Is immediate dental implant in fibula free flap beneficial for implant survival and osteoradionecrosis in jaw reconstruction?

OBJECTIVES

This study aimed to compare the risk of osteoradionecrosis and implant survival in oral cancer patients undergoing immediate dental implants during jaw reconstruction, termed "Jaw in a Day" (JIAD), with those receiving no implants or delayed implants (non-JIAD).

PATIENTS & METHODS

Clinicopathologic data were collected from prospectively enrolled JIAD patients (n = 10, 29 implants) and retrospectively from non-JIAD patients (n = 117, 86 implants). Survival analyses were performed to assess implant survival and osteoradionecrosis-free survival.

RESULTS

Osteoradionecrosis occurred in 0 % of JIAD cases compared to 19.3 % in non-JIAD cases without implants and 71.4 % in non-JIAD cases with delayed implants (p = 0.008). Osteoradionecrosis-free survival was significantly better in the JIAD group than the non-JIAD group (p = 0.0059). Implants in the JIAD group all survived regardless of radiation therapy (29/29, 100 %) and 95.1 % (58/61) of implants survived in delayed implants in non-irradiated fibula without radiotherapy. Meanwhile, only 11 of 25 implants placed in irradiated fibula flaps survived, even when the implants were placed after a median time interval of 624 days after radiotherapy, and none of them were earlier than 360 days. The survival analysis revealed a significant difference (p < 0.0001).

CONCLUSION

JIAD appears to offer superior outcomes in terms of implant survival and osteoradionecrosis prevention compared to delayed implant placement. Placing implants in irradiated fibula, even after years, significantly poses high risk of implant failure and osteoradionecrosis. JIAD represents a promising approach for optimal rehabilitation, particularly in oral cancer patients requiring postoperative radiotherapy. Proper positioning and orientation of implants and flaps are crucial for implant survival.

Long-term outcomes in virtual surgical planning for mandibular reconstruction: A cost-effectiveness analysis

OBJECTIVE

This study is an economic evaluation comparing virtual surgical planning (VSP) utilization to free hand mandibular reconstruction (FHR) for advanced oral cavity cancer, for which the cost effectiveness remains poorly understood. The proposed clinical benefits of VSP must be weighed against the additional upfront costs.

METHODS

A Markov decision analysis model was created for VSP and FHR based on literature review and institutional data over a 35-year time horizon. Model parameters were derived and averaged from systematic review and institutional experience. VSP cost and surgical time saving was incorporated. We accounted for long-term risks including cancer recurrence and hardware failure/exposure. We calculated cost in US dollars and effectiveness in quality-adjusted-life-years (QALYs). A health care perspective was adopted, discounting costs and effectiveness at 3%/year. Deterministic and probabilistic sensitivity analyses tested model robustness.

RESULTS

In the base case scenario, total VSP strategy cost was $49,498 with 8.37 QALYs gained while FHR cost was $42,478 with 8.27 QALY gained. An incremental cost-effectiveness ratio (ICER), or the difference in cost/difference in effectiveness, for VSP was calculated at $68,382/QALY gained. VSP strategy favorability was sensitive to variations of patient age at diagnosis and institutional VSP cost with one-way sensitivity analysis. VSP was less economically favorable for patients >75.5 years of age or for institutional VSP costs >$10,745. In a probabilistic sensitivity analysis, 55% of iterations demonstrated an ICER value below a $100,000/QALY threshold.

CONCLUSIONS/RELEVANCE

VSP is economically favorable compared to FHR in patients requiring mandibular reconstruction for advanced oral cancer, but these results are sensitive to the patient's age at diagnosis and the institutional VSP cost. Our results do not suggest if one "should or should not" use VSP, rather, emphasizes the need for patient selection regarding which patients would most benefit from VSP when evaluating quality of life and long-term complications. Further studies are necessary to demonstrate improved long-term risk for hardware failure/exposure in VSP compared to FHR.

Long-term survival and success rate of dental implants placed in reconstructed areas with extraoral autogenous bone grafts: A systematic review and meta-analysis

OBJECTIVE

To evaluate the long-term survival and success rates of implants placed in reconstructed areas using microvascularized or non-microvascularized extraoral bone grafts.

MATERIALS AND METHODS

An electronic search was performed in five databases and in gray literature for articles published until June, 2023. The eligibility criteria comprised observational studies (prospective or retrospective) and clinical trials, reporting survival and success rates of implants placed in extraoral bone grafts. A meta-analysis (implant failure) was categorized into subgroups based on the type of bone graft used. The risk of bias within studies was assessed using the Newcastle-Ottawa Scale.

RESULTS

Thirty-one studies met the inclusion criteria. The mean follow-up time was 92 months. The summary estimate of survival rate at the implant level were 94.9% (CI: 90.1%-97.4%) for non-vascularized iliac graft, 96.5% (CI: 91.4%-98.6%) for non-vascularized calvaria graft, and 92.3% (CI: 89.1%-94.6%) for vascularized fibula graft. The mean success rate and marginal bone loss (MBL) were 83.2%; 2.25 mm, 92.2%; 0.93 mm, and 87.6%; 1.49 mm, respectively.

CONCLUSIONS

Implants placed in areas reconstructed using extraoral autogenous bone graft have high long-term survival rates and low long-term MBLs. The data did not demonstrate clinically relevant differences in the survival, success, or MBL of grafts from different donor areas or with different vascularization. This systematic review was registered in INPLASY under number INPLASY202390004.

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.

Oral rehabilitation and associated quality of life following mandibular reconstruction with free fibula flap: a cross-sectional study

Introduction

Mandibular reconstruction with the free fibula flap (FFF) has become a standardized procedure. The situation is different with oral rehabilitation, so the purpose of this study was to investigate the frequency of implant placement and prosthetic restoration. Additionally, the patients' situation, motivation, and treatment course were structurally assessed.

Materials and methods

All cases between January 2013 and December 2018 that underwent mandibular reconstruction in our department with a free fibula flap and gave written informed consent to participate were interviewed with two structured questionnaires about their restoration and quality of life. Additionally, medical records, general information, status of implants and therapy, and metric analyses of the inserted implants were performed.

Results

In total 59 patients were enrolled and analyzed in this monocentric study. Overall, oral rehabilitation was achieved in 23.7% at the time of investigation. In detail, implants were inserted in 37.3% of patients and showed an 83.3% survival of dental implants. Of these implanted patients, dental implants were successfully restored with a prosthetic restoration in 63.6. Within this subgroup, satisfaction with the postoperative aesthetic and functional result was 79.9% and with the oral rehabilitation process was 68.2%. Satisfaction with the implant-borne prosthesis was 87.5%, with non-oral-squamous-cell-carcinoma patients being statistically significantly more content with the handling (p=0.046) and care (p=0.031) of the prosthesis.

Discussion

Despite the well-reconstructed bony structures, there is a need to increase the effort of achieving oral rehabilitation, especially looking at the patient's persistent motivation for the procedure.

