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Original Investigation
Sept/Oct 2018

Primary vs Secondary Endosseous Implantation After Fibular Free Tissue Reconstruction of the Mandible for Osteoradionecrosis

Author Affiliations
  • 1Department of Otorhinolaryngology, Mayo Clinic, Rochester, Minnesota
  • 2Department of Otolaryngology–Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri
JAMA Facial Plast Surg. 2018;20(5):401-408. doi:10.1001/jamafacial.2018.0263
Key Points

Question  Is it effective and cost efficient to perform primary dental implantation during fibula free tissue transfer for treatment of osteoradionecrosis and osteonecrosis?

Findings  In this cohort study of 23 patients, which includes those who underwent fibula free tissue transfer for osteoradionecrosis or osteonecrosis and dental implantation, primary implantation did not affect flap complication, flap viability, or implantation viability. Dental implantation performed primarily can be used sooner and is associated with decreased nonvariable costs than when it is performed secondarily.

Meaning  It is both effective and cost efficient to perform primary implantation; earlier implant use and decreased cost should prompt surgeons to consider this treatment option.

Abstract

Importance  The clinical and financial implications of the timing of dental rehabilitation after a fibula free tissue transfer (FFTT) for osteoradionecrosis (ORN) and osteonecrosis (ON) of the mandible have yet to be established.

Objective  To compare the outcomes of primary implantation vs secondary implantation after FFTT for ORN and ON of the mandible.

Design, Setting, and Participants  A retrospective review was conducted of 23 patients at a single tertiary academic referral center undergoing primary implantation or secondary implantation after FFTT for ORN and ON from January 1, 2006, to November 10, 2015.

Interventions  All patients underwent FFTT with primary implantation (n = 12) or secondary implantation (n = 11).

Main Outcomes and Measures  Outcomes of FFTT, dental implantation, implant use, diet, speech, and disease-free survival were reviewed. Fixed unit costs were estimated based on the mean cost analysis.

Results  Twenty-three patients (7 women and 16 men; mean [SD] age, 62.4 [8.2] years [range, 24-81 years]) met the inclusion criteria. Of these, 18 had ORN and 5 had ON. Dental implantation was performed at the time of FFTT for 12 patients and was performed secondarily for 11 patients. There were a mean of 5.2 implants per patient performed, for a total of 121 implants. There was 1 complete flap failure in the primary implantation group. Neither flap nor implant complications were affected by the timing of the implantation. Overall, the implant survival rate was 95% (55 of 58) in the primary implantation group and 98% (62 of 63) in the secondary implantation group. Time from FFTT to abutment placement (primary implantation, 19.6 weeks; secondary implantation, 61.0 weeks) was significantly shorter after primary implantation (P < .001). There was no clinical difference in postoperative complications and implant outcomes for ORN vs ON. Improvement in speech and oral competence in the primary implantation group vs the secondary implantation group was not statistically significant, given an experiment-adjusted P = .001 set as significant (normal speech, 9 vs 3; P = .02; and normal oral competence, 9 vs 3; P = .02). Disease-free survival was 91% (20 of 22 patients) overall. Fixed unit (U) costs were 1.0 U for primary implantation and 1.24 U for secondary implantation.

Conclusions and Relevance  Patients undergoing primary implantation after FFTT for ORN and ON had a similar rate of complications compared with those undergoing secondary implantation. However, primary implantation allowed a faster return than secondary implantation to oral nutrition and prosthesis use. The fixed unit cost was reduced for those undergoing primary implantation. Although dental implantation was safe and effective in both groups, the decreased time to use and the decreased overall cost should prompt surgeons to consider primary implantation after FFTT for ORN and ON.

Level of Evidence  3.

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