Summary Background Reconstruction and oral rehabilitation of segmental maxillofacial defects resulting from ablative surgery is commonly achieved by osteocutaneous vascularized free fibula (VFFF) transplantation combined with implant-supported dental prostheses. We systematically reviewed the literature regarding impact of oral rehabilitation with or without dental implants on functional outcome and quality of life (Qol) following reconstruction of such segmental maxillofacial defects with VFFF. Methods This systematic review was performed according to the PRISMA guidelines. A literature search was conducted using the databases of Cochrane, MEDLINE and EMBASE. Relevant search terms for maxilla or mandible, reconstruction with VFFF, and oral rehabilitation were used. Two reviewers independently assessed the publications using eligibility and research quality criteria (MINORS). Results In total, 554 unique publications were found. After scrutinization, 2 prospective studies and 8 retrospective case-series without comparison were left for ultimate analysis. Quality ranged from 44% to 88% of the maximum score. Overall survival rate of the VFFF was 99% and the survival rate of dental implants was 95%. Speech intelligibility and overall aesthetic outcome were ‘good' to ‘excellent'. No statistically significant changes in QoL were found. Methods to measure functional outcome varied strongly, making pooling impossible. Conclusions Oral rehabilitation with implant-supported dental prostheses after reconstruction of segmental maxillofacial defects with VFFF results in good to excellent speech intelligibility and aesthetics. Results are probably positively biased by the retrospective nature of the studies. In future prospective research, functional outcome measures should be addressed using standardized questionnaires and validated objective tests with adequate follow-up.

A systematic review of functional outcome and quality of life following reconstruction of maxillofacial defects using vascularized free fibula flaps and dental rehabilitation reveals poor data quality.

Purpose The primary objective of this study was to assess the difference in quality of life (QoL) in patients with dental rehabilitation using two or four implant-supported overdentures following segmental mandibulectomy defect reconstruction with fibula free flap. Material and methods This prospective, parallel designed, randomized clinical study was conducted with a 1:1 ratio. At baseline, all participants already had fibula flap reconstruction for segmental defects of the mandible and rehabilitation with conventional (non-implant supported) removable partial dentures. The participants were then randomized into two groups. Group I received implant supported overdentures on two implants, and Group II received four implants. QoL outcomes were evaluated using standardized questionnaires (EORTC_QLQ c30, H&N35, OHIP, DSI). Outcomes of treatment were evaluated at 6 months (T1) and 1 year (T2) following rehabilitation. Results A total of 52 patients were randomized into two treatment groups (26 each). After accounting for the loss to lack of follow-up, 22 patients in Group I and 24 patients in Group II were evaluated for QoL at the end of the study. There was a significant improvement in QoL with implant-assisted dental rehabilitation. However there were no significant differences in QoL between the two-implant and four-implant groups. Conclusion Implant-supported removable overdentures improve QoL outcomes in patients with reconstructed mandibles. This study showed no significant difference in QoL outcomes in patients with two- or four-implant supported removable prostheses.

Implant supported dental rehabilitation following segmental mandibular reconstruction- quality of life outcomes of a prospective randomized trial

Surgical treatment of head and neck cancer frequently results in defects that challenge conventional prosthetic rehabilitation. Successful rehabilitation using tissue supported dentures in such cases has been reported to be less than 20%. With the loss of jaw bones and thus the support, there is loss of retention to a great deal. Also, teeth loss on the side of the defect adds to failure in retention. Scar tissue formation, deviation of jaw due to muscle pull, decreased mouth opening, loss of sulcus and non vertical force are some of the common adversaries of jaw resection especially mandibular resection which pose great limitation on the stability and success of prospective prosthetic rehabilitation. The advent and application of biologically acceptable implants in clinical dentistry has contributed to restoring the defects of the deficient maxillofacial systems. Surgical intervention in patients who had received head and neck irradiation is preferably avoided as it has been associated with decreased healing and increased potential for development of osteoradionecrosis. Hence an implant as an option when surgical field has received tumerocidal radiation is empirically excluded. The purpose of this article is to review the studies and reports published in various journals related to osseointegrated implant rehabilitation in irradiated bones.