Outcomes and influencing factors of dental implants in fibula, iliac crest, and scapula free flaps: a retrospective case-control study

PURPOSE

Reconstruction with vascularized bone grafts after ablative surgery and subsequent dental rehabilitation with implants is often challenging; however, it helps improve the patient's quality of life. This retrospective case-control study aimed to determine the implant survival/success rates in different vascularized bone grafts and potential risk factors.

METHODS

Only patients who received implants in free vascularized bone grafts between 2012 and 2020 were included. The free flap donor sites were the fibula, iliac crest, and scapula. The prosthetic restoration had to be completed, and the observation period had to be over one year after implantation. Implant success was defined according to the Health Scale for Dental Implants criteria.

RESULTS

Sixty-two patients with 227 implants were included. The implant survival rate was 86.3% after an average of 48.7 months. The causes of implant loss were peri-implantitis (n = 24), insufficient osseointegration (n = 1), removal due to tumor recurrence (n = 1), and osteoradionecrosis (n = 5). Of all implants, 52.4% were classified as successful, 19.8% as compromised, and 27.8% as failed. Removal of osteosynthesis material prior to or concurrent with implant placement resulted in significantly better implant success than material not removed (p = 0.035). Localization of the graft in the mandibular region was associated with a significantly better implant survival (p = 0.034) and success (p = 0.002), also a higher Karnofsky Performance Status Scale score with better implant survival (p = 0.014).

CONCLUSION

Implants placed in vascularized grafts showed acceptable survival rates despite the potential risk factors often present in these patient groups. However, peri-implantitis remains a challenge.

Meta-analysis of the survival rate and postoperative infection rate of primary and secondary implants after vascularized fibula transplantation for reconstruction of jaw defects

OBJECTIVES

Vascularized fibula flap transplantation is the most effective and common method to repair the jaw defects. In addition, implantation is the first choice to restore dentition on the graft fibula. Implants are usually implanted at least 6 months after fibula transplantation. Primary implantation of implants during surgery can restore the dentition earlier, but whether this method can achieve the same restorative effect as secondary implantation is still uncertain. This article aims to compare the survival rate and complications between primary and secondary implantation through meta-analysis.

METHODS

This meta-analysis was conducted according to PRISMA protocol and the Cochrane Handbook of Systematic Reviews of Interventions. According to the inclusion and exclusion criteria, we selected the PubMed, Embase, Web of Science, Cochrane Library, Chinese National Knowledge Infrastructure (CNKI), Chinese BioMedical Literature Database (CBM) according to established inclusion and exclusion criteria. The Newcastle-Ottawa Scale (NOS) was used to assess the quality of the included studies. Meta-analysis was conducted to compare the survival rate and postoperative infection rate of primary and secondary implantation.

RESULTS

Seven studies were involved in our research, involving 186 patients. Five of the studies detailed implant success in 106 patients (primary implantation 50, secondary implantation 56), and four studies documented infection after implantation in 117 patients (primary implantation 52, secondary implantation 65); the survival rate of the primary implantation was 93.3%, and the incidence of postoperative infection was 17.3%. The survival rate of the secondary implantation was 93.4%, and 23.1% had postoperative infection. Meta-analysis showed that there was no significant difference in the survival rate between primary implantation and secondary implantation, OR = 0.813 (95% CI 0.383-1.725, P = 0.589 > 0.05), and there was no significant difference in the incidence of postoperative infection, OR = 0.614 (95% CI 0.239-1.581, P = 0.312 > 0.05).

CONCLUSIONS

Based on the results of this study, the research found no significant difference in the survival rate or infection rates between primary and secondary implantation. After appropriate indications selection, primary implantation can be used to reconstruct the dentition with less waiting time, reduce the impact of radiotherapy, and bring a higher quality of life for patients.

Clinical outcomes and periodontal conditions of dental implants placed in free fibula flaps (FFF): a retrospective study with a mean follow-up of 6 years

OBJECTIVES

Up-to-date literature regarding long-term success of implant rehabilitations after microvascular reconstructions with free fibula flap (FFF) is still very scarce. This study aimed to evaluate clinical outcomes, especially related to oral hygiene conditions, of patients rehabilitated with this technique.

MATERIALS AND METHODS

A total of 25 patients who underwent maxillofacial reconstructive surgery with FFF were retrospectively evaluated for soft tissues conditions, oral hygiene habits, and implant survival and success, assessed with a mean follow-up of 6 (range 2-15) years after loading.

RESULTS

Fourteen patients received full-arch fixed prostheses and 11 removable bar-supported overdentures. At the follow-up evaluation, 52% of prostheses did not allow proper accessibility for oral hygiene. Overall prosthetic survival was 100%, and implant survival and success were respectively 93.6% and 72%. Prevalence of peri-implantitis was 29% at implant level and that at patient level 96%.

CONCLUSIONS

Six-year clinical outcomes of this study reveal that poor oral hygiene practices and compliance by patients who underwent maxillofacial reconstruction with FFF are significantly associated with peri-implant disease.

CLINICAL RELEVANCE

Findings of the present study underline the need by clinicians for a careful assessment, in reference to a specific implant therapy, of patient's prosthetic accessibility for oral hygiene procedures.

The Implant-borne Articulation Splint in Fibula Free Flap Mandibular Reconstruction: A Technical Note

Computer-aided design and computer-aided manufacturing and digitally simulated surgeries have revolutionized maxillomandibular reconstruction. In particular, this technology has increased the accuracy and facilitated the process of dental implantation in fibula free flaps. Despite the efficacy of virtual planning, there is a minor degree of translational difference between digital and intraoperative measurements, which may affect the precision of implant and fibula orientations. This is especially concerning during the last stage of fibula insetting, where the graft segments have the potential to roll, yaw, or pitch. The objective of this study is to describe an advanced prosthodontic technique that ensures the fibula grafts and implants remain in a restorable position during final insetting. We describe the technique and workflow of the implant-borne articulation splint through a case presentation and demonstrate results at 4 months postoperative and postradiotherapy. Given the degree of investment placed in virtual planning, free flap reconstruction, and endosteal implants, a technique that ensures optimal restorability of each implant is pivotal. Larger studies are still required to fully elucidate the cost-effectiveness and long-term results of the implant-borne articulation splint.

