Prefabricated Fibula Flap vs Bone-Driven and Delayed Implant Installation for Jaw Reconstruction.

Importance: Restoration of dental occlusion and oral rehabilitation is the ultimate goal of functional jaw reconstruction. Objective: To evaluate the prefabricated fibula flap (PFF) technique in occlusion-driven jaw reconstruction for benign or previously treated malignant disease. Design, Setting, and Participants: This cohort study was conducted from January 2000 to December 2019 at the University of Alberta Hospital and Institute of Reconstructive Sciences in Medicine in Edmonton, Alberta, Canada, among patients who underwent PFF or bone-driven and delayed osseointegrated implant installation (BDD). Patients were followed up for a minimum of 1 year after occlusal rehabilitation. Data were analyzed from July 2021 to June 2022. Exposures: Patients underwent BDD or PFF, which consists of osseointegrated dental implant installation and skin grafting of the fibular bone 3 to 6 months before jaw tumor resection or defect reconstruction. The implant osseointegration is completed at the time of jaw reconstruction, allowing for full reconstruction, loading, and restoration of the dental occlusion in the immediate postoperative period. Main outcomes and Measure: Safety, effectiveness, accuracy, timeliness of occlusal reconstruction, and aesthetic appeal were compared between PFF and BDD. Groups were compared for the following variables: postoperative complications, number of bony segments used, number of procedures needed, total operative time, time to occlusal rehabilitation, and number of implants installed, exposed, lost, and used (ie, exposed implants - lost implants). Aesthetic appeal was assessed using standardized full-face and profile digital photographs taken before and 6 to 12 months after the operation and analyzed by 3 naive raters. Results: Among 9 patients receiving PFF (mean [SD] age, 43.3 [13.0] years; 7 men [77.8%]) and 12 patients receiving BDD (mean [SD] age, 41.9 [18.0] years; 8 men [66.7%]), the overall complication rate was similar (4 patients [44.4%] vs 3 patients [25.0%], respectively; relative risk, 1.78 [95% CI, 0.52 to 6.04]). The number of patients with implant loss was similar between PFF and BDD groups (0 patients vs 3 patients [25.0%], respectively; difference, -25.0 percentage points [95% CI, -48.4 to 9.7 percentage points]). PFF had a clinically meaningful faster mean (SD) occlusal rehabilitation compared with BDD (12.1 [1.9] months vs 60.4 [23.1] months; difference, -48.3 months [95% CI, -64.5 to -32.0 months]). The mean (SD) difference in preoperative to postoperative aesthetic score was similar between PFF and BDD groups (-0.8 [1.5] vs -0.2 [0.8]; difference, -0.6 [95% CI, -1.6 to 0.4]). Conclusions and Relevance: This study found that PFF compared with BDD was a safe, effective, and aesthetic reconstructive option for patients with benign or previously treated jaw malignant tumors. This technique may provide rapid occlusal reconstruction and oral rehabilitation.

Lateral transport osteogenesis in maxillofacial oncology patients for rehabilitation with dental implants: a retrospective case series.

OBJECTIVES: To report on the use of lateral transport osteogenesis in cancer patients after maxillo/mandibular resections and on the implant survival rate in the generated bone MATERIAL AND METHODS: Four patients treated using lateral transport osteogenesis entered this descriptive study and were retrospectively studied (mean age 55; range 41-62). RESULTS: Reconstruction of segmentary defects after surgical and radiological cancer treatment on maxilla and mandible was achieved. No relevant intra- or post-operative complications occurred. No differences on implant survival were observed between patients who had received radiotherapy and those who had not. CONCLUSIONS: This approach can be considered a recommendable reconstructive option after oral cancer treatment - including radiotherapy- particularly for high-surgical-risk, collaborative patients.

Computerized tomography, stereolithography and dental implants in the rehabilitation of oral cancer patients.

