The prosthodontic management of the maxillectomy patient.

Ablative defects of the maxilla caused by malignant tumours create a multitude of difficulties for patients and the clinical teams looking after them. Tumours of the maxilla, while relatively uncommon, require significant multi-disciplinary involvement due to their effects on the aesthetic, functional and psychological aspects of the patients involved. Patients with these tumours have worse survival than other head and neck sites, with a propensity to local and regional recurrence. As a result, prosthetic rehabilitation of this patient cohort must be timely to restore form and function before patients become adapted to their pathologically adapted state. This article will discuss classification of maxillary defects and surgical decision-making in this complex area, together with the role of the maxillofacial prosthodontist/restorative dentist in providing effective pre, peri and postoperative intervention and support to the surgical team and to the patient. While prosthetic obturation has been used historically to manage maxillectomy patients, the use of composite microvascular free flap reconstruction, with or without dental implants, is often required for high-level defects. More recently, the use of the zygomatic implant perforated flap reconstructive procedure for rapid prosthodontic rehabilitation and palatal reconstruction has been described and validated.

Hyperbaric oxygen treatment of mandibular osteoradionecrosis: Combined data from the two randomized clinical trials DAHANCA-21 and NWHHT2009-1.

PURPOSE: Osteoradionecrosis (ORN) of the mandible is a serious complication of head and neck radiotherapy. This study aims to investigate the effect of hyperbaric oxygen (HBO) treatment on ORN in two randomized, controlled multicentre trials. METHODS AND MATERIALS: Patients with ORN with indication for surgical treatment were randomised to either group 1: surgical removal of necrotic mandibular bone supplemented by 30 pre- and 10 postoperative HBO exposures at 243 kPa for 90 min each, or group 2: surgical removal of necrotic bone only. Primary outcome was healing of ORN one year after surgery evaluated by a clinically adjusted version of the Common Toxicity Criteria of Adverse Events (CTCAE) v 3.0. Secondary outcomes included xerostomia, unstimulated and stimulated whole salivation rates, trismus, dysphagia, pain, Activities of Daily Living (ADL) and quality of life according to EORTC. Data were combined from two separate trials. Ninety-seven were enrolled and 65 were eligible for the intent-to-treat analysis. The 33% drop-out was equally distributed between groups. RESULTS: In group 1, 70% (21/30) healed compared to 51% (18/35) in group 2. HBO was associated with an increased chance of healing independent of baseline ORN grade or smoking status as well as improved xerostomia, unstimulated whole salivary flow rate, and dysphagia. Due to insufficient recruitment, none of the endpoints reached a statistically significant difference between groups. ADL data could only be obtained from 50 patients. CONCLUSION: Hyperbaric oxygen did not significantly improve the healing outcome of osteoradionecrosis after surgical removal of necrotic bone as compared to standard care (70% vs. 51%). This effect is not statistically significant due to the fact that the study was underpowered and is therefore prone to type II error.

Zygomatic implant-supported prosthodontic rehabilitation of edentulous patients with a history of cleft palate: A clinical report.

Zygomatic implants are an established treatment option in the management of the atrophic maxilla and in oncology rehabilitation, but evidence for their use in patients with a history of cleft palate is sparse. Zygomatic implants were used to retain a maxillary prosthesis in 7 edentulous patients with an unrepaired or repaired cleft lip and palate. Patient records were reviewed retrospectively to assess the survival rates. The mean follow-up time was 5 years with an implant survival of 100%. Most complications were associated with the prosthetic superstructures. This clinical report demonstrates that zygomatic implants can be successfully used to provide a maxillary prosthesis in patients with a history of cleft palate.

Attitudes regarding zygomatic implant surgical and prosthodontic techniques-a cohort questionnaire study.

BACKGROUND: Zygomatic implant (ZI) surgery and restoration is a complex procedure, requiring experienced clinicians to execute with success. This study assessed the opinion and clinical experiences of a cohort of practitioners involved in provision of zygomatic implant treatment on aspects of the surgical and prosthodontic procedures. METHOD: A survey was distributed among all 176 delegates attending 'Zygomatic 2019' International Conference in the UK, and all delegates completed the survey. RESULTS: The respondents were clinicians from both prosthodontic and surgical specialties, with a range of experience. Strong agreements were found regarding the use of specific implant designs dependent on the anatomical situation, and that fixed restorations should be used where possible. There was limited agreement between respondents regarding surgical approaches to ZI treatment. CONCLUSION: The limited agreement found between respondents highlights the varied and conflicting literature available on ZI surgery. High-quality research is required to inform clinicians and assist education.

The Zygomatic Implant Perforated (ZIP) flap reconstructive technique for the management of low-level maxillary malignancy - clinical & patient related outcomes on 35 consecutively treated patients.

