Implant rehabilitation in
fibula-free flap reconstruction: A
retrospective study of cases at 1e18 years following surgery
Davide Sozzi
a, Giorgio Novelli
a, Rebeka Silva
b, Stephen T. Connelly
b,
Gianluca M. Tartaglia
c,d,*aMaxillofacial O.U.S. Gerardo Hospital Monza, Dept. of Medicine and Surgery, School of Medicine, University of Milano-Bicocca, Milan, Italy bDepartment of Veterans Affairs Medical Center, San Francisco, CA, USA
cDepartment of Biomedical Sciences for Health, Functional Anatomy Research Center (FARC), Universita degli Studi di Milano, Milano, Italy dSST Dental Clinic, Segrate, Italy
a r t i c l e i n f o
Article history:
Paper received 2 March 2017 Accepted 27 June 2017 Available online 8 July 2017 Keywords:
Fibula Reconstruction Implants
a b s t r a c t
Purpose: To determine the dental implant and prostheses success rate in a cohort of patients who underwent a vascularizedfibula-free flap (FFF) for maxillary or mandibular reconstruction.
Methods: The investigators implemented a retrospective cohort study composed of patients who had undergone primary or secondary FFF reconstruction jaw surgery plus placement of 2e6 implants in the reconstructed arch, which were restored with an implant-supported prosthesis. The sample was composed of all patients who underwent FFF surgery between 1998 and 2012 and had either simulta-neous or secondary dental implant placement. A total of 28 patients met inclusion criteria. Of these, 22 patients participated in the retrospective review. Patients were examined by an independent observer between January-December 2015. In addition, all patients completed a questionnaire to access satis-faction with the implant-supported prosthesis.
Results: The patient cohort consisted of 12 males and 10 females, age 12e70 years. A total of 100 im-plants were placed, 92 imim-plants infibular bone and 8 implants in native bone. In the maxilla, 35 implants were placed intofibular bone and 4 into native bone (11 in irradiated patients and 28 in non-irradiated patients). In the mandible, 57 implants were placed intofibular bone and 4 into native bone (15 in irradiated patients and 46 in non-irradiated patients). The mean follow-up after implant loading was 7.8 years (range 1.3e17.5 years). The implant survival rate was 98% (95% CI: 92.2%e99.5%). No statistically significant difference was found in implant success between maxillary and mandibular implants, or between radiated and non-radiated bone. The prostheses success rate, determined by clinical exam and patient satisfaction, was 100%.
Conclusion: The results of this study suggest that implant survival is high and implant-supported prostheses are a reliable rehabilitation option in patients whose jaws have been reconstruction with a FFF.
© 2017 Published by Elsevier Ltd on behalf of European Association for Cranio-Maxillo-Facial Surgery.
1. Introduction
Health-related quality of life (HRQOL), and not just disease-free survival, is seen as fundamental for patients undergoing a signi fi-cant surgical resection of a maxillary or mandibular lesion that requires reconstruction. For patients who undergo vascularized fibula-free flap (FFF) reconstructive surgery, quality of life
encompasses oral rehabilitation with an implant-supported pros-thesis (Iizuka et al., 2005; Schoen et al., 2007). The aim of this retrospective study was to evaluate the dental implant and pros-thetic results in a group of 22 patients reconstructed with FFF and who had implants placed between 1998 and 2012.
Taylor et al.first described the use of the FFF in1975. Since then, the technique has been widely used to reconstruct segmental long bone, and mandibular or maxillary deficiencies (Wei et al., 1986, 1994; Yazar et al., 2004; Lin et al., 2009). It is considered to be the gold-standard technique for reconstructing these types of defect (Urken et al., 1991a; Schrag et al., 2006). Its main advantages are as follows:
* Corresponding author. Department of Biomedical Sciences for Health, Func-tional Anatomy Research Center (FARC), Universita degli Studi Di Milano, Milano, Italy.
E-mail address:gmtartaglia@gmail.com(G.M. Tartaglia).
Contents lists available atScienceDirect
Journal of Cranio-Maxillo-Facial Surgery
j o u rn a l h o m e p a g e : w w w . j c m f s . c o mhttp://dx.doi.org/10.1016/j.jcms.2017.06.021
- The availability of an adequate quantity and quality of trans-planted bone.
- The vascular pedicle is ideal for anastomosis with vessels in the neck.
- The graft can be harvested with or without a soft tissue component, as needed for coverage.
- The bone can be easily adapted to the shape of the mandible or maxilla (Hidalgo, 1989).
For these reasons, this flap is often indicated in the recon-struction of bone and soft-tissue defects of the oral cavity. Post-ablative defects from neoplasm resection in the oral cavity and oropharynx, post-traumatic defects, osteonecrosis, and congenital abnormalities have been successfully treated with this surgical procedure (Rana et al., 2011), which can be performed in a single stage (Genden et al., 2004).