UNLABELLED: As survival rates improve it is important to consider the quality of life for oral cancer patients post-treatment. The primary goal is removal of the tumour, however, with a gradual increase in survival rates, post-operative rehabilitation is now becoming increasingly important. Specialists in restorative dentistry, along with oral and maxillofacial surgeons, general dental practitioners and other members of the multidisciplinary team play a vital role in planning treatment for, and rehabilitating, these patients. This paper presents a case series to show how recent advances in computerized tomography (CT) and the use of stereolithographic models can help in the rehabilitation of oral cancer patients. CLINICAL RELEVANCE: The principles discussed can also be applied to other patients undergoing dental implant treatment to help plan and carry out treatment and improve the quality of peri-implant tissues.

Patients with oral tumors. Part 2: Quality of life after treatment with resection prostheses. Resection prosthetics: evaluation of quality of life.

In the present study, the oral health-related quality of life of 18 patients (13 men and 5 women) was evaluated using validated questionnaires as proposed by the European Organization of Research and Treatment of Cancer (EORTC). The patients belonged to a cohort of 48 patients, whose prosthetic treatment was performed during the years 2004-2007. In the course of tumor resection, 12 patients underwent graft surgery and 14 patients radiotherapy. One patient required a nasal epithesis since resection of the nose became necessary. Five patients underwent a full block resection of the mandible, and tumor resection in 3 patients resulted in a large oronasal communication. Prosthetic rehabilitation was performed in all patients, and the follow-up period with regular care covered a minimum of 3 years. Eleven patients received dental implants for better support and retention of the prostheses. In spite of compromised oral conditions, functional restrictions, and some difficulties with the prostheses, the answers to the questionnaire were quite positive. The majority judged their general health as good or even excellent. The subjective perception of the patients may contradict the objective view by the dentist. In fact, the individual patient's history and experience provide a better understanding of the impact of oral tumors on daily life. The overall assessment identified 4 items that were perceived as major problems by all patients: swallowing solid food, dry mouth, limited mouth opening, and appearance. Prosthetic rehabilitation has only a limited influence on such problems.

Patients with oral tumors. Part 1: Prosthetic rehabilitation following tumor resection.

The present study reports on the surgical and prosthodontic rehabilitation of 46 patients, 31 male and 15 female, after resection of oral tumors. The treatment was carried out from 2004 to 2007 at the Department of Prosthodontics, University of Bern, with a follow-up time of 3 to 6 years. The average age at diagnosis was 54 years. 76% of all tumors were squamous cell carcinoma, followed by adenocarcinoma. Resection of the tumors including soft and/or hard tissues was performed in all patients. 80% of them additionally underwent radiotherapy and 40% chemotherapy. A full block resection of the mandible was perfomed in 23 patients, and in 10 patients, the tumor resection resulted in an oronasal communication. 29 patients underwent grafting procedures, mostly consisting of a free fibula flap transplant. To enhance the prosthetic treatment outcome and improve the prosthesis stability, a total of 114 implants were placed. However, 14 implants were not loaded because they failed during the healing period or the patient could not complete the final treatment with the prostheses. The survival rate of the implants reached 84.2% after 4 to 5 years. Many patients were only partially dentate before the tumors were detected, and further teeth had to be extracted in the course of the tumor therapy. Altogether, 31 jaws became or remained edentulous. Implants provide stability and may facilitate the adaptation to the denture, but their survival rate was compromised. Mostly, patients were fitted with removable prostheses with obturators in the maxilla and implant-supported complete dentures with bars in the mandible. Although sequelae of tumor resection are similar in many patients, the individual intermaxillary relations, facial morphology and functional capacity vary significantly. Thus, individual management is required for prosthetic rehabilitation.

Prosthodontic rehabilitation of patients with orofacial defects.

In 2007 in the UK, 5410 people were diagnosed with an oral cancer. It is therefore imperative that all dentists, medical practitioners and dental care practitioners are vigilant when examining the oral cavity so that any suspicious ulcers, swellings or changes in colour of the mucosa are referred at the earliest stage. To give the patient the best prognosis with an orofacial defect following tumour removal or trauma, it is most important to have the appropriate skills in a multidisciplinary team. The management of patients comprises pre-surgical, surgical and post-surgical phases.

Oral function after oncological intervention in the oral cavity: a retrospective study.

