Three-Dimensional Guided Zygomatic Implant Placement after Maxillectomy.

Zygomatic implants are used in patients with maxillary defects to improve the retention and stability of obturator prostheses, thereby securing good oral function. Prosthetic-driven placement of zygomatic implants is even difficult for experienced surgeons, and with a free-hand approach, deviation from the preplanned implant positions is inevitable, thereby impeding immediate implant-retained obturation. A novel, digitalized workflow of surgical planning was used in 10 patients. Maxillectomy was performed with 3D-printed cutting, and drill guides were used for subsequent placement of zygomatic implants with immediate placement of implant-retained obturator prosthesis. The outcome parameters were the accuracy of implant positioning and the prosthetic fit of the obturator prosthesis in this one-stage procedure. Zygomatic implants (n = 28) were placed with good accuracy (mean deviation 1.73 ± 0.57 mm and 2.97 ± 1.38° 3D angle deviation), and in all cases, the obturator prosthesis fitted as pre-operatively planned. The 3D accuracy of the abutment positions was 1.58 ± 1.66 mm. The accuracy of the abutment position in the occlusal plane was 2.21 ± 1.33 mm, with a height accuracy of 1.32 ± 1.57 mm. This feasibility study shows that the application of these novel designed 3D-printed surgical guides results in predictable zygomatic implant placement and provides the possibility of immediate prosthetic rehabilitation in head and neck oncology patients after maxillectomy.

Prosthodontic rehabilitation of head and neck cancer patients-Challenges and new developments.

Head and neck cancer treatment can severely alter oral function and aesthetics, and reduce quality of life. The role of maxillofacial prosthodontists in multidisciplinary treatment of head and neck cancer patients is essential when it comes to oral rehabilitation and its planning. This role should preferably start on the day of first intake. Maxillofacial prosthodontists should be involved in the care pathway to shape and outline the prosthetic and dental rehabilitation in line with the reconstructive surgical options. With the progress of three-dimensional technology, the pretreatment insight in overall prognosis and possibilities of surgical and/or prosthetic rehabilitation has tremendously increased. This increased insight has helped to improve quality of cancer care. This expert review addresses the involvement of maxillofacial prosthodontists in treatment planning, highlighting prosthodontic rehabilitation of head and neck cancer patients from start to finish.

The use of stretching devices for treatment of trismus in head and neck cancer patients: a randomized controlled trial.

PURPOSE: To compare the effects of two stretching devices, the TheraBite® Jaw Motion Rehabilitation System™ and the Dynasplint Trismus System®, on maximal mouth opening in head and neck cancer patients. METHODS: Patients were randomly assigned to one of two exercise groups: the TheraBite® Jaw Motion Rehabilitation System™ group or the Dynasplint Trismus System® group. Patients performed stretching exercises for 3 months. During the three study visits, maximal mouth opening was measured and the patients completed questionnaires on mandibular function and quality of life. RESULTS: In our study population (n = 27), five patients did not start the exercise protocol, eight patients discontinued exercises, and two patients were lost to follow-up. No significant differences regarding the change in mouth opening between the two devices were found. Patients had an increase in MMO of 3.0 mm (IQR - 2.0; 4.0) using the TheraBite® Jaw Motion Rehabilitation System™ and 1.5 mm (IQR 1.0; 3.0) using the Dynasplint Trismus System®. Exercising with either stretching device was challenging for the patients due to the intensive exercise protocol, pain during the exercises, fitting problems with the stretching device, and overall deterioration of their medical condition. CONCLUSIONS: The effects of the two stretching devices did not differ significantly in our study population. The factors described, influencing the progression of stretching exercises, need to be taken into account when prescribing a similar stretching regimen for trismus in head and neck cancer patients. TRIAL REGISTRATION: NTR - Dutch Trial Register number: 5589.

Multidisciplinary first-day consultation accelerates diagnostic procedures and throughput times of patients in a head-and-neck cancer care pathway, a mixed method study.