Bone Tissue Engineering (BTE) of the Craniofacial Skeleton, Part I: Evolution and Optimization of 3D-Printed Scaffolds for Repair of Defects

Bone tissue regeneration is a complex process that proceeds along the well-established wound healing pathway of hemostasis, inflammation, proliferation, and remodeling. Recently, tissue engineering efforts have focused on the application of biological and technological principles for the development of soft and hard tissue substitutes. Aim is directed towards boosting pathways of the healing process to restore form and function of tissue deficits. Continued development of synthetic scaffolds, cell therapies, and signaling biomolecules seeks to minimize the need for autografting. Despite being the current gold standard treatment, it is limited by donor sites' size and shape, as well as donor site morbidity. Since the advent of computer-aided design/computer-aided manufacturing (CAD/CAM) and additive manufacturing (AM) techniques (3D printing), bioengineering has expanded markedly while continuing to present innovative approaches to oral and craniofacial skeletal reconstruction. Prime examples include customizable, high-strength, load bearing, bioactive ceramic scaffolds. Porous macro- and micro-architecture along with the surface topography of 3D printed scaffolds favors osteoconduction and vascular in-growth, as well as the incorporation of stem and/or other osteoprogenitor cells and growth factors. This includes platelet concentrates (PCs), bone morphogenetic proteins (BMPs), and some pharmacological agents, such as dipyridamole (DIPY), an adenosine A 2A receptor indirect agonist that enhances osteogenic and osteoinductive capacity, thus improving bone formation. This two-part review commences by presenting current biological and engineering principles of bone regeneration utilized to produce 3D-printed ceramic scaffolds with the goal to create a viable alternative to autografts for craniofacial skeleton reconstruction. Part II comprehensively examines recent preclinical data to elucidate the potential clinical translation of such 3D-printed ceramic scaffolds.

Full Digital Workflow for Mandibular Ameloblastoma Management: Showcase for Technical Description

This is a showcase for technical description of a full digital workflow aimed to reconstruct and prosthetically rehabilitate the mandible after surgical resection. The surgery was performed following a computer-aided design and computer-aided manufacturing (CAD-CAM) guided workflow, using 3D reconstruction of the mandible and the fibula. After 2 years, when the ossification of the flap was reached and verified by a computed tomography (CT) scan, surgery was performed using a two-step implant rehabilitation, with successful outcomes.

Outcomes of immediate dental implants in vascularised bone flaps for mandibular reconstruction

BACKGROUND

The aim of this study is to assess the outcomes of immediate implant placement for dental rehabilitation following mandibular reconstruction with vascularised bone flaps in a single Australian tertiary cancer centre.

METHODS

A retrospective analysis of patients who underwent immediate dental implant or delayed placement in vascularised bone flaps was performed. Primary outcome measures assessed included the number of implants placed, operative time, complication rates, time to radiotherapy initiation, dental rehabilitation rates and time to dental rehabilitation.

RESULTS

In total, 187 dental implants were placed in 52 patients, of which 34 patients underwent immediate implant placement and 18 had delayed implant placement. There were no significant differences in the postoperative complication rate (32% immediate vs. 33% delayed, P = 0.89) or time to postoperative radiotherapy (median 42 days immediate vs. 47 days delayed, P = 0.24). Dental rehabilitation was achieved in 62% of the immediate cohort versus 78% of the delayed cohort. The time to be fitted with a dental prosthesis was significantly shorter in the immediate cohort (median 150 days immediate vs. 843 days delayed, P = 0.002).

CONCLUSIONS

The placement of immediate dental implants at the time of primary reconstruction of the mandible is a safe procedure and facilitates timely dental rehabilitation.

Application of a vascularized bone free flap and survival rate of dental implants after transplantation: A systematic review and meta-analysis

PURPOSE

As maxillofacial surgical techniques have advanced, vascularized bone free flap transplantation has become the standard treatment for repairing maxillofacial defects. In this meta-analysis, we summarize the survival rates of implants after VBFF surgery for maxillary and mandibular reconstructions and investigate the factors affecting patient outcomes.

METHODS

The PubMed, Embase, and Wanfang databases were searched up to May 31, 2022. The results of the treatment effect are presented as the risk ratio or odds ratio, using 95% confidence intervals. Statistical significance was calculated at α = 0.05 (two-tailed z tests).

RESULTS

35 studies were included in our analysis. The results revealed a 3-year and 5-year implant survival rate of 95.2% and 85.4% in VBFFs, respectively. The location of jaw defects (maxilla or mandible) or timing of implantation was not found to have a statistically significant influence on the survival rate. However, statistically significant differences were observed in the failure of implants placed in irradiated bone tissue.

CONCLUSIONS

Statistically significant differences were not found in the implant survival rate between simultaneous and delayed implantation, or between maxillary and mandibular defects. However, dental implants placed in irradiated flaps tended to have a lower survival rate than those surgically placed in non-irradiated flaps.

Novel and accurate 3D-Printed surgical guide for mandibular reconstruction with integrated dental implants

PURPOSE

Patients with mandibular defects due to trauma or infiltrated disease are in a need of functional mandibular implants that will completely restore the function of their lower jaw. One of the most important roles of well-functioning jaw is mastication, a complex mechanism. A conventional approach used in oral and maxillofacial surgery accomplish this aim via two major surgeries- mandibular reconstruction and surgical placement of dental implants. Little work has been done on combining the two surgeries into with using Additive Manufacturing (AM) and digital planning.

MATERIAL AND METHODS

This case study offers a mandibular implant design solution with pre-positioned dental implants that can reduce the requirement to only one surgery. Mandibular implant was designed using 3-Matic software (Materialise, Belgium). Positions for dental implants were restoratively-driven and planned on the designed mandibular implant in Blue Sky Plan 4 software (Blue Sky Bio, USA) and placed prior to mandibular reconstruction using a 3D-printed surgical guide. Finite Element Analysis (FEA) was used to evaluate the mechanical behaviour of the 3D-printed surgical guide during dental implant placement.

RESULTS

The surgical guide was fabricated using SLA and stress distribution was evaluated in ANSYS Workbench FEM software (Ansys Inc Swanson, Houston, USA). Results showed that the designed surgical guide can withstand the forces occurring during the surgery.

CONCLUSION

The proposed method substantially reduces the surgical procedure and recovery time, increases the accuracy, and allows for a predictable restorative solution that can be visualised from the beginning.

Survival of Dental Implants on Irradiated Jaws: A Systematic Review and Meta-analysis

Objectives

Dental implants play a significant role in functional rehabilitation of the oral cavity after debilitating jaw surgeries for oral cavity cancers followed by radiotherapy.

Design

The meta-analysis was done using Preferred Reporting Items for Systematic Review (PRISMA) guidelines published from January 1947 till August 2020. Twenty three articles consisting of 1246 participants with 4838 implants were included in our analysis.

Results

The mean age of the included participants was 51.4 years. 2186 and 1685 implants were placed on irradiated and non-irradiated jaws and showed a success rate of 82.47% and 89.37% respectively. Correspondingly, publication bias of p value = 0.2129 and p-value = 0.6525 was found by Egger's and Begg's test respectively for pooled data of 16 studies. The implant success rate of 70.4% on maxillary bone and 94.5% were observed on mandibular bone. Timing of implant placement and its influence on survival rate have resulted in a 75.5% survival rate of dental implants when placed primarily in comparison with 87.7% on delayed placement. The waiting interval of 14 months in delayed implant placement has shown better results.

Conclusion

Presence of radiotherapy does not play a significant role in the success rate of dental implants in oral cavity cancers. However, delayed implant placement may have a better chance of survival.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12663-022-01686-6.

