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

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.

Reconstruction of Segmental Mandibular Defects with Double-Barrel Fibula Flap and Osseo-Integrated Implants: A Systematic Review

Background: Mandibular defects resulting from oncological treatment pose significant aesthetic and functional challenges due to the involvement of bone and soft tissues. Immediate reconstruction is crucial to address complications such as malocclusion, mandibular deviation, temporomandibular joint (TMJ) changes, and soft tissue retraction. These issues can lead to functional impairments, including difficulties in chewing, swallowing, and speech. The fibula flap is widely used for mandibular reconstruction due to its long bone segment and robust vascular supply, though it may not always provide adequate bone height for optimal dental rehabilitation. This systematic review aims to determine if the double-barreled fibula flap (DBFF) configuration is a viable alternative for mandibular reconstruction and to evaluate the outcomes of dental implants placed in this type of flap. Materials and Methods: This study adhered to the Cochrane Collaboration criteria and PRISMA guidelines and was registered on the International Platform of Registered Systematic Review and Meta-Analysis Protocols Database (INPLASY2023120026). We included clinical studies published in English, Spanish, or French that focused on adult patients undergoing segmental mandibulectomy followed by DBFF reconstruction and dental rehabilitation. Data sources included Medline/PubMed, the Cochrane Library, EMBASE, Scopus, and manual searches. Two reviewers independently screened and selected studies, with discrepancies resolved by a third reviewer. Data extraction captured variables such as publication year, patient demographics, number of implants, follow-up duration, flap survival, implant failure, and aesthetic outcomes. The risk of bias was assessed using the JBI appraisal tool, and the certainty of evidence was evaluated using the GRADE approach. Results: A total of 17 clinical studies were included, evaluating 245 patients and 402 dental implants. The average patient age was 43.7 years, with a mean follow-up period of 34.3 months. Flap survival was high, with a 98.3% success rate and only four flap losses. The implant failure rate was low at 1.74%. Esthetic outcomes were varied, with only three studies using standardized protocols for evaluation. The overall certainty of evidence for flap survival was moderate, low for implant failure, and very low for aesthetics due to the subjective nature of assessments and variability in reporting. Conclusions: The primary limitations of the evidence included in this review are the observational design of the studies, leading to an inherent risk of bias, inconsistency in reporting methods, and imprecision in outcome measures. Additionally, the subjective nature of aesthetic evaluations and the variability in assessment tools further limit the reliability of the findings. The DBFF technique demonstrates excellent outcomes for mandibular reconstruction, with high flap survival and low implant failure rates, making it a viable option for dental rehabilitation. However, the evidence for aesthetic outcomes is less certain, highlighting the need for more rigorous and standardized research. This review supports the DBFF as a good alternative for mandibular reconstruction with successful dental implant integration, although further studies are needed to enhance the reliability of aesthetic evaluations.

Prosthetic rehabilitation of patients with maxillary oncology defects using zygomatic implants

PURPOSE

Prosthetics for patients after oncological resection of the upper jaw is a complex problem associated with the physiological and anatomical separation of the oral cavity and the nasal/paranasal region. This study reports the clinical results of the use of the zygomatic implants for prosthetic rehabilitation in patients with maxillectomy due to upper jaw tumors.

MATERIALS AND METHODS

The study included 16 patients who underwent prosthetic rehabilitation using a zygomatic implant after maxillectomy period from 2021 to 2023. After the tumor was removed, immediate surgical obturators were placed. Main prosthetic rehabilitation was performed 6-12 months after tumor removal, but before that, a temporary obturator was made and used. Six-twelve months after tumor resection, 1-4 zygomatic implants were inserted into the zygomatic bone unilaterally or bilaterally. A total of 42 zygomatic implants were installed, 2 of which were unsuccessful and were removed in 1 patient. The implants were placed using the surgical guide, which was planned and prepared digitally.

RESULTS

No postsurgical complications were seen, and the patients were discharged from the hospital after 7-10 days. The patients were able to return to a normal diet (hard food) after just 7 days following surgery, with no further complaints regarding function or pain, apart from the residual edema caused by the intervention.

CONCLUSIONS

The use of prostheses fixed on zygomatic implants in patients with maxillary defects is an effective method of prosthodontic rehabilitation in complex clinical cases after maxillectomy.

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.

Optimal Treatment Order With Fibula-Free Flap Reconstruction, Oncologic Treatment, and Dental Implants: A Systematic Review and Meta-Analysis

Head and neck cancer (HNC) patients benefit from craniofacial reconstruction, but no clear guidance exists for rehabilitation timing. This meta-analysis aims to clarify the impact of oncologic treatment order on implant survival. An algorithm to guide placement sequence is also proposed in this paper. PubMed, Embase, and Web of Science were searched for studies on HNC patients with ablative and fibula-free flap (FFF) reconstruction surgeries and radiotherapy (RTX). Primary outcomes included treatment sequence, implant survival rates, and RTX dose. Of 661 studies, 20 studies (617 implants, 199 patients) were included. Pooled survival rates for implants receiving >60 Gy RTX were significantly lower than implants receiving < 60 Gy (82.8% versus 90.1%, P =0.035). Placement >1 year after RTX completion improved implant survival rates (96.8% versus 82.5%, P =0.001). Implants receiving pre-placement RTX had increased survival with RTX postablation versus before (91.2% versus 74.8%, P <0.001). One hundred seventy-seven implants were placed only in FFF with higher survival than implants placed in FFF or native bone (90.4% versus 83.5%, P =0.035). Radiotherapy is detrimental to implant survival rates when administered too soon, in high doses, and before tumor resection. A novel evidence-based clinical decision-making algorithm was presented for utilization when determining the optimal treatment order for HNC patients. The overall survival of dental prostheses is acceptable, reaffirming their role as a key component in rehabilitating HNC patients. Considerations must be made regarding RTX dosage, timing, and implant location to optimize survival rates and patient outcomes for improved functionality, aesthetics, and comfort.