BACKGROUND: Head and neck cancers are fast growing tumours that are complex to diagnose and treat. Multidisciplinary input into organization and logistics is critical to start treatment without delay. A multidisciplinary first-day consultation (MFDC) was introduced to reduce throughput times for patients suffering from head and neck cancer in the care pathway. In this mixed method study we evaluated the effects of introducing the MFDC on throughput times, number of patient hospital visits and compliance to the Dutch standard to start treatment within 30 calendar-days. METHODS: Data regarding 'days needed for referral', 'days needed for diagnostic procedures', 'days to start first treatment', and 'number of hospital visits' (process indicators) were retrieved from the medical records and analysed before and after implementation of the MFDC (before implementation: 2007 (n = 21), and after 2008 (n = 20), 2010 (n = 24) and 2013 (n = 24)). We used semi-structured interviews with medical specialists to explore a sample of outliers. RESULTS: Comparing 2007 and 2008 data (before and after MFDC implementation), days needed for diagnostic procedures and to start first treatment reduced with 8 days, the number of hospital visits reduced with 1.5 visit on average. The percentage of new patients treated within the Dutch standard of 30 calendar-days after intake increased from 52 to 83%. The reduction in days needed for diagnostic procedures was sustainable. Days needed to start treatment increased in 2013. Semi-structured interviews revealed that this delay could be attributed to new treatment modalities, patients needed more time to carefully consider their treatment options or professionals needed extra preparation time for organisation of more complex treatment due to early communication on diagnostic procedures to be performed. CONCLUSIONS: A MFDC is efficient and benefits patients. We showed that the MFDC implementation in the care pathway had a positive effect on efficiency in the care pathway. As a consequence, the extra efforts of four specialist disciplines, a nurse practitioner, and a coordinating nurse seeing the patient together during intake, were justified. Start treatment times increased as a result of new treatment modalities that needed more time for preparation.

Patients with advanced periodontal disease before intensity-modulated radiation therapy are prone to develop bone healing problems: a 2-year prospective follow-up study.

PURPOSE: Intensity-modulated radiation therapy (IMRT) has changed radiation treatment of head and neck cancer (HNC). However, it is still unclear if and how IMRT changes oral morbidity outcomes. In this prospective study, we assessed the outcome of reducing post-IMRT sequelae by means of pre-radiation dental screening and eliminating oral foci. METHODS: All consecutive dentate patients > 18 years, diagnosed with primary oral or oropharyngeal carcinoma, referred for pre-treatment dental screening between May 2011 and May 2013, were included and followed for 2 years. Patients were treated with IMRT or IMRT with chemotherapy (CHIMRT). Dental screening data, demographic data, and data on oral sequelae during follow-up were recorded. Diagnosed oral foci were treated before start of the radiation therapy. RESULTS: Oral foci were found in 44/56 (79%) patients, consisting predominantly of periodontal breakdown. Bone healing problems after radiotherapy occurred more often in patients with periodontal pockets ≥ 6 mm at baseline (19 vs. 4% in patients with pockets < 6 mm). Osteoradionecrosis developed in 4/56 patients (7%) during follow-up. In line with this observation, multiple logistic regression analysis showed that the periodontal inflamed surface area, which is higher in patients with more severe periodontal disease, predicted that a patient has a higher risk on developing osteoradionecrosis or bone healing problems (p = 0.028). CONCLUSIONS: Patients with severe periodontal disease before IMRT/CHIMRT are more prone to develop bone healing problems post-radiotherapy.

Paradigm shift in head and neck oncology patient management.

OBJECTIVE: This article describes a paradigm shift in what is considered to be good care for patients living with and after (head and neck) cancer. HNO patients often experience severe and difficult physical and psychosocial problems due to the nature and location of the disease. Many disciplines are involved in their treatment, so their voice is only one amongst many others in the decision making process. For this patient group it seems complicated to put the concept of Shared Decision Making into practice. As a step in this direction, patient reported outcomes which ask patients to select the disconcerting issues and symptoms can be used as a basis for referral, supportive care and treatment decision making. We need to provide more tailored and personalized information that is specific to individual circumstances, preferences and concerns and focuses more on the impact of treatment and access to help and support. Follow up of these patients should be concentrated on both medical and emotional aspects. PRACTICE IMPLICATIONS: A shift in the way caregivers provide their information contributes to a more profound involvement of patients in treatment decisions.

