J Oral Maxillofac Surg

67:2485-2496, 2009

Oral Rehabilitation With Osseointegrated

Implants in Oncologic Patients
Matías Cuesta-Gil, MD, PhD,*
Santiago Ochandiano Caicoya, MD, DMD,†
Francisco Riba-García, MD, DMD, PhD,‡
Blanca Duarte Ruiz, MD, PhD,§
Carlos Navarro Cuéllar, MD, DMD, PhD,储 and
Carlos Navarro Vila, MD, DMD, PhD¶

Purpose: The esthetic and functional rehabilitation of oncologic patients subjected to major resection
surgery constitutes one of the greatest challenges for the head and neck surgeon. Immediate bone
reconstruction with microsurgical free tissue transfer and dental implants has constituted a genuine
revolution in the management of such patients.
Materials and Methods: We present a series of 111 oncologic patients, involving a total of 706
implants, who underwent reconstruction with pedicled or free microsurgical flaps.
Results: The osseointegration success rate was 92.9%, with a global failure rate (malpositioning or
failed osseointegration or loading) of 15%. Failure particularly affected the group of irradiated patients
and those subjected to lateral osseomyocutaneous trapezial pedicled flap reconstruction. Excellent
results were obtained with the fibular and iliac crest free flaps and osseointegrated dental implants.
Conclusions: The difficulties of prosthetic rehabilitation are discussed, along with the individualized
solutions applied, the repercussions on the temporomandibular joint, and the management protocol
adopted by our service.
© 2009 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 67:2485-2496, 2009

The restoration of function after oncologic surgery of insurmountable obstacles for dental rehabilitation and
the oral cavity constitutes one of the major challenges functional reconstruction.2-4
facing head and neck oncology.1 For many authors, Within the general objective of securing esthetic as
the facial skeletal deformities and unfavorable anat- well as functional reconstructions, dental rehabilita-
omy of the intraoral soft tissues often constituted tion is a very important consideration for achieving a
good outcome. Adequate dental rehabilitation allows
the patient to chew food and considerably improves
*Head, Oral and Maxillofacial Department, Ciudad Real General,
speech and swallowing.
Ciudad Real, Spain.
In oncologic surgery of the oral cavity, conven-
†Staff Member, Gregorio Marañón General Hospital, Madrid,
tional dental rehabilitation offers a low success rate
Spain.
because of the existing distortion of the intraoral
‡Staff Member, Ciudad Real General Hospital, Ciudad Real, Spain.
anatomy and the adverse effects of radiotherapy.5 In
§Staff Member, Ciudad Real General Hospital, Ciudad Real, Spain.
this context the development of microsurgical tech-
储Staff Member, Gregorio Marañón General Hospital, Madrid,
Spain.
niques has made it possible to design different types
¶Professor, Complutense Medical School, and Head, Oral and
of composite flaps (skin, bone, and muscle) for the
Maxillofacial Department, Gregorio Marañón General Hospital, Ma- 3-dimensional repair of oromandibular oncologic
drid, Spain. defects. Reconstruction of mandibular continuity
Address correspondence and reprint requests to Dr Navarro has been shown to improve facial harmony, al-
Cuéllar: Oral and Maxillofacial Department, Hospital General Uni- though functionality worsens when this is not as-
versitario de Guadalajara, Donantes de Sangre s/n, 19002 Guadala- sociated with dental rehabilitation.3 Osseointe-
jara, Spain; e-mail: [email protected] grated implants have afforded major advances in
© 2009 American Association of Oral and Maxillofacial Surgeons the reconstructive management of patients with
0278-2391/09/6711-0026$36.00/0 oral neoplasms, because they allow stabilization of
doi:10.1016/j.joms.2008.03.001 dental prostheses. In this way patients can be of-

2485
2486 OSSEOINTEGRATED IMPLANTS IN ONCOLOGIC PATIENTS

fered good reconstruction by securing true esthetic

Implants That

19 (10.8%)
22 (12.3%)
5 (15.6%)
26 (29.5%)
7 (16.6%)

2 (12.5%)
9 (21.7%)

6 (13.9%)

1 (14.2%)

3 (16.6%)
1 (9.1%)
3 (15%)

2 (20%)

1 (10%)

106 (15%)
and functional rehabilitation.

