Postoperative function after implant insertion in vascularized bone grafts in maxilla and mandible

Prosthetic rehabilitation in patients with jaw reconstruction by fibula free flap: A systematic review

This systematic review aimed to evaluate the dental prosthetic rehabilitation (DPR) in patients after jaw reconstruction with fibula free flap. Four databases were searched from January 2000 to January 2023. Of the 2507 studies identified, 36 observational studies were included. Cancer was the most common surgical indications for jawbone resection with 58.3 % of cases followed by benign tumours which representing 24 %. The DPR rate was estimated at 51.6 % across the studies (ranging from 38 % to 55 % depending on the benign or malignant nature of the tumors). Implant-supported prostheses represented 58.9 % of cases of which 66.9 % were fixed and 33.1 % were implant-stabilized overdentures. Virtual surgical planning (VSP) was used in 20 % of studies and aimed to improve the position of the grafted fibula, quality, and aesthetics of DPR and to decrease ischemia and the operating time. One in two authors performed DPR 12 months after jaw reconstruction. If implant survival rate reached 93 % in non-irradiated fibula, it fell to 38 %, 55 %, and 77 % if implantation occurred in the 12, 17, and 24 months after radiotherapy, respectively. Various parameters should be better investigated in further studies including the typology of the prostheses (implant-supported vs removable), the use of VSP, and the optimal time for DPR taking into account the characteristics of the tumor, the size of bone defect, and the need for external irradiation therapy.

Donor site morbidity after computer assisted surgical reconstruction of the mandible using deep circumflex iliac artery grafts: a cross sectional study

BACKGROUND

Computer Assisted Design and Computer Assisted Manufacturing (CAD/CAM) have revolutionized oncologic surgery of the head and neck. A multitude of benefits of this technique has been described, but there are only few reports of donor site comorbidity following CAD/CAM surgery.

METHODS

This study investigated comorbidity of the hip following deep circumflex iliac artery (DCIA) graft raising using CAD/CAM techniques. A cross-sectional examination was performed to determine range of motion, muscle strength and nerve disturbances. Furthermore, correlations between graft volume and skin incision length with postoperative donor site morbidity were assessed using Spearman's rank correlation, linear regression and analysis of variance (ANOVA).

RESULTS

Fifteen patients with a mean graft volume of 21.2 ± 5.7 cm³ and a mean incision length of 228.0 ± 30.0 mm were included. Patients reported of noticeable physical limitations in daily life activities (12.3 ± 11.9 weeks) and athletic activities (38.4 ± 40.0 weeks in mean) following surgery. Graft volume significantly correlated with the duration of the use of walking aids (R = 0.57; p = 0.033) and impairment in daily life activities (R = 0.65; p = 0.012). The length of the scar of the donor-site showed a statistically significant association with postoperative iliohypogastric nerve deficits (F = 4.4, p = 0.037). Patients with anaesthaesia of a peripheral cutaneous nerve had a larger mean scar length (280 ± 30.0 mm) than subjects with hypaesthesia (245 ± 10.1 mm) or no complaints (216 ± 27.7 mm).

CONCLUSIONS

Despite sophisticated planning options in modern CAD/CAM surgery, comorbidity of the donor site following  iliac graft harvesting is still a problem. This study is the first to investigate comorbidity after DCIA graft raising in a patient group treated exclusively with CAD/CAM techniques. The results indicate that a minimal invasive approach in terms of small graft volumes and small skin incisions could help to reduce postoperative symptomatology. Trial registration Retrospectively registered at the German Clinical Trials Register (DRKS-ID: DRKS00029066); registration date: 23/05/2022.

Removal of patient-specific reconstruction plates after mandible reconstruction with a fibula free flap: is the plate the problem?

Computer-aided microvascular mandible reconstruction is an increasingly common procedure in oral and maxillofacial surgery. The aim of this retrospective single-centre study was to evaluate the rate and specifics of hardware removal after fibula free flap (FFF) fixation with a patient-specific reconstruction plate. The study included patients who underwent hardware removal between April 2017 and October 2019. Statistical analyses were performed regarding the different indications for plate removal (dental implantation versus complication) and the surgical approach (intraoral versus extraoral). Plate removal was performed in 29 of 98 patients (29.6%) after FFF fixation with a patient-specific reconstruction plate. Plate removal was done prior to dental implantation in 58.6% of cases and due to complications in 41.4%. Complications seen between reconstructive surgery and plate removal were less frequent in the dental rehabilitation group (8/17 vs 12/12; P=0.002). Within this group, 35.3% of plates were removed intraorally, and the majority of partial plate removals were performed in the patients with plate removal for dental rehabilitation (72.7% vs 27.3%). Hospitalization was shorter with an intraoral approach (1.7 days vs 4.0 days, P=0.052). The removal of patient-specific reconstruction plates prior to dental implantation is often partial and can be performed intraorally. The use of patient-specific miniplates for fixation of FFF might facilitate later dental rehabilitation.

Systematic review and pooled analysis of survival rates, success, and outcomes of osseointegrated implants in a variety of composite free flaps

The aim of this review was to provide an update on survival rates of osseointegrated implants into common composite free flaps used for maxillary and mandibular reconstructions and identify factors affecting outcomes. PubMed, Medline, Embase, and Cochrane databases were searched. Included studies reported implant survival by flap type. Results were pooled and survival was estimated with the Kaplan-Meier method. Variables affecting survival were assessed using Cox regression. Thirty-two of the 2631 articles retrieved were included, totaling 2626 implants placed into fibula, iliac crest, scapula, and radial forearm free flaps. Pooled survival showed 94% 5-year survival of implants in fibula and iliac crest with no difference between groups (P = .3). Factors effecting survival included radiotherapy (HR 2.3, 95% CI 1.2-4.6, P = .027) and malignant disease (HR 2.2, 95%CI 1.6-3.1, P < .001). Implant survival appears adequate across common flap types; however, there are limited numbers reported in less common flaps.

