10.14639/0392-100X-suppl.1-41-2021-13
Head and neck cancer (HNC) patients require specialized care throughout the continuum of cancer diagnosis, treatment, and survival. Cooperation between ENT and dentists is crucial, since all of the different anatomic areas affected by cancer have distinctive characteristics and the best results in terms of life expectancy and patients’ quality of life can only be achieved through a multidisciplinary approach. The synergic cooperation of all health care workers in the early diagnosis of HNC allows a better prognosis for such patients. As soon as dentists diagnose a Potentially Malignant Disorder (PMD), patients should undergo complete ENT screening for detection of lesions in any portion of the upper aerodigestive tract. Before and after cancer diagnosis and before any oncologic treatment, it is critical that these patients undergo an accurate and complete dental and periodontal assessment to optimize treatment and minimize complications or side effects. Multidisciplinary ablative, reconstructive and prosthetic programing in Head &amp; Neck oncologic surgery has become imperative to offer patients the best functional and esthetic outcome. An improvement in oral function and associated quality of life is strictly related to correct prosthetic rehabilitation. Finally, after surgery and/or radiotherapy (RT), the main objectives of dental treatment in these patients are the prevention and therapy of dental diseases and the side effects of oncological therapies involving the oral cavity.
application/xml
1827-675X
1694
en
Giovanni Succo
https://creativecommons.org/licenses/by-nc-nd/4.0
ACTA Otorhinolaryngologica Italica
jaw reconstruction
Cooperation between ENT surgeon and dentist in head and neck oncology
Text.Serial.Journal
https://www.actaitalica.it/
41
Annual congress report
2021-05-14
2021-05-10
2021-05-14
2021-05-14
124-137
1
Giovanni Succo
2021/05/14
10.14639/0392-100X-suppl.1-41-2021-13
124
Head and Neck Oncology Service, Candiolo Cancer Institute – FPO, IRCCS, Candiolo, Italy; Department of Oncology, University of Turin, Turin, Italy
1827-675X
jaw reconstruction
137
Cooperation between ENT surgeon and dentist in head and neck oncology
https://www.actaitalica.it/article/download/1694/567
41
ACTA OTORHINOLARYNGOLOGICA ITALICA 2021;41(SUPPL.1):S124-S137; doi: 10.14639/0392-100X-suppl.1-41-2021-13




Cooperation between ENT surgeon and dentist
in head and neck oncology
Cooperazione tra otorinolaringoiatra e odontostomatologo in oncologia cervico-cefalica
Mattia Berrone1,2, Carlo Lajolo3,4, Eugenio De Corso3, Stefano Settimi3, Cosimo Rupe3, Erika Crosetti1, Giovanni Succo1,2
1
  Head and Neck Oncology Service, Candiolo Cancer Institute – FPO, IRCCS, Candiolo, Italy; 2 Department of Oncology, University
of Turin, Turin, Italy; 3 Head and Neck Department, “Fondazione Policlinico Universitario A. Gemelli – IRCCS” Rome, Italy; 4 School of
Dentistry, Università Cattolica del Sacro Cuore, Rome, Italy


