EdenteV2, Istex, Corpus, bibRecord, 005D55

Functional criteria for mandibular implant placement post resection and reconstruction for cancer

Identifieur interne : 005D55 ( Istex/Corpus ); précédent : 005D54; suivant : 005D56

Functional criteria for mandibular implant placement post resection and reconstruction for cancer

Auteurs : Mark T. Marunick ; Ellen D. Roumanas

Source :

The Journal of Prosthetic Dentistry [ 0022-3913 ] ; 1999.

RBID : ISTEX:BBD1EABA292E0F5EE5BEE1376197D8DD0A43444B

English descriptors

KwdEn :
- Alveolar ridge mucosa, Arch otolaryngol head neck surg, Beumer, Carcinoma, Clinical evaluation, Conservative approach, Cosmetic improvement, Dent assoc, Dentistry, Edentulous, Edentulous patients, Edentulous predicament, Epidermoid carcinoma, Flap, Functional criteria, Hygiene efforts, Hyperbaric, Hyperbaric oxygen, Hyperbaric oxygen therapy, Implant, Implant placement, Implant rehabilitation, Implant surgery, Insufficient interarch space, Interarch, Interarch space, Limited interarch space, Mandible, Mandibular, Mandibular opening, Mandibular reconstruction, Many patients, Marginal mandibular resection, Marunick, Mastication, Maxillary, Maxillary denture, Maxillofac, Maxillofacial prosthetics, Maximum opening, Native mandible, Neck cancer, Neck cancer patient, Neck surgery, Negative impact, Nonrandomized comparison, Numerous reports, Oral cancer, Oral cavity, Oral function, Oral maxillofac implants, Oral maxillofac surg, Oral phase, Osseointegrated, Osseointegrated implants, Osseous reconstruction, Otolaryngol, Otolaryngol head neck surg, Patient motivation, Patient population, Patient selection, Plast, Prosthesis, Prosthet dent, Prosthetic, Prosthetic dentistry, Prosthetic dentistry marunick, Prosthetic intervention, Prosthetic rehabilitation, Radiation therapy, Rational approach, Reconstr, Reconstructed mandible, Resection, Roumanas, Sensory status, Soft tissue beds, Soft tissues, Speech articulation, Squamous carcinoma, Stable prosthesis, Surg, Surgical, Surgical considerations, Surgical reconstruction, Surgical resection, Survival rates, Titanium implants, Tongue function, Tongue mobility, Tonsilar fossa, Treatment planning, Tumor prognosis, Wound closure.
Teeft :
- Alveolar ridge mucosa, Arch otolaryngol head neck surg, Beumer, Carcinoma, Clinical evaluation, Conservative approach, Cosmetic improvement, Dent assoc, Dentistry, Edentulous, Edentulous patients, Edentulous predicament, Epidermoid carcinoma, Flap, Functional criteria, Hygiene efforts, Hyperbaric, Hyperbaric oxygen, Hyperbaric oxygen therapy, Implant, Implant placement, Implant rehabilitation, Implant surgery, Insufficient interarch space, Interarch, Interarch space, Limited interarch space, Mandible, Mandibular, Mandibular opening, Mandibular reconstruction, Many patients, Marginal mandibular resection, Marunick, Mastication, Maxillary, Maxillary denture, Maxillofac, Maxillofacial prosthetics, Maximum opening, Native mandible, Neck cancer, Neck cancer patient, Neck surgery, Negative impact, Nonrandomized comparison, Numerous reports, Oral cancer, Oral cavity, Oral function, Oral maxillofac implants, Oral maxillofac surg, Oral phase, Osseointegrated, Osseointegrated implants, Osseous reconstruction, Otolaryngol, Otolaryngol head neck surg, Patient motivation, Patient population, Patient selection, Plast, Prosthesis, Prosthet dent, Prosthetic, Prosthetic dentistry, Prosthetic dentistry marunick, Prosthetic intervention, Prosthetic rehabilitation, Radiation therapy, Rational approach, Reconstr, Reconstructed mandible, Resection, Roumanas, Sensory status, Soft tissue beds, Soft tissues, Speech articulation, Squamous carcinoma, Stable prosthesis, Surg, Surgical, Surgical considerations, Surgical reconstruction, Surgical resection, Survival rates, Titanium implants, Tongue function, Tongue mobility, Tonsilar fossa, Treatment planning, Tumor prognosis, Wound closure.

Abstract

Abstract: Statement of problem. Osseointegrated implants used in the mandible post resection and reconstruction for cancer represents a treatment option with the potential for functional improvement and enhanced quality of life. Unfortunately, protocols for their use in this patient population have been empirical and technique-driven with the assumption that they will overcome most, if not all, functional deficits encountered. Purpose. The article reviews the salient oral physiologic factors for this group of patients and presents a rational approach and functional criteria for patient selection and implant placement. Other considerations discussed include: timing of implant placement, irradiated and compromised tissues, patient motivation, and tumor prognosis. Conclusion. These principles, if followed, may enhance realistic functional outcomes for this patient population. (J Prosthet Dent 1999;82:107-13.)