Dental implant-based oral rehabilitation in patients reconstructed with free fibula flaps: Clinical study with a follow-up 3 to 6 years

BACKGROUND

Oral rehabilitation of patients after maxillofacial reconstructive surgery represents a challenge and stable prosthetic retention can be achieved with the use of dental implants.

PURPOSE

This retrospective report aimed to evaluate implant-based oral rehabilitation following maxillofacial reconstruction with free fibula flaps.

MATERIALS AND METHODS

A total of 14 patients who had reconstruction with fibula flaps either by CAD/CAM or conventional surgery were included in this study. A total of 56 implants (40 in flaps, 16 in native bone) were evaluated. Follow-up after reconstructive surgery ranged between 3.25 and 6.3 years. Follow-up after implant surgery ranged between 1.5 and 3.8 years.

RESULTS

Overall survival rate was 85.7% in free fibula flaps and 85.6% in dental implants. Eight implants were lost in three patients and all of these failures were in dental implants inserted in free flaps. According to the results on patient basis, the implant survival was not influenced by any variable.

CONCLUSIONS

The maxillofacial reconstruction with free fibula flap and oral rehabilitation with implant-supported prostheses after ablative surgery can be considered as an effective and safe procedure with successful aesthetic and functional outcomes.

Virtual Surgical Planning for Mandible Reconstruction With a Double Barrel Fibula Flap and Immediate Implant Placement

This brief clinical report describes our experience with virtual surgical planning in a case of mandibulectomy and mandibular reconstruction with a double barrel vascularized osteofasciocutaneous fibula free flap and immediate implant placement in a case of mandibular ameloblastoma. Fibular segments were positioned to obtain the best result both for masticatory function and for aesthetic facial appearance. Furthermore, in this particular case, as well as being positioned for future masticatory rehabilitation, the implants have served to stabilize the fibula segments in the reconstructive intraoperative phase. A superimposition of programed surgery and 6 months postoperative computed tomography scan was performed and results are presented.

Implants in free fibula flap supporting dental rehabilitation - Implant and peri-implant related outcomes of a randomized clinical trial

OBJECTIVES

The objective of this study was to assess the difference in success rates of implants when using two or four implant-supported-overdentures following segmental mandibular reconstruction with fibula free flap.

METHODS AND DESIGNS

This prospective, parallel designed, randomized clinical study was conducted with 1:1 ratio. At baseline, all participants already had segmental reconstruction of mandible with free fibula flap. The participants were randomized into two groups: Group-I received implant-supported-overdentures on two tissue-level implants and Group-II received implant-supported-overdentures on four tissue-level implants. Success rates of the implants were evaluated at 3 months, 6 months and 12 months following implant loading using marginal bone level changes as well as peri-implant indices (Buser et al., 1990).

RESULTS

52 patients were randomized into two treatment groups (26 each), out of which 18 patients (36 implants) of Group-I and 17 patients (68 implants) of Group-II were evaluated. One implant in Group-I was lost due to infective complications and one patient in the same group had superior barrel necrosis. There was a statistically significant increase at both time points (p = 0.03, p = 0.04 at 6 months, 12 months) in the amount of marginal bone loss in Group-I (0.4 mm, 0.5 mm at 6 months, 12 months) as compared to Group-II (0.1 mm, 0.2 mm at 6 months, 12 months). There were no clinically significant changes peri-implant parameters between both groups. Peri-implant soft tissue hyperplasia was seen in both groups, 32% of implants at 3-months, 26% at 6-months and 3% at 12-months follow-up.

CONCLUSION

The results of this study show that patients with 2-implant-supported-overdentures had higher marginal bone loss as compared to patients with 4-implant-supported-overdentures. There were no clinically significant differences in peri-implant soft tissue factors in patients with 2- or 4-implant-supported-overdentures. Hyperplastic peri-implant tissues are common in the early implant-loading phase and tend to decrease over time under appropriate management.

Relationship Between Oral Perception and Habitual Chewing Side for Bare Bone Graft With Dental Implants After Mandibular Reconstruction

OBJECTIVE

The purpose of this study was to investigate the relationship between habitual chewing side and perception of the oral mucosa following reconstruction with dental implants.

STUDY DESIGN

Five patients comprised 2 males and 3 females, with ameloblastoma in 2 patients, odontogenic myxoma in 2 patients, and oral squamous cell carcinoma in 1 patient. They were treated using mandibular reconstruction with bare bone graft after segmental resection of the mandible. Perception (tactile, warm, and cold) was measured at 8 points (chin, lower lip, gingiva, and lateral edge of the tongue, bilaterally). Habitual chewing side was evaluated using a computerized index, the first chewing cycle, and a question on chewing.

RESULTS

Perception on resected sides was improved at all measurement points for tactile and cold sensitive evaluation, although sensitivities on the resected side remained below the normal range. In the relationship between habitual chewing side and implanted prostheses in reconstructed bone, the chewing side was the resected side in 2 of the 5 patients. When those 2 patients underwent prosthesis implantation after removal of denture, the chewing side changed from the nonresected side to the resected side. Implant prostheses on resected side were suggested to contribute to masticatory function. Perception in those patients was incomplete but was improved compared with other patients. When prosthesis implantation is performed on the reconstructed side, the resected side may become the habitual chewing side.

CONCLUSIONS

Recovery of perception can influence acquisition of the habitual chewing side.