The role of computer aided design/computer assisted manufacturing (CAD/CAM) and 3- dimensional printing in head and neck oncologic surgery: A review and future directions

Microvascular free flap reconstruction has remained the standard of care in reconstruction of large tissue defects following ablative head and neck oncologic surgery, especially for bony structures. Computer aided design/computer assisted manufacturing (CAD/CAM) and 3-dimensionally (3D) printed models and devices offer novel solutions for reconstruction of bony defects. Conventional free hand techniques have been enhanced using 3D printed anatomic models for reference and pre-bending of titanium reconstructive plates, which has dramatically improved intraoperative and microvascular ischemia times. Improvements led to current state of the art uses which include full virtual planning (VP), 3D printed osteotomy guides, and patient specific reconstructive plates, with advanced options incorporating dental rehabilitation and titanium bone replacements into the primary surgical plan through use of these tools. Limitations such as high costs and delays in device manufacturing may be mitigated with in house software and workflows. Future innovations still in development include printing custom prosthetics, 'bioprinting' of tissue engineered scaffolds, integration of therapeutic implants, and other possibilities as this technology continues to rapidly advance. This review summarizes the literature and serves as a summary guide to the historic, current, advanced, and future possibilities of 3D printing within head and neck oncologic surgery and bony reconstruction. This review serves as a summary guide to the historic, current, advanced, and future roles of CAD/CAM and 3D printing within the field of head and neck oncologic surgery and bony reconstruction.

Bone Augmentation for Implant Placement: Recent Advances

There are various advancements in biomaterials and methods for bone augmentation. This article aims to review the recent advances in bone augmentation for dental implants. Relevant articles on bone augmentation for dental implants were searched in PubMed/Medline, Scopus, Google Scholar, and Science Direct published in English literature published between January 1996 and March 2021. Relevant studies on bone grafts for dental implants were included and critically analyzed in this review. Various biomaterials can be used to augment bone for implant placement. Each graft procedure has advantages and disadvantages in each clinical application and needs to choose the graft material with a high success rate and less morbidity.

Double-Barrel Versus Single-Barrel Fibula Flaps for Mandibular Reconstruction: Safety and Outcomes

OBJECTIVES/HYPOTHESIS

Fibula flaps are routinely used for osseous reconstruction of head and neck defects. However, single-barrel fibula flaps may result in a height discrepancy between native mandible and grafted bone, limiting outcomes from both an aesthetic and dental standpoint. The double-barrel fibula flap aims to resolve this. We present our institution's outcomes comparing both flap designs.

STUDY DESIGN

Retrospective cohort study.

METHODS

We conducted a retrospective review of all patients undergoing free fibula flap mandibular reconstruction at our institution between October 2008 and October 2020. Patients were grouped based on whether they underwent single-barrel or double-barrel reconstruction. Postoperative outcomes data were collected and compared between groups. Differences in categorical and continuous variables were assessed using a Chi-square test or Student's t-test, respectively.

RESULTS

Out of 168 patients, 126 underwent single-barrel and 42 underwent double-barrel reconstruction. There was no significant difference in postoperative morbidity between approaches, including total complications (P = .37), flap-related complications (P = .62), takeback to the operating room (P = .75), flap salvage (P = .66), flap failure (P = .45), and mortality (P = .19). In addition, there was no significant difference in operative time (P = .86) or duration of hospital stay (P = .17). After adjusting for confounders, primary dental implantation was significantly higher in the double-barrel group (odds ratio, 3.02; 95% confidence interval, 1.2-7.6; P = .019).

CONCLUSION

Double-barrel fibula flap mandibular reconstruction can be performed safely without increased postoperative morbidity or duration of hospital stay relative to single-barrel reconstruction. Moreover, the double-barrel approach is associated with higher odds of primary dental implantation and may warrant further consideration as part of an expanded toolkit for achieving early dental rehabilitation.

LEVEL OF EVIDENCE

III Laryngoscope, 2021.

The Effect of Patient Specific Factors on Occlusal Forces Generated: Best Evidence Consensus Statement

PURPOSE

The purpose of this Best Evidence Consensus Statement was to search the literature to determine if there is a relationship between patient specific factors and occlusal force.

MATERIALS AND METHODS

A literature review was conducted in the following databases: Evidence-Based Medicine Reviews (EBMR), Cochrane Database of Systematic Reviews, Embase, and Ovid MEDLINE(R) and Epub Ahead of Print. Articles on patient factors and occlusal force were compiled by using a combination of the key words: "bite force," "occlusal force," "partial and complete edentulism," "bruxism," and "orthognathic class." Inclusion criteria included meta-analyses, systematic reviews, randomized controlled trials, case series, and journal articles. Exclusion criteria were case reports, studies in children, animals, and bench studies.

RESULTS

Of the 1502 articles that met the initial search criteria, 97 related to patient-specific factors affecting occlusal forces. These articles were evaluated, rated, and organized into appropriate categories addressing questions of foci.

CONCLUSIONS

The range of occlusal force is highly variable among subjects correlated to patient specific factors such as age, gender, partial and complete edentulism, the presence of a maxillofacial defect, location of edentulous area, orthognathic profile, and magnitude of occlusal vertical dimension. Tooth replacement therapies targeted at increasing occlusal contact seem to have a positive effect on increasing occlusal force. Bruxism does not necessarily demonstrate higher occlusal powering but may have greater tooth contact time. Occlusal force is not clearly affected by the type of dental restoration or restorative material used. The clinical significance of the changes in occlusal forces is yet to be determined.

Immediate implant placement in edentulous oral cancer patients: a long-term retrospective analysis of 207 patients

Although the functional benefits of implants in the rehabilitation of edentulous cancer patients are well-known, most studies report on postponed implant placement. The outcome of immediate implant placement regarding successful rehabilitation, implant loading and survival is unclear. Two hundred and seven edentulous oral cancer patients that received implants during ablative surgery at the Radboud University Medical Centre between 2000 and 2011 were included. Data regarding the oncological treatment, implant placement, follow-up and prosthodontic rehabilitation were recorded retrospectively with a follow-up period of 5-17 years. Functioning implant-retained dentures were made in 73.9% of the patients. Of the surviving patients, 81.9% had functioning dentures after 2 years and 86.3% after 10 years. Patients with ASA score 1 and younger patients were rehabilitated more frequently. The median time of functioning denture placement was 336 days after surgery, with a negative influence of postoperative radiotherapy. Implant survival was 90.7%, and was lower when the implant was placed in a jaw involved in the tumour. Immediate implant placement during oral cancer surgery led to a high number of edentulous patients rehabilitated with implant-retained dentures, which are placed at an early time.

Short-Term Outcomes following Virtual Surgery-Assisted Immediate Dental Implant Placement in Free Fibula Flaps for Oncologic Mandibular Reconstruction

BACKGROUND

Despite reports demonstrating feasibility of immediate dental implant placement in mandibular reconstruction with free fibula flaps for benign disease, this practice is not routinely used in the oncologic setting. The authors aim to demonstrate the safety of immediate dental implant placement for oncologic mandible reconstruction.