SUMMARY
Head and neck cancer (HNC) patients require specialized care throughout the continuum
of cancer diagnosis, treatment, and survival. Cooperation between ENT and dentists is cru-
cial, since all of the different anatomic areas affected by cancer have distinctive character-
istics and the best results in terms of life expectancy and patients’ quality of life can only
be achieved through a multidisciplinary approach. The synergic cooperation of all health
care workers in the early diagnosis of HNC allows a better prognosis for such patients. As
soon as dentists diagnose a Potentially Malignant Disorder (PMD), patients should undergo
complete ENT screening for detection of lesions in any portion of the upper aerodigestive
tract. Before and after cancer diagnosis and before any oncologic treatment, it is critical
that these patients undergo an accurate and complete dental and periodontal assessment to
optimize treatment and minimize complications or side effects. Multidisciplinary ablative,
reconstructive and prosthetic programing in Head & Neck oncologic surgery has become                 Received: October 2, 2020
imperative to offer patients the best functional and esthetic outcome. An improvement in             Accepted: January 8, 2021
oral function and associated quality of life is strictly related to correct prosthetic rehabilita-
tion. Finally, after surgery and/or radiotherapy (RT), the main objectives of dental treatment       Correspondence
in these patients are the prevention and therapy of dental diseases and the side effects of          Carlo Lajolo
oncological therapies involving the oral cavity.                                                     Head and Neck Department, “Fondazione Policli-
                                                                                                     nico Universitario A. Gemelli – IRCCS”, School
KEY WORDS: potentially malignant disorder (PMD), oral care, osteoradionecrosis, oral                 of Dentistry, Università Cattolica del Sacro Cuore,
mucositis, prosthetic implant, jaw reconstruction                                                    largo A. Gemelli 8, 00168 Rome, Italy
                                                                                                     E-mail: carlo.lajolo@unicatt.it
RIASSUNTO
I pazienti affetti da tumori della testa e del collo (HNC) richiedono cure specialistiche lungo      Funding
tutto l’iter diagnostico-terapeutico. La collaborazione tra otorinolaringoiatra e odontosto-         None.
matologo risulta fondamentale, poiché le diverse sedi anatomiche coinvolte dalla patologia
oncologica hanno caratteristiche peculiari, e i migliori risultati in termini di aspettativa e       Conflict of interest
qualità di vita possono essere raggiunti solo attraverso un approccio multidisciplinare. La          The Authors declare no conflict of interest.
collaborazione sinergica di tutti gli operatori sanitari nella diagnosi precoce di tali tumori
consente una prognosi migliore per questi pazienti; in quest’ottica, subito dopo la diagnosi di        How to cite this article: Berrone M, Lajolo C, De
patologie odontostomatologiche potenzialmente maligne (PMD), i pazienti dovrebbero sotto-              Corso E, et al. Cooperation between ENT surgeon
porsi a uno screening ORL completo per l’individuazione di lesioni del tratto aero-digestivo           and dentist in head and neck oncology. Acta Otorhi-
superiore. È fondamentale che, dopo la diagnosi di carcinoma e prima di qualsiasi tratta-              nolaryngol Ital 2021;41(SUPPL.1):S124-S137.
mento oncologico, questi pazienti ricevano una valutazione dentale e parodontale accurata              https://doi.org/10.14639/0392-100X-sup-
                                                                                                       pl.1-41-2021-13
e completa, per ottimizzare il trattamento e ridurre al minimo le complicanze o gli effetti col-
laterali. La pianificazione multidisciplinare ablativa, ricostruttiva e protesica nella chirurgia
                                                                                                     © Società Italiana di Otorinolaringoiatria
oncologica testa-collo è diventata indispensabile per offrire ai pazienti il miglior risultato       e Chirurgia Cervico-Facciale
funzionale ed estetico; un miglioramento della funzione orale e della relativa qualità di vita
è infatti strettamente correlato a una corretta riabilitazione protesica. Infine, prima e dopo
                                                                                                                    OPEN ACCESS
l’intervento chirurgico e/o la radioterapia, gli obiettivi principali del trattamento odontoia-
trico in questi pazienti sono rappresentati dalla prevenzione e dal trattamento delle malattie       This is an open access article distributed in accordance with
                                                                                                     the CC-BY-NC-ND (Creative Commons Attribution-Non-
dentali e degli effetti collaterali dei vari trattamenti oncologici a livello del cavo orale.        Commercial-NoDerivatives 4.0 International) license. The
                                                                                                     article can be used by giving appropriate credit and mentio-
PAROLE CHIAVE: disordini potenzialmente maligni (PMD), salute orale, osteoradione-                   ning the license, but only for non-commercial purposes and
crosi, mucosite orale, riabilitazione implanto-protesica, ricostruzione mandibolare, rico-           only in the original version. For further information: https://
struzione mascellare                                                                                 creativecommons.org/licenses/by-nc-nd/4.0/deed.en