A significant advantage is that FFF reconstruction offers adequate bony dimensions and bone quality, which allows for the placement and osseointegration of dental implants, and conse-quently the possibility to restore masticatory function and aes-thetics (Sumi et al., 2001). In addition, the physical distance between the donor (lower limb) and recipient site (head) allows two surgical teams to work simultaneously, thus reducing oper-ating time (Kildal et al., 2001; Chana et al., 2004).
On the other hand, the FFF procedure is not devoid of potential complications. Various leg and foot muscles originate or insert on thefibula, so their detachment and partial withdrawal during fibula harvest can cause limb dysfunctions or even gait disturbances if there is not at least 5e6 cm of residual distal fibula left behind. The potential complications have to be carefully considered against the patient's desire to have a complete tumor resection and a satis-factory reconstruction. Fortunately, there is growing evidence that donor-site morbidity is low or absent in most FFF patients, as evi-denced from studies reported in the literature where the in-vestigators have either used qualitative methods, such as questionnaires and clinical subjective evaluations (Vail and Urbaniak, 1996; Goodcare et al., 1990; Bodde et al., 2013), or quantitative methods (Baj et al., 2015) to assess morbidity.
The excellent results achieved are encouraging both for the patient and for the surgical/reconstructive team because patients now have the possibility of improved dental rehabilitation, which in the past has been limited due to the effects of the ablative sur-gery and subsequent radiation. Factors contributing to a poor prosthetic result include insufficient bone height, unfavorable soft tissue mobility, post-surgical vestibular defects, post radiation xerostomia, or mucosal atrophy. Thus, the FFF has become a cornerstone in head-and-neck reconstruction because it restores continuity to remaining native structures, and allows for dental implants to complete a stable oral rehabilitation.
2. Methods and materials
This study followed the Declaration of Helsinki and was in accordance with Italian Law. The procedures were approved by a Professional Review Board (IRB02e2010 Doc. MQ 03 AL 01). All subjects signed a written consent form, and were given a thorough explanation regarding the clinical procedures.
2.1. Patient sample
From January 2015 to December 2015, 22 patients (12 males, 10 females), aged 12e70 years (mean (SD) age 48 (16) years) who had undergone primary or secondary FFF reconstructive jaw surgery plus placement of 2e6 implants supporting an implant-supported prosthesis (Tables 1 and 2) from January 1998 to December 2012,
were examined during an annual clinical follow-up appointment. Patients with recurrence of the disease were not excluded. Out of the original 28 patients, representing 112 implants and 28 pros-theses, a total of 6 patients (4 men, 2 women) withdrew from the study. Reasons for drop-out were death, loss to follow-up, and move from the area. All patients were examined by an indepen-dent operator who was not involved in the original procedures (GN).
2.2. Surgical protocol
Preliminary screening was performed using standard clinical examination, panoramic orthopantomographs, computerized tomographic scans, study models, blood tests, and electrocardiog-raphy. All patients underwent preoperative anesthesia and cardiac consultations. Prior to FFF, a thorough medical history was ob-tained, angiography of the legs was carried out to determine three-vessel patency, and, for oncological patients, disease staging was performed. In addition, patients were queried about their alcohol and tobacco use: ‘drinkers’ were those patients who declared consuming more than half a liter a day of generic alcoholic bever-ages continuously for at least 1 year, while‘smokers’ were those patients who declared to be habitual tobacco users.
The condyle and temporomandibular joint capsule was spared in all cases. Sufficient bone was preserved to allow for a minimum of threefixation screws at both the proximal and distal end of the reconstruction plate. When harvesting thefibular graft, the motor nerve branch of theflexor hallucis longus muscle was separated fromflap pedicle vessels and preserved in all cases. The donor site was closed primarily if only bone was taken; if muscle and skin paddle were harvested along with bone, the donor site received split-thickness skin grafts. Donor sites with skin graft received a splint to stabilize the angle at 90for 10 days; splints were not applied to donor sites without skin grafts. At 1e2 weeks after surgery, all patients started lower limb and mandibular movement rehabilitation with a physical therapist, without limitations. 2.3. Implant and prosthetic procedures
Reconstructive and implant-prosthetic planning took place in two steps, as follows:
- Reconstruction planning: to identify the best position for the bonyflap for good morphological and prosthetic results (i.e. facial profile).
- Implant planning: to define the number and position of the proposed implants using CT scan data and computer aided design (CAD) software.
The reconstructed bone defects were categorized according to theBrown and Shaw (2010)classification for the maxilla and to the
paddle in the alveolar portion, the skin paddle was removed, pre-serving subcutaneous tissues, which were allowed to heal by sec-ondary intention. Care was taken to avoid injuring the vessels supplying the vascularized free flap, which would result in soft tissue necrosis.
