Dental Implantsin Oral CancerReconstruction

D

means of maxillary reconstruction. Second, for

as ameansof restoring thedentition andseparatingthe oral and nasal cavities (Fig. 1). However, manydisadvantages of tissue- and tooth-borne devicesare apparent.In the partially dentate patient, the obturator is

designed to function much like a removable partial

provide a platform for the fabrication of a retentionbar that supports the overlying obturator pros-thesis. Depending on the size and location of thedefect, the forces placed on these implants canbe unfavorable and can lead to eventual implantloss in a fashion similar to obturators supported

th in the partially edentulous patient.

siana State University Healthveport, LA 71103, USA

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.comOral Maxillofacial Surg Clin N Am 23 (2011) 337345The authors have nothing to disclose.Department of Oral and Maxillofacial Surgery, Head and Neck Surgery, LouiSciences Center Shreveport, 1501 Kings Highway, Administration Building, Shre* Corresponding author.E-mail address: dkim1@lsuhsc.edudenture, with support provided by the remaining by natural teesoft palate) and the status of the patients dentition,the conventional obturator can function quite well

the edentulous patient, use of multiple endo-sseous implants in the residual alveolar bone candental rehabilitation after bony reconstruction ofthe jaws. This article discusses these differentuses of endosseous implants in patients withhead and neck cancer.

IMPLANTS FOR MAXILLARY OBTURATORS

For more than a hundred years, use of the palatalobturator has been the principal mode of recon-struction of the maxilla after extirpative surgeryand is still considered by many to be the gold stan-dard in maxillary reconstruction. Depending on thenature of thedefect (size, vertical extent ofmaxillaryresection, degree of soft tissue loss, involvement ofD. David Kim, DMD, MD*, G.E. Ghali, DDS, M

Endosseous implants have revolutionized dentalprosthetic rehabilitation, providing a reliable,stable, and aesthetic option for dental reconstruc-tion. Dental implants have similarly improved thefunctionality of reconstructions following cancersurgery. The use of dental implants in oral cancerreconstruction can be divided into 2 categories.First, for retention of a prosthetic device, forexample, palatal obturator, used as the primary

KEYWORDS

Implants Reconstruction Jaw Mandible Maxilla Oral cancerdoi:10.1016/j.coms.2011.01.0061042-3699/11/$ see front matter 2011 Elsevier Inc. Allpalatal bone, the obturated cavity, and the remain-ing dentition. This situationmay lead to unfavorableforces on the remaining dentition, compromisingthese teeth over time. In the edentulous patient,only the remaining hard palate, the maxillary alve-olus, and the obturated cavity are available forsupport. In more extensive resections, there maybe no maxillary bone present to provide obturatorsupport, and therefore, very few options are avail-able for conventional obturator use.Similarly, retention of these prostheses can also

be problematic. In the absence of the dentition,soft tissue retention at the interface of the buccalmucosa and the obturated cavity has been consid-ered a primary retention principle in the fabricationof these devices. These devices have marginallevels of retention and are commonly a source ofannoyance from constant irritation caused by themobility of the prostheses. These factors alsolead to a large bulk of material that can make theappliance difficult to handle and relatively heavy.Endosseous and zygomatic implants can

improve a patients ability to wear these obturatorsby improving prosthetic stability and retention. Inrights reserved. ora

high implant failure rate was attributed to the useof radiation either before or after implant place-ment. Another case series reporting on a mixedgroup of patients receiving zygomatic implantsfor maxillectomies as well as traumatic injuries,severely atrophic maxillas, cleft lip, and cleft palatereported an overall failure rate of 5.9%.5

IMPLANTS IN RECONSTRUCTED JAWS

The reconstructive surgeon has several options forbony reconstruction of the maxilla or mandible.The specifics of different bone graft harvest sites