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Introduction                                                     PMDs with some geographic and epidemiologic differ-
                                                                 ences (Fig. 1).
The term “head and neck cancer” (HNC) generally compris-         The term Oral Leucoplakia (LP) describes a white patch
es malignant cancers which arise in the upper aerodigestive      or plaque, with an increased risk of malignant transforma-
tract, and the complex anatomy makes the diagnosis and           tion (or, in a few cases, it can already be a cancer) hav-
treatment of these cancers highly demanding. Cooperation         ing excluded (other) known diseases or disorders that are
between ENT and dentists is crucial to achieve good clini-       white (i.e. Frictional keratosis, Acute pseudomembranous
cal practice, since all of the different anatomic areas have     candidiasis, Leukoedema, Lichen planus (plaque type) and
distinctive characteristics. Furthermore, the oral cavity can    Lichenoid lesion and reaction, Discoid lupus erythemato-
experience both the cancer itself and the side effects of can-   sus, Hairy leukoplakia, Reverse Smoking). This definition
cer therapy of adjacent anatomic areas (i.e., the pharynx, si-   is an exclusion diagnosis and a biopsy is mandatory to ex-
nuses, major salivary glands, the nasal cavity, and the ears).   plore the pathology, which can range from squamous hy-
HNCs and their therapy can lead to devastating cosmetic          perplasia, to mild, moderate, or severe dysplasia/carcinoma
and functional deficits with resultant psychological, physi-     in situ, or to carcinoma. LP is the most frequent PMD.
cal, functional and nutritional detriments, thus a personal-     Non-homogeneous lesions have a higher risk of dysplasia
ized medical approach and minimally invasive techniques          or cancer. Severe dysplasia, aneuploidy, loss of heterozy-
can help to increase the quality of life of these patients.      gosis, HPV 16+, diameter wider than 2 cm, ventral tongue
Furthermore, on the basis of more recent experience, the         or floor of the mouth, female sex, age older than 50 years
best results in terms of life expectancy and patients’ qual-     are all risk factors for further progression toward cancer 3.
ity of life can only be achieved through a multidisciplinary     Smoking habit is a risk factor for the onset of LP, neverthe-
approach, beginning with prevention, and then early diag-        less, LP in a non-smoking patient could have a higher risk
nosis, therapy and follow-up. This review has been written       of malignant transformation.
considering the most salient aspects of the clinical collabo-    Erythroplakia (EP) is a clinical term that describes a red
ration between otolaryngologists and dentists in the early       patch or plaque, with an increased risk of malignant trans-
diagnosis and management of the patient affected by head         formation (or in many cases, its pathology shows severe
and neck cancer.                                                 dysplasia, carcinoma in situ or cancer) having excluded
                                                                 (other) known diseases or disorders that appear as red in
Diagnosis and management of potentially                          color (i.e. Oral lichen planus, Discoid lupus erythematous,
malignant disorders                                              Pemphigoid and Pemphigus, Kaposi’s sarcoma, Erythema-
                                                                 tous candidiasis, Hemangioma). It often appears as a mix-
Many different oral lesions can have an increased prob-          ture of LP and EP, known as erythroleukoplakia, since pure
ability of evolving into cancer and constitute a hetero-         EP is rare. Optimum therapy and follow-up (recall) visits
geneous group of diseases; historically, in 1978, WHO            for leukoplakia are still debated since relapses and new lo-
classified all these diseases as “oral lesions” or “oral con-    calizations are frequent, whereas a more aggressive therapy
ditions”, considering the first as a disease of the oral mu-     (mainly surgery) and follow-up regimen are suggested for
cosa and the second as systemic diseases, which can carry        erythroplakia 4.
an increased probability to develop/evolve into oral can-        Oral lichen planus (OLP) is a mucocutaneous inflamma-
cer. The WHO classification was revised in 2007 and re-          tory disorder which can affect the skin and/or mucous
cently in 2017 introduced the term potentially malignant         membrane. Oral lesions are generally bilateral, white in
disorder (PMD), based on the field cancerization concept.        color on an erythematous base, and typically reticular and/
All of these diseases have not only an increased probabil-       or radiate. The etiology of OLP is still unknown and all
ity to evolve into cancer in the affected oral mucosa, but       of the aspects of immunity have been detected as dysregu-
in addition, other primary cancers can arise in any portion      lated, with an important role played by lymphocyte T cells.
of the upper aerodigestive tract 1. A multidisciplinary syn-     Clinical features can vary (reticular, plaque, atrophic ero-
ergic approach in the early diagnosis of HNC provides a          sive and desquamative gingivitis) and in many cases, pain
better prognosis for such patients, in terms of quality of       and a burning sensation affect the patients, especially in its
life and life expectancy. As soon as dentists diagnose a         atrophic/erosive forms. On the other hand, when clinical
PMD, patients should undergo complete ENT screening              and pathological features are not conclusively detected, a
for detection of lesions in any portion of the upper aer-        final diagnosis of Oral lichenoid lesions can be made 5. The
odigestive tract 2. Leukoplakia, erythroplakia, oral lichen      risk of transformation is around 1.4% per year and tongue
planus and oral submucous fibrosis are the most frequent         lesions, erosive form and female sex are risk factors for



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  A                                 B                                                                          C




  D                                                            D                                               E




Figure 1. Potentially malignant disorders: the most common are: (A) leukoplakia; (B) erythroplakia; (C) leukoerythroplakia; (D) oral lichen planus (same patient);
(E) oral submucous fibrosis.


transformation, thus OLP patients should undergo a strict                          biopsy) or with just a diagnostic purpose (Incisional bi-
clinical follow-up (recall visits every 3 months and biopsies                      opsy) 11.
must be performed whenever lesions become more suspi-                              No criteria have been defined to choose between an exci-
cious) 5,6.                                                                        sional or incisional biopsy, but, since oral cancer therapy
Oral submucous fibrosis is a progressive fibrotic degen-                           varies according to staging, excisional biopsy should only
eration of the oral mucous membrane predominantly seen                             be considered for benign lesions or for small lesions (0.5-
in South East Asia and which affects young adults. It is                           1 cm) highly suspicious for malignancy. An excisional bi-
mainly due to the areca nut and use of its derived products                        opsy with diagnostic and therapeutic purpose can also be
(chewing): these products, mixed with tobacco, are stored                          performed in selected lesions less than 2 cm in width, if
in the buccal vestibule and chewed. The affected mucosa                            oncologic radicality can be guaranteed. In this case, the
appears initially inflamed and, with continuing carcino-                           surgical specimen should include at least 1 cm of healthy
genic stimuli, it becomes fibrotic, opaque and blanched and                        tissue all around the lesion 12. Biopsy can be performed ei-
finally, movements of the tongue and of the buccal mucosa                          ther with a cold blade or with laser according to the ex-
are impaired with a diminished opening of the mouth. Even                          perience of the surgeon, but the presence and sparing of
though some medical therapies have been suggested 7,8,                             delicate structures (i.e. arteries, nerves, gland ducts) should
treatment should consider stopping areca nut chewing,                              be considered.
monitoring for malignant transformation, and surgical pro-                         Indications for incisional biopsy are: 1) lesions of large di-
cedures to improve mouth opening 9,10.                                             mensions, 2) lesions with a high probability of malignancy
                                                                                   which could not be completely removed, 3) lesions involv-
Diagnostic procedures                                                              ing most of the oral mucosa, or 4) lesions that are difficult
PMDs, and all pathological tissue removed from the oral                            to reach. The experience of the authors is that incisional
cavity, should undergo histological examination to con-                            biopsy should be performed when malignancy is suspected,
firm the nature of the lesion. Biopsy can be performed                             even for lesions with small dimensions (1-2 cm width), for
either with a diagnostic-therapeutic purpose (Excisional                           at least two reasons: 1) small cancers could have already