Dental implants in irradiated jaws: A literature review

Statement of problem Radiotherapy has been considered a contraindication for rehabilitation with dental implants because it can change the survival rate of implants. Nevertheless, the installation of implants in irradiated patients has been used with varying success. Purpose The purpose of this systematic review was to compare the success rate of implants placed in irradiated human bone tissue with that of implants placed in nonirradiated areas. Material and methods Searches were performed in the EMBASE, Cochrane, and PubMed/Medline databases up to December 2013 to identify clinical trials addressing the subject. This systematic review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The relative risks of implant failure and survival curves were calculated considering a confidence interval of 95%. Heterogeneity was analyzed by using a funnel chart. Results A total of 40 studies involving 2220 participants and 9231 dental implants were selected. The survival curve of the studies indicated a survival rate of 84.3% for implants installed in irradiated bone tissue. The meta-analysis indicated statistically significant differences ( P Conclusions Dental implants installed in the irradiated area of an oral cavity have a high survival rate, but strict monitoring is needed to prevent complications, thereby reducing possible failures.

/pdf/irradiated-patients-and-survival-rate-of-dental-implants-a-46e2zvhbdf.pdf

Irradiated patients and survival rate of dental implants: A systematic review and meta-analysis.

Objectives The objective of this study was to assess the difference in success rates of implants when using two or four implant-supported-overdentures following segmental mandibular reconstruction with fibula free flap. Methods and designs This prospective, parallel designed, randomized clinical study was conducted with 1:1 ratio. At baseline, all participants already had segmental reconstruction of mandible with free fibula flap. The participants were randomized into two groups: Group-I received implant-supported-overdentures on two tissue-level implants and Group-II received implant-supported-overdentures on four tissue-level implants. Success rates of the implants were evaluated at 3 months, 6 months and 12 months following implant loading using marginal bone level changes as well as peri-implant indices (Buser et al., 1990). Results 52 patients were randomized into two treatment groups (26 each), out of which 18 patients (36 implants) of Group-I and 17 patients (68 implants) of Group-II were evaluated. One implant in Group-I was lost due to infective complications and one patient in the same group had superior barrel necrosis. There was a statistically significant increase at both time points (p = 0.03, p = 0.04 at 6 months, 12 months) in the amount of marginal bone loss in Group-I (0.4 mm, 0.5 mm at 6 months, 12 months) as compared to Group-II (0.1 mm, 0.2 mm at 6 months, 12 months). There were no clinically significant changes peri-implant parameters between both groups. Peri-implant soft tissue hyperplasia was seen in both groups, 32% of implants at 3-months, 26% at 6-months and 3% at 12-months follow-up. Conclusion The results of this study show that patients with 2-implant-supported-overdentures had higher marginal bone loss as compared to patients with 4-implant-supported-overdentures. There were no clinically significant differences in peri-implant soft tissue factors in patients with 2- or 4-implant-supported-overdentures. Hyperplastic peri-implant tissues are common in the early implant-loading phase and tend to decrease over time under appropriate management.

Implants in free fibula flap supporting dental rehabilitation - Implant and peri-implant related outcomes of a randomized clinical trial.

Purpose The aim of this prospective study was to assess treatment outcome and impact on quality of life with implant-retained prosthesis in reconstructed jaws in head and neck cancer patients. Materials and methods Twelve patients were rehabilitated with implant-retained dental prosthesis following free fibular graft after segmental resection. These subjects were evaluated by standardized questionnaires European Organization for Research and Treatment of Cancer QLQ-C30 (version 3) and clinical assessment for quality of life. Objective assessment of speech parameters was done with Dr. Speech Software (Tiger DRS Inc., Seattle, WA). The questionnaire consisting of information on evaluation of deglutition, salivation, status of the mandible and teeth in relation to predisease level was used for subjective judgment of speech. Results Consumption of solid, semisolid, and overcooked food was considerably better with the prosthesis. Drinking ability was not affected. Patients' voice resonance was improved, and they could sustain phonation for longer duration without difficulty. They were able to speak loudly, and their intonation pattern was also slightly better. Failure of the implants to osseointegrate at the end of 18 months was observed in 37% of the patients. This was attributed to radiation before implant insertions and periimplantitis. Despite the observed improvement in some patients, the statistical analysis of speech, swallowing parameters, and quality of life were not significant because of the paucity of numbers in this pilot study. There was no improvement in the symptoms scale scores. Conclusion Reconstruction and rehabilitation of the jaws affected by tumor restores the patient anatomically, esthetically, and functionally to optimum levels. However, a study with larger numbers of patients is necessary to ascertain the benefits of this treatment modality.