All dental implants were screw-shaped, 11.5e15 mm in length and 4.0e5.0 mm in diameter. Implant placement followed standard procedure (Brånemark et al., 1977) modified fromTartaglia et al. (2016). The implants' primary stability at placement time was assessed clinically prior to 2008; following this, primary implant stability was determined to be present or absent via both clinical examination and instrumental analysis. A stability quotient of at least 65, assessed with resonance frequency analysis (RFA), was obtained for all implants placed from 2008 (Sennerby and Meredith, 2008). Soft tissues were closed with 4e0 non-resorbable sutures, which were removed 7e10 days post-operatively. All patients received oral preoperative antibiotic ther-apy (amoxicillinþ clavulanate, 1 g every 8 h), beginning 2 days prior to surgery and continued for 7 days postoperatively for non-irradiated patients and 15 days for non-irradiated patients. Patients were instructed to maintain a soft post-procedure diet for 15 days and to maintain good oral hygiene.
Implants were uncovered 5e6 months after implantation. Before stage II surgery, a panoramic radiograph was taken to assess the stability of the bone level surrounding the implants and to ensure that there were no infections. None of the implants was immediately loaded. During the placement of the healing abut-ment, implant osseointegration was checked with the application of reverse or unscrewing torque. Following soft tissue healing, it was possible to proceed with the prosthetic phase. Depending on
Table 1
Patient characteristics and treatment. Age
(yr)
Sex Pathology Smoker Drinker
Arch Defecta Radiotherapy, waiting
period pre-implants Implants loaded (mo) Fibula coverage Double barrel Immediate implant Prosthesis/score
36 M Eosinophilic granuloma e Mandible BSB e 210 Skin e e Overdenture/B 51 M Leiomyoma e Mandible BSB e 167 Skin e e Overdenture/B 12 F Cementoma e Mandible BSB e 162 Skin e 1 Overdenture/C 57 M Squamous cell carcinoma S Mandible BSB e 138 Skin e e Overdenture/A 50 M Atrophy e Maxilla Id e 139 Skin e e Overdenture/B 45 F Squamous cell carcinoma S Maxilla IIb Yes, 19 months 138 Skin e e Screw-retained/
A
53 M Atrophy e Maxilla Id e 114 Muscle e e Screw-retained/ A
70 F Squamous cell carcinoma S Mandible SBR e 114 Skin e e Screw-retained/ B
62 F Atrophy e Maxilla Id e 115 Muscle e e Screw-retained/ B
59 M Squamous cell carcinoma S, D Mandible BSB Yes, 18 months 114 Skin e e Overdenture/A 55 M Mucoepidermoid
carcinoma
e Maxilla IIb e 102 Skin e e Cemented/B 62 M Acinic cell carcinoma e Maxilla IId e 78 Skin e 1 Overdenture/C 67 F Adenoid cystic carcinoma e Maxilla IId Yes, 20 months 76 Skin e e Overdenture/A 27 F Ameloblastoma e Mandible BR e 77 Mucosa e e Screw-retained/
A
30 M Fibromyoma e Mandible BSB e 66 Skin e e Overdenture/C 65 F Squamous cell carcinoma S, D Mandible BSB Yes, 13 months 52 Skin e Overdenture/A 27 M Ballistic trauma e Mandible BS e 54 Mucosa Yes e Cemented/B 54 M Ameloblastoma S, D Mandible BSB e 40 Mucosa e e Screw-retained/
A 31 F Fibromyxoma e Maxilla IId e 42 Mucosa e e Cemented/A 65 F Squamous cell carcinoma S Mandible BSB Yes, 18 months 36 Skin Yes e Cemented/B 30 F Ameloblastoma e Mandible BS e 16 Skin e e Cemented/B 54 M Squamous cell carcinoma S Mandible BSBR Yes, post-implants 18 Skin e 1 Overdenture/C
aDefect terminology fromBrown and Shaw (2010)for maxilla (IeVIdroman numerals refer to the increasing complexity of the orbito-nasal-maxillary vertical defect;
aeddletters refer to the increasing complexity of the dentoalveolar and palatal horizontal defect); andUrken et al. (1991a,b)for mandible (B¼ body; S ¼ symphysis; R¼ ramus). Smoker (S), Drinker (D). Prosthesis score legend AeEdletters refer to the decreasing satisfaction of the patient in accordance withHickel et al. (2010).
Table 2
Implant and patient characteristics.