Maxillofacial prosthodontics practice profile: a survey of non-United States prosthodontists.

BACKGROUND: This study surveyed non-United States maxillofacial prosthodontists (MFP) to determine their practice profile and rationale for pursuing an MFP career. METHODS: Email addresses for the MFP were obtained from the International Society for Maxillofacial Rehabilitation, American Academy of Maxillofacial Prosthetics, and International Academy for Oral Facial Rehabilitation. Emails with a link to the electronic survey program were sent to each participant. Chi-square and Mann-Whitney-U tests were used to investigate the influence of formal MFP training on professional activities and type of treatments provided. RESULTS: One hundred twelve respondents (response rate 39%) from 33 nationalities returned the survey. The top three reasons for pursuing an MFP career were personal satisfaction, prosthodontics residency exposure, and mentorship. The predominant employment setting was affiliation with a university (77%). There were significant differences between respondents with and without formal MFP training regarding provision of surgical treatments (P = 0.021) and dental oncology (P = 0.017). Most treatments were done together with otolaryngology, oral surgery (68%) and head and neck surgery (61%). Practitioners not affiliated with a university spent significantly more time in clinical practice (P = 0.002), whereas respondents affiliated with universities spent significantly more time in teaching/training (P = 0.008) and funded research (P = 0.015). CONCLUSIONS: Personal satisfaction is the most important factor in a decision to choose an MFP career. Most of the MFPs work at a university and within a multidisciplinary setting. There were differences regarding type of treatments provided by respondents with and without formal MFP training.

Predictors for trismus in patients receiving radiotherapy.

BACKGROUND: Trismus, a restricted mouth opening in head and neck cancer patients may be caused by tumor infiltration in masticatory muscles, radiation-induced fibrosis or scarring after surgery. It may impede oral functioning severely. The aims of our study were to determine: (1) the incidence of trismus at various time points; and (2) the patient, tumor, and treatment characteristics that predict the development of trismus after radiotherapy in head and neck cancer patients using a large database (n = 641). METHODS: Maximal mouth opening was measured prior to and 6, 12, 18, 24, 36, and 48 months after radiotherapy. Patient, tumor, and treatment characteristics were analyzed as potential predictors for trismus using a multivariable logistic regression analysis. RESULTS: At six months after radiotherapy, 28.1% of the patients without trismus prior to radiotherapy developed trismus for the first time. At subsequent time points the incidence declined. Over a total period of 48 months after radiotherapy, the incidence of trismus was 3.6 per 10 person years at risk. Patients who had tumors located in the oral cavity, oropharynx or nasopharynx, and the salivary glands or ear, and who had a longer overall treatment time of radiotherapy, were more likely to develop trismus in the first six months after radiotherapy. Maximal mouth opening was a predictor for developing trismus at all time points. CONCLUSION: Incidence of trismus is 3.6 per 10 person years at risk. Tumor localization and overall treatment time of radiotherapy are predictors for developing trismus the first six months after radiotherapy. Maximal mouth opening is a significant predictor for developing trismus at all time points. Regular measurements of maximal mouth opening are needed to predict trismus.

Dynasplint Trismus System exercises for trismus secondary to head and neck cancer: a prospective explorative study.

PURPOSE: The Dynasplint Trismus System (DTS) can be used to treat trismus secondary to head and neck cancer. We conducted a prospective study with the following aims: (1) to determine the effects of DTS exercises on changes in mouth opening, pain, mandibular function, quality of life (QoL), and symptomatology and (2) to analyze the patients' perception on DTS exercises, including user satisfaction, experiences, comfort, and compliance. METHODS: The patients were instructed to exercise with the DTS for at least 16 weeks. Changes in mouth opening, pain, mandibular function, QoL, and symptomatology were evaluated, as well as the patients' perception of DTS exercises. RESULTS: Eighteen consecutive patients were included. Baseline mouth opening was 22.6 mm (sd 7.6). After the patients completed the DTS exercise program, mouth opening increased (7.1 mm, sd 4.7) and perceived difficulty of opening the mouth improved significantly (p < 0.05). No significant effects were found in mandibular function, QoL, and overall symptomatology. The patients' perception was diverse. They reported effectiveness and positive feelings of the results and would recommend DTS exercises to other patients. About half of them thought DTS exercises were burdensome. CONCLUSIONS: Mouth opening increased significantly after the DTS exercise program, relative to baseline. About one third of the gained increase was lost in the follow-up period. In general, the patients were satisfied about the effects and the DTS exercise program.

