# National survey on implantation practices for free bone flaps: Key findings and insights

Sophie Dugast, Leonor Guilmault, Isabelle Bouhier, Olivier Airaudo, Julie

Longis, Helios Bertin

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Sophie Dugast, Leonor Guilmault, Isabelle Bouhier, Olivier Airaudo, Julie Longis, et al.. National survey on implantation practices for free bone flaps: Key findings and insights. Journal of Stomatology, Oral and Maxillofacial Surgery, 2025, 126 (6), pp.102271. 10.1016/j.jormas.2025.102271. hal-05230202

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Original Article

# National survey on implantation practices for free bone flaps: Key findings and insights

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CrossMark

Sophie Dugast<sup>a</sup>, Leonor Guilmault<sup>b</sup>, Isabelle Bouhier<sup>b</sup>, Olivier Airaudo<sup>c</sup>, Julie Longis<sup>a</sup>, Helios Bertin<sup>a,d,1,*</sup>

## ARTICLE INFO

**Article History:**
Received 10 January 2025
Accepted 3 February 2025
Available online 4 February 2025

**Keywords:**
Oral cancer
Dental implants
Reconstruction
National survey

## ABSTRACT

**Background:** In cervico-facial oncology, reconstructive procedures aim to ensure patient survival, restore orofacial functions, and maintain esthetic outcomes. The ultimate goal of these interventions is to provide functional rehabilitation. However, dental rehabilitation following bone-free flap reconstructions remains underutilized. This study evaluates current practices in France and identify the challenges reconstructive surgeons face in implementing dental implant rehabilitation after free bone flap reconstruction in an oncological setting.

**Methods:** A nationwide survey was conducted across 52 French hospitals to assess practices related to free bone flap reconstructions and dental implant rehabilitation. An online questionnaire collected data on the epidemiology, rehabilitation practices, team organization, and willingness towards increasing the number of rehabilitated patients following oncological surgeries.

**Results:** Nineteen centers responded, highlighting diverse practices. While most centers perform over 20 free bone flap reconstructions annually, the number of patients receiving implants post-reconstruction was relatively low, with most centers reporting between one and five implant procedures in the past year. Key obstacles to implant rehabilitation included patient irradiation (61 %), lack of financial support (61 %), absence of a practitioner network (50 %), insufficiently trained team members (33 %), risk of oncological recurrence (28 %), extended operating times for primary implantations (22 %), and difficulties with radiological follow-up due to artifacts (17 %)

**Conclusion:** Despite its potential to enhance patient quality of life, dental implant rehabilitation in oncological patients remains marginal in France. This study highlights the need for standardized protocols and improved collaboration between reconstructive surgeons and dental specialists to increase the rate of rehabilitation following free bone flap reconstructions.

© 2025 The Authors. Published by Elsevier Masson SAS. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/)

## 1. Introduction

Reconstruction in cervico-facial oncology has become an integral part is now a cornerstone of comprehensive patient care, addressing both functional and aesthetic needs. Its objectives are multifaceted: ensuring patient survival through rapid healing post-tumor excision,

thereby facilitating timely adjuvant treatments; restoring essential orofacial functions such as mastication, swallowing, and phonation; and preserving the patient's dignity by achieving a socially acceptable aesthetic outcome. The advent of free bone flaps has significantly enhanced the ability to restore tissue projection in the maxilla and mandible, contributing to improved facial symmetry. Recent advancements, particularly the use of cutting guides, have refined the positioning and spatial conformation of these flaps, further optimizing surgical outcomes [1]. The ultimate aim of reconstruction is to provide patients with stable, functional prosthetic rehabilitation. Notably, studies have shown that oncology patients with fixed prostheses experience a marked improvement in quality of life [2,3]. Despite the benefits of free bone flaps and advancements in adjuvant treatments, patient rehabilitation in the oncological context often remains compromised. As a result, the proportion of patients receiving dental

## 1. Introduction

<footnote><sup>a</sup> University of Nantes, CHU Nantes, Department of Maxillofacial Surgery and Stomatology, F-44000 Nantes, France</footnote>

<footnote><sup>b</sup> University of Nantes, CHU Nantes, Public Health Department, 44093 Nantes cedex a, France</footnote>