A systematic review of functional outcome and quality of life following reconstruction of maxillofacial defects using vascularized free fibula flaps and dental rehabilitation reveals poor data quality

BACKGROUND

Reconstruction and oral rehabilitation of segmental maxillofacial defects resulting from ablative surgery is commonly achieved by osteocutaneous vascularized free fibula (VFFF) transplantation combined with implant-supported dental prostheses. We systematically reviewed the literature regarding impact of oral rehabilitation with or without dental implants on functional outcome and quality of life (Qol) following reconstruction of such segmental maxillofacial defects with VFFF.

METHODS

This systematic review was performed according to the PRISMA guidelines. A literature search was conducted using the databases of Cochrane, MEDLINE and EMBASE. Relevant search terms for maxilla or mandible, reconstruction with VFFF, and oral rehabilitation were used. Two reviewers independently assessed the publications using eligibility and research quality criteria (MINORS).

RESULTS

In total, 554 unique publications were found. After scrutinization, 2 prospective studies and 8 retrospective case-series without comparison were left for ultimate analysis. Quality ranged from 44% to 88% of the maximum score. Overall survival rate of the VFFF was 99% and the survival rate of dental implants was 95%. Speech intelligibility and overall aesthetic outcome were 'good' to 'excellent'. No statistically significant changes in QoL were found. Methods to measure functional outcome varied strongly, making pooling impossible.

CONCLUSIONS

Oral rehabilitation with implant-supported dental prostheses after reconstruction of segmental maxillofacial defects with VFFF results in good to excellent speech intelligibility and aesthetics. Results are probably positively biased by the retrospective nature of the studies. In future prospective research, functional outcome measures should be addressed using standardized questionnaires and validated objective tests with adequate follow-up.

Reconstruction of lateral mandibular defect: a comparison of functional and aesthetic outcomes of bony reconstruction vs soft tissue reconstruction - long-term follow-up

CONCLUSION

Reconstruction with a vascularized bone flap provided superior postoperative outcomes compared with reconstruction with a soft tissue free flap. However, patients obtained acceptable long-term functional outcomes even with a soft tissue free flap and this method is an option in selected patients. A multidisciplinary approach involving dental treatments and nutrition education is important to improve postoperative function.

OBJECTIVE

To assess the postoperative outcomes of two different options for reconstruction of the lateral mandible using bony or soft tissue reconstruction.

METHODS

We divided 25 patients into 2 groups on the basis of the type of reconstruction following lateral mandibulectomy. Twelve patients underwent reconstruction using a vascularized fibular flap and 13 patients received a soft tissue free flap. We compared the postoperative functional and aesthetic outcomes and examined the time-dependent change in functional outcomes in both groups.

RESULTS

Reconstruction with a vascularized bone flap was significantly superior to reconstruction with a soft tissue free flap in deglutition and aesthetic results. There was no significant difference in speech function between the groups. Deglutition in both groups improved markedly over time and all but one patient tolerated a normal or soft diet, including those in the soft tissue reconstruction group. Denture fabrication and recreating occlusion explained the improved deglutition.

Reconstruction of mandibular defects

Defects requiring reconstruction in the mandible are commonly encountered and may result from resection of benign or malignant lesions, trauma, or osteoradionecrosis. Mandibular defects can be classified according to location and extent, as well as involvement of mucosa, skin, and tongue. Vascularized bone flaps, in general, provide the best functional and aesthetic outcome, with the fibula flap remaining the gold standard for mandible reconstruction. In this review, we discuss classification and approach to reconstruction of mandibular defects. We also elaborate upon four commonly used free osteocutaneous flaps, inclusive of fibula, iliac crest, scapula, and radial forearm. Finally, we discuss indications and use of osseointegrated implants as well as recent advances in mandibular reconstruction.

Dental implant placement after mandibular reconstruction by microvascular free fibula flap: current knowledge and remaining questions

Mandibular reconstruction by microvascular free fibula flap has dramatically improved the quality of life of patients treated by interruptive surgery. A simple prosthesis can be used for dental rehabilitation but in many cases, these prostheses remain nonfunctional. The use of osseointegrated implants restores both function and aesthetics. The technique for implantation in fibula flap is very similar to the technique in native mandible but access to the bone is the most difficult step of the surgery. The success rate for osteointegration ranges from 86% to 99% but the success rate of the prosthesis is much lower. This difference could be explained by the vertical discrepancy between the graft and the remaining mandible, which leads to an unfavourable implant-crown ratio. The quality of soft tissues is also a limiting factor for the prosthesis, and hypertrophy often appears after the placement of the abutments. The type of the prosthesis (fixed or removable) should also be discussed. Occlusal considerations should be highlighted as occlusion remains abnormal in many cases. Three-dimensional imaging might help in the planning of these complex reconstructions. A close collaboration between the maxillo-facial surgeon, the oral surgeon and the prosthodontist is necessary to obtain good results.

Comparative study of the osseointegration of dental implants after different bone augmentation techniques: vascularized femur flap, non-vascularized femur graft and mandibular bone graft

OBJECTIVES

The purpose of this study was to evaluate the osseointegration of the dental implants placed into the mandible augmented with different techniques in pigs.

MATERIAL AND METHODS

Four adult domestic pigs were used. Horizontal augmentation of the mandible was performed in animals by using vascularized femur flap (VFF), non-vascularized femur graft (NVFG) and monocortical mandibular block graft (MG). After 5 months of healing 10 dental implants were placed into each augmented site. The pigs were sacrificed after 3 months of healing. Undecalcified sections were prepared for histomorphometric analysis.