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  ENT: Ear Nose Throat Doctor

Figure 2. Diagnostic-therapeutic flow-chart for Oral Mucosal Lesions, focusing on the clinical management of Potentially Malignant Disorders (PMD) and early
diagnosis of Oral Squamous Cell Carcinoma (OSCC).


spread to the lymph nodes and 2) to facilitate the ENT on-                      sociated with dentition. Bone biopsy indications mainly
cologic surgeon in identifying the site of primary malig-                       include those lesions that do not heal through traditional
nancy 13.                                                                       dental therapies, lesions that apparently have no correlation
Incisional biopsy can include part of the healthy surround-                     with dentition, and lesions not specifically identified by
ing tissue in order to provide some information on possi-                       clinical and radiographic findings; these lesions can range
ble infiltration, but the biopsy should be collected with the                   from benign to malignant (i.e., maxillary sinus carcinomas
aim of giving the pathologist the most representative part                      to myxomas, ameloblastomas, sarcomas, keratocysts and
of the lesion (often its center); on the other hand, necrotic                   odontogenic cysts). As pathologies in this region are diffi-
areas in large lesions should be avoided because they do not                    cult to reach or are in close proximity to important anatomic
provide useful information. However, during incisional bi-                      structures, e.g., tooth roots or nerves, they often represent
opsy, attention must be paid to preservation of the original                    a challenge 14 to perform a correct biopsy without damag-
characteristics of the lesion (site, dimensions, margins), in                   ing those structures. Two types of biopsy technique can be
order to ensure the optimal conditions for possible radical                     used for diagnosing endosseous lesions according to their
excision in the case of malignancy. If the surgeon is unsure                    radiological aspect. Radiolucent lesions, especially those
about the adequacy of the specimen, multiple biopsies can                       which do not erode the cortex, require the creation of a
be performed. A diagnostic-therapeutic flow chart for oral                      bone window to be able to biopsy the lesion; all radiolucent
mucosal lesions is proposed in Figure 2.                                        lesions should be aspirated before biopsy to obtain valid in-
                                                                                formation on the contents of the lesion such as fluid-filled,
Diagnosis of intraosseous lesions                                               solid, vascular or without contents. Radiopaque lesions can
                                                                                be biopsied with special cylindrical drills (trephine drill)
of the mandible and maxillary sinus                                             capable of coring the bone itself, with a depth indicator to
Intraosseous lesions are often the result of problems as-                       reach the correct depth, and based on an earlier computed



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Figure 3. Lateral approach to the right maxillary sinus with bone window repositioning technique.