Failed*
The use of osseointegrated implants in patients

0
with maxillofacial defects has been common practice
for the past 15 years.6 In this sense Riediger7 was the
first author to place deferred implants in microsurgi-

Osseointegrated
cal flaps, and Urken et al8 pioneered immediate im-

166 (94.8%)
168 (93.8%)
30 (93.7%)
72 (81.8%)
47 (95.9%)

15 (93.7%)
39 (92.8%)

10 (90.9%)

17 (94.4%)
10 (100%)

10 (100%)
7 (100%)
6 (100%)

656 (92.9%
Implants

19 (95%)

40 (93%)
plant placement at the time of bone reconstruction.
Few studies to date have reported long-term results
in extensive patient series. One of the reasons for this
is that long-term patient survival remains limited, de-
spite the advances in surgery and adjuvant therapeu-

Implants
Radiated
tic modalities.1 In effect, many controversial aspects

75
95
17
82
28

8
23

8
26
5
8
0
6
14
395
persist regarding the effects on the implants of factors
such as radiotherapy, the reconstructive method
used, the type of bone flap used, the optimum timing

Remnant Bone
Implants in
of implant placement, and the dental rehabilitation

80
67
32
36
49
20
16
42

10
43
11
5
7
6
18
442
provided. These aspects are addressed in this study,
involving a series of oncologic patients subjected to
reconstruction with pedicled or free microsurgical
flaps.

Implants in
Bone Flaps

95
112

52

264
Materials and Methods
This study describes our cumulative experience
with the implant-based dental rehabilitation of onco-
Implants

logic patients treated at the Department of Maxillofa-

175
179
32
88
49
20
16
42

10
43
11
10
7
6
18
706
cial Surgery, Gregorio Marañón General University

Cuesta-Gil et al. Osseointegrated Implants in Oncologic Patients. J Oral Maxillofac Surg 2009.
Hospital (Madrid, Spain), over the last 15 years. The
Radiotherapy

study comprises 111 patients and a total of 706 im-

plants, 252 in the grafted bone and 454 in the rem-
20
19
7
14
4

1
4

1
3
1
2
0
1
2
79
nant bone. Prosthetic dental rehabilitation was com-
pleted in all subjects. Of the patients, 90 presented
with malignancies whereas the remaining 21 were
diagnosed with ameloblastomas. In 12 cases the le-

*Total failures: osseointegration, malpositioning, and after loading.

Rectus abdominis flap
sions were located in the upper maxillary region, and
Reconstructive

Temporoparietal
Technique

in the remaining cases they affected the mandibular

Iliac crest flap

Direct closure
Temporal flap

gums, lower jaw, tongue, floor of the mouth, jugal

Scapular flap
Scapular flap
Pectoral flap

fascia flap
Fat pad flap
Fibular flap

OMCT flap
Radial flap

mucosa, and lower lip. The patients’ ages ranged from

Local flap
Local flap
Skin graft

13 to 79 years (mean, 52 years); there were 80 male

patients and 31 female patients (72% and 28%, respec-
tively) (Table 1).
Reconstruction was carried out by use of microsurgi-
8
9
3
3
3

0
2

1
1
1
1
0
1
31
F

cal flaps in 66 patients, with fibular flaps in 29 cases

21
16
5
13
5
2
2
5

1
4
1
1
0
1
1
80
M

(Figs 1-6), iliac crest flaps in 25 (Figs 7-12), radial flaps in

8, scapular flaps in 3, and a rectus abdominis flap in 1; by
No. of
Cases

29
25
8
16
8
2
2
7

1
5
2
2
1
1
2
111

use of pedicled flaps in 34 patients, with osseomyocu-

taneous trapezial (OMCT) flaps in 16 (Figs 13-18), pec-
Table 1. PATIENT DATA

toral flaps in 8, temporal myofascial flaps in 7 (Figs

Segmental mandibular
Segmental mandibular

Segmental mandibular
Segmental mandibular

Segmental mandibular
Segmental mandibular
Marginal mandibular

Marginal mandibular

Marginal mandibular
Marginal mandibular

Marginal mandibular
Marginal mandibular
Partial maxillectomy

19-23), buccal fat pad flaps in 2, and a temporoparietal

Bone Resection

Hemimaxillectomy

No bone resection

fascia flap in 1; by use of dermal-epidermal graft in 2

patients; and by use of local flaps in 7 patients. The
duration of follow-up in the 111 patients ranged from 6
months to 9 years.
Total