BACKGROUND: The zygomatic implant perforated (ZIP) flap technique provides immediate reconstruction and rapid dental rehabilitation for low-level malignant tumors. METHODS: Patients who underwent ZIP flap reconstruction between December 2015 and February 2021 were followed prospectively. RESULTS: Thirty-five consecutively treated patients were studied with 16 undergoing surgery alone and 19 undergoing surgery followed by radiotherapy. The median time to fit the prosthesis was 29 days with all patients requiring adjuvant radiotherapy receiving their fixed dental prosthesis prior to its commencement. Vascularized flap (100%), zygomatic implant (98.4%), and prosthesis (97%) survival were excellent and the ZIP flap protocol was highly rated by patient-related outcome measures especially for the chewing domain. CONCLUSIONS: The ZIP flap technique provides an excellent means of providing an autogenous oronasal seal and a foundation for immediate cortically anchored fixed dental rehabilitation. CLINICAL SIGNIFICANCE: This technique provides rapid and robust rehabilitation for patients presenting with low-level maxillary malignancy despite the use of radiotherapy.

Zygomatic implant-based rehabilitation for patients with maxillary and mid-facial oncology defects: A review.

OBJECTIVES: This literature review reports the current evidence for the use of zygomatic implants in head and neck oncology patients for the prosthetic rehabilitation of defects of the mid-face and maxilla. METHODS: MEDLINE, Embase and Cochrane databases were searched using strict search terms. Two independent reviewers reviewed the articles and applied inclusion and exclusion criteria. RESULTS: Literature search revealed 437 articles, and following application of the inclusion criteria, 32 articles were included for analysis. Overall survival rates of 77%-100% were reported with few complications, although only four centres presented data on 20 or more patients. Primary implant placement at time of resective surgery has been shown to be an effective means of accelerating rehabilitation along with early loading protocols. The role of radiotherapy in implant failure has not been fully elucidated, and it is clear that zygomatic implants can be successfully used in the irradiated patient. Providing support for maxillary obturators was the most common use reported with both splinted and unsplinted implants. CONCLUSIONS: Zygomatic implants provide remote anchorage for a variety of oral and facial prostheses that contribute to the improved function and quality of life for patients being treated for maxillary and mid-facial tumours.

Primary vs secondary zygomatic implant placement in patients with head and neck cancer-A 10-year prospective study.

BACKGROUND: Zygomatic implants can provide excellent remote anchorage to support the prosthetic rehabilitation of patients treated for maxillary and midfacial tumors. METHODS: Patients who underwent zygomatic implant placement by the author between 2006 and 2016 as part of their oncology treatment were followed prospectively. RESULTS: Forty-nine consecutively treated patients received 131 zygomatic implants of which 9 failed and were removed from 4 patients; 24 patients (49%) received radiotherapy either before or after implant insertion. The overall 12-month survival estimate was 94% and the 60-month estimate was 92%. CONCLUSIONS: The use of zygomatic implants in the management of maxillary and midfacial malignancy is a predictable prosthetic treatment modality to support complex oral and facial prostheses. Their use with or without free tissue transfer can provide effective prosthetic rehabilitation with high implant survival irrespective of the timing of placement or the need for adjuvant radiotherapy. CLINICAL SIGNIFICANCE: Zygomatic Implants provide an excellent platform for the restoration of the dentition and facial structures affected by maxillary and midfacial malignant disease.

A novel report on the use of an oncology zygomatic implant-retained maxillary obturator in a paediatric patient.

This report details the use of zygomatic oncology osseointegrated implants to support and retain a maxillary obturator in a 13-year-old male patient who underwent a right-sided hemi-maxillectomy (Brown Class 2b) (Brown and Shaw, Lancet Oncol 11:1001-8, 2010) for a myxoid spindle cell carcinoma. At the time of maxillary resection, two zygomatic oncology implants were inserted into the right zygomatic body and subsequently utilised to provide in-defect support and retention for a bar-retained maxillary acrylic obturator prosthesis, which restored the patient's aesthetics and function to a very high level. Close follow-up over 2 years demonstrated ongoing excellent function and disease control with no deleterious effects on facial or dento-alveolar growth clinically. This is the first clinical report of its kind in the published literature detailing the use of a zygomatic implant-retained obturator in a paediatric patient.

Liverpool Opinion on Unfavorable Results in Microsurgical Head and Neck Reconstruction: Lessons Learned.

This article annotates a philosophy toward achieving best results for the patient with head and neck cancer, in particular relating to oral, mandibular, and maxillary resection. At the same time are highlighted the pitfalls that, if not avoided, are likely to result in a poor outcome even with a successful flap transfer. There is a paucity of evidence to support clinical practice in head and neck reconstruction such that much of the discussion presented is opinion-based rather than evidence-based.