Url:

https://api.istex.fr/document/BBD1EABA292E0F5EE5BEE1376197D8DD0A43444B/fulltext/pdf

DOI: 10.1016/S0022-3913(99)70136-8

Links to Exploration step

ISTEX:BBD1EABA292E0F5EE5BEE1376197D8DD0A43444B

Le document en format XML

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<notesStmt><note>Reprint requests to: DR MARK MARUNICK, WAYNE STATE UNIVERSITY, 5G UNIVERSITY HEALTH CENTER, 4201 ST ANTOINE ST, DETROIT, MI 48201, FAX: 313-577-8555</note>
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<author xml:id="author-0000"><persName><forename type="first">Mark T.</forename>
<surname>Marunick</surname>
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<roleName type="degree">DDS, MS</roleName>
<affiliation>Associate Professor, Department of Otolaryngology Head and Neck Surgery, Wayne State University</affiliation>
<affiliation>Wayne State University, Detroit, Mich., and School of Dentistry, University of California Los Angeles, Los Angeles, Calif.</affiliation>
</author>
<author xml:id="author-0001"><persName><forename type="first">Ellen D.</forename>
<surname>Roumanas</surname>
</persName>
<roleName type="degree">DDS</roleName>
<affiliation>Clinical Associate Professor, Division of Maxillofacial Prosthetics, UCLA School of Dentistry</affiliation>
<affiliation>Wayne State University, Detroit, Mich., and School of Dentistry, University of California Los Angeles, Los Angeles, Calif.</affiliation>
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<abstract xml:lang="en"><p>Statement of problem. Osseointegrated implants used in the mandible post resection and reconstruction for cancer represents a treatment option with the potential for functional improvement and enhanced quality of life. Unfortunately, protocols for their use in this patient population have been empirical and technique-driven with the assumption that they will overcome most, if not all, functional deficits encountered. Purpose. The article reviews the salient oral physiologic factors for this group of patients and presents a rational approach and functional criteria for patient selection and implant placement. Other considerations discussed include: timing of implant placement, irradiated and compromised tissues, patient motivation, and tumor prognosis. Conclusion. These principles, if followed, may enhance realistic functional outcomes for this patient population. (J Prosthet Dent 1999;82:107-13.)</p>
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<head><ce:article-footnote><ce:label>☆</ce:label>
<ce:note-para>Reprint requests to: DR MARK MARUNICK, WAYNE STATE UNIVERSITY, 5G UNIVERSITY HEALTH CENTER, 4201 ST ANTOINE ST, DETROIT, MI 48201, FAX: 313-577-8555</ce:note-para>
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<ce:note-para>0022-3913/99/$8.00 + 0. <ce:bold>10/1/97806</ce:bold>
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<ce:title>Functional criteria for mandibular implant placement post resection and reconstruction for cancer</ce:title>
<ce:author-group><ce:author><ce:given-name>Mark T.</ce:given-name>
<ce:surname>Marunick</ce:surname>
<ce:degrees>DDS, MS</ce:degrees>
<ce:cross-ref refid="aff2"><ce:sup>a</ce:sup>
</ce:cross-ref>
<ce:cross-ref refid="aff1"><ce:sup>1</ce:sup>
</ce:cross-ref>
</ce:author>
<ce:author><ce:given-name>Ellen D.</ce:given-name>
<ce:surname>Roumanas</ce:surname>
<ce:degrees>DDS</ce:degrees>
<ce:cross-ref refid="aff3"><ce:sup>b</ce:sup>
</ce:cross-ref>
<ce:cross-ref refid="aff1"><ce:sup>1</ce:sup>
</ce:cross-ref>
</ce:author>
<ce:affiliation id="aff1"><ce:label>1</ce:label>
<ce:textfn>Wayne State University, Detroit, Mich., and School of Dentistry, University of California Los Angeles, Los Angeles, Calif.</ce:textfn>
</ce:affiliation>
<ce:affiliation id="aff2"><ce:label>a</ce:label>
<ce:textfn>Associate Professor, Department of Otolaryngology Head and Neck Surgery, Wayne State University</ce:textfn>
</ce:affiliation>
<ce:affiliation id="aff3"><ce:label>b</ce:label>
<ce:textfn>Clinical Associate Professor, Division of Maxillofacial Prosthetics, UCLA School of Dentistry</ce:textfn>
</ce:affiliation>
</ce:author-group>
<ce:abstract><ce:section-title>Abstract</ce:section-title>
<ce:abstract-sec><ce:simple-para><ce:bold>Statement of problem.</ce:bold>
 Osseointegrated implants used in the mandible post resection and reconstruction for cancer represents a treatment option with the potential for functional improvement and enhanced quality of life. Unfortunately, protocols for their use in this patient population have been empirical and technique-driven with the assumption that they will overcome most, if not all, functional deficits encountered. <ce:bold>Purpose.</ce:bold>
 The article reviews the salient oral physiologic factors for this group of patients and presents a rational approach and functional criteria for patient selection and implant placement. Other considerations discussed include: timing of implant placement, irradiated and compromised tissues, patient motivation, and tumor prognosis. <ce:bold>Conclusion.</ce:bold>