Radiotherapy was applied in 79 patients, with a

total of 395 implants. In 45 cases (56.9%) the implants
CUESTA-GIL ET AL 2487

FIGURE 1. Case 1: Squamous cell carcinoma affecting left gin-

giva and left body of mandible.
Cuesta-Gil et al. Osseointegrated Implants in Oncologic Patients.
J Oral Maxillofac Surg 2009.

were placed before irradiation, whereas in the re-

maining 34 (43.1%) they were placed at a minimum of
12 months after the conclusion of radiotherapy. None
of our patients received treatment with hyperbaric
oxygen. FIGURE 3. One year after the end of radiotherapy, part of the
In all cases we placed hydroxyapatite-coated tita- osteosynthesis material was removed and 4 implants were placed
nium implants (mostly threaded). Of the global 706 in the fibular flap and 2 implants in the remnant mandible.
implants, 348 (49.3%) were inserted in mandibular Cuesta-Gil et al. Osseointegrated Implants in Oncologic Patients.
reconstruction bony flaps whereas the remaining 358 J Oral Maxillofac Surg 2009.
(50.7%) were placed in remaining maxillary bone. In
patients lacking teeth in the upper maxilla, implants vention was carried out with the patient under gen-
were positioned at this level, with the aim of poste- eral anesthesia. After placing the transmucosal healing
riorly securing a more stable and functional prosthetic posts, we waited a minimum of 15 days before start-
solution and dealing with occlusal problems that oth- ing the dental impressions to secure adequate gums.
erwise would not be solvable. In those cases with cutaneous flaps on the implants,
The second surgical phase for exposing the im- special abutments were required to traverse their full
plants was carried out after 6 months in patients not thickness.
subjected to radiotherapy and after 8 months in the Preparation of the dental prostheses for these pa-
irradiated subjects. In most cases this second inter- tients requires much more work than usual compared
with nononcologic patients, and in some cases in-
dividualized and often imaginative solutions are

FIGURE 2. Segmental mandibulectomy including right parasym-

physis and right angle of mandible. Immediate reconstruction with
a fibular free flap was performed, with postoperative radiotherapy. FIGURE 4. X-ray after placement of dental implants.
Cuesta-Gil et al. Osseointegrated Implants in Oncologic Patients. Cuesta-Gil et al. Osseointegrated Implants in Oncologic Patients.
J Oral Maxillofac Surg 2009. J Oral Maxillofac Surg 2009.
2488 OSSEOINTEGRATED IMPLANTS IN ONCOLOGIC PATIENTS

FIGURE 5. Prosthetic rehabilitation with implant fixed prosthesis:

final occlusion.
Cuesta-Gil et al. Osseointegrated Implants in Oncologic Patients.
J Oral Maxillofac Surg 2009.
FIGURE 7. Case 2: An ameloblastoma developed in the right
parasymphysis and right body of the mandible in a 38-year-old
woman.

