Soft Tissue Management: A Critical Part of Implant Rehabilitation After Vascularized Free-Flap Reconstruction

Clinical evaluation of bone quality of particulate cancellous bone and marrow, and implant prosthetic rehabilitation

This study aimed to subjectively evaluate bone quality in the particulate cancellous bone and marrow (PCBM) graft area and to assess the survival rates of implants. A retrospective review was conducted based on patient age, sex, diagnosis, reconstructed site, number of implants, prosthetic type, and duration of follow-up. Images from computed tomography (CT) before implant insertion were obtained and used in this study. We selected a 4.0-mm diameter × 8.0-mm length region of interest in the implant placement area, and measured the CT attenuation value. No significant correlations were seen between CT attenuation values and implant survival rates in the maxilla and mandible. On the other hand, CT attenuation values and implant survival rates were significantly lower in patients with malignancy than in non-malignant cases. Placing implants in PCBM grafted bone requires a full understanding of bone quality before surgery and drilling to ensure primary stability, along with consideration of soft tissue management and maintenance programs.

Digitally designed stent-assisted soft-tissue management after jaw reconstruction: a prospective cohort study

OBJECTIVES

A digitally designed stent was invented to assist vestibuloplasty and free gingival graft (FGG) after jaw reconstruction. This study aimed to compare the effects of conventional soft-tissue management comprising vestibuloplasty combined with FGG and modified soft-tissue management using a digitally designed stent on the vestibular sulcus depth (VD), keratinised-tissue width (KTW) and peri-implant tissue health in patients undergoing jaw reconstruction.

MATERIALS AND METHODS

This prospective cohort study enrolled patients who underwent jaw reconstruction using a fibular flap, iliac flap, or onlay bone graft followed by implant-supported rehabilitation at the Peking University School and Hospital of Stomatology between May 2019 and July 2022. Patients in the stent group received digitally designed stents following vestibuloplasty combined with FGG for peri-implant soft-tissue management. Patients in the control group underwent a conventional vestibuloplasty combined with FGG. VD and KTW were evaluated immediately after implant loading (T2) and 1 year after implant loading (T3), and the atrophy rates of VD and KTW were calculated. Peri-implant clinical parameters were evaluated at T3. Comparisons between the groups were performed using the Mann-Whitney U test. The effects of age, sex, primary disease, reconstruction type, reconstructed jaw and the number and location of implants on VD and KTW were evaluated using linear regression analysis.

RESULTS

There were no significant differences in the atrophy rates of VD and KTW between the stent and control groups at T2 and T3 (both P ≥ 0.05). There were no significant differences in peri-implant clinical parameters between the stent and control groups at T3 (P ≥ 0.05). Reconstruction type, location of implants and primary disease influenced VD, and reconstruction type and age influenced KTW.

CONCLUSIONS

There was no significant difference in the maintenance of VD and KTW after jaw reconstruction between soft-tissue management using a digitally designed stent and the conventional method. Further, digitally designed stents do not affect peri-implant tissue health.

CLINICAL RELEVANCE

Digitally designed stents can simplify clinical procedures without adverse effects on peri-implant tissue health, but they do not promote keratinized mucosa augmentation and vestibuloplasty.

Implant retained prosthesis on a free fibula flap: A challenging procedure for prosthetic and soft tissue management

A 39-year-old woman who had undergone fibular flap reconstruction and simultaneous implant placement after the surgical removal of a cemento-ossifying fibroma was experiencing mild discomfort 3 years later and requested an implant-supported prosthesis to restore her edentulous left maxillary quadrant. Initially, an interim removable partial denture was provided and later duplicated with clear resin. The interim prosthesis identified the excessive thickness of the grafted cutaneous soft tissue and the inadequate emergence angle of the nonfunctioning implants. By using the interim prosthesis as a surgical guide, vestibuloplasty was performed to thin the peri-implant soft tissue and the excessive skin graft from the initial maxillofacial surgery. Concurrently, the emergence angle of the implant was corrected with angled multi-unit abutments. A tissue compression stent was then made and attached to the abutments to guide the soft tissue healing process. When the peri-implant soft tissue had stabilized, a definitive implant-supported prosthesis was provided.

Vestibuloplasty and its impact on the long-term survival and success of dental implants in irradiated and non-irradiated patients after head and neck tumor therapy: a retrospective study

OBJECTIVES

This study aimed to evaluate the influence of vestibuloplasty on the clinical success and survival of dental implants in head and neck tumor patients.

MATERIALS AND METHODS

A retrospective single-center study was conducted. All patients received surgical therapy of a tumor in the head or neck and underwent surgical therapy and, if necessary, radiotherapy/radiochemotherapy. Patients with compromised soft tissue conditions received vestibuloplasty using a split thickness skin graft and an implant-retained splint. Implant survival and success and the influence of vestibuloplasty, gender, radiotherapy, and localizations were evaluated.