tomography (CT) scan. At present, guided biopsy of osse-                         ability, and specific expected toxicities from the planned
ous pathologies in the jawbone using a 3D-printed drilling                       anti-neoplastic regimen. The dentist must:
template14 allows a precise, minimally invasive approach,                        • detect and treat dental and soft tissue infections;
with an exact three-dimensional determination of the bi-                         • set up maintenance and prophylactic measures and in-
opsy location before surgery. Moreover, an intraoral ap-                             struct the patient for the duration of the therapy;
proach can easily be performed for intraosseous lesions of                       • select healthy dental elements that will support future
the maxillary sinus 15 through the execution of the biopsy                           prosthetic rehabilitation;
on an outpatient basis with local anesthesia (Fig. 3). An                        • cooperate in the reconstructive choice;
important aspect of hard tissue biopsies is to prevent the                       • define the best prosthodontic rehabilitation choice for
lesion from invading soft tissues after the biopsy examina-                          the patient on the basis of a multidisciplinary compari-
tion 16; this can be achieved by careful management of the                           son.
periosteum and by positioning resorbable membranes over                          In addition, at present, dentistry can make use of optical
the bone breach.                                                                 impression systems that can be coupled with three-dimen-
                                                                                 sional reconstructions of CT data to carry out appropriate
Oral evaluation and prophylaxis before                                           studies even in patients with advanced disease and in whom
                                                                                 it is difficult or impossible to take traditional impressions.
oncologic treatment                                                              These technologies allow the design of temporary prostho-
It is critical that, after the cancer diagnosis (i.e., during the                dontic rehabilitations by simulating surgical resection and
period of staging procedures) and before any oncologic                           by designing the prosthesis, the temporary obturator or cus-
treatment 17, these patients have an accurate and complete                       tomized bone implants on the basis of the resection.
head, neck, oral, dental, and periodontal assessment to op-                      Currently, multiplanar reconstruction (MPR) and cross-
timize treatment and minimize complications or side ef-                          sectional images associated with tridimensional (3D) re-
fects 17. Assessment should include salivary gland function,                     construction represent the most useful imaging modali-
the range of jaw opening and temporomandibular joint dys-                        ties for diagnoses and surgical planning in the head and
functions.                                                                       neck district. With the advent of virtual surgical planning,
The presence of dental foci and poor periodontal status, in                      tumors in the orofacial district require optimization of the
addition to influencing the healing of soft tissues, creates                     diagnostic radiological phase. First of all, whenever pos-
the risk of contamination of plates, screws and bone grafts                      sible, it is advisable to have a cervical-maxillofacial district
in bone reconstructions. It is also essential to take into con-                  CT examination performed after removing both the fixed
sideration that, after surgery and during adjuvant therapies,                    and mobile prosthetic metal objects from the patient’s oral
dental care is much more difficult. Patients often have con-                     cavity. This aspect has particular importance, especially as
siderable difficulty in opening their mouths and coordinat-                      a function of the localization of the tumor and its proximity
ing tongue and chewing movements, which are debilitated                          to metal artifacts, in particular, if there is a fixed supported
because of the therapies, and dental problems can be un-                         implant rehabilitation. Optimization of the radiological di-
derestimated until they are of particular severity. Further-                     agnostic path is therefore up to the clinician, who, accord-
more, other known risk factors such as irritation caused by                      ing to his/her experience and according to the patient’s gen-
ill-fitting dentures and other rough teeth surfaces must be                      eral condition, will have to immediately request a series of
explored and corrected. Pre-treatment dental care must be                        radiological examinations necessary for the staging of the
personalized and tailored to the patient’s oral condition,                       disease but also for the reconstructive programing, espe-



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cially in cases where the maxillary or mandibular bones are                 will be addressed. Preoperative comorbidities can often be
involved. This last consideration translates into requiring                 the main factor leading to poorer results and are optimized
a thin-slice CT scan (1 mm) of the maxillofacial complex                    whenever possible. A range of reconstructive options will
and at the same time as the donor site 18. Moreover, it is im-              be available and patient participation in the selection of
portant to remember that a thin-slice CT scan of this region                procedures should be emphasized.
is of great help in identifying dental foci and in planning                 The reconstructive and rehabilitative management of the
dental treatments before oncologic surgery.                                 maxilla and mandible have different characteristics and op-
                                                                            tions depending on the type of resection that will be per-
Planning of maxillary and mandibular                                        formed.
reconstruction, implant therapy and                                         Maxillary reconstruction
prosthetic rehabilitation                                                   Maxillectomy defects are complex and involve a number of
Multidisciplinary ablative, reconstructive and prosthetic                   anatomic structures such as the hard and soft palate, nasal
programing in Head & Neck oncologic surgery has be-                         cavity, maxillary sinus and, in some cases, extend to the
come imperative to offer patients, even the elderly 19, the                 orbit with various grades of functional impairment. In their
best functional and esthetic result, especially when the                    systematic review, Bidra et al. 22 have concluded that a de-
stomatognathic system is involved. In our experience, this                  scription of the defect based on six criteria (dental status,
approach has also shown a greater adhesion and participa-                   oroantral/nasal communication status, soft palate and other
tion of patients in the therapeutic process as they are aware               contiguous structure involvement, superior-inferior ex-
of the perspectives given and of the planned final result.                  tent, anterior-posterior extent, medial-lateral extent of the
Given the multifactorial challenges of maintaining quality                  defect) could be more objective and suitable for universal
of life, nutrition, and particularly oral intake, in this pa-               application in a classification system rather than a defect-
tient group, it is vital that interventions to support eating               based description alone.
and drinking address the range of problems which interfere                  The reconstructive choice (obturators, local/regional flaps,
with the physical, functional and psychosocial aspects of                   and microvascular free tissue transfer) depends primarily
opening the mouth, chewing, tasting and swallowing food.                    on the need to be able to clinically inspect the operated
Each reconstructive method has distinctive characteristics                  region and detect local recurrences. This aspect is strong-
and capabilities that can affect the subsequent phases of                   ly linked to the type and extent of the tumor. A prosthetic
the patient’s functional rehabilitation; the consideration                  maxillary obturator, local and regional flaps are generally
of these complexities in jaw reconstruction is reflected in                 indicated for smaller defects, while microvascular grafts
the wide variety of approaches and techniques that have                     are highly recommended for larger defects (Fig. 4), with
evolved over the past century 20,21.                                        particular reference to defects requiring bone support 23. An
A primary reconstruction, where possible, generates sig-                    obturator is the only solution able to give the patient a bet-
nificant benefits for a patient’s residual quality of life and              ter quality of life when a local, regional or microvascular
avoids major surgical procedures for secondary recon-                       surgical approach is not feasible due to the characteristics
struction. With the advent of virtual surgical planning, it is              and dimensions of the lesion or to poor systemic-medical
important to plan immediately what the targeted outcome                     conditions 23. Prosthodontic rehabilitation with a prosthetic
will be, regardless of the timing in which the various steps                obturator restores the missing structures and acts as a barri-




Figure 4. Maxillary reconstruction with fibula osteofasciocutaneous flap.