required. The majority of these prosthetic solutions Cuesta-Gil et al. Osseointegrated Implants in Oncologic Patients.
J Oral Maxillofac Surg 2009.
were implant-retained overdentures. This type of
prosthesis was applied by adding a wrought metal
reinforcement on the entire palatal or lingual aspect, Results
thereby preventing the prosthesis from fracturing.
Of the 706 implants used in total, 29 presented
The risk of fracture in these patients is high, because
with osseointegration failure (global osseointegration
of the postoperative loss of proprioceptive sensitivity,
failure rate, 4.1%), with variations according to the
which causes patients to apply excessive occlusal type of reconstruction involved (Table 1).
forces. In addition, to overcome the anatomic discrep- At the time of dental prosthetic rehabilitation, 31
ancies between the 2 jaws, we designed cleft pros- implants could not be used because of malpositioning
theses with asymmetric arches, thus making it diffi- (4.4%), either in relation to important lack of parallel-
cult to uniformly distribute the occlusal forces ism and excessive angulation, either lingual or vestib-
between the dental arches. In application to the up- ular, or because of placement in posterior sectors
per prostheses, these reinforcements also allow us to with an absence of occlusal space. Another 8 malpo-
design a cleft palate to improve speech and patient sitioned implants were removed and posteriorly re-
comfort. These preparations were completed in vac- placed. This latter group, in which malpositioning
uum-injected acrylic resin to minimize dimensional could be solved, was not included among the cases
alterations in the laboratory. we regarded as global failures.

FIGURE 8. The patient underwent segmental mandibulectomy and

FIGURE 6. Esthetic result 2 years after surgery. immediate reconstruction with an iliac crest free flap.
Cuesta-Gil et al. Osseointegrated Implants in Oncologic Patients. Cuesta-Gil et al. Osseointegrated Implants in Oncologic Patients.
J Oral Maxillofac Surg 2009. J Oral Maxillofac Surg 2009.
CUESTA-GIL ET AL 2489

FIGURE 9. Four dental implants were placed at the time of recon- FIGURE 11. Final occlusion.
structive surgery.
Cuesta-Gil et al. Osseointegrated Implants in Oncologic Patients.
Cuesta-Gil et al. Osseointegrated Implants in Oncologic Patients. J Oral Maxillofac Surg 2009.
J Oral Maxillofac Surg 2009.

dose of 50 to 60 Gy over the tumor bed and lymph

After prosthetic loading, 52 implants failed (7.4%) node chains. In this group of irradiated patients, 82
in 8 patients, 4 of whom had been subjected to implants were placed in 14 OMCT flaps, 95 in 19 iliac
reconstruction with an OMCT flap, whereas an iliac
crest flap, fibular flap, and greater pectoral flap was
used in 1 patient each. The last patient was treated by
direct closure. Of these 8 patients, 7 had received
radiotherapy. The total failures (osseointegration, mal-
positioning, and after loading) were 106 implants
(global failure rate, 15%) (Table 1).
We positioned 395 implants in 79 patients sub-
jected to radiotherapy. In 45 of these individuals (205
implants) the implants were placed immediately, at
the time of reconstruction, whereas in the remaining
34 patients (190 implants) they were positioned on a
deferred basis, at least 1 year after receiving the last
radiotherapy dose. Most irradiated patients received a

FIGURE 10. After an osseointegration period of 4 months, the

patient was rehabilitated with an implant fixed prosthesis. FIGURE 12. Esthetic result 3 years after surgery.
Cuesta-Gil et al. Osseointegrated Implants in Oncologic Patients. Cuesta-Gil et al. Osseointegrated Implants in Oncologic Patients.
J Oral Maxillofac Surg 2009. J Oral Maxillofac Surg 2009.
2490 OSSEOINTEGRATED IMPLANTS IN ONCOLOGIC PATIENTS

FIGURE 13. Case 3: Squamous cell carcinoma of floor of mouth

FIGURE 15. Immediate reconstruction with OMCT flap.
with extension to lingual cortex of mandible.
Cuesta-Gil et al. Osseointegrated Implants in Oncologic Patients.
Cuesta-Gil et al. Osseointegrated Implants in Oncologic Patients.
J Oral Maxillofac Surg 2009.
J Oral Maxillofac Surg 2009.

