The study group consisted of 17 patients that received microvascular free flap maxillofacial reconstructions (8 free fibula flaps (FFF), 5 radial forearm flaps (RFF) and 4 anterolateral free flaps (ALT). A total of 74 dental implants were inserted (40 dental implants in free flaps and 34 in native bone). In the study population there were one fusocellular carcinoma (FC), one mucoepidermoid carcinoma (MEC), and 15 squamous cell carcinoma (SCC) patients.
Maxillofacial surgery resection sites (1 Maxillary, 16 Mandibular sites) and flap types:
Mandibular trigone, soft palate, anterior tonsillar pillar (ALT)
Right mandible from trigone till mental foramen, mandible right from 45 to 48 (ALT)
Half-base of the tongue and oral floor (right) removal (ALT)
Upper maxilla from 13 till pterygoid process (ALT)
Oral floor and tongue right, bone baguette (RFF)
Oral floor and tongue left, bone baguette (RFF)
Mandibular trigone, cheek, bone baguette (RFF)
Mandibula left and cheek mucosa (RFF)
Oral floor and half tongue left (RFF)
Mandible left from 41 till 35 (FFF)
Mandible left and oral pelvis + tongue left (FFF)
Left mandible (FFF)
Mandibular trigone left (FFF)
Right mandible body (FFF)
Right mandible including angle (FFF)
Right mandible (FFF)
Left mandible from 33 till the angle (FFF)
Mean follow up after maxillofacial surgery was 6.16 years (mean 73.93 ± 14.48 months, range 49 to 97 months). Mean follow up- after implant insertions was 3.61 years (mean 43.50 ± 12.96, range 24 to 72.1 months). Implant survival rates and patient demographics such as, age, gender, oncologic condition, radiotherapy, chemotherapy, smoking, microvascular free flap type, implant site and type of prosthetic denture are listed on Table 1. All the patients received prosthesis (8 Toronto, 1 removable prosthesis, 3 fixed dental bridge restorations, and 5 temporary prosthesis).
Table 1
Patient demographics and implant survival
Patient | Characteristics | Failed patients/Total no of patients | Survival % | P value | Failed implants/Total no of Implants | Survival % | p value |
Sex | Male | 0/8 | 100 | 0.53 | 0/17 | 100 | 0.58 |
| Female | 1/9 | 88.8 | 1/23 | 95.6 |
Oncologic Condition | SCC | 1/15 | 93.3 | 0.88 | 1/35 | 97.1 | 0.88 |
FC | 0/1 | 100 | 0/3 | 100 |
MEC | 0/1 | 100 | 0/2 | 100 |
Site | Mandible | 1/16 | 93.8 | 0.94 | 1/38 | 97.4 | 0.95 |
| Maxilla | 0/1 | 100 | 0/2 | 100 |
Flap type | FFF | 1/8 | 87.5 | 0.47 | 1/21 | 95.2 | 0.53 |
RFF | 0/5 | 100 | 0/10 | 100 |
ALT | 0/4 | 100 | 0/9 | 100 |
Type of prosthesis | Temporary | 0/5 | 100 | 0.18 | 0/10 | 100 | 25 |
Toronto | 0/8 | 100 | 0/18 | 100 |
Removable | 0/1 | 100 | 0/2 | 100 |
Bridge | 1/3 | 66.6 | 1/10 | 90.0 |
Smoking habits | 1 smoker | 0/1 | 100 | 0.94 | 0/1 | 100 | 0.98 |
No smoker (9 ex-smokers) | 1/16 | 93.7 | 1/39 | 97.4 |
Age | =>65 | 1/12 | 91.7 | 0.71 | 1/27 | 96.2 | 0.68 |
< 65 | 0/5 | 100 | 0/13 | 100 |
Radiotherapy | yes | 0/9 | 100 | 0.47 | 0/19 | 100 | 0.53 |
no | 1/8 | 87.5 | 1/21 | 95.2 |
Chemotherapy | yes | 0/3 | 100 | 0.82 | 0/6 | 100 | 0.85 |
no | 1/14 | 92.9 | 1/34 | 97.1 |
Total | | 1/17 | 94.1 | | 1/40 | 97.5 | - |
SCC = Squamous cell carcinoma, FC = Fuso-cellular carcinoma, MEC = Mucoepidermoid carcinoma, FFF = Free fibular flap, ALT = Antero-lateral thigh flap, RFF = Radial forearm flap |
No relations were found between implant failure and gender, type of tumor, type of microvascular free flap, radiation therapy, chemotherapy, and prosthesis type. There was no correlation between any variable and success.
