Placement of dental implants in post irradiated vascularized bone graft?
I have a patient who received radiation treatment for squamous cell carcinoma of the mandible following a hemimandibulectomy. After 5 years post-treatment, the patient then received a vascularized bone graft to the area where the implants were planned for installation. Six implants were then installed in the grafted area. Shortly after implant installation, dehiscences in the soft tissues around the implants have appeared. Could this be due to peri-implantitis, osteomyelitis or osteoradionecrosis or local infection in soft tissues? What do you recommend I do?
9 Comments on Placement of dental implants in post irradiated vascularized bone graft?
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CRS
11/8/2013
Hyperbaric oxygen for the compromised blood supply which probably should have been done preop. Hopefully you won't lose the graft to ORN or infection. I would advise the grafting surgeon in case there is trouble these type of cases should be managed with adequate consultation prior to placing implants. Hopefully your surgery did not compromise the patients mandible. Good luck.
CRS
11/10/2013
I'm a little confused did you say that they waited 5 years to reconstruct? Was HBO used prior to reconstruction? Were you part of the reconstruction team? This sounds odd to me. Could you provide more detail?
Richard Hughes, DDS, FAAI
11/11/2013
The poster stated that the implants were planned to be placed after the vascular iced bone graft was placed. This all is 5 years post radiation treatment.
It's best to place prior to or way after radiation and chemo. Always confer with the radiation oncologist and oncologist. HBO can be contraindicated due to some of the chemo agents used to treat the patient.
As for dehiscence, it could be all of the above. Even the tongue pull could be a factor.
I have heard the hyCURE is good for this. I usually refresh the incision and flap and suture to an ADM which is tacked down. Close tension free! Use peridex TID
CRS
11/12/2013
Okay I don't think you understand you understand, to clarify,something needs to hold the space after hemi- mandibularectomy. If a free fibula graft was to be placed, immediate or delayed reconstruction can be utilized. And by the way HBO treatment post radiation is still indicated to restore vascularity vs reopening the flap and causing more compromise. Peridex is probably not the agent to correct the low vascularity. My point is that I hope this poster was in contact with the surgical team and has not compromised the reconstruction. This is a very complex case and requires a higher level of expertise. Not recognizing the reason for the flap dehiscence is a concern for me.
OMS resident
11/15/2013
Your comment sounds strange to me. Like CRS is saying, HBO post radiation is still indicated (Marx protocol: 20+10 "dives"), and would probably be beneficiary post tx in this case if not earlier used post radiation. Very few absolute contraindications for HBO. It would be interesting to know the total radiation dosage (Gy's).
And no, mandibular implant placement in general should not take place WAY after radiation! The three H's (hypovascular, hypocellular and hypoxic) in radiated tissue gradually aggravate with time. Even though a vascularized bone graft should be "healthy", the recipient tissue bed is still compromised. You have a approx. 4 month so called "golden window of opportunity" post radiation.
As for the hyCURE, I would not advocate this or any other "dead" tissue to be used in a case like this.
And yes, this patient should (IMHO) be handled in a H&N department by maxillofacial surgeons and formerly trained prosthodontists.
Richard HUghes, DDS, FAAI
11/15/2013
I strongly agree that these patients need to be treated by properly trained teams.
My point was about HBO, chemo and radiation. Certain chemo agents make HBO a contraindication. I would refer a CA pt to a competent OMS at an academic center for treatment. Georg Watzeg covers this in his text on Compromised Bone
Thanks for the correction on hyCURE
michaelwjohnson dds, ms
11/12/2013
In a vascularized free graft the soft and hard tissues are grafted with their own blood supply. Radiation damages vasculature in the field of radiation but, since this is transplanted tissue, the vascularity should be "normal". Many times the graft is a free fibular or scapular graft and the soft tissue is epidermis rather than mucosa. Implants that pass through epidermis often cause a granulomatous reaction in the epidermis at the transepidermal site(s). The dehiscence probably was not caused by any of your concerns. It would be wise to get primary closure back over the implants. Is there a temporary prosthesis that may be pressing on the wound? Are you an oral surgeon? If not, I would strongly suggest you refer the patient to a specialist since this type of implant surgery, with the added challenges of placing implants through epidermis and into a fibula or scapula is well out of the realm of a general practitioner.
CRS
11/13/2013
Dear Dr Johnson, thanks for your comments because of them I looked up the procedure since I don't do these procedures but rely on my colleagues. I did not realize that the overlying skin is also used. Very helpful advice and I learned something also.
Tuss
11/13/2013
I think a maxillofacial surgeon should have been consulted and probably would have also asked them to place the implant. Cancer patients have been through emough trauma to then possibly face osteoradionecrosis. You should refer now and get the patient in the right hands