 These principles, if followed, may enhance realistic functional outcomes for this patient population. (J Prosthet Dent 1999;82:107-13.)</ce:simple-para>
</ce:abstract-sec>
</ce:abstract>
</head>
<body><ce:sections><ce:para>The use of osseointegrated implants to enhance oral function and improve the quality of life for many patients has been established. Most of these studies have evaluated edentulous or partially edentulous patients with or without maladaptive responses to conventional removable prostheses.<ce:cross-refs refid="bib1 bib2 bib3 bib4"><ce:sup>1-4</ce:sup>
</ce:cross-refs>
 Other than missing teeth and atrophic alveolar ridges, the patients studied had relatively normal anatomy with no restrictions in mandibular movements or alterations in motor and sensory structures essential to oral function. In contrast, after ablative cancer surgery and reconstruction, many patients will exhibit various degrees of alterations in oral anatomy, mandibular and lingual movements, and motor and sensory deficits, dependent on the size of the tumor, structures involved in the surgery, and method of reconstruction. These alterations can have a negative impact on oral function and prosthodontic rehabilitation.<ce:cross-refs refid="bib5 bib6 bib7"><ce:sup>5-7</ce:sup>
</ce:cross-refs>
</ce:para>
<ce:para>Some authors have advocated the use of osseointegrated implants to restore function for many of these patients after their cancer surgery.<ce:cross-refs refid="bib8 bib9 bib10 bib11 bib12 bib13"><ce:sup>8-13</ce:sup>
</ce:cross-refs>
 There have been numerous reports discussing patient selection and criteria for implant placement in the patients with non–head and neck cancer,<ce:cross-refs refid="bib14 bib15"><ce:sup>14,15</ce:sup>
</ce:cross-refs>
 and some of these principles apply to patients after surgery for oral cancer. However, the most pertinent functional factors were not addressed. The unique conditions of this patient population mandates establishment of criteria for patient selection and implant placement.</ce:para>
<ce:para>Therefore the purpose of this article is to review the salient physiologic factors for this group of patients and present a rational approach for patient selection and treatment planning to enhance realistic functional rehabilitation and quality of life.</ce:para>
<ce:section><ce:section-title>ORAL PHYSIOLOGY</ce:section-title>
<ce:para>Major physiologic functions of the oral cavity are mastication, oral phase of deglutition, and speech production. Structures important for these functions are the maxilla, soft palate, mandible, tongue, temporomandibular joints, muscles of mastication, teeth, dental prostheses, cheeks, and lips. Sensory and motor innervation to these structures and levels of oral moisture are important and must be considered.<ce:cross-refs refid="bib5 bib6 bib7"><ce:sup>5-7</ce:sup>
</ce:cross-refs>
</ce:para>
<ce:para>Mastication is a learned complex neuromuscular activity that is highly dependent on the structural and neural integrity of the previously cited structures.<ce:cross-refs refid="bib16 bib17 bib18"><ce:sup>16-18</ce:sup>
</ce:cross-refs>
 The inability to accept food and liquids into the oral cavity, to efficiently masticate the food substance, and to develop the bolus into a swallow-ready state can influence dietary selection, intake, nutrition, and quality of life.<ce:cross-refs refid="bib5 bib6 bib7"><ce:sup>5-7</ce:sup>
</ce:cross-refs>
</ce:para>
<ce:para>Swallowing is a complex neuromuscular activity that requires coordination of structures in the oral cavity, pharynx, larynx, and esophagus. It usually includes 3 stages: oral phase, pharyngeal phase, and esophageal phase.<ce:cross-refs refid="bib19 bib20"><ce:sup>19-20</ce:sup>
</ce:cross-refs>
 The oral phase of swallowing requires lip closure and buccinator tension while the tongue propels the bolus to the level of the anterior faucial arches. This voluntary activity requires tongue-to-palate contact in a squeezing motion to propel the bolus posteriorly. The oral phase of swallowing ends when the swallowing reflex is triggered at the base of the anterior faucial arches.<ce:cross-ref refid="bib21"><ce:sup>21</ce:sup>
</ce:cross-ref>
 Mastication and the oral phase of swallowing are intimately related and require coordinated neuromuscular activity and interaction. Consequently, all the structures considered essential for mastication are also important for swallowing.</ce:para>
<ce:para>Speech as it relates to the oral cavity is affected most by the quality of articulation that can be achieved. Articulation is accomplished by discreet and precise positional changes of the tongue, lips, and cheeks in relation to the palate, teeth, and other oral structures.<ce:cross-ref refid="bib22"><ce:sup>22</ce:sup>
</ce:cross-ref>
 The tongue is the major articulator with the exception of the bilabial and labiodental sounds.<ce:cross-ref refid="bib23"><ce:sup>23</ce:sup>
</ce:cross-ref>
</ce:para>