Challenges during implant-assisted prosthetic rehabilitation in fibula reconstructed jaws and its management: a scoping review protocol

Introduction

Oral cancer is the sixth most prevalent cancer type worldwide. Patients are placed in a crippling predicament due to the functional and psychosocial difficulties brought on by the illness and its treatments. Both surgeons and maxillofacial prosthodontists may encounter challenges with reconstruction and therapy following cancer treatment. Over 20 years, the fibula has remained the mainstay of reconstructions for head and neck cancer. Maxillary and mandibular jaws with fibula reconstructions can use fixed or removable prosthetic rehabilitation solutions. The proposed scoping review aims to ascertain the volume and nature of evidence concerning the difficulties and corrective measures in the prosthetic rehabilitation of fibula-reconstructed head and neck cancer cases. The findings will aid in improving the prosthetic treatment care for the affected population.

Materials and Methods

The Joanna Briggs Institute (JBI) scoping review protocol will be followed in developing and reporting the scoping review methodology. Methods to identify the relevant literature will involve the systematic search of databases like PubMed, Scopus, Google Scholar, Cochrane Library, and gray literature sources for pertinent articles on the subject. Only papers published in English literature will be considered for the review, and the data collection period is limited to the past 20 years. The screening process will utilize defined inclusion/exclusion criteria for Title/Abstract and Full-text screening by two independent reviewers in covidence, and a third reviewer will resolve any conflicts. The data extracted will include specific details about the participants, concept, population, study methods, challenges encountered during prosthetic rehabilitation, and their management. Inductive thematic analysis and descriptive statistics will be applied where appropriate. The narrative synthesis of the evidence will be accomplished through data extraction in a tabular format, and the results will be presented as a narrative summary.

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.

Long-Term Outcomes of Dental Rehabilitation and Quality of Life after Microvascular Alveolar Ridge Reconstruction in Patients with Head and Neck Cancer

Background/Objectives: Dental rehabilitation after extended tumour resection and jaw reconstruction is challenging. The present study aimed to report the prosthetic outcome and quality of life (QoL) in patients with head and neck cancer (HNC) after microvascular alveolar ridge reconstruction. Methods: The prosthetic outcomes of all consecutive patients with HNC who underwent microvascular alveolar ridge reconstruction at the University Hospital Salzburg between 2011 and 2018 were investigated. Oral health-related QoL (OHrQoL) and overall QoL were assessed using the validated Oral Health Impact Profile-49 (OHIP-49) and Short Form-36 questionnaires. Results: During the study period, 115 consecutive patients with head and neck cancer underwent microvascular jaw reconstruction. Among them, 23.3% and 27.4% received conventional tissue-borne prostheses and implant-supported prostheses, respectively, while 48.7% did not undergo dental rehabilitation. The prosthetic outcome was not associated with tumour stage (p = 0.32). Oral health-related quality of life (OHrQoL) was best in patients with implant-supported dental rehabilitation (OHIP-49 median score = 7) and worst in those with conventional removable dentures (OHIP-49 median score = 54). The corresponding OHIP-49 median score for patients who could not undergo dental rehabilitation was 30.5. All Short Form-36 subscale scores were equal to or higher than the malignancy norm scores. Conclusions: After microvascular jaw reconstruction, approximately one-third of the HNC patients received adequate implant-supported dental rehabilitation. However, the risk of dental rehabilitation failure was 50%. The different prosthetic outcomes affected OHrQoL, but not overall QoL.

Prevalence of free flap failure in mandibular osteoradionecrosis reconstruction: a systematic review and meta-analysis

Our study aimed to estimate the prevalence of total free flap failure following free flap reconstruction for mandibular osteoradionecrosis (mORN) and assess the impact of potential moderators on this outcome. A comprehensive systematic literature search was independently conducted by two reviewers using the Medline, Scopus, Web of Science and Cochrane Library databases. Quality assessment of the selected studies was performed, and prevalence estimates with 95% confidence intervals (CI) were calculated. Outlier and influential analyses were conducted, and meta-regression analyses was employed to investigate the effects of continuous variables on the estimated prevalence. Ultimately, forty-six eligible studies (involving 1292 participants and 1344 free flaps) were included in our meta-analysis. The findings of our study revealed a prevalence of 3.1% (95% CI 1.3-5.4%) for total free flap failure after reconstruction for mORN. No study was identified as critically influential, and meta-regression analysis did not pinpoint any potential sources of heterogeneity. These findings provide valuable insights for researchers and serve as a foundation for future investigations into the management of mandibular osteoradionecrosis and the prevention of free flap failure in this context.

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.

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.

Predictability of single versus double-barrel vascularized fibula flaps and dental implants in mandibular reconstructions: A systematic review and meta-analysis of prospective studies

STATEMENT OF PROBLEM

Patients with vascularized bone flaps from the fibula have reduced bone height, in which case a higher prosthetic abutment is needed for their implant-supported prosthesis. Although the double-flap technique seems promising, systematic reviews and meta-analyses of prospective studies are lacking.