Kim & Ghali338Placement of endosseous implants into the re-maining bone surrounding the maxillary defect(pterygoid plates, zygoma, residual maxilla)(Fig. 2) has been advocated to avoid these unfa-vorable forces.1 However, these implants havepoor osteointegration potential and are difficult torestore and maintain.Although the zygomatic implant was initially

intended for aiding in the prosthetic rehabilitationof the atrophic maxillary alveolus,2 it has beenadapted often in combination with traditional endo-sseous implants for maxillary obturator supportand retention.3,4 Some of the limitations of implantplacement in the bone surrounding the maxillec-tomy defect are mitigated by the use of thesespecialized implants, in that they are able toengage more distant bone. Very little literatureexists on the use of zygomatic implants for thisindication, and little is known about the long-termimplications of these devices in maxillary recon-struction, but their use seems to be a reliable and

Fig. 1. Traditional maxillary obturator with retentionclasps on remaining dentition.effective adjunct to traditional implants for pros-thesis support (Fig. 3). In a series by Schmidt andcolleagues,3 21% of zygomatic implants failed atthe time of stage II implant surgery. This relatively

Fig. 2. (A) Traditional endosseous implant placed in the pwho underwent right hemimaxillectomy. (B) Radiograph oor free flap donor sites are beyond the scope ofthis article, but the characteristics of some of theseoptions as they pertain to implant reconstructionsare worthy of mention. Regardless of the tech-nique used for jaw reconstruction, the surgeonshould consider the goal of full dental rehabilitationas the ultimate end point of the reconstruction.Advancements in reconstructive surgery have

taken cancer reconstruction from a high-risk after-thought of cancer treatment to a reliable and ex-pected component of cancer surgery. The use ofregional flaps and free tissue transfer has allowedfor more complex reconstructions and improvedfunctional outcomes. Similarly, the necessity fordental reconstruction has followed with theseadvancements, and in many cases, it is no longersatisfactory to have a successful cancer ablationand an edentulous reconstructed jaw.The time-honored gold standard in jaw recon-

struction is the free iliac crest bone graft. Bone har-vested from the anterior or posterior iliac crest isplaced in a mandibular defect as a block ora corticocancellous graft, or a combination of the2 (Fig. 4). Because of the nonvascular nature ofthese grafts, this procedure is generally performedas a secondary operation many months after theinitial cancer ablation to avoid the high incidenceofgraft lossand infectionwhenperformedprimarily.This type of mandible reconstruction is most suitedfor relatively short defects of the lateral mandible

terygoid plates to aid obturator stability in a patient

f the same patient.

omis. (pat

Dental Implants in Oral Cancer Reconstruction 339Fig. 3. (A) Patient who underwent near-total maxillectimplants supporting a bar-retained obturator prosthesin support and retention. (D) Radiograph of the samethat do not cross themidline and is a highly effectivetechnique for reconstruction in benign tumor resec-tions such as ameloblastomas. The usefulness ofthis type of reconstruction is somewhat decreasedin cancer reconstruction because many patientsrequire postoperative radiation treatment that caninhibit bone graft healing and consolidation. Pre-operative and postoperative hyperbaric oxygen(HBO) therapy and the use of regional flaps toprovide vascularized tissue to the area have beenadvocated by some investigators to improve thevascular quality of the wound bed and grafthealing.6 Although useful in selected cases, theemergence of microvascular free tissue transferhas largely supplanted these techniques.

Fig. 4. (A) Secondary reconstruction of lateral mandibua cortical block and cancellous marrow. (B) Radiograph ofy after resection for fungal infection with 2 zygomaticB, C) Obturator designed to engage framework to aidient.Composite microvascular tissue transfer hasrevolutionized cancer reconstruction, in thatbone and soft tissue can be transferred froma distant site in the same operative encounter asthe ablative surgery and, in most instances, froma single donor site. The literature is replete withvarious donor sites advocated for use in maxillaryandmandibular reconstruction, including the ilium,fibula, scapula, radius, rib, and metatarsal. Eachdonor site has its own advantages and disadvan-tages, and an ideal replacement for maxillary ormandibular bone and intraoral soft tissue doesnot exist yet. However, of the donor sites currentlyavailable for jaw reconstruction, the ilium andfibula have emerged as the most desirable. Of

lar defect with anterior iliac crest bone graft usingthe consolidated bone graft in the same patient.