<ce:para>The degree of dysfunction or impairment in mastication, the oral phase of swallowing, and speech are determined by the site and size of the tumor, the extent of resection, and the type of reconstruction. Attending doctors must be aware of and consider these factors when evaluating and treatment planning patients previously treated for head and neck cancer. Failure to do so can result in unforeseen difficulties during treatment and a disturbing disparity between patient-doctor expectations and actual functional outcome. A systematic review of the major structures essential for oral function should reduce or eliminate these often predictable disparities.</ce:para>
</ce:section>
<ce:section><ce:section-title>SOFT TISSUE CONSIDERATIONS</ce:section-title>
<ce:para>The tongue is an organ composed of muscles that are capable of performing highly coordinated task specific activity, which can be under voluntary control or reflex in nature. The role that this organ plays in the physiology of oral function cannot be overstated; its anatomic characteristics and mobility are well-suited and specific to mastication and deglutition. The tongue is also a major player for speech articulation. Clinical evaluation should include form, range of motion, alteration in motion, sensory status, salivary control, dietary survey, and speech assessment. When equivocal clinical assessments are derived, consultation with a speech pathologist and objective studies such as a modified barium swallow can be used to access oral transit times and potential for dysphagia and aspiration.<ce:cross-ref refid="bib24"><ce:sup>24</ce:sup>
</ce:cross-ref>
 With multiple negative clinical and objective assessment findings related to tongue status, one can predict a decreased prognosis for both conventional and implant prosthodontic intervention. Severe impairment of tongue function cannot be overcome with implants (Fig. 1, <ce:italic>A</ce:italic>
 and <ce:italic>B</ce:italic>
 ).<ce:display><ce:figure><ce:label>Fig. 1</ce:label>
<ce:caption><ce:simple-para>Edentulous patient post right floor of mouth, right lateral tongue, and right mandibular resection. Remaining tongue was used for wound closure. <ce:bold>A,</ce:bold>
 Altered alveolar ridge and tongue contour on right and limited interarch space. Patient is shown at maximum opening with tongue at rest. <ce:bold>B,</ce:bold>
 Patient at maximum opening with tongue protruded. Altered and dysfunctional lingual movement when patient is instructed to protrude tongue is due to fibrosis and tethering of tongue secondary to tumor resection and wound closure. This aberrant and limited lingual mobility is accompanied by sensory alterations due to loss of right lingual nerve. Such severe impairment of tongue function with or without limited interarch space cannot be overcome with implant rehabilitation.</ce:simple-para>
</ce:caption>
 <ce:link locator="gr1"></ce:link>
</ce:figure>
</ce:display>
</ce:para>
<ce:para>The lips allow the transfer of food and liquids in an efficient controlled manner. They also prevent the loss of food and liquid from the oral cavity.<ce:cross-ref refid="bib25"><ce:sup>25</ce:sup>
</ce:cross-ref>
 Lip position and mobility are important for speech articulation, primarily dental labial sounds. The inability of the lips to control saliva and retain it in the mouth can have a negative impact on the quality of speech. Any alteration of the lips that reduces their capacity to perform these tasks or significantly restrict oral orifice size also diminishes oral function.<ce:cross-ref refid="bib7"><ce:sup>7</ce:sup>
</ce:cross-ref>
 The lips should be assessed for symmetry, flexibility, mobility, sensory status, intracommissure width, and ability to make and maintain a competent lip seal. Incompetent lip seal can be a very disconcerting oral functional problem. Limited lip mobility and lip seal may be exacerbated by prosthetic intervention (Fig. 2, <ce:italic>A</ce:italic>
 through <ce:italic>D</ce:italic>
 ).<ce:display><ce:figure><ce:label>Fig. 2</ce:label>
<ce:caption><ce:simple-para>Edentulous patient referred for treatment after mandibular resection (from right midbody to left posterior body) and had scapular microvascular free flap reconstruction. Prosthetic presentation included maxillary denture and mandibular denture (implant assisted). Implants placed 9 months after surgical reconstruction. Patient’s complaints included inability to function with prostheses because of loss of food and liquids out of mouth due to incompetent lip seal. <ce:bold>A,</ce:bold>
 Patient at rest position with prostheses out. Reconstructed mandible is visible lingual to lower lip. There was insufficient interarch space with lack of lip seal. <ce:bold>B,</ce:bold>
 Patient with prostheses out unsuccessfully attempting to make lip seal. <ce:bold>C,</ce:bold>
 Patient with maxillary denture and mandibular implant-assisted removable denture in place attempting to make lip seal. Mandibular prosthesis was retained by using temporary soft liner in base of prosthesis that engaged implants. When prostheses were in place, they exacerbated insufficient interarch space and compromised motor and sensory post surgical lip function. Consequently, patient was unable to function with prostheses. <ce:bold>D,</ce:bold>