PURPOSE

The purpose of this systematic review and meta-analysis was to evaluate the grafted areas of single barrel fibular flaps (SBFF) and double-barrel fibular flaps (DBFF) by considering failure rates, dental implant complications, and bone union at the osteotomy sites.

MATERIAL AND METHODS

A systematic review and meta-analysis was performed in accordance with the preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement, population, intervention, control, and outcomes (PICO) question, and the National Health and Medical Research Council scales. The event rate of complications and failures was calculated with a confidence interval (CI) of 95%.

RESULTS

A total of 13 prospective studies with 441 participants and 330 graft sites were identified. A total of 235 participants had SBFF with 445 implants, and 95 had DBFF with 164 implants. The overall combined graft failure rates were 4.2% for SBFF and 3.2% for DBFF. The complication rate was 10% for SBFF and 1.9% for DBFF. Implant failure was at 4.7% in the SBFF group and 3.4% in the DBFF group.

CONCLUSIONS

Complication rates and implant failures were similar for SBFF and DBFF. Therefore, for long-term oral rehabilitation, both SBFF and DBFF are suitable procedures for mandibular reconstruction.

Factors Affecting Complete Oral Rehabilitation in Patients With Vascularized Free Fibula Flap Mandibular Reconstruction: A 10-Year Retrospective Study

The fibula is the preferred bone flap for mandibular reconstructions due to its many advantages, including the possibility to insert dental implants. All patients who received a mandibular reconstruction with a vascularized free fibula flap at the Uppsala University Hospital between 2009 and 2019 were retrospectively examined regarding the proportion of implant insertion and factors that affected implant outcome. Forty-one patients had 42 fibula flap reconstructions. Eleven patients (27%) received dental implants and 8 (20%) completed dental rehabilitation. Patient death and cancer recurrence were the main reasons for not receiving implants. The survival rates of implants placed in irradiated and nonirradiated fibulas were 15% and 76%, respectively. Less than 20% of reconstructed patients received an implant-supported prosthesis. Implants placed in an irradiated fibula should be considered at high risk for implant loss.

Outcomes and influential factors in functional and dental rehabilitation following microvascular fibula flap reconstruction in the maxillomandibular region: a systematic review and meta-analysis

BACKGROUND

This systematic review and meta-analysis aimed to evaluate the factors influencing and success rates of dental implants for functional and dental rehabilitation following microvascular fibula flap reconstruction in the maxillomandibular region.

MAIN TEXT

We conducted a comprehensive search of electronic databases, including MEDLINE, Web of Science, Embase, Scopus, and Cochrane's CENTRAL, as well as gray literature sources and manual searches of notable journals. The search was performed from inception until February 2023. Studies were included if they examined functional and dental rehabilitation outcomes in patients receiving maxillofacial reconstruction using microvascular fibula flaps and were retrospective or prospective cohort studies involving human subjects. Case-control studies, research involving other reconstruction methods, and animal-based studies were excluded. Data was extracted and confirmed by two independent researchers, and risk of bias was assessed using the Newcastle-Ottawa Scale. Meta-analyses were conducted for dental implant and graft success rate, with separate analyses for different factors affecting the outcome. Heterogeneity was evaluated using Cochran's Q test and the I² test. The pooled success rate for implants was 92% and for grafts, 95%, with significant heterogeneity. Implants in fibular grafts had a 2.91 times higher failure rate than those in natural bones. Radiated bone and smoking were identified as factors influencing implant failure, with radiated bone having a 2.29 times higher risk and smokers having a 3.16 times higher risk compared to their respective counterparts. Patient-reported outcomes showed improvements in key areas such as dietary intake, mastication, speech, and esthetics. The success rates declined over time, emphasizing the importance of long-term follow-up.

CONCLUSIONS

Dental implants in free fibula grafts generally have favorable success rates, with minimal bone resorption, manageable probing depths, and limited bleeding on probing. Implant success is influenced by factors such as smoking and radiated bone.

How does the Number of Implants Affect Stress Distribution in Fibula Graft at the Posterior of the Mandible? A Finite Element Analysis

Objectives

Evidence about the implant protocol and success in the osseous microvascular grafts is not sufficient. Stress distribution around dental implants is one of the important factors determining treatment success. The purpose of this study was to evaluate stress distribution in the bone supporting the implants inserted in the fibula free flap, in patients with large defects in the posterior of the mandible by finite element analysis (FEA).

Materials and Methods

The CBCT was obtained from one patient with fibula free flap in the posterior of the mandible and also from a 4.1 × 10 mm implant (Zimmer, Zimmer dental, Carlsbad, USA). Two 3D finite models were designed containing three or four implants. The implants were splinted by a suprastructure. Vertical load (300 N) and oblique load (50 N) were applied to the suprastructure. The von Mises stress distribution and the micromotion of implants were evaluated.

Results

No significant difference was observed between implants micromotion in two models. According to stress distribution analysis and determining maximum stress regions, the model with four implants imposes more stress on titanium components and surrounding bone.

Conclusion

The stress distribution around the implants of mandibular models with posterior defect that was reconstructed with fibula free flap is better in models with three fixtures versus four fixtures.