PURPOSE: To assess self-perceived oral function of patients with oral cavity cancer at different stages of treatment, ie, before oncologic intervention, 5 weeks after intervention, and 5 years after intervention. PATIENTS AND METHODS: A cohort of 158 patients with malignancy in the oral cavity treated by surgery in 1999 or 2000 was included. From this cohort we interviewed 69 patients by telephone in 2005 and collected data on dental status, disorders of chewing and swallowing, xerostomia, preference of food consistency, tube nutrition, weight loss, and speech for different stages of treatment. RESULTS: For patients treated in the maxilla region we observed a significant (P < .05) recovery of perceived chewing ability after 5 years to the level experienced before oncologic intervention. Patients treated in the mandible region reported a deteriorated dental state, chewing ability, lip competence, and xerostomia after 5 years. Patients treated in the tongue and mouth-floor region experienced deterioration for dental state, chewing ability, and xerostomia after 5 years compared with the level before the oncologic intervention. CONCLUSIONS: Our telephone interview on oral function provided supplementary information on how patients experienced their problems with oral function during various phases of oncologic treatment. A retrospective interview may thus help to add information to incomplete retrospective data.

Maxillofacial restoration after head and neck tumor therapy.

Oral and pharyngeal cancers are among the leading cancer sites. Surgery, radiation, chemotherapy, or combination therapies are common treatment modalities. Radiotherapy and chemotherapy cause significant morbidity and long-term irreversible sequelae in the oral cavity. Surgical resection can be mutilating, disfiguring, and deeply affect self-image. Orofacial defects have unique limitations and challenges for both the surgeon and the maxillofacial prosthodontist. Microvascular surgical techniques and the use of osseointegrated implants improve the rehabilitation potential of the various head and neck defects. This article reviews current treatment modalities of tumor therapy, their consequences, and the restoration of maxillofacial defects.

The Management of Patients after Surgical Treatment of Maxillofacial Tumors.

Morphological and functional disturbances induced by postsurgical defects and loss of tissues in the stomatognathic system due to the treatment of tumors in the maxillofacial region determine the therapeutic needs of patients. The study aimed at clinical and epidemiological evaluation of patients under prosthetic treatment in order to establish the algorithm for rehabilitation. The study group was composed of the patients after midface surgery (45.74%); surgery in a lower part of the face (47.38%); mixed postoperative losses (3.44%); loss of face tissues and surgery in other locations in the head and neck region (3.44%). The supplementary treatment was applied in 69.63% of patients. Clinical and additional examinations were performed to obtain the picture of postoperative loss, its magnitude, and location to plan the strategy of prosthetic rehabilitation. The management algorithm for prosthetic rehabilitation in patients after surgical treatment of maxillofacial neoplasms was based on its division in stages. The location and magnitude of postoperative losses, as well as the implementation of supplementary treatment of the patients after treatment of maxillofacial tumors, influence the planning of prosthetic rehabilitation that plays a key role and facilitates the patients' return to their prior living situation, occupational and family lives.

Retrospective review of 78 rehabilitated head and neck postoncological patients: a new classification method.

BACKGROUND: Numerous studies have been published about the prosthetic rehabilitation of the postoncological maxillo-facial patient, but the guidelines that emerge lack a correlation between the anatomical classification of the treated site, which generally is preparatory upon surgery, and the type of prosthetic rehabilitation appropriate to the new anatomical and functional condition. With this correlation, it would be possible to obtain a multidisciplinary and predictable therapeutic process, able to identify from the beginning the best type of prosthetic rehabilitation. METHODS: The authors analyzed a sample of 78 patients treated in the Maxillofacial Surgery Unit of "Sapienza" University of Rome for a tumor of the head and neck area, and at a later stage prosthetically rehabilitated in the years from 2010 to 2013 in the Prosthetic Rehabilitation Unit of the same University because of the consequences of the ablative surgery. After having analyzed data concerning the treatment of the maxillofacial tumor, Authors classified the kind of prosthetic rehabilitation. Removable prosthesis was chosen in 18 cases, while implant (or teeth)-supported rehabilitation was performed in 60 cases. RESULTS: Authors correlated the kind of surgical reconstruction to the prosthetic rehabilitation performed. In the maxilla removable prosthesis was chosen in 8 cases, while implant supported rehabilitation was performed in 18 cases. In the mandible 10 cases were rehabilitated through a removable prosthesis and 42 through a teeth or implant supported prosthesis. CONCLUSIONS: It is evident the need to perform a careful evaluation of the patient, in order to identify the best possible prosthetic rehabilitation.