RESULTS

Mean bone-implant contact (BIC) values for implants placed into MG, NVFG and VFF were 57.38 ± 11.97%, 76.5 ± 7.88%, 76.53 ± 8.15%, respectively. The BIC values of NVFG and VFF group were significantly greater than MG group (P<0.001). On the other hand, there was not statistically significant difference between NVFG group and VFF group (P=0.999).

CONCLUSION

NVFG as well as VFF can be considered as a promising method for augmentation of alveolar defects and the placement of the implants. The selection of non-vascularized graft or vascularized flap depends on the condition of the recipient site.

Long-term outcome of dental implants placed in revascularized fibula free flaps used for the reconstruction of maxillo-mandibular defects due to extreme atrophy

PURPOSE

the objectives of this study were to evaluate (a) the clinical outcome of revascularized fibula flaps used for the reconstruction of extremely atrophic jaws and (b) the survival rates of dental implants placed in the reconstructed areas.

MATERIALS AND METHODS

between 1999 and 2004, 12 patients presenting with extreme atrophy of the edentulous jaws were reconstructed with fibula free flaps. Five to 12 months after the reconstructive procedure, 75 titanium dental implants were placed in the reconstructed areas, while prosthetic rehabilitation was started 4-6 months afterward. The mean follow-up of patients after the start of prosthetic loading was 77 months (range: 48-116).

RESULTS

an uneventful healing of the bone transplants occurred in all patients. One out of the 75 dental implants placed was not loaded due to prosthetic reasons. No dental implants failed to integrate before prosthetic loading, while three were removed during the follow-up period. Despite the high survival rate of dental implants (95.8%), a relevant number of them presented relevant peri-implant bone-level loss, ranging from 1 to 7 mm for maxillary dental implants and from 1 to 4.5 mm for mandibular dental implants.

CONCLUSION

although no failures of the bone transplants occurred and a high long-term survival rate of dental implants were observed, this study showed that fibula free flaps do not guarantee dimensional stability of peri-implant bone, despite the immediate blood supply delivered by the vascular pedicle. The peri-implant bone resorption was higher when compared with the one related to dental implants placed in native bone.

Preoperative chemoradiotherapy in the management of oral cancer: a review

INTRODUCTION

Multi-modality treatment concepts involving preoperative radiotherapy (RT) or chemoradiotherapy (CRT) and subsequent radical resection are used much less frequently than postoperative treatment for oral and oropharyngeal squamous cell carcinomas. In some centres, however, the preoperative approach has been established for several years.

MATERIAL

The present review is a compilation of the existing evidence on this subject.

METHODS

In a literature-based meta-analysis, the survival data of 1927 patients from 32 eligible publications were analysed.

RESULTS

The calculated survival rates of documented patients show remarkably good results with preoperative CRT and radical surgery. However, the findings of this analysis are based on data with a large proportion of studies using consecutive patient series.

CONCLUSION

Hard evidence providing sufficient data from prospective randomised studies is as yet missing for preoperative CRT. Prospective randomised studies are mandatory in this area.

Craniofacial osseointegration

In year 2007, 30 years have elapsed since the first patient was supplied with a craniofacial osseointegrated implant. The reason for implanting in this patient was a severe conductive hearing loss, which necessitated the use of a bone conduction hearing aid. By utilizing the possibility to transmit sound to the cochlea via direct bone conduction, a new era in audiology was established. Further applications of osseointegration in the craniofacial field is related to the rehabilitation of patients with defects from cancer therapy, malformations, traumatic amputations and burns. Specific fields of osseointegration in this respect are due to possible side effects from radiotherapy and chemotherapy that will affect osseointegration negatively. Other aspects are related to osseointegration in children. This review will focus on the knowledge gained during the first 30 years of craniofacial osseointegration.

Scapular angle osteomyogenous flap in postmaxillectomy reconstruction: Defect, reconstruction, shoulder function, and harvest technique

BACKGROUND

Maxillary reconstruction continues to challenge in terms of optimal aesthetic and functional outcomes. The aim of this study was to describe the utility of the scapular angle osteomyogenous flap in a series of maxillectomy patients and to examine the donor site morbidity.

METHODS

This is a retrospective series of 14 patients undergoing maxillectomy and either primary or secondary reconstruction. The scapular angle can be oriented vertically and horizontally. Aesthetic, functional, and operative morbidity is described. The Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire was used to examine shoulder and upper limb morbidity.

RESULTS

Perioperative morbidity occurred in 4 patients. There were no free flap failures. Functional and aesthetic outcomes were acceptable with all patients having intelligible speech and none requiring nutritional supplementation. The DASH was completed by 12 of 14 patients. The mean and median DASH scores were 10.6 and 13, respectively. All patients gained full range of shoulder movement by 6 months after surgery.

CONCLUSIONS

The scapular angle flap is well suited for maxillary reconstruction and donor site morbidity is low.

Efficacy of conventional and implant-supported mandibular resection prostheses: study overview and treatment outcomes

STATEMENT OF PROBLEM

While surgical restoration of mandibular resections has advanced dramatically with free-flap techniques, oral function and patient perceptions of function, as well as treatment outcomes, often indicate significant impairment.

PURPOSE

This longitudinal prospective study was designed to determine whether conventional prostheses (CP) or implant-supported prostheses (IP) and current surgical reconstructive procedures restore patients' oral functions and quality of life to their status prior to segmental mandibulectomy with immediate fibula free-flap reconstruction. Study design and implementation, characteristics of the study sample, treatment completion rates, and selected presurgical and postsurgical functional and perceptual outcomes are presented.

MATERIAL AND METHODS

Forty-six subjects were enrolled. Longitudinal evaluations of medical and dental histories, oromaxillofacial examinations, questionnaires, and sensory and functional tests were planned before and after surgery and after CP and IP treatment. Sample characteristics are described with descriptive statistics and comparisons of subject responses to questionnaire items at entry and postsurgical intervals were made with Fisher exact tests (alpha=.05).