Modeling Methods in Craniofacial Virtual Surgical Planning

Despite the widespread use of virtual surgical planning (VSP), few papers describe the modeling methods used to generate the digital simulations that underpin VSP. This paper aims to review the modeling methods that are currently available for use in VSP and the implications of their use in clinical practice. A literature review was undertaken of the two broad categories of modeling techniques; contour-based planning-namely mirroring from the contralateral side, templating from a normative database, and extrapolation from surrounding landmarks-and occlusal-based planning (OBP). The indications for each modeling method were discussed, including mandibular/maxillary reconstruction, pediatric craniofacial surgery, and orthognathic, as well as the limitations to the accuracy of modeling types. Unilateral defects of the upper/midface, wherein contour accuracy is paramount, are best reconstructed using mirroring methods, whereas bilateral defects-or cases with asymmetry due to craniofacial dysmorphology-are most suited to normative-data-based methods. Cases involving resection of the alveolar margin, in which functional occlusion is the primary outcome are best managed with OBP. Similarly, orthognathic surgery typically uses OBP, although complex cases involving asymmetry, such as clefts, may benefit from a combination of OBP and normative data methods. The choice of modeling methods is, therefore, largely driven by the defect type and the goals of reconstruction.

Guided Zygomatic Implantology for Oral Cancer Rehabilitation: A Case Report

Oral rehabilitation after maxillary oncological resection is challenging. This case report presents the rehabilitation of a 65-year-old Caucasian male adenoid cystic carcinoma patient using a myo-cutaneous thigh flap, zygomatic implant placement, and an immediate fixed provisional prosthesis made with computer-aided technologies. The patient presented complaints of asymptomatic enlarged swelling of 5-mm on the right hard hemi-palate. There was an oro-antral communication deriving from a previous local excision. Preoperative radiographs showed the involvement of the right maxilla, maxillary sinus, and nose with a suspect involvement of the maxillary division of the trigeminal nerve. Treatment was planned through a fully digital workflow. A partial maxillectomy was performed endoscopically, and maxilla was reconstructed using an anterolateral thigh free flap. Two zygomatic implants were inserted simultaneously. A provisional fix full-arch prosthesis was manufactured preoperatively through a fully digital workflow and was placed in the operating room. Following post-operative radiotherapy, the patient received a final hybrid prosthesis. During the follow-up period of two years, the patient reported good function, aesthetics, and significant enhancement in quality of life. According to the results of this case, the protocol represented can be a promising alternative for oral cancer patients with large defects, and can lead to an improved quality of life.

Prosthetic Rehabilitation Options in Post-Ablative Maxillomandibular Microvascular Reconstructions

Objective

Surgery remains the mainstay for managing most neoplasms arising in the head and neck area. Removable or fixed prostheses are commonly used for prosthetic rehabilitation of head and neck defects following surgical resection. Some major challenges in prosthetic rehabilitation after maxillomandibular microvascular reconstruction include excessive prosthetic space, soft tissue bulk, and occlusal disharmony in the remaining dentition. This review focuses on the challenges we have experienced in the real clinical scenario while rehabilitating reconstructed maxillomandibular defects and the effective prosthetic treatment options that could be considered in each situation.

Discussion

Digital revolution has changed all arenas of life, and it has created a significant impact on cancer treatment planning and the delivery of quality treatment to the needy. Creating adequate retention while ensuring stability and support for the prosthesis can be challenging with temporary acrylic and cast partial removable dentures. Endosseous dental implants are considered a stable, reliable, and esthetic option for reconstruction with advantages such as increased chewing efficiency, preservation of the remaining bone height and width, and improved quality of life. The FP3 to RP5 (Misch's classification) are some commonly followed prosthetic rehabilitation options after microvascular reconstruction. The prosthetic design should permit the usage of interdental aids that ensure the longevity of prostheses.

Conclusion

Occlusion-driven/prosthetic-driven implant-assisted prostheses are considered a reliable option that ensures stable and functional oral rehabilitation among patients with free fibula flap reconstruction. Multidisciplinary teamwork is mandatory for an optimal outcome that improves patients' quality of life.

Rehabilitation of long-term mandibular defects by whole-process digital fibula flap combining with implants: A case report

Currently, the gold standard and workhorse in mandibular reconstruction is the free vascularized fibula flap. Particularly for patients who have had mandibulectomy for a long time, it is still difficult to precisely reconstruct the mandibular contour and successfully restore the patient's chewing function and esthetics. For the restoration and rehabilitation of long-term mandibular abnormalities, three-dimensional (3D) virtual surgical planning (VSP) and 3D-printed surgical guides are essential. Digital design and manufacturing were used to improve the accuracy of prostheses and facilitate occlusal reconstruction. Therefore, equipped with the methods of 3D VSP, 3D-printed surgical guides, free vascularized fibular flap, and immediate dental implants, this clinical report provides a feasible solution for mandibular reconstruction.

Bite Force Evaluation in Implant-Assisted Prosthetic Rehabilitation of Reconstructed Jaws Utilizing Vascularized Free Fibula Flap: A Retro-Prospective Cohort Study

Introduction

Maxillary and mandibular defects due to tumor ablation pose considerable challenges to the reconstructive surgeon and in prosthetic management. Dental implants placed in vascularized fibula free flaps are considered to be a dependable technique for prosthetic rehabilitation in head and neck cancer patients. Although, there is evidence of survival of dental implants in the reconstructed jaw bones, there is lack of information regarding the masticatory performance and prosthetic success. The maximum bite force achieved through the prosthetic appliance is a measure of the therapeutic outcome. The purpose of this study was to determine the maximum bite force achieved through implant-assisted prosthetic rehabilitation in reconstructed jaw bones utilizing vascularized free fibula flap.

