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Prosthetic rehabilitation in post-oncologic patients after bone reconstruction are not substantially different than those of patients affected by severe atrophia of upper or lower jaw after bone reconstruction. Aim of this paper is to evaluate the possibilities of prosthetic rehabilitation on these patients and to present our method. Prosthesis-based oral rehabilitation of such tumor cases rapresents a challenge. The report analyses two cases of patients who underwent ablative oral surgery. Both have received a fibula free vascularised flap. The first was rehabilitated with a removable prosthesis fixed on the residual teeth, while the second with an implant supported prosthesis. In case of carcinoma resection of the oral mucosa, the removable prosthesis guarantees a simplification in dental care operations. On the other hand, irradiated mucosa is frequentely unable to tolerate the friction created by the acrylic base. However, the fixed prosthesis can limit the view during follow-up controls. In our school, according to all exposed reasons, we consider the implant supported overdenture prosthesis to be the best choice for those patients.
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Annali di stomatologia
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Prosthetic rehabilitation in post-oncological patients: Report of two cases
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Prosthetic rehabilitation in post-oncological patients: Report of two cases
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    Prosthetic rehabilitation in post-oncological
    patients: Report of two cases




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    Edoardo Brauner, DDS                                           red mandibular movements and deviation of the residual
    Andrea Cassoni, MD                                             fragment medially towards the resected side.
    Andrea Battisti, MD                                            In these cases, significant facial deformity and loss of oral
    Davina Bartoli, MD                                             function such as speech, oral competence, swallowing and
    Valentino Valentini, MD                                        saliva retention, have a detrimental psychological impact




                                                                                              zi
                                                                   on patients. When the resection only involves the alveo-
    “Sapienza” University of Rome, Italy                           lar portion of the bone or is confined to the associated soft
    Department of Oral Sciences (A. Polimeni)                      tissues, it ensures maxillary continuity. Nevertheless,




                                                                       na
    Maxillofacial Surgery Unit (G. Iannetti)                       there are obvious facial disfigurements which may lead pa-
                                                                   tients to struggle with conventional dentures because of
    Corresponding author:                                          altered oral anatomy, obliteration of sulci and loss of sen-
    Dott. Edoardo Brauner                                          sorial and motor innervation.
    Viale Regina Margherita, 169                                   The more extended the ablative surgery, the stronger the




                                                                     er
    00161 Rome, Italy                                              complications.
    Tel.:068541754
    E-mail: edoardobrauner@tin.it                                  Case reports

                                                             nt    More than 360 patients affected by oral cancer underwent
                                                                   surgery between 2000 and 2008 at the maxillo-facial unit
                                                                   of the Policlinico “Umberto I” in Rome. About 40% of them
                                                   iI
    Summary                                                        had been rehabilitated either with fixed or removable con-
                                                                   ventional prosthesis; 70% of the rehabilitated patients re-
    Prosthetic rehabilitation in post-oncologic patients after     ceived a conventional removable or fixed prosthesis ac-
    bone reconstruction are not substantially different than       cording to the residual teeth and bone, the remaining 30%
                                        on

    those of patients affected by severe atrophia of upper or      received a fix or removable implant-supported prosthesis
    lower jaw after bone reconstruction.
                                                                   .The report analyses two cases of patients who underwent
    Aim of this paper is to evaluate the possibilities of pros-
    thetic rehabilitation on these patients and to present our     ablative oral surgery. Both received a fibula free vascu-
    method. Prosthesis-based oral rehabilitation of such           larised flap and were rehabilitated: first with a removable
                               i


    tumor cases rapresents a challenge.                            prosthesis fixed on the residual teeth and oral mucosa; se-
                            iz



    The report analyses two cases of patients who under-           cond one with a removable prosthodontic suprastructure
    went ablative oral surgery. Both have received a fibula        implant-supportated (overdenture).
    free vascularised flap. The first was rehabilitated with a
    removable prosthesis fixed on the residual teeth, while
           Ed




                                                                   Case 1
    the second with an implant supported prosthesis.
    In case of carcinoma resection of the oral mucosa, the
    removable prosthesis guarantees a simplification in            The patient – a 41 years old woman – at the clinical exa-
    dental care operations. On the other hand, irradiated mu-      mination reffered a generalized pain on the right side of
    cosa is frequentely unable to tolerate the friction created    the face and showed a omolatheral tonsillar pillar intu-
    by the acrylic base. However, the fixed prosthesis can         mescence (Fig. 1).
    limit the view during follow-up controls.                      Histological analysis revealed an epidermoidal carcinoma
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    In our school, according to all exposed reasons, we con-       of the right tonsil. The patient was subjected to three che-
    sider the implant supported overdenture prosthesis to          miotherapy cycles reducing the mass by 80%. Furthermore,
    be the best choice for those patients.
                                                                   the patient received immediate surgery consisting in he-
                                                                   mimandibulectomy with the excision of the tonsillar lodge,
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    Key words: oral cancer, fibula free flaps, oral rehabilita-    lateral pharynx wall, lateral and posterior right hemitongue,
    tion, function.                                                maxillar tuberosity and soft palate. A temporal flap was used
                                                                   to cover the surgery site. A reconstructive plate was used
                                                                   to rebuild the right hemimandibula.
©