RESULTS

A total of 247 dental implants in 49 patients (18 women and 31 men; mean age of 63.6 years) were evaluated. During the observation period, 6 implants were lost. The cumulative survival rate was 99.1% after 1 year and 3 years and 93.1% after 5 years for patients without vestibuloplasty, compared to a survival and success rate of 100% after 5 years in patients with vestibuloplasty. Additionally, patients with vestibuloplasty showed significantly lower peri-implant bone resorption rates after 5 years (mesial: p = 0.003; distal: p = 0.001).

CONCLUSION

This study demonstrates a high cumulative survival and success rate of dental implants after 5 years in head and neck tumor patients, irrespective of irradiation. Patients with vestibuloplasty showed a significantly higher rate of implant survival and significantly lower peri-implant bone resorption after 5 years.

CLINICAL RELEVANCE

Vestibuloplasty should always be considered and applied if required by the anatomical situations to achieve high implant survival/success rates in head and neck tumor patients.

Analysis of Factors Determining Patient Survival after Receiving Free-Flap Reconstruction at a Single Center-A Retrospective Cohort Study

BACKGROUND

Microsurgical tissue transfer revolutionized reconstructive surgery after extensive trauma, oncological resections, and severe infections. Complex soft tissue reconstructions are increasingly performed in multimorbid and elderly patients. Therefore, it is crucial to investigate whether these patients benefit from these complex procedures.

OBJECTIVE

To evaluate the outcome for multimorbid patients who underwent microsurgical soft tissue reconstruction and to identify potential risk factors that may increase mortality.

METHODS

This single-center study retrospectively analyzed prospectively collected data of patients receiving free gracilis (GM) or latissimus dorsi muscle (LDM) flap reconstruction between September 2017 and December 2021. Cases were divided into two groups (dead vs. alive), depending on patient survival. Patient demographics, comorbidities and medication, perioperative details, free flap outcome, as well as microcirculation were determined.

RESULTS

A total of 151 flaps (LDM, n = 67; GM, n = 84) performed in 147 patients with a mean age of 61.15 ± 17.5 (range 19-94) years were included. A total of 33 patients (22.45%) passed away during the study period. Deceased patients were significantly older (Alive: 58.28 ± 17.91 vs. Dead: 71.39 ± 11.13; p = 0.001), were hospitalized significantly longer (Alive: 29.66 ± 26.97 vs. Dead: 36.88 ± 15.04 days; p = 0.046) and suffered from cardiovascular (Alive: 36.40% vs. Dead: 66.70%; p = 0.002) and metabolic diseases (Alive: 33.90% vs. Dead: 54.50%; p = 0.031) more frequently, which corresponded to a significantly higher ASA Score (p = 0.004). Revision rates (Alive: 11.00% vs. Dead: 18.20%; p = 0.371) and flap loss (Alive: 3.39% vs. Dead: 12.12%; p = 0.069) were higher in patients that died by the end of the study period.

CONCLUSIONS

Free flap transfer is safe and effective, even in multimorbid patients. However, patient age, comorbidities, preoperative ASA status, and medication significantly impact postoperative patient survival in the short- and mid-term and must, therefore, be taken into account in preoperative decision-making and informed consent.

Clinical outcomes of keratinized mucosa augmentation in jaws reconstructed with fibula or iliac bone flaps

This prospective study was undertaken to evaluate the treatment outcomes of keratinized mucosa augmentation (KMA) on the buccal and palatal/lingual sides of implants in jaws reconstructed after oncological surgery. Forty-two implants in 12 patients whose jaws had been reconstructed with a fibula or iliac bone flap were included. KMA was performed at 3 months after implant placement; this included an apically displaced partial-thickness flap and a free gingival graft (FGG) around the implants to increase the keratinized mucosa width (KMW). Patients were followed up for at least 6 months post-surgery. KMW, shrinkage, and patient pain and discomfort measured on a visual analogue scale were analysed. A histological analysis was performed of tissue epithelium from two patients. The results showed that KMW was >2 mm on both the buccal and palatal/lingual sides during follow-up. Before surgery, histological analysis showed epithelium with no epithelial spikes; normal keratinized epithelial spikes were observed at 8 weeks after KMA. Greater KMW was observed around implants in reconstructed maxillae than around those in reconstructed mandibles (P < 0.001). Patients felt more pain at the donor site than at the recipient site during the first 3 days post-surgery. KMA with FGG was predictable in reconstructed jaws and may help maintain the long-term stability of implants.