Methods

The study included a total of 65 implants, from 16 patients who underwent surgical resection of jaw bones due to benign tumors followed by rehabilitation with implant-assisted fixed or removable prosthesis. The maximum bite force was determined with a transducer. Occlusal interferences were analyzed with mounted casts. The parameters were reviewed every 3 months have T 0 marked the baseline assessment, and T 3, T 6, T 9, T 12, and T 15 were subsequent review periods.

Results

The mean occlusal force was increased in most of the patients through 15 months (P < 0.01). The maximum bite force measured in the reconstructed mandible and maxilla were 225.63 N and 176.51 N, respectively. Occlusal interferences were absent in 68.8% of the study population.

Conclusion

The bite force measured in reconstructed maxilla and mandible is comparable to the masticatory force measured with conventional implant supported prosthesis in native mandible and maxilla.

Towards Optimum Mandibular Reconstruction for Dental Occlusal Rehabilitation: From Preoperative Virtual Surgery to Autogenous Particulate Cancellous Bone and Marrow Graft with Custom-Made Titanium Mesh-A Retrospective Study

The purpose of this retrospective study was to evaluate computer-assisted virtual surgery and the outcomes of mandibular reconstruction using an autogenous particulate cancellous bone and marrow (PCBM) graft combined with a custom-made titanium mesh (TiMesh) using a three-dimensional (3D) printing model. Eighteen consecutive patients were included, and preoperative virtual simulation surgery was performed using digital data. Segmental bone defects showed deviation of the mandible due to displacement of the condyle and segments, unnatural length of the mandibular body, or poorer intermaxillary relationship compared to the marginal bone defect caused by previous operations. These mandibular disharmonies could be simulated, and virtual surgery was performed on a computer with adjustment of displaced mandibular segments, length of the mandibular body, and dental arch with digital bone augmentation. TiMesh was manually pre-bent using a 3D printing model, and PCBM from the iliac crest was grafted with TiMesh. The short-term clinical results were good; reconstruction of the alveolar crest was prosthetically desirable; and minor complications were observed. In conclusion, virtual reconstruction is crucial for treating complex deviated mandibles. Accurate condylar and dental arch positions with an optimum mandibular length are important for prosthetically satisfactory mandibular reconstruction.

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.

Refabrication of an implant-retained obturator using the denture duplication technique in a bilateral maxillectomy patient with a free fibula osteocutaneous flap

PURPOSE

We aimed to introduce a simple method for refabrication of an implant-retained obturator using the denture duplication technique while retaining the custom abutments for a patient who underwent bilateral maxillectomy and reconstruction with a free fibula osteocutaneous flap. We have proposed this technique to facilitate the impression-making procedure for this extensive maxillary defect and to avoid lengthy and complicated laboratory procedures.

METHODS

A custom tray was developed by duplicating the fitting surface of an old obturator using silicone putty. The tray was used for a bite-pressure impression wherein both definitive impression and jaw relation were obtained simultaneously, reducing the time required for the placement of a new obturator.

CONCLUSIONS

We used the denture duplication technique to refabricate an implant-retained obturator while retaining the custom abutments. Decreased chairside time, fewer visits, the use of easily available materials, and uncomplicated laboratory procedures make this technique more economical and acceptable for patients. Using this approach, the patient was able to use the old prosthesis until the delivery of the new prosthesis. The replacement obturator that was developed using this method maintained an acceptable level of oral function.

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.

Analysis of Dental Implant Rehabilitation in the Reconstructed Jaw by Deep Circumflex Iliac Artery Flap, a Retrospective Study

The purpose of this study is to analyze the clinical results of the implant rehabilitation for a jaw reconstructed by the deep circumflex iliac artery (DCIA) flap. A total of 13 patients were included in this study from 2010 to 2020. Medical records were collected retrospectively and analyzed. The mandible was involved in 10 cases and the maxilla was in 3 cases. The average width of the DCIA flap was 8.6 mm, and the height was 20.65 mm. A total of 41 dental implants with a diameter of 3.9–5.0 mm and a length of 10.0–11.5 mm were placed at an average of 12.3 months after the reconstruction. The average follow-up period after delivering a permanent prosthesis was 15 months (range, 2 to 51 months) and the overall mean follow-up period was 48 months. In all, 3 implants of the total 41 implants were removed. The DCIA flap is the most suitable for reproducing the original contour of the original jawbone compared with the fibular flap. In addition, the height and width of the reconstructed bone is appropriate for implant placement, which is advantageous for the rehabilitation of oral function and aesthetics using the implant.