Implant-Supported Telescopic Crown-Retained Overdentures for Oral Rehabilitation of Patients with Severe Bony Defects: A 5-Year Retrospective Study.

PURPOSE: To evaluate the performance of dental implant-supported telescopic crown (TC)-retained overdentures to restore the oral function of patients who have insufficient jawbone volume resulting from tumor resection or trauma. MATERIALS AND METHODS: From January 2004 to December 2008, implant-supported TC-retained overdentures were used to restore the oral function of patients with severe bony defects resulting from tumor resection or trauma. Clinical data, including implant success and survival rates, biologic and mechanical complications, prosthodontic maintenance efforts, and patient satisfaction, were analyzed annually after delivery of the final prostheses. RESULTS: Twenty-four patients were treated, and a total of 88 implants were inserted to support TC-retained overdentures. The mean modified plaque index of implants remained low (<20%), and the majority of implants (>76.3%) in the study showed the absence of bleeding on probing at follow-up visits. Peri-implant marginal bone loss (MBL) ranged from 0.8 to 1.2 mm. There was no statistically significant difference in the MBL between maxillary and mandibular implants (P = .43). The implant success rate was 100% after 5 years, and the prosthodontic maintenance and complication rate was 0.22 times per year. More than 90% of patients were satisfied with the restoration of their oral function using TCs. CONCLUSION: Based on our study of 24 patients treated with TC-retained overdentures, it appears that this treatment may be a viable option for patients with insufficient jawbone volume.

Malignant neoplasms of the hard palate and upper alveolar ridge.

Malignant neoplasms of the hard palate and upper alveolar ridge can arise from the epithelial (mucosal), salivary, hematopoietic, or mesenchymal tissues in this region. Unlike other regions in the head and neck, only about two thirds of malignant neoplasms of the hard palate are squamous cell carcinomas, and few large series have reported treatment protocols and outcomes for patients with these tumors. In this review, we will describe our series of 51 patients with malignant neoplasms of the hard palate and upper alveolar ridge. This review will emphasize the surgical treatment program and rehabilitative techniques developed at the University of Pittsburgh.

Longitudinal follow-up of osseointegrated implants in patients with resected jaws.

PURPOSE: To investigate the effects of bone grafting and radiotherapy on implant survival rates. MATERIALS AND METHODS: This follow-up study involved 36 patients with 180 implants who were treated between January 1989 and December 2000 by prosthodontic rehabilitation using osseointegrated implants following jaw resection. They comprised 20 patients with malignant tumors, 12 with benign tumors, and 2 patients each with osteomyelitis and cysts. RESULTS: A total of 15 implants (11 in the maxilla and 4 in the mandible) were removed for various reasons during the follow-up study. Implant survival rates were calculated using the Kaplan-Meier method; the overall survival rate for the 180 implants was 88.6%. Specific implant survival rates were as follows: in residual bone, 73.8% for the maxilla and 95.2% for the mandible; in grafted bone, 80% for the maxilla and 94.1% for the mandible; in irradiated bone, 79.7%; and in nonirradiated bone, 93.5%. DISCUSSION: Radiotherapy, a dose of 30 Gy, was performed in patients with malignant tumors but not in patients with benign tumors, cysts, or osteomyelitis. No differences were found in the results for implants placed due to jaw resection for malignant tumors and those for implants placed due to benign tumors, cysts, or osteomyelitis. Implants lost varied in length from 7 to 18 mm. Among these, loss was more frequent with shorter implants (lengths to 10 mm). CONCLUSION: The clinical results obtained in the present study compare favorably with those obtained by others. However, jaw reconstruction and rehabilitation should not be performed by the oral surgeon alone; oral and maxillofacial function should be restored using a team approach in close cooperation with specialists in prosthodontics and periodontics to improve the result of implant treatment.

Long-term results of endosteal implants used for restoration of oral function after oncologic surgery.