The prosthodontic pathway of the oral cancer patient.

UNLABELLED: Oral cancer patients undergo life-altering curative treatment that consists of surgery or a combination of surgery and radiotherapy. This can severely alter the functional anatomy of the oral cavity and create a challenging environment for successful oral rehabilitation. A multidisciplinary team approach is required to rehabilitate these patients successfully. It is essential to have assessment by an oral rehabilitation specialist before treatment, especially where primary rehabilitation interventions are being considered. Following cancer treatment, patients may suffer from a range of difficulties, from dento-facial appearance, to chewing, speech and swallowing. This dysfunction often leads to psychosocial problems, such as reduced self esteem, social contact and quality of life. Conventional prosthodontics has a role to play in the management of these patients but osseointegrated implants (OII), can be required to overcome the anatomical and physiological barriers. OII can be used in an environment where there is poor soft tissue function or little bone support, and where there is a dry mouth. CLINICAL RELEVANCE: This paper introduces readers to the prosthodontic pathway taken by some oral cancer patients. It provides an overview of current oral rehabilitation techniques that supplement the supportive dental care provided by general dental practitioners and their team after cancer treatment.

A survey of general dental practitioners in the North West of England concerning the dental care of patients following head and neck radiotherapy.

AIMS: The aim of this survey was to investigate the views of general dental practitioners (GDPs) on their perceived roles and the barriers regarding dental care of patients following head and neck radio-therapy. METHODS: From a total of 1163 GDPs on the Mersey Postgraduate Dental Deanery mailing list, 369 were selected at random. Questionnaires were sent out in February 2010 followed by reminders a month later. A study-specific questionnaire was piloted prior to the survey. RESULTS: One hundred and ninety-eight of the potential 336 respondents returned valid questionnaires, a response rate of 59%. They did not respond to all questions. Of those who responded, 99/188 (53%) were either 'not at all' or 'little' happy about managing these patients and 118/183 (64%) and 100/173 (58%), respectively, perceived that complex management and the new General Dental Services (nGDS) contract introduced in 2006 were 'quite a bit' or 'very much' barriers to treatment. The majority of the respondents felt that they were 'quite a bit' or 'very much' happy to carry out routine fillings (177/195; 90%), periodontal treatment (166/195; 85%), removable dentures (161/195; 83%), crown and bridge work (123/192; 64%), and root canal therapy (114/195; 58%) but only 53/191 (28%) to perform dental extractions. Over half of the respondents felt that they had 'quite a bit' or a 'main role' in managing radiotherapy caries, xerostomia, detecting recurrence and offering smoking-cessation advice. CONCLUSION: The majority of the GDPs who responded had been involved in the management of patients who had undergone radio-therapy to the head and neck. A substantial number perceived barriers to care, such as the complexity of the treatment and the nGDS contract. These findings need further investigation. Continuing professional development would be helpful to improve GDPs' confidence in dealing with this group of patients.

Mandibular two implant-supported overdentures as the first choice standard of care for edentulous patients--the York Consensus Statement.

The Annual Conference of the BSSPD (British Society for the Study of Prosthetic Dentistry) was held in York on 6 and 7 April 2009. At the symposium on mandibular overdentures, presenters offered a synopsis of the research available on the efficacy of implant-supported mandibular overdentures in the edentulous mandible. Emphasis was given to both qualitative and quantitative research based on patient-centred outcomes of treatment. A draft consensus was circulated to all presenters and to the Council members of the BSSPD and to BSSPD members on the Society's website. The statement was modified in the light of their comments, audience feedback following the presentations and members' feedback. We hope that this consensus statement will be a useful guide for patients and clinicians and that it will act to stimulate wider debate. We also hope that it will prove useful to other patient and professional organisations and will inform discussions with providers of national healthcare and with independent funders.

Computerised dental implant rehabilitation planning and execution following mandibular resection: a case report.

This paper discusses the merits of Computer Tomography (CT) based dental implant planning in the rehabilitation of patients following oral cancer This case report describes the process of prosthetic work-up, computerised implant planning, surgical treatment and successful prosthetic oral rehabilitation of a patient following segmental mandibulectomy and post-operative radiotherapy for intra-osseous squamous cell carcinoma (SCC).

Oral rehabilitation of a patient with diffuse lymphangiomatosis affecting the maxilla: a case report.

A case is presented in which diffuse lymphangiomatosis resulted in the complete loss of the maxillary dentoalveolar complex and underlying basal bone. The complex investigation and treatment of this patient over a 10-year period is presented, and the importance of a multidisciplinary team approach in providing a functional and esthetic rehabilitation is highlighted. The use of a vascularized bone graft based on the deep circumflex iliac artery and subsequent restoration with an implant-supported prosthesis is described.