Oral rehabilitation after squamous cell carcinoma mandibular resection

Introduction: Squamous cell carcinoma of the oral cavity is the most common cause of mandibular defect. The functional and aesthetic impacts of this surgery must be considered. The number of mandibular resections depends on the TNM classification of the tumor. Mandibular reconstruction by a fibula free flap has become the gold standard. Unfortunately, not all mandibular resections are rehabilitated. The purpose of this study is to evaluate oral rehabilitation after mandibular resection in patients with squamous cell carcinoma. Materials and methods: A retrospective study was conducted to evaluate oral rehabilitations according to the type of surgical resection and reconstruction. The secondary evaluation criteria were type of rehabilitation, implant success rate, post-radiotherapy delay, rehabilitation success rate, and causes of non-rehabilitation. Results: The study included 157 patients with mandibular resection. Of the patients, 26.7 percent received oral rehabilitation. All rehabilitation with implants was functional. The main causes of non-rehabilitation were death or recurrences related to the progression of the disease, postoperative anatomical difficulties, and cost of oral rehabilitation. Conclusion: Oral rehabilitation after mandibular resection surgery is insufficient. A rehabilitation unit including a maxillofacial surgeon, oral surgeon, and dentist is essential. Implementation of the unit should be considered as soon as possible. The cost of rehabilitation should not be a limiting factor.

Esthetic and functional reconstruction of large mandibular defects using free fibula flap and implant-retained prosthetics - a case series with long-term follow-up

Background

The reconstructive and rehabilitative management of large mandibular defects with basal continuity is challenging in many respects, especially in the vertical dimension. The free fibula flap is an under-utilised but efficient approach in this indication. The aim of this case series is to demonstrate its use and long-term success.

Case presentation

Three cases are presented, where the patient had a large bone defect (at least 5 cm in length and 1 cm in the vertical dimension), but the continuity of the mandible was maintained. Two cases were related to pathological fracture and one was a large defect due to oncological surgery. Vertical augmentation with free microvascularised fibula flap was carried out, followed by implant-retained prosthetic therapy. Clinical status has been followed up for 5 to 6 years, with special attention to the condition of the peri-implant tissues and any radiographically detectable alterations or complications. No complications occurred during the follow-up. Function and esthetics have remained unchanged throughout.

Conclusions

Free microvascularised fibula flap reconstruction combined with implant-retained prosthetics allows a lasting functional and esthetic solution in the discussed indication.

Survival of dental implants and occurrence of osteoradionecrosis in irradiated head and neck cancer patients: a systematic review and meta-analysis

OBJECTIVES

This systematic review assesses dental implant survival, calculates the incidence rate of osteoradionecrosis, and evaluates risk factors in irradiated head and neck cancer patients.

MATERIALS AND METHODS

Various databases (e.g., Medline/Embase using Ovid) and gray literature platforms were searched using a combination of keywords and subject headings. When appropriate, meta-analysis was carried out using a random effects model. Otherwise, pooled analysis was applied.

RESULTS

A total of 425 of the 660 included patients received radiotherapy. In total, 2602 dental implants were placed, and 1637 were placed in irradiated patients. Implant survival after an average follow-up of 37.7 months was 97% (5% confidence interval, CI 95.2%, 95% CI 98.3%) in nonirradiated patients and 91.9% (5% CI 87.7%, 95% CI: 95.3%) after an average follow-up of 39.8 months in irradiated patients. Osteoradionecrosis occurred in 11 cases, leading to an incidence of 3% (5% CI 1.6%, 95% CI 4.9%). The main factors impacting implant survival were radiation and grafting status, while factors influencing osteoradionecrosis could not be determined using meta-analysis.

CONCLUSION

Our data show that implant survival in irradiated patients is lower than in nonirradiated patients, and osteoradionecrosis is-while rare-a serious complication that any OMF surgeon should be prepared for. The key to success could be a standardized patient selection and therapy to improve the standard of care, reduce risks and shorten treatment time.

CLINICAL RELEVANCE

Our analysis provides further evidence that implant placement is a feasible treatment option in irradiated head and neck cancer patients with diminished oral function and good long-term cancer prognosis.

Implant Dental Rehabilitation of Fibula-Free Flap Reconstructed Jaws

BACKGROUND

The possibility of placing dental fixtures in the reconstructed regions allows us to overcome the problems related to dental rehabilitation with removable prosthesis. The aim of this study was to assess the clinic-radiological outcome in a series of patients who underwent fibula flap jaws reconstruction and rehabilitation with implant-supported prosthesis with a minimum follow-up of 24 months.

MATERIAL AND METHODS

The study included 10 patients who underwent reconstruction with fibula free flap between 2010 and 2018. Albrektsson criteria were used to define the implant survival. The follow-up evaluation was performed according to a standardized protocol including clinical examination, radiological evaluation (panoramic radiograph) and patient interview.

RESULTS

A total of 45 implants were positioned.The time between mandibular reconstruction and implant placement ranged from 13 months to 39 months.The prosthesis used was fixed in 6 cases and supported overdenture in 4 cases.No implant failure was observed.Regarding implant survival no infections were observed in these series. Nine patients out of 10 had no pain and signs of mobility. Seven patients out of 10 had absence of peri-implant radiolucency at the panoramic radiograph.One patient presented with an overgrowth of granulomatous soft tissue around the implant abutments that caused pain.

CONCLUSIONS

Implant placed in vascularized bone grafts are a safe and reliable opportunity to rehabilitate patients following mandibular resection. The results of this series demonstrate a high survival rate for implants placed in reconstructed mandibles with an improvement of the quality of life.