METHODS

In 2017, the authors' center began immediate dental implant placement in free fibula flaps for oncologic patients undergoing mandibulectomy reconstruction. Immediate dental implant placement patients were compared to a historical cohort also reconstructed with computer-aided design and manufacturing technology beginning in 2011 (n = 34) as a noninferiority study design. Primary outcomes of interest included 90-day complications, time to radiotherapy, and time to and number of patients achieving dental restoration.

RESULTS

Sixty-one patients underwent free fibula flaps following mandibulectomy using computer-aided design and manufacturing. Seventy-two dental implants were placed in the immediate dental implant placement cohort (n = 27). No differences were noted in major or minor 90-day complications between groups (p > 0.05). Radiotherapy was required in 55 percent in the immediate dental implant placement cohort versus 62 percent in the historical cohort, with no significant difference in time to radiotherapy (67.6 days versus 62.2 days, respectively). One dental implant was removed for nonosseointegration noted during vestibuloplasty. Fourteen (51.8 percent) immediate dental implant patients had complete dental restoration at 90 days compared with none in the historical cohort (p < 0.05).

CONCLUSIONS

Immediate dental implant placement is a safe procedure with an unchanged short-term complication profile and no delay in radiotherapy initiation. Patients undergoing immediate dental implant placement are more likely to complete full dental rehabilitation. Long-term and health-related quality-of-life outcomes remain to be determined.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

"Three-in-one" patient-specific surgical guides for simultaneous dental implants in fibula flap jaw reconstruction: A prospective case series

BACKGROUND

Conventional freehand immediate placement of dental implants is technically challenging in the jaw reconstructive surgery. Computer-aided surgery might be the best solution, however, there has not been any standard approach to ensure the accuracy and efficiency of simultaneous dental implants in fibula flap jaw reconstruction.

PURPOSE

We aim to evaluate the clinical outcome of simultaneous dental implant in fibula flap using the "three-in-one" patient-specific surgical guide (3-in-1-PSSG) in an open-label, prospective, single-arm, and single-center clinical trial.

MATERIALS AND METHODS

A novel computer-aided designed and three-dimensional (3D) printed 3-in-1-PSSG, which contains functions of fibula segmentation, surgical plate positioning and implant placement, was used to facilitate the reconstructive surgery and simultaneous dental implant placement. The intraoperative success of dental implant placement, implant survival rate and accuracy of dental implant placement were reported.

RESULTS

From November 2018 to June 2020, 15 consecutive patients with 48 dental implants were enrolled in this study. Fifteen 3-in-1-PSSGs were fabricated with a mean number of dental implants per guide of 3.2 ± 1.5. The intraoperative success rate of this approach was 14 out of 15. With an average follow-up period of 40 weeks, the overall implant survival rate was 83.3% (40/48). Eight implants were removed due to two fibula flap failures. The mean deviation at the implant platform and implant apex were 2.8 mm (interquartile range [IQR]: 1.9-3.4) and 3.2 mm (IQR: 2.0-4.6), and the angular deviation was 2.5° (IQR: 1.1-6.8).

CONCLUSIONS

Our preliminary data indicated that the 3D printed 3-in-1-PSSG facilitated simultaneous dental implant in fibula flap jaw reconstruction with a favorable intraoperative success and short-term clinical outcome. It might be a viable alternative to allow one-step immediate oral rehabilitation in patients underwent jaw reconstruction with free flaps. Long-term results with a larger sample size are warranted.

Management of an Imminent Pathological Fracture of a Fibular Neomandible Via a Minimally Invasive Approach-A Case Report

Fibular free flap reconstruction remains the workhorse of postmandibulectomy reconstruction. Dental implantation to support a dental prosthesis is a sought-after outcome when the area of resection involves tooth-bearing zones. Chronic perisoft tissue pedicle hyperplasia with secondary infection leading to gradual bone loss is a simple complication to manage in the general population, but it becomes a serious issue in the fibula mandibular reconstruction patient in that it can lead to pathological fracture of the fibula. A case of a patient with a near fracture of his fibula mandibular reconstruction, and its management via a minimally invasive approach is presented.

Dental Implant Survival in Vascularized Bone Flaps: A Systematic Review and Meta-Analysis

BACKGROUND

Maxillofacial reconstruction with vascularized bone restores facial contour and provides structural support and a foundation for dental rehabilitation. Routine implant placement in such cases, however, remains uncommon. This study aims to determine dental implant survival in patients undergoing vascularized maxillary or mandibular reconstruction through a systematic review of the literature.

METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, the literature was queried for implant placement in reconstructed jaws using Medical Subject Headings terms on PubMed, Embase, and Cochrane platforms. Weighted implant survivals were calculated for the entire cohort and subcohorts stratified by radiotherapy. Meta-analyses were performed to estimate effect of radiation on implant osseointegration.

RESULTS

Of 3965 publications identified, 42 were reviewed, including 1084 patients with 3636 dental implants. Weighted implant survival was 92.2 percent at a median follow-up of 36 months. Survival was 97.0 percent in 269 implants placed immediately in 60 patients versus 89.9 percent in 1897 delayed implants placed in 597 patients, with follow-up of 14 and 40 months, respectively. Dental implants without radiotherapy exposure had better survival than those exposed to radiation (95.3 versus 84.6 percent; p < 0.01) at a median follow-up of 36 months. Meta-analyses showed that radiation significantly increased the risk of implant failure (risk ratio, 4.74; p < 0.01) and suggested that implants placed before radiotherapy trended toward better survival (88.9 percent versus 83.4 percent, p = 0.07; risk ratio, 0.52; p = 0.14).

CONCLUSIONS

Overall implant survival was 92.2 percent; however, radiotherapy adversely impacted outcomes. Implants placed before radiotherapy may demonstrate superior survival than implants placed after.

Application of optimized digital surgical guides in mandibular resection and reconstruction with vascularized fibula flaps: Two case reports

RATIONALE

Currently, digital surgical techniques have been widely used in the precise treatment of mandibular resection and reconstruction with fibula flaps. Utilizing these innovative techniques in surgical planning and hardware fabrication before surgery has shown to provide great help. However, it is difficult for even experienced surgeons to place the preformed reconstruction plate in the same position as its preoperative design, causing surgical results to differ from preoperative planning. This study aims to solve these acknowledged challenges by creating newly designed equipment.

PATIENT CONCERNS

Two patients suffering from long-term expansion of the mandible were admitted to our department. Case I was a 39-year-old female patient who was concerned about the disease in the middle of the mandible, Case II was a 45-year-old female patient who was concerned about the disease at the left mandibular angle and ramus region.

DIAGNOSES

Two patients were diagnosed with the mandibular ameloblastoma based on computed tomography (CT) scan and pathological results.

INTERVENTIONS

Personalized 3-dimensional (3D) surgical guides were applied to 2 patients with mandibular ameloblastoma who underwent mandibular resection and reconstruction with vascularized fibula flaps using a specially optimized and designed reconstruction guide plate.

OUTCOMES

We achieved precise mandibular repair with such a guide in full accordance with the preoperative plan and ensured the restoration of patient facial symmetry.