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M. Berrone et al.




er to communication among the various cavities. The most        time, virtual surgical planning is a recognized technology
common problem with prosthetic treatment is in attaining        for optimizing surgical outcome and minimizing operat-
adequate retention, stability, and support. The size and lo-    ing time. Recent advances in mandibular reconstruction
cation of the defect usually influence the amount of impair-    could be further refined through the application of the “two
ment and consequently the degree of difficulty regarding        arches” concept. To optimize the outcome of the free fibula
prosthetic rehabilitation. Residual dentition and the possi-    flap in mandibular reconstruction, the central portion of the
bility of implant placement to stabilize the obturator play     mandible can be divided into upper and lower arches dur-
a key role. Advances in microvascular surgical techniques       ing preoperative evaluation and planning 29 in order to rec-
require comprehensive treatment planning guidelines for         oncile both the functional dental rehabilitation needs and
functional rehabilitation 24. Free-tissue transfer offers the   the esthetic ones dictated by the lower edge of the mandi-
most effective and reliable form of reconstruction for com-     ble. CAMR allows osteotomy lines to be easily programed
plex maxillectomy defects. At present, a combination of         oblique to the long axis of the fibula and mandible in an
reconstructive techniques using local flaps, free flaps and     attempt to increase the contact area between the two bone
implant-prosthetic procedures allows satisfactory results to    surfaces 30. The combination of mandibular and fibular cut-
be obtained in both functional and esthetic terms. Zygo-        ting guides and templates allows a precise and seamless
matic implantology and the advent of customized titanium        surgical reconstruction; this technology is especially useful
subperiosteal implants represent new and important thera-       in minimizing operating time in complex defects where an
peutic options from both a reconstructive and rehabilitative    osteofasciocutaneous flap is used for defect reconstruction
point of view 25.                                               and multiple osteotomies are required for bone modeling.
                                                                The possibility of accurately programing the position of the
Mandibular reconstruction                                       bone segments is also important in the patient’s prosthetic
Mandibular defects due to major surgery can be classified       rehabilitation; accurate occlusal restoration is definitely a
according to location and extent, as well as involvement of     key point to maintain stability over time without functional
mucosa, skin, and tongue. From the point of view of bone,       repercussions at the articular level; however, satisfactory
mandibular defects can be continuous or discontinuous in        rehabilitation only becomes achievable with a correctly po-
relation to the bone invasion by the tumor and the possibil-    sitioned implant 31. Dental implants in patients with fibula
ity of being able to perform a marginal or segmental man-       flaps are an appropriate and successful option for dental
dibulectomy.                                                    rehabilitation, even in those with risk factors such as smok-
Vascularized bone flaps, in general, provide the best func-     ing, alcohol use, and irradiation 32. Implant virtual planning
tional and esthetic outcome, with the fibula flap remaining     during CAMR must be considered an integral part of the
the gold standard for mandible reconstruction in segmental      reconstructive program to place fibular segments in the op-
mandibulectomy. This flap can be modeled with multiple          timum position from both a functional and esthetic point
osteotomies and can provide bone, muscle and skin for           of view regardless of their effective placement during sur-
composite reconstruction. Oral tongue/floor of mouth squa-      gery 31 (Fig. 5). Moreover, correct programing, in selected
mous cell carcinoma with a depth of invasion up to 10 mm        cases, can also allow the use of dental implants to stabilize
involves extrinsic muscles, and lingual neurovascular/          the bone segments in reconstructions that require a double
lymphatic bundles require a “compartmental” hemiglos-           barrel fibula flap 31. CAMR offers the possibility of pro-
sopelvectomy to improve locoregional control by “en bloc”       graming and executing both mandibular reconstruction and
removal of tumor and its pathways of spread 26,27. Com-         prosthetic implant rehabilitation in a single surgical and
partmental surgery (CTS) has been proposed in advanced          prosthetic session called “jaw in a day”. This procedure re-
lesions with the intent to remove the tumor en bloc, within     quires very accurate programing from both a surgical and
the entire hemitongue and floor-of-mouth compartment,           implant-prosthetic point of view and careful coordination
along with the tract between the primary tumor and neck         between all of the teams during surgery. We should remem-
lymph nodes, the T-N tract, and draining lymph nodes, thus      ber how CAMR plays an important role in secondary man-
standardizing the surgical technique and improving locore-      dibular reconstructions too. The possibility of programing
gional control 28.                                              reconstructions using the mirroring technique to restore
The introduction of computer-assisted mandibular recon-         good mandibular symmetry makes this type of reconstruc-
struction (CAMR) with the pivotal role of virtual surgical      tion highly predictable from an esthetic and functional
planning has further increased the accuracy of the preop-       point of view. On the other hand, patients with advanced
erative plan and gives greater precision to the surgical pro-   stages of oral cancer and reconstructed mandibles are
cedure and a reduction in surgical time 18. At the present      nearly always additionally treated with radiotherapy and/