<footnote><sup>c</sup> Department of Head and Neck Oncology, Gustave Roussy Cancer Campus, 94805 Villejuif, France</footnote>

<footnote><sup>d</sup> University of Nantes, Univ Angers, CHU Nantes, INSERM, CNRS, CRCI2NA, F-44000 Nantes, France</footnote>

<footnote>* Corresponding author.
E-mail addresses: sophie.dugast@chu-nantes.fr (S. Dugast), leonor.guilmault@chu-nantes.fr (L. Guilmault), isabelle.bouhier@chu-nantes.fr (I. Bouhier), olivier.AIRAUDO@gustaveroussy.fr (O. Airaudo), julie.longis@chu-nantes.fr (J. Longis), helios.bertin@chu-nantes.fr (H. Bertin).</footnote>

<footnote n="1">¹ Given his role as Editor, Hélios Bertin had no involvement in the peer-review of this article and has no access to information regarding its peer-review. Full responsibility for the editorial process for this article was delegated to the Associate Editor-in-Chief Barbara Lerhe.</footnote>
rehabilitation—whether implant-based or conventional—after free
bone flap reconstruction for cancer treatment is notably low, with
estimates around 38% [4]. Several challenges contribute to these lim-
ited rehabilitation rates. Conventional prostheses frequently fail to
adapt to the altered morphology created by the flaps, as their skin
paddles or muscular components often obliterate the vestibular relief
necessary for proper retention. Dental implants, which serve to stabi-
lize or ideally fix prostheses, offer a solution by minimizing the pros-
thetic volume. Implantation into free bone flaps can be categorized
based on timing: delayed implantation is the most commonly
employed approach. This technique involves placing the implants
several months post- reconstruction, typically after any radiotherapy
treatment has concluded. The delayed approach provides key advan-
tages, including a reduced risk of implant failure and the benefit of
longer oncological follow-up, allowing for better assessment of poten-
tial disease recurrence [4-6]. However, this approach often involves
prolonged treatment durations, with rehabilitation timelines esti-
mated to be twice as long as for primary implantation, sometimes
extending over several years [7]. Adjuvant radiotherapy, frequently
required for malignancies involving bone invasion with prescribed
doses exceeding 50 gray to the tumor bed, presents additional chal-
lenges. Such treatments often result in complications, including
restricted mouth opening, xerostomia, osteoradionecrosis and
impaired tissue healing, all of which can hinder the success of
implants and subsequent rehabilitation. Numerous studies have dem-
onstrated that dental implantation in irradiated terrain is feasible and
should no longer be contraindicated solely due to radiation exposure,
given the substantial benefits it offers [5,8]. An alternative increas-
ingly described in the literature over the past two decades is primary
implantation of free bone flaps, performed during the initial recon-
structive surgery. This approach significantly shortens rehabilitation
times, enabling patients to achieve a functional rehabilitation more
rapidly. However, successful implantation in free bone flaps demands
specific expertise and close collaboration with multidisciplinary
teams, including dentists and prosthetists. Such collaboration is often
hindered by logistical challenges, as these specialists are not always
co-located with oncology or reconstructive surgery teams. Despite
the growing recognition of the benefits of implant placement in free
bone flaps for prosthetic stabilization, this practice remains uncom-
mon in the oncological population and lacks standardization, particu-
larly in France. To address this gap, our study aims to evaluate
current free bone flap implantation practices in France, identify the
challenges faced by oncological surgeons in adopting these techni-
ques, and assess the willingness of reconstructive surgeons to expand
their efforts in rehabilitating a greater number of patients.

## 2. Methods

1. Target population

We identified and contacted 52 French hospitals (public and pri-
vate) that perform free bone flap reconstructions. Selection was
based on data from the French health insurance body for 2022-2023,
focusing exclusively on centers with demonstrated experience in free
bone flap procedures. The practice survey was also distributed to all
members of GETTEC (Groupe d'Étude des Tumeurs de la Tête et du Cou).
To maintain consistency, we requested only one response per recon-
struction team at each center. However, in cases where a center
hosted independent reconstruction teams—such as maxillofacial sur-
geons, otorhinolaryngologist surgeons, or plastic surgeons—multiple
responses from the same institution were allowed.