According to the results, overall implant survival rate was 97.5 %. There was one implant failure (inserted in FFF) in a female patient due to SCC relapse. As treatment, the implant was removed at a surgical revision appointment. There were no implant failures in native bone.
Four of the patients had additional health conditions as follows, 1 human papilloma virus, 1 breast cancer, 1 ovarian and uterus cancer, 1 colorectal polyp.
There were post-operative maxillofacial complications in eight patients. Two of these patients had additional complications after implant insertion operations, and one of these patients lost one implant because of SCC relapse in the same region.
Complications and treatments modalities are listed below:
Complications after ALT flaps
-
SCC relapse in oral pelvis. Treatment: surgical removal
-
Cutaneous fistula. Treatment: surgical revision.
-
Osteoradionecrosis and pseudarthrosis at 8 months in the right mandible. Treatment: FFF right reconstruction after partial mandibulectomy
-
Trismus. Treatment: scar debridement with forearm reconstruction
Complications after RFF flaps
-
Cutaneous fistula. Treatment: pectoralis flap reconstruction
-
Intraoral small dehiscence of sutures and spinal nerve suffering with paresthesia of hand's first finger. Treatment: controls, solved by the time
Following implant insertion: White lesion in posterior left tongue with biopsy that reveal hyperkeratosis. Treatment: Prosthetic adjustments and controls.
Complications after FFF flaps
-
Painful neuropathy of the lower face 3rd (left mandible). Treatment: Clinical follow up controls and pain therapy.
-
Tumor relapse of SCC after 10 months in inferior right mandibular crest. Treatment: surgical revision and removal of 1 implant.
-
Cutaneous fistula during osteodistraction. Treatment: Additional surgery with fistulectomy operation and removal of distractor during surgery.
Three of the patients had complications after delivery of dental prosthesis and in each case, prosthesis was adjusted without any additional problems.
Prosthetic complications
Two patients had chipping of dental prosthetics. Treatment: Restoration of chipped teeth.
One patient with oral mucositis. Treatment: prosthesis was removed temporarily for few months and healing abutment was repositioned.
Nine patients received radiotherapy and two of them developed osteoradionecrosis. Eight patients did not receive any radiation therapy. Detailed information about radiotherapy dose, modality and complications associated with radiotherapy for each patient are listed on Table 2.
Table 2
Radiotherapy and complications after radiotherapy
Patient number and radiotherapy | Complications |
1-No | cutaneous fistula during osteodistraction SCC relapse 3 years after MX surgery |
2-No | none |
3- No | none |
4-No | oral mucositis |
5- No | SCC relapse 4 years after MX surgery |
6-Yes (66Gy Total) | cutaneous fistula after 2 months and osteoradionecrosis after 10 months |
7-Yes (66Gy Total; 59Gy N+; 54 Gy N-) ended in 20/03/2017 | intraoral small dehiscence of sutures after one month, hyperkeratosis after 2 years |
8-No | none |
9-Yes 66Gy Total; barrage 2Gy (40 Gy surgical area; 36Gy high risk areas: N+; 34Gy low risk areas: N-) | none |
10-Yes but interrupted because of mucositis | oral mucositis |
11-No | neurophatic pain at the lower face 3rd left side SCC tumor relapse 4 years after MX surgery and one implant failure |
12-Yes (66Gy T; 56Gy N) | cutaneous fistula after 2 months |
13-Yes (60Gy) | none |
14-No | none |
15- Yes (60Gy Total) | mandibular pseudoarthrosis and osteoradionecrosis after 6 months SCC tumor relapse located in left tongue and oral floor after 4 years |
16-Yes (66Gy surgical area; 59,4 Gy high risk areas; 51,6 Gy low risk areas) | Trismus after 2.5 years |
17- Yes (66GY T; 56Gy N) | none |
MX: Maxillofacial, SCC: Squamous cell carcinoma |