these 2 sites, the fibula has numerous advantagesover the ilium, with few drawbacks.The iliac crest bone can be harvested as a bone-

only, anosteocutaneous, or amyo-osteocutaneous(internal oblique) flap, basedon thedeepcircumflexiliac artery (DCIA) and the accompanying deepcircumflex iliac vein (DCIV). This flaps greatestadvantage is the bone volumeavailable for transfer,which is more than suitable for implant placement.Although the volume of the bone is good, the lengthof the bone available is somewhat limited, and thevolume of soft tissue that must be included withthis flap can be bulky (Fig. 5). The DCIA and DCIVprovide a fair length of pedicle for mandible recon-struction, but their use in the maxilla usuallyrequires vein grafts. Finally, harvesting of the DCIA

skin paddle, and has the possibility of potentialvascular compromise to the foot.Much of the criticism regarding the effective-

ness of the fibula in mandible reconstruction isaimed at its lack of vertical height. On average,the fibulas height is between 13 and 15 mm andis very close to that of an edentulous mandible(Fig. 6), but the fibula certainly lacks the height ofa dentate mandible (Fig. 7). Various techniquesto increase the fibulas height have beenproposed, such as distraction osteogenesis ofthe segments or double barreling of the fibula(Fig. 8), but a relatively simple technique is to

Kim & Ghali340flap requires disruption of the anterior abdominalwall and upper leg muscle attachments, leading tohernias and gait disturbances, respectively. Collec-tively, these drawbacks have somewhat overshad-owed this flaps significant bone volume advantageover the fibula and has affected its acceptance asa suitable donor site for jaw reconstruction.Accord-ingly, implantation into iliac crest grafts has notbeen reported much, and very little literature isavailable for review.The fibula can also be harvested as a bone-only,

an osteoseptocutaneous, or a myo-osteocutane-ous flap (soleus or flexor hallucis longus). Thefibula flap was introduced for use in mandiblereconstruction in 1989 by Hidalgo7 and has beenthe first choice for jaw reconstruction for manyreconstructive surgeons. The fibula flap is popularfor several reasons, including the ease of harvest,ability to work in 2 teams, availability of a long bonysegment for harvest, low morbidity, and goodpedicle length and caliber of vessels. Its disadvan-tages are few, but critics have argued that thebone is of insufficient height, has an inflexible

Fig. 5. Iliac crest flap with internal oblique muscle

harvested. Note the relatively short pedicle length.simply adapt the fibula to abut the native mandiblein a slightly more superior position than the inferiorborder (Fig. 9). Of course, a slight cosmetic defor-mity with a lack of bone at the inferior border mayoccur, but this deformity is generally minor and oflittle concern to most patients.Presurgical planning with the restoring prostho-

dontist is mandatory before implant surgery. Asurgical guide can be fabricated based on theprosthodontists estimation of the location of thereconstructed bone and his/her ideal locationsfor implant fixtures. In some cases, this guidemay not be helpful because of inaccurate estima-tion of the bone location but can serve as a blue-print for the next-best implant location. Conebeam computed tomographic scans and implantplanning software help mitigate these limitationsin the planning phase.The actual implant placement procedure is no

different from that in traditional implant surgery;however, a few principles should be followed.When accessing the implantation sites, if a skinpaddle exists over the flap or graft, care shouldbe exercised to preserve the perforator to theskin when designing the incision. Skin paddlerevascularization from the surrounding mucosa isunpredictable at best, and at present, there is noway to determine if the skin paddle will survivewithout its native blood supply. In most mandibular

Fig. 6. Radiograph of fibula flap reconstruction ofanterior mandible. The height of the fibula closely

approximates the edentulous posterior rightmandible.

(Fig. 11). The minimum dimension of an implantis generally considered to be 3.5 mm in diameterand 10 mm in length. With this in mind, the

the adequacy of their dimensions is variable.

Fig. 9. Radiograph of right mandible reconstruction,with fibula placed slightly superior to the inferiorborder and secured with a miniplate to more closelyapproximate the alveolar bone height of the dentatemandible.