dental rehabilitation as a result of peri-implant bone

crest flaps, and 75 in 20 fibular flaps. The rest of the resorption attributable to cratering or progressive
implants were inserted in nonreconstructed lower or horizontal and vertical bone resorption. This is a se-
upper jaw and in remnant maxillary bone. Of the 29 rious complication, because it invariably leads to im-
osseointegration failures, 27 (93%) occurred in irradi- plant loss. We related these bone losses to excessive
ated patients, and all were located in zones exposed occlusal loading not parallel to the axis, poorer bone
to the maximum radiation dose. Of these 27 non- quality of the clavicular acromion for accepting im-
osseointegrated implants in irradiated patients, 21 plants, and the permanent adverse effects of radio-
(77%) were positioned in bony flaps and all had been therapy on osseointegration. Once established, such
positioned immediately. The 6 nonosseointegrated progressive bone resorption was found to persist
implants located in remnant lower jaw were posi- even after freeing of the occlusal loading attachments;
tioned on a deferred basis after radiotherapy. in all such cases we had to remove the latter.
Of the 52 implants that failed after rehabilitation, 48 In 2 of our patients subjected to rehabilitation of
(92%) had been exposed to radiotherapy and in 40 the both jaws, fracture of the resin prosthesis occurred,
total radiation dosage exposure was in the implant probably as a consequence of excessive occlusal
zone. The remaining 4 failures after rehabilitation forces appearing after surgery with loss of the pa-
corresponded with implants positioned in bony flaps tients’ proprioceptive defense mechanism. For this
but that had not been subjected to radiotherapy. reason, we always designed these prostheses with
In 3 cases (2 OMCT flaps and 1 iliac crest flap) metal reinforcement.
subjected to radiotherapy with maximum dosing on Prosthesis volume and weight tend to be greater in
the implants, a total of 10 implants were lost after such cases than in the usual patients; as a result,

FIGURE 14. The patient underwent bilateral neck dissection and FIGURE 16. Placement of 4 dental implants in mandible and 4
a segmental mandibulectomy and had a surgical defect. implants in maxilla.
Cuesta-Gil et al. Osseointegrated Implants in Oncologic Patients. Cuesta-Gil et al. Osseointegrated Implants in Oncologic Patients.
J Oral Maxillofac Surg 2009. J Oral Maxillofac Surg 2009.
CUESTA-GIL ET AL 2491

FIGURE 17. Prosthetic rehabilitation with both removable

prosthesis.
Cuesta-Gil et al. Osseointegrated Implants in Oncologic Patients.
J Oral Maxillofac Surg 2009.

leverage much greater than usual is exerted on the

implants. For this reason, a large number of implants
should be available, with correct designing of the rods
and extension arms and positioning of the special
attachments to ensure correct force distribution, as
well as avoidance of rod fracture (a situation recorded
in 3 cases in our series) and excessive stress on the
implants. In none of our cases were serious compli-
cations derived from implant treatment.
All but 2 of our patients were satisfied with the
esthetic and functional results obtained after dental
rehabilitation. In the 2 dissatisfied patients, function
of the dental prostheses worsened—in 1 case because
of trismus and in the other because of severe lip
incompetence. The prostheses were removed in both
cases.
In general, the esthetic effect and speech function
improved considerably after rehabilitation. Chewing
and swallowing were restored in two thirds of cases,

FIGURE 19. Case 4: A 61-year-old woman with cystic adenoid

carcinoma in the right maxilla. She underwent resection and
immediate reconstruction with a temporal muscle flap. Post-
eriorly, a collapse of the premaxilla and a loss of occlusion
developed. OPT after hemimaxillectomy and remnant teeth is
shown.
Cuesta-Gil et al. Osseointegrated Implants in Oncologic Pa-
tients. J Oral Maxillofac Surg 2009.

allowing the intake of a normal solid diet. Tongue and

lip mobility could not be adequately restored in all
cases. In 12 patients we performed vestibuloplasties
and lingual debridement, with the fitting of implant-
supported acrylic laminas to maintain the space and
in some cases to fix dermal-epidermal free flaps. The
FIGURE 18. Esthetic result 8 years after surgery. patients with tongue and lip dysfunction achieved
Cuesta-Gil et al. Osseointegrated Implants in Oncologic Patients. acceptable competence after dental and occlusal re-
J Oral Maxillofac Surg 2009. habilitation.
2492 OSSEOINTEGRATED IMPLANTS IN ONCOLOGIC PATIENTS

FIGURE 20. Extraction of remnant teeth and immediate placement of 4 dental implants in remnant bone.
Cuesta-Gil et al. Osseointegrated Implants in Oncologic Patients. J Oral Maxillofac Surg 2009.