Accuracy of secondary maxillofacial reconstruction with prefabricated fibula grafts using 3D planning and guided reconstruction.

BACKGROUND: We compared the pre-operative 3D-surgical plan with the surgical outcome of complex two-stage secondary reconstruction of maxillofacial defects using inserted implants in the prefabricated fibula graft. METHODS: Eleven reconstructions of maxillofacial defects with prefabricated fibulas were performed using a 3D virtual planning. Accuracy of placement of the fibula grafts and dental implants was compared to pre-operative 3D virtual plans by superimposing pre-operative and post-operative CT-scans: we first superimposed the CT-scans on the antagonist jaw, to represent the outcome of occlusion, and then superimposed on the planned fibula segments. RESULTS: Superimposing the CT scans on the antagonist jaws revealed a median deviation of the fibula segments and implants of 4.7 mm (IQR:3-6.5 mm) and 5.5 mm (IQR:2.8-7 mm) from the planned position, respectively. Superimposing of the CT scans on the fibula segments revealed a median difference of fibula and implant placement of 0.3 mm (IQR:0-1.6 mm) and 2.2 mm (IQR:1.5-2.9 mm), respectively. CONCLUSIONS: The final position of the fibula graft is determined by the occlusion of the denture, which is designed from the 3D plan. From a prosthodontic perspective, the accuracy of 3D-surgical planning of reconstruction of maxillofacial defects with a fibula graft and the implants allows for a favorable functional position of the implants and fibula graft.

Accuracy of fibula reconstruction using patient-specific CAD/CAM reconstruction plates and dental implants: A new modality for functional reconstruction of mandibular defects.

BACKGROUND: The purpose of this study was to analyze the accuracy of mandibular reconstruction using patient-specific computer-aided designed and computer-aided manufactured (CAD/CAM) reconstruction plates as a guide to place fibula grafts and dental implants in a one-stage procedure using pre-operative 3D virtual planning. METHODS: Seven consecutive patients were analyzed retrospectively, the 3D accuracy of placement of the fibula grafts and dental implants was compared to the virtual plan. RESULTS: Six out of seven flaps survived for an average follow-up time of 9.4 months. The outcome was compared to the virtual plan, superimposed on the mandible. For the fibula segments, the mean deviation (SD) was 3.0 (1.8) mm and the mean angulation (SD) was 4.2° (3.2°). For the implants, the mean deviation (SD) was 3.3 (1.3) mm and the mean angulation (SD) was 13.0° (6.7°). The mean (SD) mandibular resection plane deviation was 1.8 (0.9) mm. CONCLUSIONS: A patient-specific reconstruction plate is a valuable tool in the reconstruction of mandibular defects with fibula grafts and dental implants. Implant angulation showed a greater deviation from the virtual plans in patients with a sharp ventral fibula rim, where the guide is removed after pilot drilling of the implants.

Overdentures on primary mandibular implants in patients with oral cancer: a follow-up study over 14 years.

We aimed to assess oral functioning, patients' satisfaction, condition of peri-implant tissues, and survival of implants up to 14 years after their insertion in patients with oral cancer who had had mandibular overdentures placed over primary implants. Endosseous dental implants were inserted prospectively in the interforaminal region of the mandible during resection of the tumour in 164/180 patients with oral cancer. All 58 patients were evaluated by questionnaires and clinical assessments during a final assessment in 2012. Implant-retained mandibular overdentures were inserted, and prosthetic rehabilitation and oral functioning were not associated with primary site or stage of the tumour, number or type of implants inserted, or the type of reconstruction. Over time the peri-implant mucosa was usually free of inflammation. More implants were lost in patients treated by radiotherapy (27/318, 8.5%) than in those not so treated (1/206, 0.5%). Patients who had been treated by irradiation reported more problems in oral functioning and less satisfaction than those who had not. Patients with an implant-retained mandibular overdenture reported fewer problems in oral functioning than patients without an overdenture. Primary insertion of an implant should be routinely incorporated in the surgical planning for patients with oral cancer, as oral functioning in those wearing mandibular overdentures improved considerably and peri-implant health was at least reasonable.