Dental Implants in Oral Cancer Reconstruction 341reconstructions, these perforators emerge fromthe ligual aspect of the reconstructed mandibleas is the case with the fibula osteoseptocutaneousflap, iliac crest osteocutaneous flap, and pectora-lis major myocutaneous flaps placed before freebone grafting of the mandible. Therefore, the inci-sion should be made at the skin-mucosa interfaceon the lateral or buccal aspect of the skin paddle.This incision allows lingual retraction of the skinpaddle and provides access to the bone and fixa-tion hardware. Some circumstances may requirethe perforators to emerge laterally to the mandible,so careful review of the operative report should bedone before implant surgery.Similar to mandibular reconstruction, if a fibula

osteoseptocutaneous flap is used for maxillaryreconstruction, often, the perforator to the skinemerges from the palatal aspect of the skin paddle.Again, the incision is made on the lateral aspect ofthe skin to preserve this blood supply andminimizethe risk of devitalizing the skin (Fig. 10).Once the bone is exposed, a minimal amount of

periosteal stripping should be performed topreserve as much vascular supply to the neo-mandible as possible. Implant placement should

Fig. 7. Radiograph of fibula flap reconstruction ofa right mandible with poor height compared witha dentate contralateral mandible.be avoided in the osteotomy sites because healingmay be somewhat incomplete and successfulintegration of the implants may be compromised

Fig. 8. Radiograph of short-segment mandible recon-struction with double-barrel fibula flap.TIMING OF IMPLANTS

Implants are most commonly placed secondarilyinto reconstructed jaws, but several investigatorsadvocate implant placement at the time of theinitial surgery for reconstruction in cases of benigntumor resections.9 However, many patients whoundergo reconstructive surgery for malignantdisease require postoperative radiation therapy.Although the free tissue reconstructed jaw canminimum dimension of the reconstruction mustbe 5.5 mm in width and 10 mm in height. In a studyby Frodel and colleagues,8 the dimensions ofcadaveric specimens of several bone flap harvestsites were compared. The bone from the iliac crestand fibula were found to have consistentlyadequate bone dimensions for implantation basedon the similar minimum dimensions as notedearlier. Although implantation may be possiblewith other bone harvest sites (scapula, radius),Fig. 10. Implants placed into fibula reconstruction ofright maxillectomy defect. The incision to access thefibula is made through the buccal aspect of the skinpaddle because of the palatal location of theperforators.

maandthe

Kim & Ghali342withstand radiation therapy quite well, there is noconsensus regarding the placement of dentalimplants before or after radiation therapy. On onehand, if implants are placed secondarily, radiation

Fig. 11. (A) Exposure of fibula-reconstructed anteriornative mandible, avoiding the osteotomy and fibula-mafter implant placement. (D) Radiograph of fixed prostreatment theoretically predisposes these patientsto complications, including implant failure, wounddehiscence, and osteoradionecrosis. Althoughseveral reports have shown favorable implantsuccess rates in reconstructed jaws exposed toradiation,10,11 these studies predictably showa lower survival rate for implants in irradiatedthan in nonirradiated reconstructed jaws. Ina review by Teoh and colleagues,12 the survivalrate for implants placed in nonirradiated fibulaflaps was 99%, whereas the rate for those placedin irradiated flaps was 92%. Some studies havesuggested the use of HBO therapy to improvethe success of osteointegration in these patients13;however, there have been several reports refutingthe efficacy of HBO treatment.11,14 Specifically,Schoen and colleagues15 suggested that therewas no statistical difference in implant survival intheir randomized groups of patients treated withHBO and those not treated with HBO receivinganterior mandibular implants. Of 26 patients,osteoradionecrosis occurred in 1 patient whoreceived HBO therapy.Placement of implants at the time of the primary

reconstructive surgery also has its potential prob-lems, including the possibility of recurrence of thecancer, interference with radiation treatment,potential for poor implant position, and increasedduration of surgery. In a simulation study, Friedrichand colleagues16 simulated an external radiationsource aimed at a titanium implant and measured

ndible defect. (B) Implant placement into fibula andible interface sites. (C) Radiograph taken immediatelyses.the dose of radiation in the immediate surround-ing tissue. Results revealed a 16% reduction ofradiation dose directly behind the implant and an8% increase in dose in the areas immediately infront of and next to the implant. It was concludedthat considerable scatter of external radiationoccurs with titanium implants and the increaseddose at the implant-bone interface may affectbonehealingor lead toosteoradionecrosis.Further-more, De Ceulaer and colleagues,17 in a recentreview of 21 patients who received implants eitherprimarily during the initial surgery or secondarily,found 3 cancer recurrences in the mucosa directlysurrounding the implants. All 3 recurrencesoccurred in patients who had implants placedprimarily. The investigators stated that no conclu-sions can be made because of the small samplesize, but this study indicates that the risk of recur-rence is real, although not quantifiable at present.In secondary implant placement, no consensus