Assessment of quality of life after implant-retained prosthetically reconstructed maxillae and mandibles postcancer treatments.

Background This study aimed to evaluate the rate of osseointegration (ROI) and overall success rate (OSR) of implants placed in native and grafted jaws with or without radiotherapy at a 5-year follow-up in Indian head and neck cancer patients. Material and methods Thirty head and neck cancer patients from various socioeconomic strata were accrued. Eighty-five implants were inserted in 17 native and 13 grafted jaws. Nineteen patients received radiation therapy. A 5-year follow-up ROI and OSR of implants were reported. Results The 5-year ROI and OSR were 88% and 77%, respectively. ROI was 93% for grafted, 85% for native, 83% for irradiated, and 100% for nonirradiated jaws. OSR was 73% for grafted, 80% for native, 71% for irradiated, and 89% for nonirradiated jaws. Patients from higher socioeconomic strata had higher OSR (92%) as compared with those belonging to lower socioeconomic strata (65%). Conclusion The failure rate observed in this study was 24% for implants placed in head and neck cancer patients at a 5-year follow-up.

Implant-retained dental rehabilitation in head and neck cancer patients: an assessment of success and failure.

An 11-year-old woman reported with rhabdomyosarcoma of the right eye, with cranial involvement. The patient had received multimodal treatment comprising chemotherapy and orbital exenteration. Implant-retained orbital restoration was considered after a decade of the curative treatment. One implant was placed in the supraorbital ridge and the other implant, in the frontal process of the zygoma. Subsequently, implant-supported magnet-retained prosthesis was fabricated.

Implant-retained orbital prosthesis

Aim. To assess quality of life and speech after rehabilitation with implant-retained dental prosthesis in head and neck cancer patients. Material and Methods. Twenty-six patients who were diagnosed with tumour of the maxilla and mandible were selected for rehabilitation with implant-retained dental prosthesis following resection and reconstructive surgery. They were evaluated for quality of life (EORTC QLQ-C30 and H-N35 questionnaires, version 3), speech, and swallowing (questionnaire and Dr. Speech software, version 4) before implant treatment and at six-, twelve-, and eighteen-month followup. Statistical analysis of quality of life, speech, and swallowing for different duration of their preoperative status was done. Quality of life, speech, and swallowing in grafted and native groups and radiated and nonradiated groups were also compared. Results. Quality of life was statistically significant in scale of pain, speech, and trouble with social eating, pain killers, and weight loss. It was insignificant when radiated and nonradiated or grafted and native jaw groups were compared. Improvement in movement of the tongue, swallowing ability, salivation taste, and intelligibility of speech was also observed. Conclusion. The surgical treatment of head and neck cancers with microvascular surgery and dental rehabilitation with implants restores function, esthetics, and patient’s well-being.

/pdf/assessment-of-quality-of-life-and-speech-after-implant-53ghszcaff.pdf

Hrishikesh A. Pusalkar

Papers

Assessment of quality of life after implant-retained prosthetically reconstructed maxillae and mandibles postcancer treatments.

Implant-retained dental rehabilitation in head and neck cancer patients: an assessment of success and failure.

Implant-retained orbital prosthesis

Assessment of Quality of Life and Speech after Implant-Retained Oral Rehabilitation in Head and Neck Cancer Patients