LESSONS

Optimized reconstruction guide template could accurately locate the preformed reconstruction plate. This component had the ability to ensure that the location of the actual reconstruction plates were highly consistent with preoperative designed models.

Delayed Reconstruction of Palatomaxillary Defect Using Fibula Free Flap

Introduction. The objective of this study was to evaluate a surgical technique and to present the results of delayed reconstruction of palatomaxillary defects using fibula free flap (FFF). Methods. A review was conducted for nine patients who underwent palatomaxillary reconstruction using FFF. Primary disease, type of reconstruction, defect area, fibula segment length and number of osteotomies, radiotherapy, and implant installation after FFF reconstruction were analyzed. Results. All nine patients underwent delayed reconstruction. The fibula shaft was osteotomized into two segments in seven patients and three segments in one patient with bilateral Brown’s revised classification IV/d defect. One case was planned by using a computer-aided design computer-aided manufacturing (CAD/CAM) system with a navigation system. The mean length of the grafted fibula bone was 68.06 mm. Dental implant treatment was performed in six patients. Six patients received radiation therapy, and there were no specific complications related to the radiation therapy. In one case, the defect was reconstructed with FFF flow-through from a radial forearm free flap. Conclusion. This clinical study demonstrated that the fibula flap is an ideal donor-free flap in a palatomaxillary defect. Delayed reconstruction using an FFF can reduce the complication and failure rates.

What is the optimal timing for implant placement in oral cancer patients? A scoping literature review

BACKGROUND

Oral cancer patients can benefit from dental implant placement. Traditionally, implants are placed after completing oncologic treatment (secondary implant placement). Implant placement during ablative surgery (primary placement) in oral cancer patients seems beneficial in terms of early start of oral rehabilitation and limiting additional surgical interventions. Guidelines on the ideal timing of implant placement in oral cancer patients are missing.

OBJECTIVE

To perform a scoping literature review on studies examining the timing of dental implant placement in oral cancer patients and propose a clinical practice recommendations guideline.

METHODS

A literature search for studies dealing with primary and/or secondary implant placement in MEDLINE was conducted (last search December 27, 2019). The primary outcome was 5-year implant survival.

RESULTS

Sixteen out of 808 studies were considered eligible. Both primary and secondary implant placement showed acceptable overall implant survival ratios with a higher pooled 5-year implant survival rate for primary implant placement 92.8% (95% CI: 87.1%-98.5%) than secondary placed implants (86.4%, 95% CI: 77.0%-95.8%). Primary implant placement is accompanied by earlier prosthetic rehabilitation after tumor surgery.

CONCLUSION

Patients with oral cancer greatly benefit from, preferably primary placed, dental implants in their prosthetic rehabilitation. The combination of tumor surgery with implant placement in native mandibular bone should be provided as standard care.

Peri implant bone resorption on microvascular free fibula flap: a radiographic retrospective study

Introduction: As the vascularization of the microvascular free fibula flap enables to maintain an osteogenic potential, osseointegrated implants have a 86% to 99% success rate. Thus, only few studies consider peri-implant bone resorption (PIBR). The aim of the study was to radiologically evaluate PIBR on fibula flaps. Materials and methods: Data were retrospectively collected. Gender, age, reason for interruptive mandibulectomy, previous radiotherapy, number of implants placed on the reconstruction, length and number of segments of the reconstruction, height of resorption were collected for each patient. Measurements were made on panoramic radiograph. Results: 85 clinical reports were reviewed for 39 retained. Peri-implant bone resorption was observed in 21 (53.9%) patients. The average age of the resorption group was 55.4 . All of the 5 patients with 4 or 5 implants on their reconstruction did not developed PIBR. 59.1% of patients with 1 segment reconstruction developed PIBR, 54.6% with 2 segments and 33.3% with 3 segments. Discussion: Age and poor oral hygiene appeared to be clearly more related to PIBR. An important number of implant (4 or 5) and a reconstruction with more than 1 segment seemed to decrease PIBR. Further studies are required to confirm these hypotheses.

Primary vs Secondary Endosseous Implantation After Fibular Free Tissue Reconstruction of the Mandible for Osteoradionecrosis

Importance

The clinical and financial implications of the timing of dental rehabilitation after a fibula free tissue transfer (FFTT) for osteoradionecrosis (ORN) and osteonecrosis (ON) of the mandible have yet to be established.

Objective

To compare the outcomes of primary implantation vs secondary implantation after FFTT for ORN and ON of the mandible.

Design, Setting, and Participants

A retrospective review was conducted of 23 patients at a single tertiary academic referral center undergoing primary implantation or secondary implantation after FFTT for ORN and ON from January 1, 2006, to November 10, 2015.

Interventions

All patients underwent FFTT with primary implantation (n = 12) or secondary implantation (n = 11).

Main Outcomes and Measures

Outcomes of FFTT, dental implantation, implant use, diet, speech, and disease-free survival were reviewed. Fixed unit costs were estimated based on the mean cost analysis.

Results

Twenty-three patients (7 women and 16 men; mean [SD] age, 62.4 [8.2] years [range, 24-81 years]) met the inclusion criteria. Of these, 18 had ORN and 5 had ON. Dental implantation was performed at the time of FFTT for 12 patients and was performed secondarily for 11 patients. There were a mean of 5.2 implants per patient performed, for a total of 121 implants. There was 1 complete flap failure in the primary implantation group. Neither flap nor implant complications were affected by the timing of the implantation. Overall, the implant survival rate was 95% (55 of 58) in the primary implantation group and 98% (62 of 63) in the secondary implantation group. Time from FFTT to abutment placement (primary implantation, 19.6 weeks; secondary implantation, 61.0 weeks) was significantly shorter after primary implantation (P < .001). There was no clinical difference in postoperative complications and implant outcomes for ORN vs ON. Improvement in speech and oral competence in the primary implantation group vs the secondary implantation group was not statistically significant, given an experiment-adjusted P = .001 set as significant (normal speech, 9 vs 3; P = .02; and normal oral competence, 9 vs 3; P = .02). Disease-free survival was 91% (20 of 22 patients) overall. Fixed unit (U) costs were 1.0 U for primary implantation and 1.24 U for secondary implantation.

Conclusions and Relevance

Patients undergoing primary implantation after FFTT for ORN and ON had a similar rate of complications compared with those undergoing secondary implantation. However, primary implantation allowed a faster return than secondary implantation to oral nutrition and prosthesis use. The fixed unit cost was reduced for those undergoing primary implantation. Although dental implantation was safe and effective in both groups, the decreased time to use and the decreased overall cost should prompt surgeons to consider primary implantation after FFTT for ORN and ON.

Level of Evidence

3.

Prognostic factors associated with achieving total oral diet following osteocutaneous microvascular free tissue transfer reconstruction of the oral cavity

INTRODUCTION

Osteocutaneous microvascular free tissue transfer (OMFTT) is the current standard in reconstruction of large bony defects of the oral cavity. Although being able to swallow ranks as a top priority for patients undergoing OMFTT, factors associated with achieving an oral diet following surgery remain unclear. We sought to describe the rate of total oral diet achievement, and to identify possible pre-, intra-, and post-operative factors associated with achievement in patients undergoing OMFTT.