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                                                                                                  A




  B                                                 C                                                           D




Figure 5. CAMR (A) with implant virtual planning (B); intraoperative positioning of implants into the fibula (C); final reconstructive complex (D): plate, fibula flap
and dental implants.


or chemotherapy. The combination of these treatment mo-                              neck region 33,34; one of the most debated aspects is when
dalities increases the risk for impaired wound healing after                         dental implants must be placed to have the least possible
secondary (pre)prosthetic surgery, despite precautions such                          complications 34. The presence of dental implants does not
as hyperbaric oxygen therapy. Therefore, the patient’s need                          increase the risk of complications after surgery or during
and desire for dental rehabilitation must be weighed against                         radiation treatment. Implants do not alter radiation dosim-
the risk of complications after (pre)prosthetic surgery.                             etry but do appear to positively impact early postoperative
                                                                                     patient quality of life 31. Based on the international litera-
Implant surgery and prosthetic rehabilitation                                        ture 35-40 and personal experience 18,31,41,42, the authors rec-
Improvement in oral function and related quality of life                             ommend following what is reported in Figures 6, 7 and 8.
would be expected with correct prosthetic rehabilitation.                            A further aspect that plays a fundamental role in patients recon-
The main problems that may hamper proper prosthodontic                               structed and rehabilitated with supported implant prostheses is
rehabilitation of these patients include a severe reduction in                       the management of peri-implant soft tissue. The reconstruct-
the neutral zone, an impaired function of the tongue, and a                          ed soft tissue lacks the physiological properties and function
very poor load-bearing capacity of the remaining soft tissue                         of native mucosa. In reconstructions where an intraoral skin
and mandibular bone.                                                                 component is present, after implant-prosthesis restoration, ex-
From a prosthetic rehabilitation point of view, it is very im-                       cessive soft-tissue bulk, movement, chronic inflammation and
portant to consider how radiation therapy can influence the                          hypertrophy are readily observed around implants and risk
reconstructive dental therapeutic program and procedures,                            compromising the long-term success of the implant. Various
although a definitive decision on radiotherapy (RT) is usu-                          clinical reports suggest different approaches, with contradic-
ally made after definitive histological examination. The                             tory results. A detailed soft-tissue analysis in these patients is
evolution of implant hardware and improvement in treat-                              essential. It is clear that normal attached gingiva and alveo-
ment strategies during recent years have affirmed that den-                          lar mucosa differ from soft tissue reconstructed with skin and
tal implant-supported rehabilitation is a valuable treatment                         muscle 36. It is very important that these cases are treated and
option for patients with a history of RT in the head and                             managed by specifically trained implantologists (Fig. 9).



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M. Berrone et al.




  FVCF: free vascularized composite flap; FVSTFF: free vascularized soft tissue flap; LRF: local/regional flaps; PMF: pectoralis major flap; IANT: inferior alveolar
  nerve transposition; MTP: mandibular reconstructive plate

Figure 6. Mandible malignant neoplasms with bone involvement: reconstructive and dental rehabilitative program.




  FVCF: free vascularized composite flap; FVOF: free vascularized osteofascial flap; FVSTF: free vascularized soft tissue flap; LRF: local/regional flaps; PMF:
  pectoralis major flap; NVBG: non vascularized bone graft; MRTP: mandibular reinforcement titanium plate

Figure 7. Mandible benign neoplasms with bone involvement: reconstructive and dental rehabilitative program.



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Figure 8. General concepts for fibula segments and dental implants planning and positioning.




Figure 9. Prosthetic implant supported rehabilitation after mandibular reconstruction with fibula free flap.


On the basis of the above considerations, the importance                           Management of radiotherapy complications
of a multidisciplinary approach is clear. To date, not all of                      and oral health supportive care
the Italian national health care system offers oral rehabilita-
tion after Head & Neck cancer treatment: the Italian health                        Radiotherapy (RT) now plays a fundamental role in the
system does not consider the functional and esthetic reha-                         treatment of HNCs, and nearly 75% of all these patients
bilitation of patients who have undergone impairments to                           undergo this therapy with curative, adjuvant, or palliative
the stomatognathic system due to radical surgery for tumor                         intent 43. Unfortunately, RT, especially when combined
removal since prosthetic and implant rehabilitation is sub-                        with chemotherapy, may cause acute and/or late onset side
ject to prohibitively high costs. Moreover, it is necessary to                     effects on oral and maxillofacial tissue, and in particular,
train specific staff so that they have a complete knowledge                        osteoradionecrosis (ORN), oral mucositis, hyposalivation,
of both the oncologic problems and the most suitable reha-                         and dental caries 44. The development of more accurate
bilitation techniques for these patients (Fig. 10).                                RT techniques (e.g. intensity-modulated radiation therapy



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  A                                                  B                                             C




  D                                                  E                                                    F




Figure 10. ORN of the left jaw (A); dental implant involvement in the ORN (B); orthopantomography after 3 months from surgery (left mandibulectomy, recon-
structive plate with pectoralis major flap (C); conventional prosthetic dental rehabilitation (D-F).