 Condition shows implants in reconstructed mandible.</ce:simple-para>
</ce:caption>
 <ce:link locator="gr2"></ce:link>
</ce:figure>
</ce:display>
Inadequate oral orifice size may complicate or preclude implant or prosthesis placement and limit oral hygiene efforts. Patients should be informed of these findings and limitations of prosthetic intervention before treatment is initiated.</ce:para>
</ce:section>
<ce:section><ce:section-title>HARD TISSUE CONSIDERATIONS</ce:section-title>
<ce:para>Quality and quantity of available bone to accept implants in the head and neck cancer patients is of no less concern than in the patient who has not been treated for oral cancer. Recipient sites can include native mandible and neomandible derived from various osseous free bone grafts and microvascular osseous free flaps. The native or donor bone must provide adequate width to accept the implants and sufficient height to allow placement of implant fixtures of appropriate length to support or retain the planned prosthesis under functional load over time.<ce:cross-refs refid="bib11 bib12 bib13"><ce:sup>11-13</ce:sup>
</ce:cross-refs>
 If the basic osseous requirements are not met or cannot be achieved with secondary procedures, the patient is not a candidate for implant rehabilitation.</ce:para>
<ce:para>Various surgical techniques are available and have widened the options for soft and hard tissue reconstruction in the head and neck region. However, a number of factors must be considered in the selection process. Oftentimes, the reconstructive environment may not be optimum for a conventional bone graft because of decreased vascularity of the involved area and significant loss of soft tissues. Nonvascularized grafts exhibit significant degrees of resorption in previously irradiated fields. Bony and soft tissue restoration of the oral cavity can be performed by using vascularized free flaps with a high degree of predictability in a single stage reconstruction procedure at the time of tumor resection.<ce:cross-refs refid="bib26 bib27 bib28"><ce:sup>26-28</ce:sup>
</ce:cross-refs>
 At our institutions, the fibula free flap has become the mainstay of mandibular reconstruction. Its main advantages include ample bone length, consistent shape, and low donor site morbidity. Multiple osteotomies may be performed and allow for a more natural contour and symmetry of the mandible. A surgical stent is used during insetting of the flap to ensure correct maxillomandibular relations.<ce:cross-ref refid="bib29"><ce:sup>29</ce:sup>
</ce:cross-ref>
 Delayed implant placement allows the opportunity to study the patient’s postoperative function, disease status, and oral needs. In our experience, the success rate of implants in fibula flaps is high and demonstrates the favorability of this type of bone to osseointegration.<ce:cross-ref refid="bib12"><ce:sup>12</ce:sup>
</ce:cross-ref>
</ce:para>
<ce:para>Of equal functional concern is the intraoral volume, contour, interarch relationship, and nature and quality of the enveloping soft tissues around the native or reconstructed mandible. Large bulky reconstructions that cannot be corrected by secondary debulking procedures, and placement of appropriate denture-bearing tissue grafts can preclude implant placement as can insufficient interarch space and trismus (Figs. 3 and 4).<ce:display><ce:figure><ce:label>Fig. 3</ce:label>
<ce:caption><ce:simple-para>Patient was treated 18 months earlier at another institution with full-course radiation therapy and neck dissection for squamous cell cancer, involving left floor of mouth. Identified with recurrent cancer involving left floor of mouth, patient underwent salvage surgery that included segmental resection of mandible from midbody on left to just anterior to right mental foramen. Left ventral and lateral surface of tongue, entire floor of mouth, and one third of left base of tongue were removed en bloc with mandible. Left hypoglossal nerve was preserved. Reconstruction included osseomyocutaneous fibular free flap. Patient has decreased mobility of entire tongue and altered sensation of reconstructed left tongue, mandible, and lower lip. Patient with tongue protruded. Soft tissue bulk of reconstructed left mandible compared with native mandible on right are apparent as is altered reconstructed left side of tongue compared with right side. Tongue releasing procedures and debulking soft tissue component of ridge reconstruction would be required before prosthetic rehabilitation.</ce:simple-para>
</ce:caption>
 <ce:link locator="gr3"></ce:link>
</ce:figure>
</ce:display>
<ce:display><ce:figure><ce:label>Fig. 4</ce:label>