METHODS

Retrospective review between January 1, 2010 and March 31, 2018 at two tertiary academic centers.

RESULTS

249 patients (67% male, mean age 58 years) met inclusion criteria, with a median follow up of 15 months. Overall, 142 (57%) of patients achieved a total PO diet post-operatively, with median time to achievement of 3.2 months. Multivariate analysis identified that lack of concurrent glossectomy (SHR 1.72 [1.09-2.70], p = 0.02), N0/1 disease (SHR 1.92 [1.16-3.13], p = 0.011), avoidance of post-operative fistula formation (SHR 1.96 [1.22-3.23], p = 0.005), pre-operative G-tube independence (SHR 3.33 [1.69-6.25], p < 0.001), and successful dental rehabilitation (SHR 2.08 [1.43-3.03], p < 0.001) are independently associated with total oral diet achievement.

CONCLUSIONS

Bony resections not requiring glossectomy, limited nodal disease burden, pre-operative gastrostomy-independence, avoidance of post-operative fistula, and dental rehabilitation are independently associated with achievement of total oral diet following OMFTT reconstruction of the oral cavity. Counseling patients on associated risk factors is important in guiding post-treatment expectations. Minimization of post-operative fistula, and maximization of dental rehabilitation may significantly improve total oral diet achievement in this patient population.

Oral rehabilitation following fasciocutaneous free-flap reconstruction: A retrospective study

Aim:

The aim of this study is to retrospectively, observe a consecutive series of patients with segmental mandibulectomy defects reconstructed with fasciocutaneous free flaps and mandibular resection prostheses, and to review treatment concepts for the management of such patients.

Settings and Design:

Observational study done at Memorial Sloan Kettering Cancer Center, New York, NY, USA.

Materials and Methods:

Records were reviewed of all patients who had fasciocutaneous free-flap reconstruction and fabrication of mandibular resection prostheses following segmental mandibulectomy between 2000 and 2017 at a tertiary cancer center. Mandibular resection prosthesis fabrication interval data, as well as follow-up interval data, were recorded.

Statistical Analysis Used:

Descriptive statistics.

Results:

Twenty-one consecutive patients had mandibular resection prostheses fabricated following segmental mandibulectomy and fasciocutaneous free-flap reconstruction during the study. The median time for mandibular resection prosthesis delivery following surgery was 9 months (range 4–41 months). There was a median of two-follow-up visits (range 0–4) within the first 90 days of mandibular resection prosthesis delivery.

Conclusions:

Oral rehabilitation with mandibular resection prosthesis following segmental mandibulectomy and fasciocutaneous free-flap reconstruction is an attainable treatment goal for the oncologic patient. Reviewing the proposed course of care is helpful for patient management.

Fibular Reconstruction of the Maxilla and Mandible with Immediate Implant-Supported Prosthetic Rehabilitation: Jaw in a Day

The fibula free flap is a workhorse flap used to reconstruct ablative, osseous defects in the upper and lower jaws. Traditionally, the fibula free flap is inset into the defect freehand; dental implants are placed secondarily; and final prosthetic rehabilitation often occurs more than 1 year after ablative surgery. Virtual surgical planning and rapid prototyping of cutting guides and guide stents for head and neck reconstruction have facilitated improved accuracy in fibular transfer. This article describes the Jaw in a Day technique, allowing maxillary or mandibular resection, fibular free flap reconstruction, immediate implant placement, and prosthetic rehabilitation in a single operation.

Osseointegration of dental implants in ectopic engineered bone in three different scaffold materials

The in vivo regeneration of bone flaps might be an alternative to autogenous bone grafting. The first human case of mandibular reconstruction using the greater omentum as a bioreactor was reported in 2016. However, whether engineered bone will support the osseointegration of dental implants has not yet been investigated. In this study, bone tissue engineering was performed in the greater omentum of nine miniature pigs using bone morphogenetic protein 2, bone marrow aspirate, and three different scaffolds: hydroxyapatite, biphasic calcium phosphate (BCP), and titanium. After 8 weeks, two implants were placed in each scaffold; after another 8 weeks, the bone blocks were harvested for radiographic, histological, and histomorphometric analysis. All implants exhibited sufficient primary stability, and the success rate was 100%. The bone-to-implant contact ratios (BICs) were 38.2%, 68.5%, and 42.9%; the inter-thread bone densities were 29.4%, 64.9%, and 33.5%; and the peri-implant bone-scaffold densities were 56.4%, 87.6%, and 68.6% in the hydroxyapatite, BCP, and titanium groups, respectively. The BIC showed a strong correlation (r = 0.76) with the peri-implant bone-scaffold density. This study shows that de novo engineered bone leads to successful osseointegration and therefore may allow implant-based prosthodontic rehabilitation.

Oral rehabilitation for patients with marginal and segmental mandibulectomy: A retrospective review of 111 mandibular resection prostheses

STATEMENT OF PROBLEM

Treatment and timing considerations for patients seeking oral rehabilitation after marginal or segmental mandibulectomy (with osseous reconstruction) are not well understood.

PURPOSE

The purpose of this retrospective review study was to report the type and timing of oral rehabilitation for mandibular defects without discontinuity and to describe additional treatment considerations for rehabilitation.

MATERIAL AND METHODS

The records were reviewed of all patients who received a mandibular resection prosthesis after marginal mandibulectomy, marginal mandibulectomy with fasciocutaneous free-flap reconstruction, and segmental mandibulectomy with fibula free-flap reconstruction between 2000 and 2017 in the tertiary cancer care institution. Patients not treated by the Dental Service in the institution were excluded. The specific type of rehabilitation was noted, as was the time interval between primary surgery and prosthesis delivery.

RESULTS

During the study period, 111 consecutive patients were treated by the Memorial Sloan Kettering Cancer Center Dental Service for mandibular rehabilitation. Forty-three patients underwent marginal mandibulectomy, 9 patients underwent marginal mandibulectomy with fasciocutaneous free-flap reconstruction, and 59 patients underwent segmental mandibulectomy with fibula free-flap reconstruction. Most patients in all 3 groups received mandibular resection prostheses without the use of endosseous implants. Only 4 (8%) patients who had undergone marginal mandibulectomy underwent endosseous implant placement, all of which followed marginal mandibulectomy in anterior mandibular segments without free-flap reconstruction. Patients who underwent marginal mandibulectomy with fasciocutaneous free-flap reconstruction were only restored with removable mandibular resection prostheses, and none had endosseous implants. In patients who underwent segmental mandibulectomy, 13 (22%) were rehabilitated with endosseous implants. The majority in this cohort (>50%) received radiation therapy as part of their treatment. The median time to oral rehabilitation was 8 months after marginal mandibulectomy, 14 months after marginal mandibulectomy with fasciocutaneous free-flap reconstruction, and 12 months after segmental mandibulectomy with fibula free-flap reconstruction.