RESULTS

Conventional prostheses were completed in 33 of 46 subjects, and 16 of 33 CP subjects were treated with IP. Reasons for noncompletion of IP were recurrent/metastatic disease (16), refusal of implant therapy (7), lost to follow-up (4), treatment with a reconstruction plate (1), excessive radiation at implant sites (1), and death (1). All 16 recurrences/metastases occurred within 13 months of surgery. Only 3 of the 58 implants placed in 17 participants were considered failures. One failed due to lack of integration 31 weeks following placement, and 2 were buried due to unacceptable positioning for prosthetic restoration during denture fabrication. The remaining 55 implants were successful at final evaluation, ranging from 58 to 123 weeks following implant placement (mean duration=78.9 +/- 16.0 weeks).

CONCLUSIONS

While 72% (33/46) of the subjects enrolled were able and willing to complete treatment with CP, only 35% (16/46) completed IP treatment. Careful consideration must be given to selection of the type of prosthetic rehabilitation and the timing of implant placement if an IP is planned.

Augmentation procedures for the rehabilitation of deficient edentulous ridges with oral implants

OBJECTIVES

To analyze publications related to augmentation procedures and to evaluate the success of different surgical techniques for ridge reconstruction and the survival/success rates of implants placed in the augmented areas.

MATERIAL AND METHODS

Clinical investigations published in English involving at least 5 patients and with a minimum follow-up of 6 months were included. The following procedures were considered: a) Guided bone regeneration (GBR); 2) Onlay bone grafts; 3) Inlay grafts; 4) Bone splitting for ridge expansion (RE); 5) Distraction osteogenesis (DO); and 6) Revascularized flaps. Success rates of augmentation procedures and related morbidity, as well as survival and success rates of implants placed in the augmented sites were analyzed.

RESULTS

Success rates of surgical procedures ranged from 60% to 100% for GBR, from 92% to 100% for onlay bone grafts, from 98% to 100% for ridge expansion techniques, from 96,7% to 100% for DO, and was 87.5% for revascularized flaps, whereas survival rates of implants ranged from 92% to 100% for GBR, from 60% to 100% for onlay bone grafts, from 91% to 97.3% for RE, from 90.4% to 100% for DO, and, finally, was 88.2% for revascularized flaps.

CONCLUSION

On the basis of available data it was shown that it was difficult to demonstrate that a particular surgical procedure offered better outcome as compared to another. The main limit encountered in this review has been the overall poor methodological quality of the published articles. Therefore larger well-designed long term trials are needed.

Masticatory and swallowing threshold performances with conventional and implant-supported prostheses after mandibular fibula free-flap reconstruction

STATEMENT OF PROBLEM

Significant strides in microvascular surgical techniques allow predictable restoration of bony and soft tissue orofacial defects. In combination with prosthetic rehabilitation, varying degrees of improvement in esthetics, speech intelligibility, and swallowing have been noted; however, the relative impact of conventional and implant-supported prostheses on restoration of masticatory function are not known.

PURPOSE

The purpose of this study was to determine whether conventional or implant-supported dental prostheses and current surgical reconstructive procedures restore patients' masticatory function to presurgical levels.

MATERIAL AND METHODS

Of the 46 subjects enrolled in this study, 23 (7 edentulous and 16 partially dentate) completed conventional prosthesis (CP) treatment and masticatory evaluation, and of these, 15 (3 edentulous and 12 partially dentate) completed treatment and evaluation with an implant-supported prosthesis (IP). Standardized masticatory performance tests with peanuts and carrots as the test food were made on the defect and nondefect sides. Tests of swallowing threshold performance were made with carrots as the test food. Statistical analysis included repeated-measures analysis of variance (ANOVA) with post hoc Tukey HSD tests (alpha=.05).

RESULTS

Masticatory function at entry was markedly compromised. Further performance declines were noted following surgery (PS) on both the defect and nondefect sides. Restoration with CP and IP produced improvements (significant for defect side only, P<.05) in performance over the PS interval and were not significantly different from performances at entry prior to surgery. In addition, the performance on the defect side with the IP was significantly greater than the performance with the CP (P<.001).

CONCLUSION

Impairment in masticatory ability remains following free-flap reconstruction prior to prosthetic rehabilitation. Both CP and IP may provide improved masticatory ability, permitting patients to regain the functional level they possessed prior to surgical intervention. The IP may contribute to greater support and stability of the prosthesis, resulting in increased use for mastication and superior performance on the defect side compared to the CP.

Rehabilitation of oral function in head and neck cancer patients after radiotherapy with implant-retained dentures: effects of hyperbaric oxygen therapy

Surgical treatment of malignancies in the oral cavity and subsequent radiotherapy often result in an anatomic and physiological oral condition unfavorable for prosthodontic rehabilitation. The objective of this prospective study was to assess the effect of hyperbaric oxygen therapy on treatment outcome (condition of peri-implant tissues, implant survival, oral functioning and quality of life) of prosthodontic rehabilitation with implant-retained lower dentures in radiated head and neck cancer patients 6 weeks and 1 year after placing the new dentures. The treatment outcome was assessed in a group of 26 head neck cancer patients who were subjected to radiotherapy after tumour surgery. Standardized questionnaires were completed and clinical and radiographic assessments were performed. After randomization, endosseous Brånemark implants were placed in the anterior part of the mandible either under antibiotic prophylaxis (13 patients) or under antibiotic prophylaxis combined with pre and postsurgery hyperbaric oxygen (HBO) treatment (13 patients). In the HBO and non-HBO group eight implants (implant survival 85.2%) and three implants (implant survival 93.9%) were lost, respectively. Peri-implant tissues had a healthy appearance in both groups. Osteoradionecrosis developed in one patient in the HBO group. All patients functioned well with their implant-retained lower denture. The quality of life related to oral functioning and denture satisfaction were improved to a comparable extent in the HBO and non-HBO group. Implant-retained lower dentures can improve the quality of life related to oral functioning and denture satisfaction in head and neck cancer patients. Adjuvant hyperbaric oxygen therapy could not be shown to enhance implant survival in radiated mandibular jaw bone.

