. The main
reason was patient-related factors, for
example economic reasons in patient no.
3, unwillingness to tolerate the surgical
procedures in patient no. 1, and being
afraid of additional surgery due to concerns over his quality of life and a high
dose of radiotherapy in patient no. 4.
Patients with oral malignancies are
often treated with surgery followed by
radiation therapy. Once irradiated, the
bones potential for implant placement
can be compromised severely or lost
because its osteogenic potential and
microvascularity are decreased. Adjunctive therapies such as hyperbaric oxygen
treatment and subsequent implant placement in irradiated bone have been proposed14. The influence of hyperbaric
oxygen therapy remains uncertain but promising2.
The effects of irradiation on the cellular
and structural components of bone and the
overlying soft tissues are well known but
the possible effects of irradiation on the
prognosis of endosseous implant therapy
and on the process of osseointegration are
controversial8. The success rates in irradiated patients are far lower and vary with
anatomical location25. In 1991, PAREL &
TJELLSTROM17 presented the results of

Swedish and US experience with extraoral

osseointegration. Their study indicated
that the success rate of orbital implants
in patients who had not received radiotherapy was 94%. The implant success
rate in irradiated patients was 61%. The
success rates in the midface and in
radiated patients proved more variable.
They concluded that irradiated patient
should be approached with care and in
an environment that fully appreciated
the risks associated with external beam
therapy17. WOLFAARDT et al.25 reported a
69% success rate for extra-oral implants
inserted in irradiated patients. CHARPIOT
et al.6 analysed retrospectively cases of
craniofacial epitheses implanted since
1992. The average rate of osseointegration
was 96% in the absence of irradiation, and
82% following irradiation, with significant
differences according to the site of the
implant (worse in the nasal site)6.
Although, the number of implants is too
small to draw a conclusion, this study was
in accordance with the aforementioned
studies and revealed that the success rate
in non-irradiated and irradiated patients
was 100% and 80%, respectively.
Intraoral implants are connected
through the oral mucosa, which is bathed
in saliva, providing a tenacious protective
environment for the soft tissueabutment
interface. In the case of extraoral implants,
the biological and mechanical milieu is
very different. The osseous encasement of
the extraoral implant varies greatly
between regions, and the length of the
implants is far shorter than that of intraoral
implants24. The loads applied to extraoral
implants are different and the connection
through the skin to the external environment provides a totally different soft tissue
environment for the abutment18. Extraoral
implants can only be evaluated by assessing implant immobility and the peri-abutment skin reaction; they cannot be
routinely radiographed25. The skin around
the implants must be cared for regularly by
the patients, with daily cleansing combined with adjustments by the clinician
at follow-up visits.
Once implants are successfully placed,
three basic retentive systems can be used:
the bar and clip, the ball and keeper, and
the magnet and keeper. The bars and clips,
as used in this study, can be utilized for
each patient to ensure mechanical advantage. Disadvantages are the cost and the
increased difficulty for the patient in performing the necessary implant-associated
hygiene. GRANSTROM et al.9 pointed out
that the use of bars and clips attached to
implants to facilitate positioning of the
prosthesis limits ease of use, implant

hygiene and there is a risk of fracture with

a significantly negative effect on implant
survival. The ball and keeper and magnet
and keeper systems are easy to use. They
require no special laboratory procedures,
which reduces costs. They can be cleaned
easily by the patient and maintained by the
dentist. The use of magnets is advantageous compared with conventional bars
and clips, because magnetic retention creates relatively low moment forces on the
supporting abutment, allowing easy
hygiene control and removal of the prosthesis by the patient3. In most instances,
they are placed in a straight line, which
may decrease stability7,14. A survey was
conducted in 1 Swedish, 3 Canadian and
24 US centres that provided implant-supported facial prosthetic treatment19. All
centres responded to the survey. 357
patients began treatment, 338 completed
treatment: 165 in Sweden, 131 in the USA
and 42 in Canada. The incidence of facial
sites treated with implant-supported prostheses indicated that the auricular (72%)
region was the most common site, followed by the orbital (20%), nasal (6%),
and combination (2%). Clips were the
predominant mechanism used to retain
auricular prostheses. Orbital prostheses
were fabricated with a wider variety and
combination of attachments. The results of
this survey indicate a need for further
investigation regarding the most efficacious attachment method for patients treated with implant-supported facial
prostheses19.
In the present study, patient satisfaction
was higher with implant-retained prostheses than with conventional adhesive
retained ones. In patients without
implants, prosthetic retention was
achieved using tissue undercuts such as
orbital socket and external auditory canal,
eye glasses, and skin adhesives. Implant
patients benefited from bars and magnetic
attachments. Adhesive-retained facial
prostheses had to be remade more frequently than the implant-retained ones
due to the discolouration and deterioration
of the silicone prosthesis after frequent use
of the adhesives and solvents. The prosthetic challenges were mainly the fabrication of the ocular prostheses and
attachment between the silicone prosthesis
and the acrylic template (acrylic resin
substructure), which was made to attach
the sleeve of the bar or magnet keeper.
Craniofacial osseointegration enhances
the quality of life for patients who wear
facial prostheses. This study concludes
that implant-retained facial prostheses
are better tolerated than adhesive-retained
prostheses and give the patients self-con-

Extraoral prostheses using extraoral implants

fidence. Radiotherapy is not a contraindication for the use of osseointegrated
implants in the maxillofacial region, but
the loss of implants is higher than in nonirradiated sites. Clinicians considering the
use of extraoral implants in irradiated
patient should do so with great care, within
a clinical environment familiar with the
care of this category of patient.
Funding

None.
Competing interests

None declared.
Ethical approval

None.
Acknowledgements. The authors thank
Professors Dr. Yavuz Aslan, Dr. Canan
Hekimoglu, and Dr. Filiz Keyf for helpful
discussions on treatment of the cases.

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Address:
Fatih Oghan and Gurel Pekkan
Department of Otolaryngology and
Department of Dentistry
Training and Research Hospital
Dumlupinar University
Merkez Kampus
Tavsanli Yolu 10
Km
43270
Kutahya
Turkey
Tel: +90 274 265 20 31x2172
Fax: +90 274 265 22 77.
E-mail: fatihoghan@hotmail.com
gurelp@gmail.com