Discussion insensitivity, changes in the masticatory muscles, loss

of proprioceptive sensitivity and of labial vestibular
In many cases restoration of mandibular continuity
space, altered tongue mobility, and irregularities in
is not sufficient to achieve correct intraoral rehabili-
bone contour.9,10 All this causes most patients to be
tation because we must also solve the problems relat-
unable to wear removable dentures. If, in addition,
ing to speech, mastication, and salivation, in addition
radiotherapy is applied, the patients will have xero-
to improving the esthetic outcome.3 Apart from cor-
stomia and mucosal atrophy, which further compli-
rect dental rehabilitation, the achievement of ade-
cate the wearing of removable dentures, because they
quate chewing function requires good lingual mobil-
tend to cause local irritation, ulceration, and bone
ity, adequate facial competence, cheek suction effect,
exposure. Our experience with classical prostheses of
a competent soft palate, and correct coordination of
this kind has been very discouraging, and we do not
the dental surfaces of both jaws.9 In such patients
most of these structures and their function are af-
fected by surgery and radiotherapy; as a result, only
one third of patients subjected to implant-supported
dental rehabilitation are able to recover acceptable
chewing and swallowing function.5 Dental restora-
tion is not only beneficial for chewing and nutrition
but also favors speech and facial esthetics. Moreover,
it reduces salivation by allowing the lower teeth to
correctly direct the flow of saliva, and lower lip sup-
port increases salivary retention and avoids dribbling.
The orofacial anatomic alterations resulting from
tumor resection, regional surgery, and placement of a
pedicled or microsurgical flap include an increase in
thickness as a result of the skin of the flap used,

FIGURE 22. Intraoral view of fixed removable prosthesis and final

FIGURE 21. Intraoral view of bar fixed to implants. occlusion.
Cuesta-Gil et al. Osseointegrated Implants in Oncologic Patients. Cuesta-Gil et al. Osseointegrated Implants in Oncologic Patients.
J Oral Maxillofac Surg 2009. J Oral Maxillofac Surg 2009.
CUESTA-GIL ET AL 2493