    Introduction                                                   After thirteen years of follow up, we decided to reconstruct
                                                                   the hemimandibula using a fibular free flap (Figs. 2, 3).
    Prosthetic rehabilitations in post-oncological patients af-    The overage time from start of surgery until bridge con-
    ter bone reconstruction are not substantially different than   nection was 24 months. In this period periodic follow-up
    those of patients affected by severe atrophy of upper or       was carry out regarding to the need of giving the chance
    lower jaw after bone reconstruction.                           to make periodic follow up, to rebuild the lost soft tissues
    Obviously, in those patients the balance and symmetry of       and to give good occlusion and function even if the ma-
    the mandibular function is compromised leading to alte-        sticatory muscles were excised, to restore the residual te-

    Annali di Stomatologia 2010; I (1): 19-25                                                                             19
    E. Brauner et al.




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    Figure 1 - The patient before surgery                     Figure 3 - The patient after reconstructive surgery
    • a Extraoral view                                        • a Extraoral view
    • b Intraoral view                                        • b Intraoral view
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                                                              eth and – finally – for the economic possibilities of the pa-
                                                              tient.
                                                              Given that the patient had not been chewing for fifteen ye-
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                                                              ars, she had lost her oral function and, for this reason, we
                                                              decided to begin rehabilitation with a combined provisio-
                                                              nal prosthesis. Fixed crowns were used on the teeth and
                                                              removable prosthesis for the edentoulous portions for the
©




                                                              rest (Fig. 4).
                                                              Six months later, the prosthetic rehabilitation was finalized
                                                              positioning definitive crowns on the natural teeth connected
                                                              with telescopic crowns fixed to the removable proshesis,
                                                              in order to give the patient a normal profile adding and whe-
                                                              re necessary, acrylic gingiva (Fig. 5).
                                                              The result was a very confortable prosthesis ensuring both
    Figure 2 - CT reconstruction of lower jaw after surgery   aesthetics and functionality (Fig. 6).

    20                                                                             Annali di Stomatologia 2010; I (1): 19-25
    Prosthetic rehabilitation in post-oncological patients: report of two cases




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    Figure 4 - The provisional prosthetic rehabilitation




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                                                                     Figure 6 - The patient after oral rehabilitation
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    Figure 5 - The final prosthetic rehabilitation                   • a Extraoral view
                                                                     • b Intraoral view


    Case 2                                                           stual implant insertion (Fig. 11).
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                                                                     After Six months an implant supported prosthesis was
    The patient, a 38 year old female, reported an intume-           made (Fig. 12).
    scence on the body and ramus lower right jaw (Fig. 7). The
    preoperative radiograph examination showed an extended           Discussions
©




    lesion on the mandibular angle. The histological exam re-
    vealed an ameloblastoma (Fig. 8).                                In the last years, immediate surgical reconstructions of the
    The patient then received surgery consisting in hemi-            complex soft-tissue and bone defect caused by the tumor
    mandibulectomy and contestual reconstruction with a dou-         surgery using vascularized free flaps has revolutionized
    ble barrel free fibula flap (Figs. 9, 10).                       post-surgical oral reconstruction and dental prosthetic re-
    A year later the patient received surgery based on the fi-       habilitation.
    bula flap remodeling, an eterologus bone graft, positioning      The use of osseointegrated dental implants obtain a right
    of a resorbable Bio Gide collagen membrane and conte-            prosthetic treatment following ablative surgery has been

    Annali di Stomatologia 2010; I (1): 19-25                                                                              21
    E. Brauner et al.




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                                                                    Figure 8 - X-Ray Before surgery
                                                                    • a Panoramic radiograph
                                                                    • b CT image
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    Figure 7 - The patient before surgery
    • a Extraoral view
    • b Intraoral view
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    found to be beneficial in some cases (Chan 1997, Goia-
    to 2009).
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    Concerning the reconstruction choice between fixed or re-
    movable prosthesis, technical considerations are impor-
    tant: implant position, aesthetic result etc.; psychological
    considerations: acceptability of a removable prosthesis;
©




    and last but not least, the economic possibilities.
    Conventional removable prosthesis after oral mucosa can-
    cer guarantees good control of the mucosa by the operator
    and at the same time, good hygiene control by the patient,
    These factors that can simply cause periimplatitis and even
    oncologic relapses.                                             Figure 9 - X-Ray after reconstructive surgery
    On the other hand, the contact with soft tissues which cau-     • a Panoramic radiograph
    ses mechanical courting, can bring about local irritation and   • b CT-3D after surgery