Functional outcomes for clinical evaluation of implant restorations.

The functional outcomes related to treating patients afflicted with tooth loss are an important hallmark in substantiating prosthodontic intervention. The Oral Rehabilitation Outcomes Network (ORONet) conducted two international workshops to develop a core set of outcome measures, including a functional domain. The process followed the general format used in the Outcome Measures in Rheumatology (OMERACT) workshops to develop consensus for clinical outcome measures in arthritis research, which included: developing a comprehensive list of potential outcomes in the literature; submitting them to a filter for validity, clinical discrimination, and feasibility; and ranking those measures meeting all the filter criteria for relative value. The search was conducted to include functional assessments of speech, swallowing, mastication, nutrition, sensation, and motor function as they relate to dental implant therapies. This literature review surveyed 173 papers that produced some result of these descriptors in the functional domain. Of these, 67 papers reported on functional assessments and further defined objective and subjective outcomes. Many of these results were patient-perceived improvements in function, while others were objective assessments based on established methodologies and instruments. Objective evaluations of masticatory function and speech may meet criteria for validity and discriminability for selected interventions, but are generally not feasible for routine use in clinical care settings. The current recommendation is to employ a well-validated survey instrument that covers mastication and speech, such as the Oral Health Impact Profile (OHIP-14, short form), recognizing that patient perceptions of function may differ from objective ability.

Psychologic outcomes in implant prosthodontics.

Consensus regarding outcomes of the treatment of tooth loss, especially the psychologic outcomes, is needed to guide discovery of best practices and enable a better understanding of patient management for this chronic condition. This paper presents the findings of the ORONet Psychological Working Group for prosthodontics and aims to identify psychologic outcomes with properties deemed critical to meet clinical trial and clinical practice needs for the future. References obtained using a PubMed/Medline search were reviewed for clinical outcomes measures of interest. Clinical outcomes measures were judged relative to the criteria of truth, discrimination, and feasibility. Of the psychologic outcome measures identified in this systematic review, only the OHIP-14 was thought to be suitable for use in general practice and multi-institutional outcome registries and clinical trials. Development of clinically useful psychologic outcomes for future use could benefit from developmental methods and tools outlined in the patient-related outcomes field of clinical care.

Economic outcomes in prosthodontics.

PURPOSE: A systematic literature review was conducted to identify the types of economic measures currently used in implant prosthodontics and determine the degree to which cost of care is considered in the context of any positive outcome of the care provided. MATERIALS AND METHODS: A literature search was conducted using the following set of terms plus some additional hand searching: "dental implants" (Mesh) AND ("cost") OR "maintenance" OR "healthcare policy" OR "access to care" OR "third party" OR "economic") AND (("1995/01/01"[PDat]:'2009/12/31"[PDat]) AND (Humans[Mesh]) AND (English[lang])). RESULTS: After a review of the 466 titles and abstracts identified by the search, 18 articles were accepted for further consideration, as some attempt at economic outcome measures was made. An additional four articles were identified by hand searching. The 22 accepted articles were grouped into four basic categories: (1) measure of costs of treatment (direct, indirect, and maintenance costs), (2) cost-effectiveness mathematical modeling applied to simulate the lifetime paths and cost of treatment, (3) cost-effectiveness analysis/cost minimization, and (4) willingness-to-pay, willingness-to-accept. Attempts at determining the costs of treatment varied widely. When the OMERACT filters were applied to the various measures it was felt that discrimination and/or feasibility was a problem for most of the current economic outcome measures. CONCLUSIONS: Measures of cost-benefit, cost-effectiveness, and cost-utility are currently the gold standard; however, feasibility of such analyses is an issue. Collaboration with health economists to guide future research is highly recommended.

Oral Rehabilitation Outcomes Network-ORONet.