<ce:caption><ce:simple-para>Patient received radiation therapy for floor of mouth cancer and developed osteoradionecrosis. After hyperbaric oxygen therapy, debridement, and surgical closure with pectoralis major flap, osteoradionecrosis persisted and progressed to pathologic fracture of mandible. Mandible was resected from right posterior body to left anterior ramus with left angle maintained. Reconstruction was accomplished with osseous microvascular fibula free flap. Patient at maximum opening with tongue protruded. There is decreased mandibular opening as measured from incisal edges of maxillary teeth to crest of ridge of reconstructed mandible. Restricted tongue mobility and radiation caries are illustrated. Decreased interarch space precluded implant rehabilitation from both functional and cosmetic consideration. Altered tongue mobility precluded implant placement from functional consideration. Rehabilitation of this patient would be enhanced with tongue-releasing procedures to improve tongue mobility. Osseous recontouring of anterior border of malpositioned left ramous would also improve range of motion of mandible by eliminating contact with maxillary tuberosity.</ce:simple-para>
</ce:caption>
 <ce:link locator="gr4"></ce:link>
</ce:figure>
</ce:display>
Compromised interarch space may not allow adequate room for prosthetic restoration. The requirement for freeway space and adequate functional room to accept food into the oral cavity and manipulate the food bolus during mastication and deglutition must be considered. Acceptable conditions in regard to bulk and interarch space must also be assessed for 3-dimensional interarch relationships. Many interarch discrepancies can be compensated for with varied options provided by the implant-assisted overdenture approach. In correcting these discrepancies, the effects on lip support, mobility, and maintenance of lip seal during function must be considered. Occlusal platform position or placement must also be evaluated for possible effects on tongue space. Maxillary occlusal platforms that interfere with palatal contour can negatively influence certain aspects of speech, mastication, and swallowing. Severe inter-arch disparities may compromise rehabilitation. Patients should be fully appraised of these potential functional implications before implants are placed.</ce:para>
</ce:section>
<ce:section><ce:section-title>PERI-IMPLANT SOFT TISSUE CONSIDERATIONS</ce:section-title>
<ce:para>Implant abutments that traverse thick, movable, soft tissue beds before entering the oral cavity, frequently are plagued with soft tissue maintenance problems. The cause of these problems is often related to tissue movement, plaque accumulation, and ineffective oral hygiene efforts due to discomfort when attempting to perform oral hygiene, lack of access to the implants, and/or lack of motivation. These factors can affect peri-implant health and possibly long-term retention of the implant. Secondary surgical procedures are usually necessary to debulk or decrease mobility of soft tissue beds and improve the quality of these tissues before or during implant placement, at stage II implant surgery, and occasionally after stage II implant surgery.</ce:para>
</ce:section>
<ce:section><ce:section-title>TIMING OF IMPLANT PLACEMENT</ce:section-title>
<ce:para>Placement of osseointegrated implants at the time of surgical resection and osseous reconstruction has been reported<ce:cross-refs refid="bib9 bib10"><ce:sup>9,10</ce:sup>
</ce:cross-refs>
 and promoted on the basis of eliminating a separate surgical sitting, avoiding the need for hyperbaric oxygen, and reducing delays in prosthetic rehabilitation. However, this approach frequently results in compromised implant position and orientation limiting optimal prosthetic rehabilitation. Functional issues that have been discussed cannot be assessed until healing has been achieved. A better appreciation for tumor prognosis after definitive (permanent section) microscopic evaluation of surgical margins, neck node status regarding the number and size of positive lymph nodes and extracapsular spread, lifestyle (alcohol, tobacco, other drug abuse) of the patient, and compliance for follow-up evaluations are all important factors to consider and are usually more predictable and apparent when implant placement is performed in a delayed manner. Even if indicated, it would be imprudent from an oncologic standpoint to place implants when tumor prognosis is poor and risk for recurrence is high. For patients with advanced staged resectable squamous cell carcinoma, 5-year survival rates range from 5% to 40%.<ce:cross-ref refid="bib30"><ce:sup>30</ce:sup>
</ce:cross-ref>
 Standard recommended treatment for these lesions would include surgery and radiation therapy.</ce:para>
<ce:para>Reviewed by sites of tumor that can result in segmental or marginal mandibular resection for treatment, 5-year survival rates for stage IV floor of mouth are 7% to 32%.<ce:cross-refs refid="bib31 bib32"><ce:sup>31,32</ce:sup>
</ce:cross-refs>
 Survival rates for stage III and IV tongue are 15% to 30%,<ce:cross-ref refid="bib33"><ce:sup>33</ce:sup>
</ce:cross-ref>
 stage IV gingiva and alveolar ridge mucosa are 15%,<ce:cross-ref refid="bib34"><ce:sup>34</ce:sup>