Location Maxilla¼ 8 Mandible¼ 14 Reconstruction Primary¼ 21
Secondary¼ 1
Radiotherapy 5 (pre-implant)þ 1 (post-implant) Mean time to place implants post-radiation therapy: 14.6 months
Soft tissue coverage Residual mucosa¼ 2 Muscle¼ 4
Skin paddle de-epithelialization¼ 16 Maxillary implants (n¼ 39) Pre irradiatedflap ¼ 0
Post irradiatedflap ¼ 4 Irradiated native bone¼ 2 Non irradiatedflap ¼ 31 Non irradiated native bone¼ 2 Mandible implants (n¼ 61) Pre irradiatedflap ¼ 11
Post irradiatedflap ¼ 4 Irradiated native bone¼ 0 Non irradiatedflap ¼ 42 Non irradiated native bone¼ 4 Implants Total¼ 100
Fibularflap ¼ 92 Native bone¼ 8 Implants lost 2
Peri-implant disease 2
Implant follow-up Mean¼ 8.30 y Median¼ 8 y Range¼ 1e17 y Loaded implant follow-up Mean¼ 7.8 y
patient need, number of implants, and restorative space, different types of prostheses were employed:
- RPD: Overdenture (bar-retained or O-ring-retained), as described byFerrario et al. (2004);
- SFPD: Screw-retained prosthesis, as described byFerrario et al. (2004);
- CFPD: Cement-retained prosthesis, as described byPreiskel and Tsolka (1998).
In accordance with Ferrario et al. (2004), equilibrated neuro-muscular functional occlusion was achieved by means of functional bilateral occlusal contacts and masticatory neuromuscular re-education.
2.4. Criteria of success
An implant was considered successful if there was absence of implant-related pain, suppuration, swelling, mobility, discomfort, ongoing pathological processes, peri-implantitis, neuropathies, or persistent paresthesia, according to van Steenberghe (1997). The prosthesis was considered successful by the clinical team if it was functioning, stable, and pain-free, according to Tartaglia et al. (2016).
Complications were classified as follows: prosthetic failure necessitating removable or repair, abutment-prosthesis screw loosening requiring re-tightening, and fracture of the prosthesis. In addition, patient satisfaction regarding both the aesthetics and function of the entire reconstruction was assessed using a ques-tionnaire with five possible rating categories: (A) excellent/very good e the patient was entirely satisfied, and the prosthesis could not be detected with the tongue (seamless between dental pros-thesis and the new alveolar process); (B) good e the patient was entirely satisfied, but the prosthesis could be detected with the tongue; (C) sufficient/satisfactory e esthetic shortcomings and/or discomfort during chewing were reported, but a replacement was not necessary; (D) poor e the patient requested an improvement to be made to the prosthesis; and (E) unsatisfactory e the patient was completely dissatisfied and required a new prosthesis, but declined replacements of the same type or made with the same material (Hickel et al., 2010).
2.5. Statistical analysis
Mean and standard deviation (SD) are reported for quantitative data. The chi-squared test was used to evaluate the relationship between irradiation and position. For the survival analysis, patients were censored if they had not experienced the required end-point at follow-up. A KaplaneMeier survival curve was performed, and survival rate and its 95% CI (confidence intervals) were calculated. All analyses were performed using STATA 14.1 (StataCorp, College Station, TX). A two-sided p-value< 0.05 was considered statistically significant.
3. Results
A total of 22 patients who underwent FFF reconstruction at our institution between 1998 and 2012 and had immediate or sec-ondary dental implant surgery, were examined by an independent observer in 2015. The mean follow-up after implant loading was 7.8 years (range 1.3e17.5 years). Eighteen patients had primary reconstruction after hemimandibular/maxilla resection for onco-logical pathology (10 for malignant lesions and 8 for aggressive or recurrent benign lesions), three patients underwent surgery to
correct severe maxillary atrophy, and one had secondary recon-struction after a gunshot wound (Table 1). Five oncological patients had post-resection radiotherapy before implant placement and one patient had radiotherapy after implant placement.
Fourteen patients underwent mandible reconstruction with a classic mono-barrelfibula and two underwent double-barrel FFF. The choice of technique depended on the necessity to minimize the height discrepancy between native and grafted bone, and when the FFF pedicle length allowed it. No patient in this series required additional bone grafting or distraction osteogenesis. Sixteen patients received a composite osteocutaneous flap, four received an osteomuscularflap, and the remaining two patients only had a bony flap, covered with residual mucosa. Fourteen patients (four maxilla, 10 mandible) underwent surgical removal of plates and screws at the time of implant surgery because of interference with implant positioning. Most patients (n ¼ 19) underwent dental implant placement as a secondary surgery, which was performed 7e24 months (mean 11 months) after FFF reconstruction. If radiation therapy was required, implants were delayed after the completion of radiation therapy. In only three cases, implants were placed at the time of FFF surgery; these were all patients with good prognosis with respect to their pathology. A total of 92 implants were placed in the fibular flaps and eight implants in native bone. In the maxilla, 35 implants were placed intofibular bone and four into native bone (six in irradiated pa-tients and 33 in non-irradiated papa-tients). In the mandible, 57 implants were placed intofibular bone and four into native bone (15 in irradiated patients and 46 in non-irradiated patients). None of the implants had registered rotational, horizontal, or vertical mobility upon placement. All implants were submerged; no transmucosal implants were placed.