Influence of Previous Radiotherapy on Free Tissue Transfer in the Head and Neck Region: Evaluation of 455 Cases

OBJECTIVE/HYPOTHESIS

The aim of this retrospective cohort study was to investigate the effect of prior radiotherapy (XRT) on the outcome of microvascular free tissue transfer in the head and neck region.

METHODS

Four hundred fifty-five patients, subdivided into three groups, were analyzed. Groups I (no previous XRT, n=110), II (previous radiochemotherapy with 50 Gy focus dosage in the primary treatment regime for oral cancer, n=322), and III (secondary reconstruction after XRT-induced complications, n=23) were compared regarding flap success rate, postoperative complications, postoperative mortality, duration of intensive care (DOIC), and hospitalization (DOH).

RESULTS

Flap success did not differ significantly across groups (I: 95.5%, II: 93.2%, III: 91.3%. Risk of postoperative complications was significantly lower for group I (12.7%) compared with groups II (23.9%) and III (39.1%). DOIC and DOH were significantly shorter for patients in group I than for those in groups II and III.

CONCLUSIONS

XRT before free tissue transfer does not significantly increase flap loss or postoperative mortality but does increase postoperative complications and length of hospitalization.

Clinical outcome of dental implants placed in fibula-free flaps used for the reconstruction of maxillo-mandibular defects following ablation for tumors or osteoradionecrosis

OBJECTIVES

(a) To evaluate the clinical outcome of fibula revascularized flaps used for the reconstruction of maxillary and mandibular defects due to resection for tumors or osteoradionecrosis and (b) to evaluate the survival and success rates of implants placed in the reconstructed areas.

MATERIAL AND METHODS

In a 8-year period (1995-2002), 59 patients, 38 males and 21 females, aged from 13 years to 69 years (mean age: 48.7 years), presenting with maxillary and mandibular defects due to resection for tumors or osteoradionecrosis, were reconstructed with fibula-free flaps. Of the 59 patients, 16 received 71 implants for the prosthetic rehabilitation of the reconstructed edentulous areas.

RESULTS

Out of 59 fibula-free flaps, three failed and had to be removed, nine underwent partial necrosis involving the bone segment and/or the skin paddle but survived, while the remaining 47 healed uneventfully. The mean follow-up of patients after the reconstruction was 55 months (range: 24-120 months). The cumulative survival rate of fibula-free flaps was 94.9%. The mean follow-up of the 16 patients treated with dental implants and implant-supported prostheses was 50.2 months (range: 24-96 months). The cumulative implant success and survival rates of implants were 98.6% and 93.1% respectively.

CONCLUSION

The reconstruction of maxillo-mandibular defects following ablation for tumors or osteoradionecrosis with fibula-free flaps has been demonstrated to be a reliable technique with good long-term results. Implants placed in the reconstructed areas were demonstrated to integrate normally, with success and survival rates comparable to those obtained in case of implants placed in native bone.

Complete rehabilitation of the mandible following segmental resection

Segmental resection of the mandible leads to significant patient morbidity. Loss of mandibular support to the teeth, tongue and lip causes dysfunctional mastication, swallowing, speech, airway protection and oral competence. Patients also suffer disfigurement following segmental mandibulectomy because the mandible is an important aesthetic landmark. The degrees to which dysfunction and disfigurement occur depend both on the location of the mandibular segment removed and the amount of surrounding soft tissue excised. Between January 1985 and December 2004, 780 fibula osteoseptocutaneous flaps have been used for head and neck reconstruction at the Chang Gung Memorial Hospital, Taiwan. The fibula flap has proven to be the bony flap of choice because it has a lengthy bicortical segment of bone available, a reasonably long vascular pedicle, large diameter vessels, good bone quality, and is easily contoured with multiple osteotomies. The flap can be harvested while ablation is being performed. In addition, a reliable, mobile, thin skin component can always be included to address the soft tissue reconstructive requirements. A chimeric design employing a portion of the soleus muscle can provide further reconstructive options. Ideally complete rehabilitation of the mandible involves placement of titanium osseointegrated implants, which allow dental restoration. Primary placement of implants is preferred in patients without cancer. Selection of candidates to receive osseointegrated implants is paramount. The temporomandibular joint remains a challenge to reconstruct adequately.

Effects of the placement of endosseous implants in vascularized bone grafts on bone union in beagle dogs

Recently, reconstructive surgery with revascularized osteocutaneous flaps has been used to restore function in patients with bone defects caused by surgery for oral cancer. However, few basic studies have addressed problems such as the union of bone segments after osteotomy, the effects of dental implant placement on blood flow, and bone formation at the bone:implant interface in grafted bone. Nine adult beagle dogs were divided into three groups of three dogs each. Each group received osteotomized vascularized tibial grafts, osteotomized tibial grafts with implants (implants placed in contralateral limbs as control), or simple (non-vascularized) tibial grafts. The development of bone around the implants was studied by histological examination, contact micro-radiography (CMR), and fluorescent bone labeling. In the dogs receiving osteotomized vascularized tibial grafts, bone bridging was confirmed at both the medial and distal junctions of the bone segments after 4 weeks. Additional newly formed bone was observed after 8 weeks, and bone union at the surface of the segments was completed after 12 weeks. In contrast, bone formation was clearly delayed in dogs receiving simple (non-vascularized) tibial grafts. Histologically, no difference in bone union was evident between limbs with dental implants in tibial bone and control limbs without implants, suggesting that implant placement does not negatively affect revascularization. Fluorescent bone labeling technique confirmed high vascularity of the vascularized tibial bone grafts but not of the simple (non-vascularized) tibial bone grafts early after the procedure. Our results suggest that osseointegration occurred around dental implants placed at the same time as reconstruction with osteotomized vascularized bone grafts in this animal model.