86% in the immediate implantation group subjected

to complementary radiotherapy, and a success rate of
only 64% in the case of implants positioned after
irradiation. Gürlek et al16 in turn reported a success
rate of 91.5% in oncologic patients, with no signifi-
cant differences in failure rates in remnant bone or in
flap bone tissue.
There has been considerable controversy over the
indication of implant-supported rehabilitations in irra-
diated maxillas. In the last 2 decades, many studies
have attempted to establish the influence of radiother-
apy on bone and osseointegration, as well as the
convenience of prior hyperbaric oxygen therapy. In
this context, until only a few years ago, mandibular
irradiation was considered to be an absolute contra-
FIGURE 23. Esthetic result 10 years after surgery. indication to implant placement. The first studies re-
Cuesta-Gil et al. Osseointegrated Implants in Oncologic Patients. ferred to animal models and the placement of ex-
J Oral Maxillofac Surg 2009.
traoral implants in the craniofacial region for epithesis
or splint retention. Jacobsson et al,17 in 1988, re-
ported 5 failures in 35 implants (success rate, 86%),
advise their application in these patients. Osseointe- whereas Parel and Tjellström,18 in 1991, reported a
grated implants have contributed to solve such prob- 61% success rate for implants in irradiated bone.
lems, because they allow correct rehabilitation of the Schweiger,19 in 1989, showed the existence of true
bone-tooth unit via the application of stable implant- osseointegration in irradiated canine maxillary bone,
supported and implant-retained prostheses.2,10 although the results were less predictable and exten-
In our series the results of osseointegration and sive than in normal bone. On the other hand, Marx
implant viability after loading have generally been and Morales20 analyzed the osseointegration surface
good. Osseointegration failure (4.1% in our study) is (peri-implant trabecular bone) obtained after 4 months
intimately associated with 3 factors: maximum radia- in 3 types of bone (transplanted, normal mandible,
tion dose, immediate implantation, and implants in and irradiated bone). In transplanted bone they found
OMCT flaps. 72% of the implant-bone interface to be occupied by
Failure of already rehabilitated implants almost al- newly formed bony tissue, whereas in normal and
ways occurs in irradiated patients and is much more irradiated bone the figures were 50% and 40%, respec-
common in relation to OMCT flaps, because the distal tively, with the surface in these latter 2 cases being
segment of the scapula used for the reconstruction sufficient to support occlusal loading.
has a poorer blood supply. Our osseointegration fail- On the basis of the principles established by
ure rate (4.1%) and global failure rate (15%, compris- Marx,21 hyperbaric oxygen began to be used to in-
ing osseointegration, malpositioning, and failure after duce neoangiogenesis and increase fibroblast activity,
loading) are similar to the figures given in the litera- ensuring increased oxygen partial pressure in previ-
ture. Albrektssön et al11 reported success rates of ously hypoxemic and ischemic irradiated areas. The
94.7% and 83.1% in the lower maxilla and upper universally accepted protocol comprises 30 ses-
maxilla, respectively, among irradiated patients after sions—20 before implantation and 10 after sur-
3 years. In oncologic patients subjected to flap recon- gery— by use of hyperbaric oxygen (100%, at 2.4
struction, success rates of 85% to 99% have been atm), with a duration of 90 minutes per session.21
reported.12,13 Schliephake et al,14 on the basis of Larsen et al,22 in rabbit tibia and using hyperbaric
more rigorous criteria, reported a mean cumulative oxygen in various groups of animals, found an impor-
survival rate of 56.5% at long term (10 years), with tant reduction in implant osseointegration surface in
improved results in the case of deferred implants irradiated bone not subjected to hyperbaric oxygen
(67.1%) versus immediate implants (36.2%), and with treatment, though without establishing whether this
no influence from different factors such as prior ra- reduction is of significance in relation to implant
diotherapy, implant positioning in flap bone or rem- support. Tate et al,23 in a similar study, reported no
nant maxilla, or type of bone graft or bone free graft such differences, however. In 1993 Taylor and Worth-
used. ington24 presented a series comprising 21 implants in
Urken,15 in a series of 81 patients involving 360 previously irradiated mandibular bone. After a fol-
implants, reported a global success rate of 95% in low-up of between 3 and 7 years, no implants were
nonirradiated oncologic patients, a success rate of lost.
2494 OSSEOINTEGRATED IMPLANTS IN ONCOLOGIC PATIENTS