2. Questionnaire design and distribution

An online questionnaire was developed using the Sphinx platform
(Le Sphinx, Chavanod, France) and distributed via email to surgeons

performing reconstructions with free bone flaps. The questionnaire
was designed in collaboration with the facility's public health team,
which specializes in medical surveys. It underwent a thorough
review and was approved after testing by three senior surgeons spe-
cializing in oncological reconstruction (SD, JL, HB) and two public
health department members (LG, IB). The target respondents
included maxillofacial surgeons, otorhinolaryngologist surgeons, and
plastic surgeons, with specific contacts varying based on local practi-
ces. In some instances, multiple specialists within the same center
were contacted to optimize survey participation.

All collected data were anonymized, with only the respondent's
specialty and center being recorded for analysis.

The questionnaire consisted of 26 questions addressing:

- Epidemiology of free flap reconstruction at each center.

- Dental rehabilitation procedures and practices.

- The organization and coordination of reconstruction-to-rehabili-
tation handovers.

- Barriers and limitations to dental rehabilitation.

- Willingness to participate in a multicenter prospective clinical
  trial aimed at increasing rehabilitation rates in cancer centers.

The survey was distributed in May 2024, with three reminder
emails sent at 15-day intervals. The survey period concluded in July
2024.

3. Results

1. Epidemiology data

Out of the 52 centers contacted across 12 towns in France, 19 responded to our survey, with a total of 218 surgeons initially contacted. Among the respondents, 11 were maxillofacial surgeons (58 %) and eight were otorhinolaryngology surgeons (42 %). Notably, none of the respondents were plastic surgeons. Regarding the type of facilities, the majority of responding centers were university hospitals (12/19, 63 %), followed by cancer centers (4/19, 21 %) and peripheral hospitals (3/19, 16 %). In terms of free flap types, all centers reported using fibula free flaps, while most also performed scapulo-dorsal free flaps (16/19). Iliac crest and rib free flaps were less commonly utilized (4/19 and 2/19, respectively). The composition of surgical teams varied across centers. Seven centers had two practitioners specializing in free bone flap reconstructions, nine employed four specialists, and three had more than five surgeons involved in these procedures. Regarding the volume of free bone flap reconstructions, the majority of centers reported performing >10 procedures annually. Specifically, five centers performed between 10 and 20 procedures annually, four conducted 21 to 30, three completed 31 to 40, and two carried out 41 to 50. Notably, three centers performed >60 flaps per year, while two estimated fewer than 10 procedures annually.

A summary of these epidemiological data is provided in Table 1.

2. Rehabilitation data

Sixteen centers reported treating patients with free flap recon-
structions who subsequently underwent implant-supported rehabili-
tation. The number of patients who benefited from implant-
supported reconstruction after free bone flap procedures–either pri-
mary or secondary–was estimated at one to five in 12 centers, 6 to
10 in three centers, and 11 to 15 in one center.