Types of prostheses employed differed among patients, depending on need, occlusion, and number of implants able to be placed. Only two implants were lost in two different patients, both 2 months after loading with an overdenture prosthesis. The pros-theses were serviceable in both cases because the residual three implants were sufficient for their stability. In one patient there was a longitudinal splitting of the cortical bone in a double-barrel reconstruction during implant placement, but this did not compromise implant stability and its integration. Two patients were treated for peri-implantitis: however, these events did not compromise the implant stability or osseointegration. No patient experienced a fractured implant in this retrospective review.
The implant survival rate, defined implants being in situ, stable, and functioning, was 98% (95% CI: 92.2e99.5%) (Table 3). The prosthesis success rate, defined as being functional, stable, and pain-free, according toTartaglia et al. (2016), that achieved a pa-tient satisfaction rating of sufficient/satisfactory, or better, was 100%. Prosthodontic maintenance, such as prosthetic tooth frac-tures, prosthesis rebasing, and prosthesis margin adaptation, were not considered complications. Maintenance procedures were required for most patients, and these were given special attention. Prosthetic maintenance was more difficult for CFPD than for SFPD and RPD. In the RPD bar retained group, a tendency to gingival hyperplasia was observed.
Comparison between irradiated versus non-irradiated implants, or between arches (maxilla versus mandible), showed no statistical differences (p¼ 0.688,
c
2). No statistical differences were notedwhen comparing implants placed in native versus fibular bone (p ¼ 0.708,
c
2). All patients had high satisfaction rates for oral4. Discussion
The last few decades have seen encouraging functional, esthetic, and survival rate outcomes for patients receiving oral rehabilitation with FFF and dental implants, as reported by various authors. Wu and his group reported a 1-year and 5-year implant success rate of 95% and 87%, respectively, with infection, tumor recurrence, and soft tissue proliferation accounting for the majority of failures (Wu et al., 2008). Chiapasco et al. followed 16 patients with implants and implant-supported prostheses for a mean of 50 months and determined that the implant success and survival rates were 98.6% and 93.1%, respectively (Chiapasco et al., 2006). Using a KaplaneMeier analysis, Kramer et al. achieved a success rate of 96.1% in 16 patients with a total of 51 implants after 3.8 years (Kramer et al., 2005). In a group of 33 patients, most of whom were smokers and had undergone mandibular irradiation, Jacobson et al. found an overall 1- and 5-year survival rate for 140 implants of 94% and 83%, respectively, although implants in irradiatedfibular bone achieved only a 38% survival rate (Jacobsen et al., 2014). A problem in the analysis of the literature is that investigators sometimes only report implant survival rate, whereas for implant success rate there is heterogeneity in the definition for this group of patients. Thus, our retrospective assessment of implant survival rates in FFF and assessment of our success definition criteria could serve as a standardized tool in this group of patients. Ultimately, this clinical tool will benefit this high-risk group of patients and help clinicians gain confidence that an improved quality of life is achievable following maxillary/mandibular reconstruction.
In consideration of the challenges a post-resection, FFF-recon-structed patient is presented with, an implant-supported pros-thesis offers the best chance for a stable and functional oral rehabilitation (Schoen et al., 2007). Absence of pain and suppura-tion, primary stability, and functional loading ability were consid-ered in our criteria for implant success. In this retrospective study, all implants that met the above-mentioned success criteria were used tofinalize the case, which is the ultimate goal of this complex and expensive medical and dental treatment. Moreover, in this high-risk population, wefind it unrealistic to apply the same in-clusion criteria that one would apply to the typical, general population.
Low vertical height, pathological maxillomandibular relation-ships, or mobile soft tissue surrounding the implants are consid-ered to be common causes of implant failure in maxillary reconstructions (Chiapasco et al., 2006; Schultes et al., 2002). Insufficient height of the fibula may be an obstacle for prosthetic treatment due to the large bony step between the native mandible and the graft (Bodard et al., 2011). Multiple solutions have been
proposed in the literature, including vertical osteodistraction (Chiapasco et al., 2006), aligning the graft with the alveolar crest at the time of placement (Smolka et al., 2008), or combining a non-vascularized bone graft onlay with FFF (Hayter and Cawood, 1996). However, we prefer a double-barrel technique, in line with B€ahr
et al., 1998(Figs. 1 and 2).
The grafted soft tissue introduces tissue thickness and mobility that may induce peri-implant inflammatory problems and pocket formation (Fierz et al., 2013). As described byHayter and Cawood (1996), we believe that the ideal soft tissue for implants is non-mobile, thick mucosa free from wrinkles or hair. We do not recommend palatal mucosa grafts, as described by many authors (Hayter and Cawood, 1996; Schrag et al., 2006; Chang et al., 2011). Instead we prefer to perform skin paddle removal. Sensibility and motricity loss are other important factors to be considered and evaluated in terms offinal outcome results.