The aim of the present study was to analyse the long-term survival rate of endosteal implants used for restoration of oral function in patients having undergone oncologic surgery. Eighty-three consecutive patients, who had received a total of 409 endosteal implants ad modum Brånemark, subsequent to resections of soft tissue and bone during ablation of oral malignancies, were enrolled into the study. A life-table analysis was used to determine the survival rate of the implants placed during a period of 13 years. Log rank tests and Cox regression analysis were employed to identify relevant effects of surgical parameters on implant survival. A total of 38 implant failures were encountered. Most of the losses (n = 19) occurred during the first year of functional loading. Subsequent failures were evenly distributed across the remaining follow-up period. The cumulative overall survival rate of implants was 56.5%. Previous radiation therapy, insertion into grafted bone or original jaw bone and the technique of grafting did not significantly affect the survival rates. In the Cox regression analysis, the timing of implant placement in the group of patients with bone grafts (primary vs. secondary placement) was significantly related to the survival rate (P = 0.0197), with a lower survival rate of 36.2% for primary insertion of implants and 67.1% for secondary placement.

Evaluation of microvascular bone graft reconstruction of the head and neck with 3-D 99mTc-DPD SPECT scans.

OBJECTIVE: We conducted a prospective investigation to evaluate the diagnostic accuracy of computer-aided 3-dimensional (3-D) technetium 99m dicarboxypropane methylene diphosphonate ((99m)Tc-DPD) single photon emission computed tomography (SPECT) reconstruction in the evaluation of microvascular bone flaps used for maxillofacial reconstruction. STUDY DESIGN: Twenty patients who received 20 autogenous microvascular bone flaps for reconstruction of the mandible and maxilla were evaluated. Forty bone scans with subsequent computer-aided reconstruction were performed. Each graft could be assessed within 48 to 72 hours after surgery. The second bone scan was performed between 12 and 14 days after surgery. RESULTS: Complications were observed in 5 grafts. SPECT investigation performed at the 2 time points after reconstruction showed a significantly higher tracer uptake in grafts with an uncomplicated further course than in those that developed complications. CONCLUSIONS: Computer-aided 3D (99m)Tc-DPD SPECT reconstruction serves as a useful prognostic tool and helps in the very early recognition of complications. This technique adds significantly to the value of planar bone scintigraphy and conventional SPECT images.

Osteosarcoma of the jaw. The Chaim Sheba Medical Center experience.

OBJECTIVE: The purpose of this article is to present 14 cases of osteosarcoma of the jaw treated at our medical center from 1989 to 1998. These cases are discussed in the light of a comprehensive review of 774 cases reported in the English literature over the past 3 decades. Differences between osteosarcoma of the jaws and osteosarcoma of the long bones are examined. SUBJECTS AND METHODS: The patients ranged in age from 8 to 78 years, the mean age being 33 years. Each patient had a histopathologically established diagnosis of osteosarcoma of the jaw. Records were reviewed for epidemiologic data, treatment modalities, and survival. RESULTS: Of the 14 patients, 6 (42%) had tumors in the mandible and 8 (58%) had tumors in the maxilla. Of the mandibular tumors, 5 occurred in the body of the mandible; all maxillary tumors originated in the alveolar ridge and involved the maxillary sinus. The chief complaint was an intraoral or extraoral painless swelling. Histopathologic types included chondroblastic, osteoblastic, fibroblastic, and malignant fibrous histiocytoma-like. Pathologic grade was determined to be high (3 or 4) in 13 cases and low (1) in only 1 mandibular case. All patients underwent surgical resection and immediate reconstruction. Adjuvant therapy included postoperative radiation (5 patients), postoperative chemotherapy (2 patients), and preoperative chemotherapy and postoperative radiation (1 patient). CONCLUSIONS: The results of the present study support the literature indicating that osteosarcoma of the jaw differs from osteosarcoma of the long bones in its biological behavior even though they have the same histologic appearance. Because of differences in tumor characteristics, the introduction of chemotherapy did not dramatically alter the prognosis of osteosarcoma of the jaw. Early diagnosis and radical surgery are the keys to high survival rates.

Temporalis myofascial flap in maxillofacial reconstruction: clinical and histological studies of the oral healing process.