exists for how long an interval is ideal betweenthe primary reconstructive surgery and implantplacement. However, some studies recommenda period of 1 year after cancer surgery to allow forcomplete bonehealing, improvednutritional status,andmonitoring of disease recurrence.9,18 In benigndisease, implant reconstruction can proceed once

it is determined that bone healing has beenachieved (usually between 4 and 6 months).Finally, there is debate as to whether dental

reconstruction is even necessary in the patientwith cancer. In a review of 28 patients who under-went prosthetic reconstruction, Leung andCheung19 revealed that only 32% of the patientshad no limitations of food consistency and 28.6%had problems associated with prosthetic insta-bility. Indeed, many patients with a successfulbone and soft tissue reconstruction of their jawsdo not desire further dental reconstruction. Inthe available literature, rates of full dental rehabilita-tion in patients with cancer can vary (20%100%).8,9,2022 This variation can be explained by

if no skin paddle is present, a vestibuloplasty can

Fig. 12. Periimplantitis around the framework ofimplant-stabilized maxillary prosthesis of the fibula-reconstructed maxilla.

to fibula-reconstructed mandible. Supraperiosteal dissec-skin placed over the fibula to gain vestibule depth andd with a custom-fabricated acrylic splint for a period of

Dental Implants in Oral Cancer Reconstruction 343the nature of the retrospective case series patientselection bias that makes up the bulk of the litera-ture. In the authors own informal case series,only 20% with tumor who underwent bone recon-struction have gone on to have dental implants. Inthe United States, with poor medical insurancecoverage for dental implants, the most obviousobstacle is the cost of treatment. However, inresearch from countries where these services arecovered throughnational healthplans, there are stilla significant number of patients who do not opt fordental rehabilitation. Obviously, several factors caninfluence a patients decision of not to seek dentalrehabilitation. Many patients are able functionadequately without dental prosthetics, with onlyminor limitations of food intake.

MANAGEMENT OF SOFT TISSUE

Ablative surgery for oral cancer generally requiresexcision of the attached gingival tissue. Thistissue, which is tightly adherent to the underlyingbone, has the ideal characteristics for implantemergence. The nature of the attached gingivaprovides immobile tissue around implant

Fig. 13. (A) Second-stage surgery of implant placed intion performed for vestibuloplasty. (B) Split-thicknessfixed tissue surrounding implants. This setup is secure

3 to 4 weeks.abutments and ease of oral hygiene to preventperiimplantitis (Fig. 12). Unfortunately, the softtissues imported with various reconstruction tech-niques do not adequately replicate the uniqueproperties of keratinized gingiva. The skin paddlesof osteocutaneous flaps provide the necessarytissue to close oral wounds and allow separationof the mouth and neck during the initial healingof the flap. However, the thick, mobile nature ofthis tissue is a poor medium for implantemergence.Several techniques are available to address

these issues. First, thinning of the skin paddlecan be performed at any phase of the implanttreatment plan. The authors prefer to performthis procedure at the time of second-stage surgeryrather than at implant placement to assureadequate soft tissue coverage of the bone andimplants at the time of placement. Thinning canbe done in a traditional open method or withaggressive liposuction as described by Holmesand Aponte-Wesson.23 In lieu of flap thinning, or

for many patients because of the presence of

and cosmetic outcomes can be achieved. The

Kim & Ghali344future of dental rehabilitation in patients withcancer holds much promise and can positivelyaffect patients quality of life with improved func-tion and cosmesis. It is still a long, multistageprocess for patients to endure, but the end resultcan potentially allow patients to minimize theconsequences, limitations, and stigmata of abla-tive cancer surgery.

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SUMMARY

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Dental Implants in Oral Cancer Reconstruction 345

Dental Implants in Oral Cancer ReconstructionImplants for maxillary obturatorsImplants in reconstructed jawsTiming of implantsManagement of soft tissueSummaryReferences