Microsurgical Workhorse Flaps in Head and Neck Reconstruction

The aim of reconstruction after resection of head and neck tumors is to achieve acceptable functional and esthetic results with minimal donor site morbidity. Although many flaps have been developed for bone and soft tissue reconstructions, our experience in the past years has identified the anterolateral thigh flap (cutaneous or myocutaneous), the radial forearm flap, and the osteoseptocutaneous fibula flap as the most useful flaps for head and neck reconstruction. These three flaps can be used for reconstruction of almost all kinds of defects, either as a single flap or in combination. The harvest of these flaps is relatively simple and straightforward. All flaps have adequate pedicle vessel length and caliber. Donor site morbidity is negligible. As most reconstructive microsurgeons do not have enough patient volume to master many different kinds of flaps in their professional life, we recommend focusing on these three flaps as workhorse flaps instead of hunting for many other flaps for head and neck reconstruction.

The use of implant retained mandibular prostheses in the oral rehabilitation of head and neck cancer patients. A review and rationale for treatment planning

Surgical treatment of malignancies in the oral cavity (tongue, floor of the mouth, alveolus, buccal sulcus, oropharynx) often results in an unfavourable anatomic situation for prosthodontic rehabilitation. The outcome is a severe disturbance of oral functioning despite the improved surgical techniques for reconstruction that are currently available. Radiotherapy, which often is applied postsurgically, worsens oral functioning in many cases. Main problems that may hamper proper prosthodontic rehabilitation of these patients include a severe reduction of the neutral zone, an impaired function of the tongue, and a very poor load-bearing capacity of the remaining soft tissues and mandibular bone. Many of these problems can, at least in part, be diminished by the use of endosseous oral implants. These implants can contribute to the stabilisation of the prostheses and intercept the main part of the occlusal loading. Surgical interventions after radiotherapy are preferably avoided because of compromised healing, which may lead to development of radionecrosis of soft tissues and bone as well as to increased implant loss. If surgical treatment after radiotherapy is indicated, measures to prevent implant loss and development of radionecrosis have to be considered e.g. antibiotic prophylaxis and/or pre-treatment with hyperbaric oxygen (HBO). To avoid this problem, implant insertion during ablative surgery has to be taken into consideration if postoperative radiotherapy is scheduled or possibly will be applied. This approach is in need of a thorough pre-surgical examination and multidisciplinary consultation for a well-established treatment planning. The primary curative intent of the oncological treatment and the prognosis for later prosthodontic rehabilitation have to be taken into account too.

Reconstruction of maxillary and mandibular defects using prefabricated microvascular fibular grafts and osseointegrated dental implants - a prospective study

The fibular flap can be used for a variety of indications. Recently, the treatment of four patients with severely atrophied upper jaws using a method to prefabricate the vascularized fibular graft has been published. This technique consists of a two-stage operation procedure that allows simultaneous prosthodontic rehabilitation and immediate placement of dental implants. In this paper eight patients with 29 ITI implants (Straumann AG, Waldenburg, Switzerland) who had reconstruction of either the upper or lower jaw are presented. The aim of the study was (i) to evaluate the behavior of the newly formed soft tissue around implants inserted in the fibula by applying periodontal parameters, (ii) to monitor prospectively the integration of the implants in the fibular graft, and (iii) to assess the osseous integration of the fibular graft used for reconstruction of the upper or lower jaw. Two implants failed during the observation time because of avascular bone at the distal end of the fibular graft. Stabilization of the graft, however, was never compromised. Due to the prefabrication firmly attached gingiva-like soft tissue could be provided preventing periimplant soft tissue inflammation and facilitating oral hygiene. After 1 year of observation the mean attachment level was similar to implants placed in original bone whereas vertical bone loss measured radiographically was lower in the present study. This may indicate that the remodeling of a bicortical bone requires a longer period of time compared with the bone of the alveolar crest. The prospective 1-year results are promising but long-term evaluation of periodontal and radiological parameters are required.

Oral rehabilitation after mandibular reconstruction using an osteocutaneous fibula free flap with endosseous implants

BACKGROUND

The development of endosseous implants and free vascularized bone grafting has permitted increased possibilities of oromandibular reconstruction in patients with oral cancer. In this study, a concept combining surgical and prosthodontic treatments for mandibular fibula free flap reconstruction after tumor surgery was made based on a classification of bone defects. A follow-up study was performed to evaluate the treatment concept for oral rehabilitation in order to identify possible factors which may influence the functional result.

MATERIAL AND METHODS

A follow-up examination included 28 patients who underwent the ablative tumor surgery and mandibular reconstruction during a 4-year period. The follow-up protocol included clinical examination, radiological evaluation, and an interview using a standardized questionnaire. The timing of the study was set to allow for a minimum 2-year follow-up (mean 45 months).