    22                                                                                  Annali di Stomatologia 2010; I (1): 19-25
    Prosthetic rehabilitation in post-oncological patients: report of two cases




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                                                                       Figure 11 - Implant placement
    Figure 10 - Extraoral view
                                        on

                                                                       • a Intraoperative view
                                                                       • b Panoramic radiograph after implant placement



    decubiti. Therefore, it is very difficult to apply the same the-
                               i


    rapy for each patient. Moreover, the reconstruction, even
                            iz



    if it is the best choice, cannot always guarantee morpho-
    logy similar to the patient’s natural pre-operative condition,
    particularly after large reconstructions. In these cases, a
           Ed




    removable solution can be the best choice both for ae-
    sthetic and functional results because of the use of acry-
    lic resin in removable prosthesis.
    Prosthetic rehabilitation in patient after ablative oral sur-
    gery is finalizzated to restore both oral function and facial
    contour form, in order to enable the patient to recover phy-
    sically and psychologically to the fullest and hence regain
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    a normal life and employment. It would seem logical to use
    endosseous implants in conjunction with free flap recon-
    structive techniques, to achieve the goal of complete oral
    rehabilitation (Chan 1997, Goiato 2009).In bone recon-
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    structed patients either with free vascularized or non va-         Figure 12 - Intraoral view after rehabilitation
    scularized grafts, implants can be inserted at the moment
    of the first surgery (1-stage surgery) or after 6-8 months
    (2-stage surgery). Therefore, we call the first technique a        not allow to establish a correct inclination of the implants,
©




    primary insertion and the second a postponed insertion             with high failure risks. The primary insertion was associated
    (Chang 1998) (Chiapasco 2000; Zlotolow 1992; Antony                with a major loss of marginal bone, due to an early pre-
    1996; Cuesta-Gil 2009).                                            mature load force (Chiapasco 2006). The biomechanics
    Especially for free revascularised flaps, the primary in-          of the implant load, the mechanical stress moved to the
    sertion allows better access to the bone structure, redu-          bone interface and the subsequent reaction of the bone
    cing the time of prosthetic rehabilitation and eliminating a       to the stress, may increase if the implants are placed in
    second time surgery and accidental lesions of the vascular         the wrong way. Excessive non-axial implant loads may da-
    peduncle. On the other hand, the primary insertion does            mage the bone interface surface, causing loss of margi-

    Annali di Stomatologia 2010; I (1): 19-25                                                                                 23
    E. Brauner et al.


    nal bone and implant failure. The secondary insertion, also       After one year, the implant rates failures due to resorption
    used by our school, may take place 4-6 months later, af-          of the marginal bone of the implants, as far as fixed pro-
    ter bone callus formation if the patient does not need to         stheses are concerned, are around 2.5% for the upper jaw-
    undergo a post-surgical radio therapy treatment. Such a           bone and 1% for the mandible. On the other hand, failu-
    period allows bone integration of the flap and of the bone        re rate, for overdenture (removable prostheses fixed to the




                                                                                                        i
    callus in the osteotomy areas. Thus, better osteointegra-         implants), attained 4.5% for the jawbone and 2% for the




                                                                                                      al
    tion and reduction of the flap stress are possible.               mandible (Snauwaert 2000).
    However, the patient needs to undergo one more surge-             It would also be interesting to evaluate the overdentures
    ry. This may turn out to be a benefit for the cosmetic and        anchored to the implants using a solidifying bar between
    functional result of the reconstruction, since it would allow     the implants, the “dolder bar” and those anchored to sin-




                                                                                                    on
    to reshape the flap if necessary. It is possible to study the     gle implants. The bar would reduce micromotions and
    models, to build diagnostics wax-ups for the production of        would facilitate the success of the implants. According to
    surgical stent. The use of a surgical stent directing implant     some authors, just 24.4% of the ball-retained prostheses
    position as dictated by the diagnostic wax-up aided in the        have not met any accident versus 57.1% of those fixed to




                                                                                                  zi
    correct three-dimensional positional for the prosthetic plat-     the bar; the difference is significant (Nedir 2006). As far
    form. Such waxing would guide the surgeon, according to           as the ball retained is concerned, 72.5% of the prosthe-
    the prosthetic requirements of each case. This is not the         ses have not met any accident one year after the location
    case of primary insertions.                                       of the implants; 2 or 3 years later, the percentages were




                                                                          na
    According to some authors, the long-term rates implant pro-       around 52.5% and 37.5%. Three years later, the percen-
    gnosis, both for the autologous grafts and the revascula-         tages of prostheses supported by the bar one year after
    rised flaps, are similar to the long-term rates of native bone    the location that have not met accidents varied from 92.9%
    implants (Albrektsson 1986; Arvidson 1998; Buser 1997;            to 71.4% (Nedir, 2006; Chan 1997).