In agreement with international literature, we believe that bicortical or tricortical placement of the dental implants increases success rate because the central marrow has low bone density and poor chance of participating in osseointegration (Bodard et al., 2011; Sumi et al., 2001; Chang et al., 2011). In addition, osteot-omy sites should be avoided because they are often the weakest part of the reconstruction (Bodard et al., 2011). Reconstructive plates are best positioned to reduce interference with subsequent dental implant placement, especially in native bone where screws are placed bicortically. In accordance withSchrag et al. (2006), we believe that simultaneous implant placement during FFF recon-struction should be considered in cases of non-neoplastic pathol-ogy because both reconstructive hardware and dental implant positioning can be virtually planned, and there is no concern for the ramifications of radiation therapy, where the effects on implants and surrounding tissues cannot be fully predicted.
For those patients who received radiation therapy, we per-formed cautious, delayed implant placement in those who were well motivated and disease free. Moreover, the RT protocol treat-ment was just adjuvant, because all cases were treated with radical surgery in order to minimize complications relating to the vascu-larization of the tissues. Jacobsen et al. (2014) concluded that irradiation of grafted bone seemed to be a high risk factor for implant failure. However, there is no general agreement that endosseous implants fail more frequently due to radiation therapy (Granstr€om, 2003), and some authors do not consider implant placement contraindicated for cancer patients who undergo sub-sequent radiation therapy (Schepers et al., 2006; Schoen et al., 2007; Smolka et al., 2008). Other investigators showed that radiotherapy reduces vascularization, inducing reparativefibrosis, and lowers infection resistance, which results in poor implant
Table 3 Life table analysis.
Years At loading 1 2 3 4 5 6 7 8 9 10 11 12 13 17
Number of implants 100 100 89 89 74 67 63 50 46 24 11 4
CSR 98 88 88 73 66 62 50 50 46 24 24 11 11 4
Percentage 98% 98% 98% 98% 98% 98% 98% 98% 98% 98% 98% 97% 97% 97%
Implants added per year 11 15 7 4 13 4 22 13 7 4
Maxilla, native bone Nib 2 1 1
Ib 2 2
Mandible, native bone Nib 4 4 Ib
Maxilla,fibula bone Nib 31 3 4e1 4 12e1 8
Ib 4 4
Mandible,fibula bone Nib 42 7 4 3e1 4 3 6 4 7 4
Ib 15 4e1 3 4 4
prognosis (Hundepool et al., 2008; Ihde et al., 2009; Fenlon et al., 2012; Ferrari et al., 2013). According to these authors, a recovery period of at least 12 months following radiation should be allowed before attempting implantation, to reduce the risk of failure, as bone regeneration after radiotherapy is depressed by 70.9%, with recovery of up to 28.9% in 1 year (Jacobsson et al., 1985; Hayter and Cawood, 1996).
It is our experience that most patients (95%) affected by malig-nant oncological pathology reject additional surgical procedures for implant placement and subsequent prosthetic reconstruction, in light of their diagnosis and prognosis. However, oral rehabilitation with FFF and dental implants should not be a secondary consider-ation; we view it as an integral component of the primary treat-ment plan, and as an opportunity to improve the patient's quality of life post-resection. Dental prosthetic rehabilitation can lead to satisfying and effective mastication, and the esthetic support of the cheeks and lips. Achieving these results could help patients over-come the frequent reminder of their illness and psychological trauma-related aspects of their disease. For these reasons, dentally
oriented management of the hard and soft tissues is not just sug-gested, but also highly recommended (Iizuka et al., 2005). 5. Conclusion
With careful planning of implant position, implant survival is high and implant-supported prostheses are a reliable dental reha-bilitation option in patients whose jaws have been reconstructed with FFF. A few technical precautions that increase the implant survival rate are described in this paper. Our group's implant sur-vival and prostheses success rates are comparable to what has been reported in the literature, without differences between patients with benign or malignant diseases. According to the literature (Kwakman et al., 1997; Rogers et al., 2005) and our experience, of the patients with malignant pathology, only a limited number choose to accept the FFF option with implant-support prosthesis, which is ostensibly related to the psychological distress of the illness. Nevertheless, for patients with benign or malignant pa-thology, this option is an excellent solution for jaw reconstruction
and oral rehabilitation, producing excellent results in long-term follow-up.