(IMRT) has decreased the number of side effects in the                         ing local or systemic antibiotics, hyperbaric oxygen (HBO)
oromaxillofacial district 45; nevertheless, ORN remains the                    therapy) 48 or surgical (debridement of necrotic bone, se-
most important event which can sometimes impair a pa-                          questrectomy, mandibular excision) 49.
tient’s quality of life.: it can occur in 2 to 22% of irradiated               Oral mucositis (OM) is an acute response to treatment that
patients.                                                                      affects most patients receiving RT or chemotherapy for
Osteoradionecrosis can be defined as irradiated exposed                        HNC. In patients receiving a typical 6- to 7-week course
necrotic bone which has not healed over a 3-month period,                      of RT, OM presents as erythema of the oral mucosa in
in the absence of cancer recurrence 46. Since teeth extrac-                    the first 2-3 weeks of RT and progresses to ulceration and
tions are risk factors for ORN development 47, a thorough                      pseudomembranes as the dose of radiation increases 50.
dental examination and removal of oral foci are generally                      The general long-term prognosis is reasonably good since
recommended before starting RT to minimize the risk of                         most lesions resolve within 2-4 weeks after stopping RT
ORN. The removal of oral foci before RT, taking advantage                      or chemotherapy. Although OM is considered to be a self-
of the healing capability of unaffected bone and mucosa,                       limited injury in some patients, it could be a lethal injury
seems to reduce ORN onset. No evidence-based guideline                         in moderately to severely ill patients, which could lead
exists to help the clinician in the decision-making process,                   to obligatory cessation of RT. Since an established treat-
but some indications, mainly based on expert opinion, may                      ment does not exist, OM prevention can be crucial. Benzy-
be highlighted: impacted third molars with radiographic                        damine mouthwash can be used to prevent OM in patients
signs of pericoronitis, teeth with periapical lesions, unre-                   with HNC receiving moderate dose radiation therapy (up
storable teeth, and teeth affected by periodontitis (Pocket                    to 50 Gy), without concomitant chemotherapy 51. Although
Probing Depth (PPD) ≥ 5 mm, Clinical Attachment Loss                           many studies had stated that sucralfate has no significant
(CAL) ≥ 8 mm, Grade 2 Tooth Mobility or worse, Grade 2                         advantage for preventing OM in patients receiving chemo-
Furcation Involvement (FI) or worse) should be extracted.                      radiotherapy, a recent systematic review found that cancer
Every tooth extraction should be performed with antibiotic                     patients treated with sucralfate mouthwash before receiv-
and antiseptic prophylaxis in order to prevent any possible                    ing chemotherapy had a significantly reduced incidence of
socket infection and protect the reparatory mechanisms of                      severe OM compared with controls 52.
the wound. Furthermore, a minimum interval of 15 days                          Xerostomia and hyposalivation remain a significant bur-
should elapse between the last extraction and the beginning                    den for many individuals treated with RT. Several treat-
of RT. In the case of ORN onset, its treatment can be non-                     ment strategies have been proposed for the management of
surgical (encouraging oral hygiene improvement, prescrib-                      xerostomia and they all aim to reduce patients’ symptoms



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and/or increase salivary flow. Easy remedies are proper hy-       Conclusions
dration, an increase in humidity at night-time, avoidance of
                                                                  Head and Neck cancer treatment is intrinsically complex,
irritating toothpaste and crunchy/hard foods, and the use
                                                                  and at the present time, it is necessary to create and make
of sugar-free chewing gums/candies. Medications include
                                                                  available measures capable of dealing with the disease in
mucosal lubricants, saliva substitutes, and saliva stimu-
                                                                  a multidisciplinary 54 way and with multimodality treat-
lants. Hyposalivation and oral flora impairment are often
                                                                  ments. It is important to emphasize that it takes years of
the cause of a high predisposition to dental caries. Preven-
                                                                  strict collaboration between ENT and dentists to reach a
tion of dental caries should be directed at the treatment of
                                                                  good working relationship, and garner sufficient experi-
xerostomia-related complaints, oral hygiene, change of di-
                                                                  ence and familiarity with oncological therapies. This also
et, control of cariogenic flora, and the use of frequent fluo-
                                                                  becomes possible through the organization of interdisci-
ride applications. With a daily topical 1.0% sodium fluoride
                                                                  plinary training courses which, in addition to training new
gel application by custom-made fluoride carriers, caries
                                                                  operators, allow continuous comparison and updating be-
occurrence can be greatly reduced. Due to the previously
                                                                  tween the teachers themselves.
mentioned hyposalivation-related problems, fluoridation
has to be continued on a lifelong basis (if hyposalivation
persists), and high concentrations in toothpaste (5000 ppm        References
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