In 1998 Niimi et al25 described a series of 228 keratinized epithelium; this and the lack of adequate
implants placed in irradiated maxillas in the United oral hygiene in many patients, together with alcohol
States and Japan. Their results showed a 98% success and tobacco abuse, lead to repeated peri-implant in-
rate (ie, close to 100%) for irradiated mandibles sub- flammatory episodes, producing the loss of 8 implants
jected to hyperbaric oxygen therapy. In the case of in our series (globally, 1.1% of failures).
the upper jaw the corresponding success rate was Osseointegrated implants allow us to design highly
72%. Similar figures were published by Ali et al,26 with stable prostheses requiring no soft tissue support. In
a 60% success rate in the upper maxilla and a 100% most cases this circumstance avoids the need to re-
success rate in the lower jaw. duce the thickness of the soft tissues of the flaps and
The literature thus concludes that implants can be perform vestibuloplasties. By eliminating the friction
placed in irradiated jawbone by following a careful forces of the prostheses, we can avoid ulceration,
protocol, even in patients who have not received pain, and bone exposure. Nevertheless, vestibuloplas-
hyperbaric oxygen therapy.25 Nevertheless, hyper-
ties and lip- and tongue-releasing procedures proved
baric oxygen appears to be essential for ensuring
necessary in 12 patients. These techniques were car-
upper maxillary success rates approaching those ob-
ried out with the help of implant-supported acrylic
tained in the mandible (72% without oxygen and 80%
laminas and in some cases were associated with a
with hyperbaric oxygen therapy).25,27 In our service
hyperbaric oxygen therapy is not available, although dermal-epidermal free graft.
we believe that the evidence found in the literature The decision to construct a removable implant-
supports its usefulness. supported prosthesis or a fixed prosthesis should be
It has been well established that correct implant based on a series of considerations: the available oc-
positioning with regard to parallelism between the clusal space, the thickness of the gums or flap skin,
implants, as well as the occlusal relation established the presence or absence of an antagonistic arch, the
and lingual-vestibular or palatal-vestibular emergence, number and position of available implants, the pres-
contributes to improve occlusal force transmission, ence of lingual or labial hypoesthesia, the integrity
facilitating dental rehabilitation and increasing the and function of the temporomandibular joints, and
long-term success rate. the cooperation that may be expected from the pa-
In the early days of microsurgery implants used to tient for ensuring correct prosthesis hygiene.
be placed with the flap on the operating table, that is, In all patients we attempted to place a single type
before placement in the definitive position in the of prosthesis—in most cases implant-retained over-
cervicofacial region. As a result, implant positioning dentures. These prostheses facilitate occlusal fitting,
was not always correct. In our series, placement ex- require fewer implants, facilitate gingival hygiene,
cessively vestibular, lingual, or distal required the distribute the occlusal forces (thereby avoiding stress
removal of 16 implants. Another 15 implants could on the implants), and are less expensive. Fixed pros-
not be used because of malpositioning resulting from theses afford improved patient satisfaction, although
a lack of occlusal space, although their extraction did in general, we believe that this solution is less indi-
not prove necessary. cated in such patients because the treatment involved
At present, this complication is much less frequent is more complex and costly and requires a larger
because, as has been mentioned previously, the flap is number of implants (with perfect placement). More-
now first placed in its definitive position, followed by
over, occlusal fitting is more difficult, hygiene is
implant placement, thus allowing more exact verifi-
poorer, and the follow-up of implants and of possible
cation of the occlusal relations and the selection of
oncologic disease relapse is likewise poorer.
ideal implant positioning. Practically all implants
In all cases our oncologic patients were subjected
placed in this way proved useful for the fitting of
to a very rigorous follow-up protocol after surgery and
prostheses. The use of surgical splints in these pa-
tients is often not useful, because of the existing the end of radiotherapy. In addition to the periodic
anatomic distortion and thickness of the cutaneous evaluations of their background disease, the implant-
flaps. rehabilitated patients were examined regularly to es-
In these patients the peri-implant tissues are often tablish the implant and peri-implant tissue conditions.
composed of irradiated oral mucosa or the cutaneous Thanks to this exhaustive follow-up, in 3 patients it
portion of the regional or microsurgical flap. Different proved possible to detect new epidermoid carcino-
histologic and imaging studies of the cutaneous por- mas in the very early stages (second primary malig-
tion surrounding the implant occasionally show com- nancies). Because of the promptness of diagnosis,
plete mucosalization of the epidermis, thereby ensur- these patients were subjected to local resection with
ing good sealing of the zone. However, it is common wide safety margins and simple reconstructive proce-
to find gingival areas with a total lack of attached dures.
CUESTA-GIL ET AL 2495

In our department the following protocol is used to 2. Prosthetic dental rehabilitation in such patients
ensure the maximum possibilities of success with poses numerous technical difficulties because of
implants in oncologic patients: the anatomic and functional alterations pro-
duced after surgery.
1. A waiting period of at least 12 months is ob- 3. Percentage osseointegration in these patients is
served after the end of radiotherapy before almost analogous to that recorded in the nonsur-
implant placement because the healing and gical population.
regeneration capacity of irradiated bone is 4. Mandibular reconstruction without dental reha-
known to be 5-fold greater 12 months after the bilitation only contributes to improve facial es-
conclusion of radiotherapy. thetics.
2. Continued tobacco smoking by the patient im- 5. Implants exposed to maximum radiation doses
plies a very high risk of implant failure and present the highest complication rates.
tumor relapse. Although our patients agree in 6. Implants in OMCT flaps present significantly
writing to stop smoking, in practice few actu- greater failure rates than when iliac crest and
ally do so. fibular flaps are used.
3. At the time of implant placement, and with the
patient under general anesthesia (if local anes-
thesia is used, vasoconstrictors on the mucosa References
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