References
B€ahr W, Stoll P, W€achter R: Use of the ‘double barrel’ free vascularized fibula in mandibular reconstruction. J Oral Maxillofac Surg 56: 38e44, 1998
Baj A, Lovecchio N, Bolzoni A, Mapelli A, Giannì AB, Sforza C: Stair ascent and descent in assessing donor-site morbidity following osteocutaneous freefibula transfer: a preliminary study. J Oral Maxillofac Surg 73: 184e193, 2015
Bodard AG, Salino S, Bemer J, Lucas R, Breton P: Dental implant placement after mandibular reconstruction by microvascular freefibula flap: current knowledge and remaining questions. Oral Oncol 47: 1099e1104, 2011
Bodde EW, de Visser E, Duysens JE, Hartman EH: Donor-site morbidity after free vascularized autogenousfibular transfer: subjective and quantitative analyses. Plast Reconstr Surg 111: 2237e2242, 2013
Brånemark PI, Hansson BO, Adell R, Breine U, Lindstr€om J, Hallen O, et al: Osseointegrated implants in the treatment of the edentulous jaw. Experience from a 10-year period. Scand J Plast Reconstr Surg 16: 1e132, 1977
Brown JS, Shaw RJ: Reconstruction of the maxilla and midface: introducing a new classification. Lancet Oncol 11: 1001e1008, 2010
Chana JS, Chang YM, Wei FC: Segmental mandibulectomy and immediate freefibula osteoseptocutaneousflap reconstruction with endosteal implants: an ideal treatment method for mandibular ameloblastoma. Plast Reconstr Surg 113: 80e87, 2004
Chang YM, Wallace CG, Tsai CY, Shen YF, Hsu YM, Wei FC: Dental implant outcome after primary implantation into double-barreledfibula osteoseptocutaneous freeflap-reconstructed mandible. Plast Reconstr Surg 128: 1220e1228, 2011
Chiapasco M, Biglioli F, Autelitano L, Romeo E, Brusati R: Clinical outcome of dental implants placed infibula-free flaps used for the reconstruction of maxillo-mandibular defects following ablation for tumors or osteoradionecrosis. Clin Oral Implants Res 17: 220e228, 2006
Fenlon MR, Lyons A, Farrell S, Bavisha K, Banerjee A, Palmer RM: Factors affecting survival and usefulness of implants placed in vascularized free composite grafts used in post-head and neck cancer reconstruction. Clin Implant Dent Relat Res 14: 266e272, 2012
Ferrari S, Copelli C, Bianchi B, Ferri A, Poli T, Ferri T, et al: Rehabilitation with endosseous implants infibula free-flap mandibular reconstruction: a case se-ries of up to 10 years. J Craniomaxillofac Surg 41: 172e178, 2013
Ferrario VF, Tartaglia GM, Maglione M, Simion M, Sforza C: Neuromuscular coor-dination of masticatory muscles in subjects with two types of implant-supported prostheses. Clin Oral Implants Res 15: 219e225, 2004
Fierz J, Hallermann W, Mericske-Stern R: Patients with oral tumors. Part 1: pros-thetic rehabilitation following tumor resection. Schweiz Monatsschr Zahnmed 123: 91e105, 2013
Genden EM, Rinaldo A, Suarez C, Wei WI, Bradley PJ, Ferlito A: Complications of free flap transfers for head and neck reconstruction following cancer resection. Oral Oncol 40: 979e984, 2004
Goodcare TE, Walker CJ, Jawad AS: Donor site morbidity following osteocutaneous freefibula transfer. Br J Plast Surg 43: 410e412, 1990
Granstr€om G: Radiotherapy, osseointegration and hyperbaric oxygen therapy. Periodontol 2000 33: 145e162, 2003
Hayter JP, Cawood JI: Oral rehabilitation with endosteal implants and freeflaps. Int J Oral Maxillofac Surg 25: 3e12, 1996 Review. Erratum in: Int J Oral Maxillofac Surg 25: 248, 1996
Hickel R, Peschke A, Tyas M, Mjo I, Bayne S, Peters M, et al: FDI World Dental Federation: clinical criteria for the evaluation of direct and indirect restorations e update and clinical examples. Clin Oral Invest 14: 349e366, 2010 Hidalgo DA: Fibula freeflap: a new method of mandibular reconstruction. Plast
Reconstr Surg 84: 71e79, 1989
Hundepool AC, Dumans AG, Hofer SO, Fokkens NJ, Rayat SS, van der Meij EH, et al: Rehabilitation after mandibular reconstruction withfibula free-flap: clinical outcome and quality of life assessment. Int J Oral Maxillofac Surg 37: 1009e1013, 2008
Ihde S, Kopp S, Gundlach K, Konstantinovic VS: Effects of radiation therapy on craniofacial and dental implants: a review of the literature. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 107: 56e65, 2009
Iizuka T, H€afliger J, Seto I, Rahal A, Merickse-Stern R, Smolka K: Oral rehabilitation after mandibular reconstruction using an osteocutaneousfibula free flap with endosseous implants. Clin Oral Implants Res 16: 69e79, 2005