CONCLUSIONS

Timing for oral rehabilitation may differ depending on the treatment modality followed for mandibular tumors in the patient with oral cancer. However, most patients in this cohort underwent rehabilitation with removable mandibular resection prostheses regardless of the timing of care. Endosseous implants were used infrequently, but research is needed to better understand their potential role and indication in the patient with oral cancer.

The Biaxial Double-Barrel Fibula Flap-A Simplified Technique for Fibula Maxillary Reconstruction

PURPOSE

Previously described techniques for microvascular fibula reconstruction of Brown Class II to IV maxillectomy defects are complex, require multiple osteotomies, result in a short pedicle, and inadequately reconstruct the dental alveolus in preparation for endosseous implants. This report describes a simplified technique for Brown Class II to IV defects that re-creates facial support, allows for dental reconstruction with appropriately positioned implants, and maintains adequate pedicle length.

MATERIALS AND METHODS

A retrospective chart review was performed of all patients with Brown Class II to IV maxillectomy defects immediately reconstructed with a biaxial double-barrel fibula flap technique. The reconstructive surgeon evaluated each patient at least 1 month after reconstruction for enophthalmos, facial symmetry, nasal patency, satisfactory jaw position, deglutition, intelligible speech, and intraoperative need for vein grafting.

RESULTS

The sample was composed of 6 patients (mean age, 54 yr; range, 33 to 78 yr; 67% women) who underwent reconstruction with the biaxial double-barrel fibula flap technique for Brown Class II to IV defects. None of these patients required vein grafting. None of these patients had flap failure. Diagnoses for these patients were a hybrid odontogenic tumor (n = 1), squamous cell carcinoma (n = 3), adenoid cystic carcinoma (n = 1), and sinonasal melanoma (n = 1). All 6 patients had excellent facial contour and malar projection, regular oral intake, 100% intelligible speech, and a new maxillary skeletal Class I relation without need for intraoperative vein grafting. One patient developed enophthalmos related to inferior rectus sacrifice and removal of orbital fat. Complications included development of nasal synechia and occlusion of the maxillary sinus ostium (n = 1).

CONCLUSIONS

The biaxial double-barrel fibula flap technique achieves the goals of providing adequate facial support and an alveolar segment amenable to implant dentistry. It allows for intelligible speech, deglutition, orbital support, and separation of the oronasal, orbital, and sinus cavities. In addition, it minimizes the need for vein grafting.

Impact of 3D virtual planning on reconstruction of mandibular and maxillary surgical defects in head and neck oncology

PURPOSE OF REVIEW

This review describes the advances in 3D virtual planning for mandibular and maxillary reconstruction surgical defects with full prosthetic rehabilitation. The primary purpose is to provide an overview of various techniques that apply 3D technology safely in primary and secondary reconstructive cases of patients suffering from head and neck cancer.

RECENT FINDINGS

Methods have been developed to overcome the problem of control over the margin during surgery while the crucial decision with regard to resection margin and planning of osteotomies were predetermined by virtual planning. The unlimited possibilities of designing patient-specific implants can result in creative uniquely applied solutions for single cases but should be applied wisely with knowledge of biomechanical engineering principles.

SUMMARY

The high surgical accuracy of an executed 3D virtual plan provides tumor margin control during ablative surgery and the possibility of planned combined use of osseus free flaps and dental implants in the reconstruction in one surgical procedure. A thorough understanding of the effects of radiotherapy on the reconstruction, soft tissue management, and prosthetic rehabilitation is imperative in individual cases when deciding to use dental implants in patients who received radiotherapy.

Oral rehabilitation of the cancer patient: A formidable challenge

Rehabilitation of oral functions following surgery on the jaws is a goal that is often difficult to achieve. Removable dentures supported by remaining teeth or gum are often unstable and seldom satisfactory. On the other hand, endosseous (dental) implants offer a mechanism to provide stability to the dentures. This review, discusses factors related to the tumor, patient, treatment, and physicians which impact upon the feasibility and success of dental implants in patients with oral cancer.

Novel Patient-Specific 3-Dimensional Printed Fixation Tray for Mandibular Reconstruction With Fibular Free Flaps

Segmental mandibular defects secondary to infectious, traumatic, and pathologic conditions can be debilitating because of their impact on function and facial esthetics. Several reconstructive techniques are available, with vascularized flaps commonly used for the reconstruction of large bony or composite segmental defects. The free fibular flap for mandibular reconstruction is well documented and remains a commonly used flap because of its bone length, versatility, distant location from the head and neck region that allows for a 2-team approach, and ability to simultaneously place endosseous implants. Virtual surgical planning (VSP) and guided resection and reconstruction of maxillofacial defects have facilitated complex 3-dimensional (3D) reconstruction. The accuracy and fidelity of VSP are dependent on the intraoperative execution of the VSP, with computer-aided design and computer-aided modeling of patient-specific cutting guides and hardware providing a template for its execution. The goal of this report is to describe the authors' experience with the use of a novel 3D printed fixation tray designed from the VSP data. It provides dual functionality by aiding in alignment and stabilization of the fibular segments and concomitantly providing patient-specific anatomic references for indexing of bony and soft tissue components. This tray enables rapid ex vivo configuration of the fibula segment(s) with the reconstruction bar relative to the native mandibular segments and allows the compiled construct to be transferred to the head and neck for insetting as a precisely configured single unit.

Prosthetic Rehabilitation After Fibular Free Flap Surgery of Mandibular Defects in a Patient With Oral Squamous Cell Carcinoma

OBJECTIVE

This report is to present the treatment procedure and clinical considerations of prosthodontic management of a patient who had undergone a partial mandibulectomy and fibular free flap surgery.

DESIGN

A 59-year-old man with a squamous cell carcinoma received a partial mandibular resection. Microsurgical reconstruction with a fibular free flap surgery and implant-supported zirconia-fixed prosthesis produced by computer-aided manufacturing led to successful results for the oral rehabilitation of mandibular defects.

CONCLUSIONS

The implant-supported zirconia-fixed prosthesis can be recommended for use in patients with mandibulectomy and fibular free flaps. Close cooperation between the surgeon and the prosthodontist is mandatory for the satisfaction of the patient.

Contemporary mandibular reconstruction

PURPOSE OF REVIEW

Multiple disease processes, including neoplasia, trauma, and medication side-effects, necessitate segmental resection and subsequent reconstruction of the mandible. As surgical techniques have advanced, several technologies have been developed with the potential to significantly transform a surgeon's approach to the restoration of mandibular continuity. The purpose of this review is to highlight many of these relatively newer tools and discuss their evolving role in mandibular reconstruction.

RECENT FINDINGS

Several contemporary studies have documented the application of different approaches and modifications to mandibular reconstruction - including computer-aided design or computer-aided modeling, contemporary plating systems, osseointegrated implants, and various modifications to existing osseocutaneous free tissue transfer options - and have reported relatively high success rates.

SUMMARY

In discussing these reports, we present a survey of current and developing technologies in the field of mandibular reconstruction and aim to provide sufficient context for the gradual integration of these techniques into practice.