OBJECTIVES: To report our experience with temporalis myofascial flaps (TMF), describe the healing process of uncovered flaps in the mouth, and the histology of the repaired mucosa in the long term. DESIGN: Prospective clinical and histological study. SUBJECTS: 36 patients who received a TMF over a 6.5 year period for serial assessment of the oral healing, 24 patients whose scars over the reconstructed area were assessed clinically, and 11 whose repaired mucosa was assessed histologically. MAIN OUTCOME MEASURES: To follow the clinical process of oral healing of the TMF and describe the repaired mucosa healed over the flap. RESULTS: The uncovered TMF in the mouth healed gradually starting with an acute inflammatory phase, going through chronic inflammatory and proliferative phases with eventual epithelialisation of the oral mucosa. There were no major complications. The healed mucosa showed mild scarring in 70% of cases and the repaired mucosa had characteristic histological features that were distinct from the normal mucosa. CONCLUSION: The TMF is an extremely reliable and versatile flap for maxillofacial reconstruction which heals gradually with eventual coverage by mildly scarred repaired mucosa.

A new submerged split-thickness skin graft technique to rebuild peri-implant keratinized soft tissue in composite flap reconstructed mandible or maxilla.

OBJECTIVE: The objective of this study was to introduce our preliminary experience on a submerged split-thickness skin graft (STSG) technique combined with secondary vestibuloplasty to rebuild keratinized peri-implant soft tissue and oral vestibule for patients with large oromandibular defects reconstructed by composite flaps. PATIENTS AND METHODS: Five patients were enrolled in this study. Stage 1 was submerged STSG and simultaneous implant placement. Stage 2 was the uncovering of the STSG and vestibuloplasty. The implant-borne fixed denture was inserted after this 2-stage treatment. All patients were followed for at least 12 months (average 18 months). RESULT: Eighteen implants were placed. The rebuilt peri-implant keratinized soft tissue was healthy clinically. The STSG graft had firm adherence to the underlying periosteum. The vestibule had adequate depth to maintain local hygiene. All implants were osseointegrated and all implant-borne prostheses were functioning well. CONCLUSION: Submerged STSG technique combined with secondary vestibuloplasty may become a feasible and effective solution to rebuild keratinized soft tissue before dental implant restoration.

Rehabilitation using immediate loading in patients with partial resection of the jaw

ABSTRACT: Ameloblastoma is a rare tumor that affects the maxillomandibular region. Surgical resection is often indicated, and oral rehabilitation becomes a challenge. This study aims to report on the mandibular rehabilitation with implant supported prosthesis using immediate loading with subsequent resection. A patient with a confirmed diagnosis of multicystic ameloblastoma in the left jaw underwent a partial resection of the mandible and a reconstruction with a titanium plate. After 2 years of follow-up with clinical examinations and imaging testing and with no signs of recurrence, the patient underwent the technique of immediate load implants, rehabilitating the mandible with an implant supported fixed prosthesis and the maxilla with a conventional complete denture. During the seven years of follow-up with the patient, there was no sign of recurrence of ameloblastoma. The rehabilitation with oral implants under immediate loading demonstrated to be successful, and the cemented cylinder technique used in this study coupled with passivity showed a favorable prognosis for the longevity of implants.

Oral rehabilitation with dental implants after cancer treatment.

BACKGROUND: Patients who undergo surgical management of oral cancer may greatly benefit from an implant-supported prosthesis. This study reports on the clinical experience of dental implant placement in patients following resection of oral cancer over a 15-year period. Controversies including the use of dental implants in irradiated tissues, and hyperbaric oxygen treatment will also be discussed. METHODS: Thirty-one patients who had dental implants placed as part of their oral rehabilitation between 1992 and 2007 were investigated. Demographic data and factors including implant survival, type of prosthesis provided, radiotherapy and the hyperbaric oxygen therapy were analysed. RESULTS: In this retrospective study, there was a retention rate of 110 implants from a total of 115 implants placed. A high rate of implant retention was found, with 5 implant failures from a total of 115 implants placed. The 5 failed implants occurred in free flap bone that had been irradiated. CONCLUSIONS: Dental implants provide an important role in the oral rehabilitation of oral cancer patients. There may be an increased risk of implant failure in free flap bone that has been irradiated.