Jacobsen C, Kruse A, Lübbers HT, Zwahlen R, Studer S, Zemann W, et al: Is mandibular reconstruction using vascularizedfibula flaps and dental implants a reasonable treatment? Clin Implant Dent Relat Res 16: 419e428, 2014
Jacobsson MG, J€onsson AK, Albrektsson TO, Turesson IE: Short- and long-term ef-fects of irradiation on bone regeneration. Plast Reconstr Surg 76: 841e845, 1985
Kildal M, Wei FC, Chang YM: Mandibular reconstruction withfibula osteosepto-cutaneous freeflap and osteointegrated dental implants. Clin Plast Surg 28: 403e410, 2001
Kramer FJ, Dempf R, Bremer B: Efficacy of dental implants placed into fibula-free flaps for orofacial reconstruction. Clin Oral Implants Res 16: 80e88, 2005
Kwakman JM, Freihofer HP, van Waas MA: Osseointegrated oral implants in head and neck cancer patients. Laryngoscope 107: 519e522, 1997
Lin JY, Djohan R, Dobryansky M, Chou SW, Hou WH, Chen MH, et al: Assessment of donor-site morbidity using balance and gait tests after bilateralfibula osteo-septocutaneous freeflap transfer. Ann Plast Surg 3: 246e251, 2009
Preiskel HW, Tsolka P: Telescopic prostheses for implants. Int J Oral Maxillofac Implant. 13: 352e357, 1998
Rana M, Warraich R, Kokemuller H, Lemound J, Essig H, Tavassol F, et al: Recon-struction of mandibular defects e clinical retrospective research over a 10-year period. Head Neck Oncol 3: 23, 2011
Rogers SN, Panasar K, Pritchard D, Lowe R, Howell R, Cawood JI: Survey of oral rehabilitation in a consecutive series of 130 patients treated by primary resection for oral and oropharyngeal squamous cell carcinoma. Br J Oral Max-illofac Surg 43: 23e30, 2005
Schepers RH, Slagter AP, Kaanders JH, van den Hoogen FJ, Merkx MA: Effect of postoperative radiotherapy on the functional result of implants placed during ablative surgery for oral cancer. Int J Oral Maxillofac Surg 35: 803e808, 2006
Schoen PJ, Raghoebar GM, Bouma J, Reintsema H, Vissink A, Sterk W, et al: Reha-bilitation of oral function in head and neck cancer patients after radiotherapy with implant retained dentures: effects of hyperbaric oxygen therapy. Oral Oncol 43: 379e388, 2007
Schrag C, Chang YM, Tsai CY, Wei FC: Complete rehabilitation of the mandible following segmental resection. J Surg Oncol 94: 538e545, 2006
Schultes G, Gaggl A, K€archer H: Stability of dental implants in microvascular osseous transplants. Plast Reconstr Surg 109: 916e921, 2002
Sennerby L, Meredith N: Implant stability measurements using resonance fre-quency analysis: biological and biomechanical aspects and clinical implications. Periodontol 2000 47: 51e66, 2008
Smolka K, Kraehenbuehl M, Eggensperger N, Hallermann W, Thoren H, Iizuka T, et al: Fibula freeflap reconstruction of the mandible in cancer patients: eval-uation of a combined surgical and prosthodontic treatment concept. Oral Oncol 44: 571e581, 2008
Sumi Y, Hasegawa T, Miyaishi O, Ueda M: Interface analysis of titanium implants in a human vascularizedfibula bone graft. J Oral Maxillofac Surg 59: 213e216, 2001
Tartaglia GM, Maiorana C, Gallo M, Codari M, Sforza C: Implant-supported imme-diately loaded full-arch rehabilitations: comparison of resin and zirconia clin-ical outcomes in a 5-year retrospective follow-up study. Implant Dent 25: 74e82, 2016
Taylor GI, Miller GD, Ham FJ: The free vascularized bone graft. A clinical extension of microvascular techniques. Plast Reconstr Surg 55: 533e544, 1975
Urken ML, Weinberg H, Vickery C, Buchbinder D, Lawson W, Biller HF: Oro-mandibular reconstruction using microvascular composite free flaps. Arch Otolaryngol Head Neck Surg 117: 733e744, 1991a
Urken ML, Weinberg H, Vickery C, Buchbinder D, Lawson W, Biller HF: Oro-mandibular reconstruction using microvascular composite freeflaps. Report of 71 cases and a new classification scheme for bony, soft-tissue, and neurologic defects. Arch Otolaryngol Head Neck Surg 11: 733e744, 1991b
Vail TP, Urbaniak JR: Donor-site morbidity with use of vascularized autogenous fibular grafts. J Bone Jt Surg Am 78: 204e211, 1996
van Steenberghe D: Outcomes and their measurement in clinical trials of endo-sseous oral implants. Ann Periodontol 2: 291e298, 1997
Wei FC, Chen HC, Chuang CC: Fibular osteoseptocutaneousflap: anatomic study and clinical application. Plast Reconstr Surg 78(2): 191e200, 1986
Wei FC, Seah CS, Tsai YC: Fibula osteoseptocutaneousflap for reconstruction of composite mandibular defects. Plast Reconstr Surg 93: 296e306, 1994
Wu YQ, Huang W, Zhang ZY, Zhang ZY, Zhang CP, Sun J: Clinical outcome of dental implants placed infibula-free flaps for orofacial reconstruction. Chin Med J (Engl) 121: 1861e1865, 2008