The published literature describing clinical evidence used in treatment decisionmaking for the management of tooth loss continues to be characterized by a lack of consistent outcome measures reflecting not only clinical performance but also a range of patient concerns. Recognizing this problem, an international group of clinicians, educators, and scientists with a focus on prosthodontics formed the Oral Rehabilitation Outcomes Network (ORONet) to promote strategies for improving health based on comprehensive, patient-centered evaluations of comparative effectiveness of therapies for oral rehabilitation. An initial goal of ORONet is to identify outcome measures for prosthodontic therapies that represent multiple domains with patient relevance, are amenable to utilization in both institutional and practice-based environments, and have established validity. Following a model used in rheumatology, the group assessed the prosthodontic literature, with an emphasis on implantbased therapies, for outcomes related to longevity and functional, psychologic, and economic domains. These systematic reviews highlight a need for further development of standardized outcomes that can be integrated across clinical and research environments.

Clinical outcomes measures for assessment of longevity in the dental implant literature: ORONet approach.

The Oral Rehabilitation Outcomes Network (ORONet) Longevity Working Group undertook a search of the literature from 1995 to 2009 on randomized controlled trials related to longevity of osseointegrated implants. Outcomes measures used in these studies were identified and subjected to the OMERACT component criteria of truth, validity, and feasibility. Through this process, it was a challenge to identify clinical outcomes measures that fully met the criteria. An attenuated version of the component criteria was applied, and clinical measures were identified for implant outcomes, prosthetic outcomes, and indices. A recommendation on standardized reporting periods was also presented for future consideration. The endpoint of the evaluation process is to develop consensus on clinical outcomes measures that can be applied across broad populations for osseointegrated implant care. The present ORONet initiative represents a beginning toward continual improvement and consensus development for clinical outcomes measures for osseointegrated implants.

TheraBite exercises to treat trismus secondary to head and neck cancer.

PURPOSE: The aim of this study was to evaluate the effect of TheraBite exercises on mouth opening and to analyze factors influencing this effect in a patient record evaluation. METHODS: Effect of exercises with a TheraBite to treat trismus was evaluated in 69 head and neck cancer patients of two university medical centers. Mouth opening was measured as interincisal distance in millimeters. Patient, tumor, and treatment characteristics were analyzed for their relationship with change in mouth opening. Variables univariately associated (p ≤ 0.05) with change in mouth opening were entered in a logistic regression analysis as possible predictors for an increase in mouth opening of the smallest detectable difference of 5 mm or more. RESULTS: Mean initial mouth opening was 22.0 mm (SD 6.4); mean increase in mouth opening was 5.4 mm (SD 5.7). "Chemotherapy", "medical center", and "time from oncological treatment to start exercises" were significantly associated with an increase in mouth opening. In the logistic regression analysis, "medical center" (ß = 1.97) and "time from oncological treatment to start exercises" reduced the odds of reaching an increase in mouth opening of 5 mm or more, ß = -0.11 per month. CONCLUSIONS: After TheraBite exercises, mouth opening increased averagely with 5.4 mm. The odds of an increase in mouth opening of 5 mm or more reduces if the time from oncological treatment to start exercises lengthens, corrected for the effect of medical center.

Fully 3-dimensional digitally planned reconstruction of a mandible with a free vascularized fibula and immediate placement of an implant-supported prosthetic construction.

BACKGROUND: Reconstruction of craniofacial defects becomes complex when dental implants are included for functional rehabilitation. We describe a fully 3-dimensional (3D) digitally planned reconstruction of a mandible and immediate prosthetic loading with a fibula graft in a 2-step surgical approach. METHODS: A 54-year-old man had development of osteoradionecrosis of the mandible. The resection, cutting and implant placement in the fibula were virtually planned. Cutting/drilling guides were 3D printed, and the suprastructure was computer-aided design and computer-aided manufacturing milled. RESULTS: For the first operation, the implants were inserted in the fibula, and the position was registered by an optical scanning technique that defined the final planning of the suprastructure. For the second operation, the osteoradionecrosis was resected, the fibula was harvested and, with the denture fixed on the preinserted implants, placed in the mandibula guided by the occlusion. CONCLUSION: It was possible to plan a mandibular reconstruction with immediate prosthetic loading completely by 3D virtual techniques.