Long-term outcomes of implant-based dental rehabilitation in head and neck cancer patients after reconstruction with the free vascularized fibula flap

The study aimed at evaluating, comprehensively, implant-based dental rehabilitation in head and neck cancer patients after maxillofacial reconstruction with a vascularized free fibula flap (FFF). Data were obtained by retrospectively reviewing the medical records of patients treated in Amsterdam UMC-VU Medical Center. Dental implant survival and implant success according to the Albrektsson criteria were analyzed. Additionally, prosthetic-related outcomes were studied, with a focus on functional dental rehabilitation. In total, 161 implants were placed in FFFs, with a mean follow-up of 4.9 years (range 0.2-23.4). Implant survival was 55.3% in irradiated FFFs and 96% in non-irradiated FFFs. Significant predictors for implant failure were tobacco use and irradiation of the FFF. Implant success was 40.4% in irradiated FFFs and 61.4% in non-irradiated FFFs, mainly due to implant failure and non-functional implants. Implant-based dental rehabilitation was started 45 times in 42 patients, out of 161 FFF reconstructions (27.9%). Thirty-seven patients completed the dental rehabilitation, 29 of whom achieved functional rehabilitation. Irradiation of the FFF negatively influenced attainment of functional rehabilitation. For patients with functional rehabilitation, the body mass index varied at different timepoints: FFF reconstruction, 24.6; dental implantation 23.5; and after placing dental prosthesis, 23.9. Functional implant-based dental rehabilitation, if started, can be achieved in the majority of head and neck cancer patients after FFF reconstruction. Actively smoking patients with an irradiated FFF should be clearly informed about the increased risk for implant and prosthetic treatment failure.

Donor- and recipient-site morbidity of vascularized fibular and iliac flaps for mandibular reconstruction: A systematic review and meta-analysis

The aim of this article is to evaluate the early and late morbidities of the donor- and recipient-site in patients undergoing mandibular reconstruction using either vascularized fibular flap (VFF) or vascularized iliac flap (VIF). Electronic databases, including PubMed, Web of Science, Cochrane Central and Embase, were explored for literature published until October 2020. A total of twenty-four articles reporting complications following mandibular reconstruction surgery with follow-up periods ranging from six to 63 months were selected based on the exclusion criteria. For each research, the JBI Critical Assessment Tool and the ROBINS-I Tool were used to analyze the methodological quality and the risk of bias. A single-arm meta-analysis was performed to have a synthesized analysis of the donor- and recipient-site early and late morbidities. Results showed that the early morbidities in VFF group ranged from 3% to 12%, and the late morbidities in VFF group ranged from 5% to 67%. In VIF group, the early morbidities ranged from 3% to 16%, and the donor-site late morbidities ranged from 6% to 43%. Complications with the top three morbidities in the VFF group were: chronic sensory disturbances at the donor-site (67%), malocclusion (22%) and chronic lower limb weakness (20%); and in the VIF group were: chronic sensory disturbances at the donor-site (43%), chronic pain at the donor-site (26%), chronic gait disturbance (20%). Further controlled clinical trials are needed to assess the long-term outcome of VFF or VIF grafting.

Multidisciplinary Approach to Rehabilitation after Tumor Resective Jaw Surgery: A 9-Year Follow-Up

A 36-year-old male patient presented at the Department of Maxillofacial Surgery, University Hospital Clinic Zagreb in December 2010 due to a swelling of the left body of the mandible that was noticed 4 months earlier. The patient was referred regarding an atypical clinical and radiological finding in the form of a multicystic appearance in the corpus of the left mandible and teeth mobility in the same region. A probatory biopsy was performed under local anesthesia and sent for histopathologic examination which reported odontogenic myxoma. The tumor was removed with a marginal resection of the mandible from the left first incisor to the left second molar. Two years after surgery, in January 2013, the patient was referred to the oral surgeons for implant-prosthodontic rehabilitation. Two narrow implants were placed at positions 32 and 36, and three months afterwards, implant-retained denture was made using locator connections to compensate lost teeth and to correct the ratio of soft tissues and facial contours. The patient was followed-up for 9 years without any functional and aesthetic problems. Loosing function and aesthetic morbidity, after radical surgical treatment, often have compromised the quality of life of this group of patients. It is important to highlight the need for multidisciplinary collaboration for the complete rehabilitation of the patient after surgical oncology of the maxillofacial region.

Outcomes following Microvascular Mandibular Reconstruction in Pediatric Patients and Young Adults

Background:

The etiology and treatment of complex mandibular defects in children differ markedly from those of adults, although treatment with free bone flaps is historical in both groups. While adult outcomes and complication rates are well known, few pediatric data exist, especially for patients with congenital deficiencies. This study reports early and late outcomes from a cohort of young, primarily syndromic patients undergoing microvascular mandibular reconstruction.

Methods:

This is a retrospective case series of patients who underwent microvascular mandibular reconstruction between 1995 and 2016.

Results:

Thirteen patients received a total of 13 fibula transfers and 1 medial femoral condyle transfer. Most patients carried a congenital diagnosis (77%), and the average age during surgery was 11.7 ± 5.7 years. The median (interquartile range) [IQR] length of follow-up was 6.3 (5.7) years. There was a 100% flap survival rate, although 86% of all patients experienced at least one complication. Half of all procedures resulted in an early complication. Nine patients (69%) developed late complications, of which temporal mandibular joint ankylosis was the most common (n = 5; 38%).

Conclusions:

This study is one of few detailing outcomes following mandibular reconstruction by free flap transfer in pediatric patients. These patients were primarily syndromic with appreciable complication rates higher than in other adult and pediatric studies. Some complications are manageable or self-resolving, but others lead to functional problems that may require late operative interventions to correct. Microsurgical treatment should be reserved for children with large, complex mandibular defects when other options are unavailable or have been exhausted.