</ce:cross-ref>
 stages III and IV tonsil are 27% to 45% and 17% to 20%, respectively.<ce:cross-refs refid="bib35 bib36"><ce:sup>35,36</ce:sup>
</ce:cross-refs>
</ce:para>
<ce:para>For sites of tumor where 2- and 3-year disease-free survival rates are available, stages III and IV tongue are 51% to 53%,<ce:cross-ref refid="bib34"><ce:sup>34</ce:sup>
</ce:cross-ref>
 60% and 50% for stages III and IV gingiva and alveolar ridge mucosa, respectively,<ce:cross-refs refid="bib37 bib38"><ce:sup>37,38</ce:sup>
</ce:cross-refs>
 and for stages III and IV tonsil are 42% to 58% and 25% to 49%, respectively.<ce:cross-refs refid="bib39 bib40"><ce:sup>39,40</ce:sup>
</ce:cross-refs>
</ce:para>
<ce:para>Given the poor prognosis for advanced staged disease, the conservative approach of delayed implant placement from 2 years up to 5 years for this subset of patients can be appreciated. This conservative approach can be overruled by the request of a fully informed patient if functional and cosmetic improvement can be achieved with implant rehabilitation. Fully informed is meant to include projected long-term use of the implants based on survival and recurrence rates for the tumor, perceived functional and cosmetic improvement, and financial and maintenance responsibilities for definitive prosthetic rehabilitation.</ce:para>
<ce:para>Five-year survival rates for lower staged disease for these sites is much better. Stages I and II floor of mouth are 57% to 100% and 49% to 80%, respectively.<ce:cross-ref refid="bib34"><ce:sup>34</ce:sup>
</ce:cross-ref>
 Stages I and II tongue are 48% to 75% and 45% to 68%, respectively.<ce:cross-refs refid="bib33 bib34"><ce:sup>33,34</ce:sup>
</ce:cross-refs>
 Stages I and II gingival and buccal mucosa are 65% to 78%.<ce:cross-ref refid="bib34"><ce:sup>34</ce:sup>
</ce:cross-ref>
 Stages I and II tonsil are 76% to 100% and 40% to 83%, respectively.<ce:cross-ref refid="bib34"><ce:sup>34</ce:sup>
</ce:cross-ref>
 Given the better prognosis for stages I and II disease, a more liberal delayed approach of implant placement of 1 to 2 years is recommended.</ce:para>
<ce:para>Even with delayed conservative approach to implant placement, patients should be informed of the incidence and risk of recurrent disease before implant placement (Fig. 5).<ce:display><ce:figure><ce:label>Fig. 5</ce:label>
<ce:caption><ce:simple-para>Four years before implant placement, patient had left marginal mandibular resection for treatment of verrucous carcinoma with no postsurgical radiation therapy. Eighteen months after implant placement, patient had recurrent verrucous carcinoma associated with peri-implant tissue and adjacent gingival tissue. Treating restorative dentist had removed definitive fixed implant partial denture before referral to medical center for management.</ce:simple-para>
</ce:caption>
 <ce:link locator="gr5"></ce:link>
</ce:figure>
</ce:display>
The only exception to this would be when implants are placed after a 5-year tumor-free period from the completion of their cancer treatment, because they would be considered cured of their cancer. The cause of expedient rehabilitation promoted by placement of osseointegrated implants at the time of surgical resection and osseous reconstruction, although well intended, can be unpredictable in regard to functional outcome and result in less than optimal rehabilitation compared with a delayed approach to the placement of implants.<ce:cross-refs refid="bib11 bib12 bib13"><ce:sup>11-13</ce:sup>
</ce:cross-refs>
</ce:para>
<ce:para>A large percentage of these patients with advanced staged tumors also receive postoperative radiation therapy. The concern of implant osseointegration and long-term maintenance in a field exposed to canceriocidal doses of irradiation with or without hyperbaric oxygen therapy have not been resolved. Numerous reports and our own experience demonstrate reduced success rates of implants in previously irradiated bone.<ce:cross-refs refid="bib41 bib42 bib43 bib44"><ce:sup>41-44</ce:sup>
</ce:cross-refs>
 Radiation has been shown to significantly affect the healing and remodeling process, which is a prerequisite for long-term osseointegration.<ce:cross-refs refid="bib45 bib46"><ce:sup>45,46</ce:sup>
</ce:cross-refs>
</ce:para>
<ce:para>Hyperbaric oxygen therapy, which has been used for the treatment of irradiation damaged tissue, including osteoradionecrosis, is currently advocated to help improve integration in irradiated tissues.<ce:cross-refs refid="bib47 bib48 bib49"><ce:sup>47-49</ce:sup>
</ce:cross-refs>
 However, hyperbaric oxygen therapy cannot be applied to all irradiated patients. There are many prohibitive factors such as cost, time involvement, limited availability of treatment centers, complications, and absolute contraindications. Other issues that arise relate to the need for postimplantation irradiation therapy. If irradiation is to be performed in areas where implants have been placed, our policy and those of other centers has been to remove all prostheses, frameworks, and abutments before treatment.<ce:cross-ref refid="bib50"><ce:sup>50</ce:sup>