Fourteen teams reported having already placed dental implants in
free bone flaps, with eight having performed primary implantation
(during the reconstruction surgery) and eleven having conducted
secondary implantation. Among the centers that have already
<table><caption>**Table 1**
Epidemiology data.</caption><tbody><tr><td>Surgical specialty n (%)</td><td></td></tr><tr><td>Maxillofacial surgeon</td><td>11 (58)</td></tr><tr><td>Otorhinolaryngology surgeon</td><td>8 (42)</td></tr><tr><td>Plastic surgeon</td><td>0</td></tr><tr><td>Medical facility n (%)</td><td></td></tr><tr><td>University Hospital</td><td>12 (63)</td></tr><tr><td>Cancer center</td><td>4 (21)</td></tr><tr><td>Non-university hospital</td><td>3 (16)</td></tr><tr><td>Private hospital</td><td>0</td></tr><tr><td>City n (%)</td><td></td></tr><tr><td>Paris</td><td>5 (26)</td></tr><tr><td>Marseille</td><td>2 (11)</td></tr><tr><td>Nantes</td><td>2 (11)</td></tr><tr><td>Nice</td><td>2 (11)</td></tr><tr><td>Annecy</td><td>1 (5)</td></tr><tr><td>Bordeaux</td><td>1 (5)</td></tr><tr><td>Lille</td><td>1 (5)</td></tr><tr><td>Rennes</td><td>1 (5)</td></tr><tr><td>Rouen</td><td>1 (5)</td></tr><tr><td>Tours</td><td>1 (5)</td></tr><tr><td>Toulouse</td><td>1 (5)</td></tr><tr><td>Valencienne</td><td>1 (5)</td></tr><tr><td>Estimated no of bone free flaps for malignant tumors per year n (%)</td><td></td></tr><tr><td>&lt;10</td><td>2 (11)</td></tr><tr><td>10-20</td><td>5 (26)</td></tr><tr><td>21-30</td><td>4 (21)</td></tr><tr><td>31-40</td><td>3 (16)</td></tr><tr><td>41-50</td><td>2 (11)</td></tr><tr><td>51-60</td><td>0</td></tr><tr><td>&gt;60</td><td>3 (16)</td></tr><tr><td>Type of flap performed n (%)</td><td></td></tr><tr><td>FFF</td><td>19 (100)</td></tr><tr><td>SD</td><td>16 (84)</td></tr><tr><td>DCIA</td><td>4 (21)</td></tr><tr><td>Rib-FF</td><td>2 (11)</td></tr><tr><td>Others</td><td>0</td></tr><tr><td>Reconstructive surgeons on the team n (%)</td><td></td></tr><tr><td>1</td><td>0</td></tr><tr><td>2</td><td>7 (37)</td></tr><tr><td>3</td><td>0</td></tr><tr><td>4</td><td>9 (47)</td></tr><tr><td>5</td><td>0</td></tr><tr><td>&gt;5</td><td>3 (16)</td></tr></tbody></table>

FFF, Fibula Free Flap; SD, Scapulo Dorsal Free Flap; DCIA, Deep Circumflex Iliac Artery Free Flap; Rib-FF, Rib Free Flap.

performed primary implantation, six (6/8) treated one to five patients over the past three years, one (1/8) treated six to ten patients, and one (1/8) reported over 20 cases. Delayed implantation was more common, with seven centers (7/11) estimating the number of patients implanted in the last three years at one to five, one (1/11) at six to ten, two (2/11) at 11 to 15, and one (1/11) at over 20 patients.

In cases of delayed implantation, the average time observed by practitioners after surgery was primarily between 13 and 24 months (9/11). One center follows a delay of three to six months, while another observes a delay of seven to 12 months.

Data on implant rehabilitation are summarized in Table 2.

### 3. Indications and team organization

The timing and coordination of implant placement in free bone flap reconstructions vary widely among surgeons. In preoperative consultations, 57 % of surgeons address rehabilitation and the implantation procedure, while 43 % defer this discussion until after the completion of oncological treatment. Additionally, 29 % of surgeons organize a meeting with an oral or dental surgeon during the preoperative phase to plan for prosthetic rehabilitation, and 14 % seek health insurance reimbursement for the process.

Radiotherapy presents a significant challenge for implantation. Thirteen surgeons (13/19, 68 %) identified radiotherapy as an obstacle, with 92 % of them considering it a hindrance to secondary

implantation and 62 % viewing it as a barrier to primary implantation. Notably, 23 % of practitioners completely avoid both primary and secondary implant placement in case of radiotherapy.

Pre-implant planning tools, such as surgical guides, are utilized by 12 of the 14 surgeons or teams performing implantations. Among those conducting primary implantation, 57 % consistently use these guides, while 43 % apply them only occasionally. For secondary implantation, 50 % of surgeons choose not to use guides, 30 % use them systematically, and 20 % apply them selectively.

Implant placement and team organization show considerable variation across centers. While 31 % of surgeons perform implant placements themselves, most (85 %) collaborate with oral surgeons or specialist dentists to position the implants (Fig. 1). Of those placing implants, 50 % handle only secondary implantations, while the remaining 50 % perform both primary and secondary procedures. Regarding prosthetic fabrication, 67 % of cases are managed within the reconstructive surgeon's facility, while others involve external dentists, including those from the surgeon's network (47 %), the patient's regular dentist (13 %), or external teams (13 %).