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

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

Lateral segmental mandibulectomy reconstruction with bridging reconstruction plate and anterolateral thigh free flap: a case series of 30 consecutive patients

Lateral posterior segmental mandibular defects present a reconstructive challenge and an osseous flap would be the gold standard to reconstruct such a defect. However, combining a mandibular reconstruction plate (MRP) with a soft-tissue free flap (to restore mucosal integrity and provide durable coverage of the plate itself) offers an alternative option for posterior segmental mandibular defects in patients who are not suitable for osseous reconstruction, or do not choose it. We retrospectively reviewed 30 consecutive patients (19 male and 11 female) who underwent reconstruction of a segmental mandibulectomy defect using a bridging MRP and anterolateral thigh (ALT) free flap. The mean (range) age was 67 (31-87) years. The American Society of Anesthesiologists' (ASA) status of the study population comprised Grade 1 (n = 10), Grade 2 (n = 18), and Grade 3 (n = 2). The majority of patients had oral cavity squamous cell carcinoma (n = 26) involving the mandible, two had osteoradionecrosis, and two mucoepidermoid carcinoma. Four patients had complications specific to the reconstruction, and flap loss occurred in one (96.7% success rate). Metalwork infection occurred in three, including one plate extrusion and one plate fracture. The median length of stay was 10 days, and mean (range) duration of follow up 23.3 (1-96) months. This technique is an alternative reconstructive option for the non-tooth-bearing mandible. Reconstructing a posterolateral segmental mandibulectomy defect with a bridging MRP and ALT free flap offers a robust reconstructive alternative with a favourable complication profile.

Donor-Site Morbidity after Fibula Transplantation in Head and Neck Tumor Patients: A Split-Leg Retrospective Study with Focus on Leg Stability and Quality of Life

The free fibula flap has been one of the most important microvascular grafts for orofacial reconstruction for more than 30 years. The complication rates at the donor-site reported in literature are considered to be low, but the published data vary greatly in some cases. In particular, restrictions in the stability and balance of the involved leg and their effects on the quality of life have been described very inconsistently to date. Therefore, this study mainly focuses on the stability and balance of the affected leg in a split-leg design. Between December 2014 and January 2018, out of 119 subjects who underwent mainly jaw ablative tumor surgery and reconstruction using a fibula flap, 68 subjects were examined for donor site morbidity. Besides reporting general types of complications, two specific test procedures were used. The Star Excursion Balance Test (SEBT) as a practical test for ankle function and the Foot and Ankle Disability Index (FADI) as a questionnaire in order to assess quality of life, depending on the lower leg function. SEBT revealed an average of 55.3 cm with the operated leg as the supporting leg, which corresponds to 95.5% of 57.9 cm achieved with the healthy leg as the supporting leg. An average FADI score of 89.4% was recorded. SEBT and FADI seem to be suitable methods of examination for subjects post fibular transplantation and pointed out minimal limitations of the involved legs in comparison to the unaffected legs. These limitations were clinically not relevant and they had minor influence on the subjects’ quality of life and their daily activities.

Revascularized Fibula Free Flap Reconstruction and Curvilinear Transport Distraction Osteogenesis in Closure of Large Postmaxillectomy Defects: A New Gold Standard?

Introduction:

The revascularized fibula free flap (RFFF) is the most popular method of postmaxillectomy reconstruction. This article proves that the use of curvilinear transport distraction osteogenesis (CTDO) is an efficacious way in closing large defects in the maxilla and a superior alternative to the RFFF.

Methods and Materials:

In a prospective cohort study of six postmaxillectomy patients, CTDO was applied and the new bone (regenerate) was compared with the parent bone from which it had been regenerated. These results were compared with a retrospective group of six participants of similar age and sex who had undergone RFFF reconstruction as an external control. Clinical measurements taken at the depth of the alveolar vestibule were recorded at three different exact points juxtaposed, namely (A) lateral incisor, (B) first premolar, and (C) first molar. These areas of interest were similar to those chosen on the CT scans. Impressions were taken from all the patients and stone casts were made. The width of the alveolar bone was computed based on the measurements made from the stone casts. The stone casts were then used to calculate the width and depth of the soft tissue and bone in the maxilla in the (A), (B), and (C) regions.

Results:

The regenerate possessed anatomical and physiological characteristics equal to the parent bone. For the CTDO patients, prosthetic rehabilitation of the dentition was supported by dental implants after osseointegration of the latter into the newly created bone and soft tissue.

Discussion:

The production of the curvilinear bone and soft tissue along a horizontal plane has been demonstrated. The new alveolar bone achieved the correct width and depth to create a physiological vestibule and a functional/esthetic zone for the placement of dental implants. In addition, the shape of the palatal vault was also maintained. The CTDO method is a reliable method of maxillary reconstruction and has a better anatomical and functional outcome than the RFFF.

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

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

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.

Role of Axial Split Osteotomy of Free Fibula Flap in Mandibular Reconstruction and Dental Rehabilitation

The fibula free flap (FFF) is regarded as the gold standard in mandibular reconstruction. Dental rehabilitation is important to improve the health-related quality of life of patients undergoing mandibular reconstruction. FFF provides adequate cortical bone osseous tissue for use in dental implantation. The application of “axial split osteotomy” via a double-barrel fibula graft may enable discrepancies between the native mandible and FFF to be avoided, thereby improving the likelihood of early and successful dental rehabilitation.

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.