                                                                        er
    Garrett 2006). Despite the different quantity of bone, no         It is not always possible to choose a fixed rehabilitation sin-
    significant differences for the implants survive expectan-        ce the bone quantity, as well as its quality and the finan-
    cy have been reported between the fibula (D1 bone for-            cial aspects are essential.
    med by the cortical and a tiny part of the medulla) and the
    iliac crest (D2 bone formed by the bone cortical with a mi-
    nor thickness and a considerable spongious component),
    according to Misch classification.
    Such results confirm the prosthetic rehabilization with en-
                                                                nt    Conclusions

                                                                      In the case of carcinoma resection of the oral mucosa, the
                                                                      removable prosthesis guarantees a simplification in den-
                                                      iI
    dosseous implants on those patients and the positive role         tal care operations. On the other hand, it may cause me-
    of the prosthetic load on the metabolism of bone transplant.      chanical stimulus due to contact with soft tissues, with sub-
    (Hotz 1996; Chiapasco 2001; Garrett 2006).                        sequent local irritation and ulcer.
                                       on

    A different consideration must be made for those patients          As for prosthetic rehabilitations of the irradiated patients,
    who have undergone radiotherapy or must undergo it; in            the removable prostheses implant-retained (overdenture)
    these patients, in fact, to minimize the failure possibilities,   seem to expose those patients to a higher risk of muco-
    it is suggested to wait almost 12 months from the end of          sa ulceration caused by the continous inflammatory con-
    radiotherapy (Chiapasco 1999).                                    dition of the tissues. A fixed prosthesis operation that would
                              i


    According to letterature, in the case of reconstruction using     fix on to the implants would be better than a removable op-
                           iz



    implants in non-revascularised bone, it is better to place        tion, considering the ankylosis relation established between
    the implants with an interval of time of 3-6 months from the      the implant and the bone (Rohner 2002; Snauwaert, 2000;
    reconstruction phase, in order to allow an adequate re-           Garrett 2006).
           Ed




    vascularization of the graft and to reduce the bone re-           After one year, the implant failures rates due to a resor-
    sorption which, in bone grafts, is higher during this first pe-   ption of the marginal bone of the implants, as far as fixed
    riod (Goga 1999; Kovacs 2000; Chiapsco 2000; Cuesta-              prostheses are concerned, are around 2.5% for the upper
    Gil 2009). In those cases, the percentages of implants fai-       jawbone and 1% for the mandible. On the other hand, the
    lure are similar to those of implants placed in the native        percentages of failure, in case of overdenture (mobile pro-
    bone (<10%) (Chiapasco 1999; Hotz 1996; Garrett 2006).            stheses anchored to the implants), attained 4.5% for the
    The percentages of failure were significantly higher              jawbone and 2% for the mandible (Snauwaert 2000; Cue-
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    (about 30%) for the implants placed contestually to re-           sta-Gil 2009).
    construction (Chiapasco 1999; Cuesta-Gil 2009).                    A removable prosthesis after oral mucosa cancers ensures
    Ideally, a strip of adherent keratinized oral mucosa thin-        good control of the mucosa by the operator and, at the
    ner than 2 mm should be used, in order to reduce the risks        same time, good hygiene control by the patient, who usual-
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    of periimplants socket and in order to facilitate the dental      ly is a alcoholist, a smoker and does not pay great atten-
    care operations (Sieg 1999).                                      tion to hygiene; factors which can simply cause periim-
    Some remarks are needed regarding the choice of fixed             platitis and even oncological relapses. On the other
    or removable prosthesis.                                          hand, the soft tissues touch, that causes mechanical cour-
©




    The psychological reasons are very important: for exam-           ting, can bring about local irritation and ulcer.
    ple, the patient has to agree on a removable prosthesis.           Therefore, it is very difficult to apply the same thera-
    Technical reasons, however, are fundamental for the final         py for each patient. In our school, according to all ex-
    choice.                                                           posed reasons, we prefer the implant supported over-
    A fixed implant supported prosthesis would be better, ra-         denture prosthesis (Weischer, 1996). This combination
    ther than a removable option, considering the ankylosis           suits the need of reducing unfavourable micromotions
    relation established between the implant and the bone             with the periodical control requirements by an oncolo-
    (Rohner 2002; Snauwaert 2000; Garrett 2006).                      gical patient.

    24                                                                                    Annali di Stomatologia 2010; I (1): 19-25
    Prosthetic rehabilitation in post-oncological patients: report of two cases


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    Annali di Stomatologia 2010; I (1): 19-25                                                                                               25