Practitioners identified several barriers to successful implantation. The most significant challenges were patient irradiation and lack of financial support, both cited by 61 % of respondents. Other obstacles included the absence of practitioner networks (50 %), insufficient training within teams (33 %), risk of oncological recurrence within two years (28 %), extended operative time for primary implantation (22 %), and difficulties with radiological follow-up due to imaging artefacts (17 %) (Fig. 2).

Four surgeons expressed interest in further training in implantology to enhance their team's capabilities. All practitioners underscored their commitment to increasing the number of patients rehabilitated following free bone flap reconstruction for malignant oral cavity tumours. Furthermore, 77 % of teams expressed support for participating in a prospective multicenter study on primary implantation. Lastly, one surgeon conveyed concerns about implanting free bone flaps due to the potential impact on patient follow-up and the vascularization of the flap, preferring to avoid implants to ensure optimal patient care.

### 4. Discussion

The primary aim of this study was to provide an overview of implant rehabilitation practices following reconstruction with free bone flaps in France. In order to enhance oncological reconstruction practices, it is crucial to address the rehabilitation aspect, which, in France, remains marginal and lacks standardization. This study aggregated data from 12 major French cities involved in cervico-facial reconstruction. Among these, 12 centres performed over 20 free bone flaps annually, with three high-volume centers exceeding 60 cases per year. The majority of free flaps performed were fibula and scapulodorsal flaps. The fibula flap is particularly well-suited for implant placement due to its bicortical structure and bone density [9], while the scapulodorsal flap, despite its potential, tends to offer less favorable primary retention for implants due to its spongy bone structure. Importantly, no significant difference in implant survival has been demonstrated between these two types of flaps [10]. Our prior systematic review supports the notion that implant placement within free bone flaps does not compromise flap vascularization [7]. One of the key postoperative challenges is the presence of excess, often mobile soft tissue, which can contribute to peri-implantitis or long-term implant failure. Pyne et al. recommend placing a skin graft over the dental implants immediately after placement to promote a more stable, non-mobile neogingiva and keratinized mucosa, rather than relying on the traditional mobile fibular flap tissue coverage [11]. Regarding flap positioning, some authors advocate for the double-barrel technique to reduce prosthetic height, although this approach limits the available pedicle length [12].
<table><caption>**Table 2**
Data on implant rehabilitation.</caption><tbody><tr><td>Have any of your patients who have undergone free flap reconstruction received implant-supported prostheses? n (%)</td><td></td></tr><tr><td>Yes</td><td>16 (84)</td></tr><tr><td>No</td><td>3 (16)</td></tr><tr><td>Estimated no of patients who underwent implant-supported rehabilitation after free bone flaps in the past year n (%)</td><td></td></tr><tr><td>1–5</td><td>12 (75)</td></tr><tr><td>6–10</td><td>3 (19)</td></tr><tr><td>11–15</td><td>1 (6)</td></tr><tr><td>16–20</td><td>0</td></tr><tr><td>>20</td><td>0</td></tr><tr><td>Has your team ever placed oral implants in free bone flaps? n (%)</td><td></td></tr><tr><td>Yes</td><td>14 (74)</td></tr><tr><td>No</td><td>5 (26)</td></tr><tr><td>Have you ever placed implants primarily, i.e., during reconstruction surgery? n (%)</td><td></td></tr><tr><td>Yes</td><td>8 (57)</td></tr><tr><td>No</td><td>6 (43)</td></tr><tr><td>In the past three years, how many patients do you estimate you have implanted during reconstruction surgery? n (%)</td><td></td></tr><tr><td>1–5</td><td>6 (75)</td></tr><tr><td>6–10</td><td>1 (13)</td></tr><tr><td>11–15</td><td>0</td></tr><tr><td>16–20</td><td>0</td></tr><tr><td>>20</td><td>1 (13)</td></tr><tr><td>Have you ever placed secondary implants in free bone flaps? n (%)</td><td></td></tr><tr><td>Yes</td><td>11 (79)</td></tr><tr><td>No</td><td>3 (21)</td></tr><tr><td>In the past three years, how many patients do you estimate you have implanted secondarily? n (%)</td><td></td></tr><tr><td>1–5</td><td>7 (64)</td></tr><tr><td>6–10</td><td>1 (9)</td></tr><tr><td>11–15</td><td>2 (18)</td></tr><tr><td>16–20</td><td>0</td></tr><tr><td>>20</td><td>1 (9)</td></tr><tr><td>For delayed implantation, what timeframe do you typically follow after reconstructive surgery? n (%)</td><td></td></tr><tr><td>3–6 months</td><td>1 (9)</td></tr><tr><td>7–12 months</td><td>1 (9)</td></tr><tr><td>13–24 months</td><td>9 (82)</td></tr><tr><td>>24 months</td><td>0</td></tr></tbody></table>