RESULTS AND CONCLUSION

At the time of examination, prosthesis-based oral rehabilitation was completed in six patients (21%), and the prosthodontic work was still unfinished in four other patients. The other 18 had no dental prosthetic rehabilitation. Thirteen patients received a total of 37 oral implants, and 23 implants were functionally loaded. No implant loss was recorded. Oral functions such as speech, diet tolerance and oral competence were not directly affected by the presence of dentures. A decisive factor affecting the oral function was the extent of soft-tissue loss. According to the classification described here, the extent of the mandibular defect did not correlate with oral functions. The application of oral implants seemed to be advantageous for the oral rehabilitation of patients who had undergone intraoral resections.

Segmental mandibulectomy and immediate free fibula osteoseptocutaneous flap reconstruction with endosteal implants: an ideal treatment method for mandibular ameloblastoma

Thirteen patients with large ameloblastomas of the mandible underwent segmental mandibulectomy and immediate reconstruction, with simultaneous placement of osseointegrated implants. All patients received palatal mucosal grafts around the dental implants 6 to 10 months after surgical treatment and received implant-supported prostheses another 1 to 2 months later. There were five female and eight male patients, with a mean age of 32 years (range, 17 to 50 years). The mean length of the mandibular defect was 8.8 cm (range, 5 to 13 cm). All free fibula flap procedures were successful, with no reexplorations or partial flap losses. There was no clinical or radiographic evidence of failure during the osseointegration process for any implant. With functional occlusal loading, the marginal bone loss around the implants was less than 1.5 mm in a mean follow-up period of 40 months (range, 18 to 70 months). There were no recurrences during that time. The technique described allows improved access to the bone at the time of reconstruction, immediate assessment of alveolar ridge relationships, and accurate fixation of the implant-fibula construct. The advantages of this procedure include a reduced risk of recurrence with segmental resection, reliable mandibular reconstruction, and reduction of the number of surgical procedures, allowing full oral rehabilitation in a shorter time. It is concluded that segmental mandibulectomy and immediate vascularized fibula osteoseptocutaneous flap reconstruction, with simultaneous placement of osseointegrated implants, represent an ideal treatment method for large ameloblastomas of the mandible.

Complex oncologic reconstruction of a mandibular and floor of mouth defect with a fibula free flap in an achondroplastic patient

The fibular free flap is seen as one of the foremost technical options in mandibular reconstruction, especially in those defects where long bone is required. Cases with squamous-cell carcinoma of the floor of the mouth with mandibular spread and subsequent segmentary mandibular removal are the cornerstone examples. A case of squamous-cell carcinoma of the whole floor of the mouth with mandibular invasion is reported. Radical resection of the floor of the mouth and bilateral mandibular horizontal ramus was performed, with a bony defect extending from angle to angle. The patient revealed an achondroplastic condition, with remarkable dwarfism and long-bone morphological alterations, that minimized the potential fibular length to transfer. A microsurgical reconstruction with an osteocutaneous fibular free flap was undertaken. The flap design was technically compromised by the forward bowing of the fibula and the ossification of the interosseous membrane. Specific intraoperative strategies for dealing with anatomic variations are discussed. The fibular free flap is an excellent technique for mandibular reconstruction. Morphological deviations can modify the design of the flap. Achondroplasia is not a deterrent in successful use of the free fibula flap for reconstruction of the head and neck in adequately selected cases.

Vascular Iliac Crest With Inner Table of the Ilium as an Option in Maxillary Reconstruction

Reconstruction of large maxillary defects has been a long-standing challenge to the reconstructive surgeon. Total maxillary reconstruction is desirable but often not possible; ideally, this would provide all the anatomical structural support, function, and esthetics missing because of the defect. A case is presented in which all the criteria for total maxillary reconstruction have been fulfilled. The patient is a 60-year-old man who had wide excision of his maxilla for ameloblastoma, followed by temporal bone flap reconstruction, which failed. He presented to our institution for further evaluation and possible treatment options; these were discussed with the patient and the multidisciplinary team that deals with congenital and acquired deformities in the head and neck area. An iliac crest free flap that included the inner table of the ilium based on the deep circumflex iliac artery was used for the reconstruction. The procedure is described, including restoration of a nasal lining. Osseointegrated implants were used for dental rehabilitation. Ameloblastoma is briefly discussed. The goals of maxillary rehabilitation and obstacles to obtaining those goals are presented. Options available for maxillary reconstruction are discussed, along with some of their advantages and disadvantages, as is the reason why the iliac crest free flap with the inner table of the ilium was chosen. An iliac crest free flap with microvascular anastomosis to facial vessels was used to reconstruct a large maxillary defect. Osseointegrated implants were used to facilitate dental rehabilitation. Our patient has excellent restoration of oronasal function with a satisfactory esthetic result.

Functional Rehabilitation of the Atrophic Mandible and Maxilla with Fibula Flaps and Implant-Supported Prosthesis

Historically, nonvascularized bone grafts have been the standard treatment for severe mandibular and maxillary atrophy, followed by immediate or delayed implant placement. Extreme atrophy is an unfavorable biological and mechanical location for nonvascularized autologous bone transplants. The authors present the results of a multidisciplinary treatment protocol for rehabilitation of extreme mandibular and maxillary atrophy by use of the vascularized fibular flap. This protocol includes bone augmentation, implant surgery, soft-tissue management, and prosthetic restoration. Since 1993, 18 patients with a mean age of 47.5 years presented with extreme mandibular and/or maxillary atrophy and underwent alveolar crest augmentation with vascularized fibular flaps. Bone healing was achieved in 17 of the 18 patients. Seventy-three osteointegrated implants were inserted in 12 of 17 fibular flaps. Altogether, 62 implants were loaded and 11 dental prostheses were made. Average follow-up of the loaded implants was 41 months. The success rate of loaded implants was 100 percent. The authors strongly recommend the use of the fibular bone flap when dealing with extreme atrophy of the mandible and maxilla and suggest the protocol outlined in this review.