</ce:cross-ref>
</ce:para>
</ce:section>
<ce:section><ce:section-title>SUMMARY</ce:section-title>
<ce:para>The use of osseointegrated implants after surgical resection and reconstruction of the mandible is a potential opportunity to improve the functional rehabilitation and quality of life for these patients. The decision-making process and patient selection for implant use is complex. Considerations include tumor prognosis, method of surgical reconstruction, secondary effects of radiation therapy, decreased mandibular opening, amount and quality of bone available, alcohol, tobacco, or other substance abuse history, and patient motivation. Additional factors that must be considered include the neuromuscular, sensory, and mobility status of the tongue, lips, and circum oral soft tissue structures. Interarch space, maxillomandibular discrepancies, bulk, and quality of peri-implant and denture-bearing soft tissue must also be evaluated.</ce:para>
<ce:para>To date, the emphasis has been on osseous reconstruction of the mandible, osseointegration of the implants, and soft tissue reconstruction of the tongue and surrounding tissue with little emphasis or mention of the other factors important to oral function and competency. Unfortunately, a stable implant-retained prosthesis does not predictably result in either subjective or objective improvement in mastication or oral function. The predictability of improvement in oral function with implant rehabilitation is very good if the discussed functional considerations are evaluated and determined to be acceptable and all other criteria for implant placement have been met. Functional factors need not be considered if treatment goals and patient expectations are limited to retaining a prosthesis and cosmetic improvement. The dilemma of treatment planning and patient selection for implant rehabilitation in this patient population involves tempering the benefits of a stable prosthesis within the confines of the anatomic, motor, and sensory status of the oral cavity and circum oral structures with realistic patient and doctor expectations.</ce:para>
</ce:section>
</ce:sections>
</body>
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<mods version="3.6"><titleInfo lang="en"><title>Functional criteria for mandibular implant placement post resection and reconstruction for cancer</title>
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<titleInfo type="alternative" lang="en" contentType="CDATA"><title>Functional criteria for mandibular implant placement post resection and reconstruction for cancer</title>
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<name type="personal"><namePart type="given">Mark T.</namePart>
<namePart type="family">Marunick</namePart>
<namePart type="termsOfAddress">DDS, MS</namePart>
<affiliation>Associate Professor, Department of Otolaryngology Head and Neck Surgery, Wayne State University</affiliation>
<affiliation>Wayne State University, Detroit, Mich., and School of Dentistry, University of California Los Angeles, Los Angeles, Calif.</affiliation>
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<name type="personal"><namePart type="given">Ellen D.</namePart>
<namePart type="family">Roumanas</namePart>
<namePart type="termsOfAddress">DDS</namePart>
<affiliation>Clinical Associate Professor, Division of Maxillofacial Prosthetics, UCLA School of Dentistry</affiliation>
<affiliation>Wayne State University, Detroit, Mich., and School of Dentistry, University of California Los Angeles, Los Angeles, Calif.</affiliation>
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<abstract lang="en">Abstract: Statement of problem. Osseointegrated implants used in the mandible post resection and reconstruction for cancer represents a treatment option with the potential for functional improvement and enhanced quality of life. Unfortunately, protocols for their use in this patient population have been empirical and technique-driven with the assumption that they will overcome most, if not all, functional deficits encountered. Purpose. The article reviews the salient oral physiologic factors for this group of patients and presents a rational approach and functional criteria for patient selection and implant placement. Other considerations discussed include: timing of implant placement, irradiated and compromised tissues, patient motivation, and tumor prognosis. Conclusion. These principles, if followed, may enhance realistic functional outcomes for this patient population. (J Prosthet Dent 1999;82:107-13.)</abstract>
<note>Reprint requests to: DR MARK MARUNICK, WAYNE STATE UNIVERSITY, 5G UNIVERSITY HEALTH CENTER, 4201 ST ANTOINE ST, DETROIT, MI 48201, FAX: 313-577-8555</note>
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Functional criteria for mandibular implant placement post resection and reconstruction for cancer

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