Despite the high rates of free bone flap reconstructions for malignant tumors of the oral cavity, the number of patients who received implants in the past year remains low. In centers that have already performed primary implantation, most estimated having implanted only one to five patients over the past three years. Similarly, among the 11 expert centers that had performed secondary implantations, more than half also reported implanting one to five patients over the last three years. This indicates that implant rehabilitation remains rare in the oncology population. Several studies have explored the long-term functional and esthetic outcomes of reconstructions using free bone flaps [13,14]. These studies found that functional and esthetic scores were notably lower in patients who did not receive dental rehabilitation or who developed malocclusion. Furthermore, Yang et al. observed that the most significant alterations in orofacial function following oral cavity cancer were linked to failures in prosthetic dental rehabilitation [14]. Implant-supported prostheses

significantly enhance patients' quality of life by improving functional outcomes [3,15].

Key challenges to implant placement in free bone flap reconstructions include radiotherapy, which was identified as a major obstacle by 68% of surveyed surgeons. This is particularly relevant for secondary implantation, as 62% of surgeons still view irradiation as a hindrance in these cases, compared to 42% for primary implantation. Numerous studies have demonstrated that the risk of implant failure increases when radiation doses exceed 50 Gy, as is common in head and neck cancer treatments, where tumor bed doses often reach 60 to 65 Gy [5,16]. The current approach focuses on reducing the irradiation dose to the flap, thereby minimizing side effects on the healthy transplanted bone and implants. Notably, Fenske et al. reported no recurrence of malignant disease in osseous free flaps, regardless of whether postoperative radiotherapy was administered [17]. Implant success rates in irradiated patients are estimated to range between

<figure><img src="image_5.png" /><figcaption>**Fig. 1.** Responsible personnel for implant placement in free bone flaps at your center.</figcaption></figure>
<figure><img src="image_6.png" /><figcaption>**Fig. 2.** Primary obstacles to free bone flap implantation.</figcaption></figure>

82 % and 97 %, compared to 87 % to 100 % in non-irradiated populations [8]. Given the improved quality of life that prostheses can offer these patients, radiotherapy should no longer be considered a contraindication for implant use in oncology [2,5,7].

In this study, 82 % of centers performing secondary implantations reported a consensual delay of 13 to 24 months after surgery, and when applicable, after radiotherapy, before placing implants. This aligns with several studies showing a higher implant failure rate in the first twelve months post-radiotherapy [4–6]. Beyond the risk of implant failure, radiotherapy often causes sequelae such as xerostomia, osteoradionecrosis and restricted mouth opening, further complicating implant management. The development of osteoradionecrosis (ORN) is a serious complication for patients with oral cancer. However, several studies have shown that implant placement does not increase this risk, which ranges from 0 to 6 % in all patients treated with Intensity Modulated Radiation Therapy [18]. Toneatti et al. reported 11 cases of ORN among 425 irradiated patients following implantation, corresponding to an incidence rate of 3 % [5]. Similarly, our previous study comparing primary and secondary implantation in oral cancer found four cases of ORN out of 284 patients [7]. Concerning xerostomia, Wolf et al. reported significantly lower implant success rates of 69 % in patients with advanced xerostomia, compared to 78.6 % in those with lower grades of xerostomia [16]. The prevalence of trismus in head and neck cancer patients varies widely, ranging from 8 % to 62 % [19]. In oral cancer patients, trismus arises from a multifactorial etiology, often linked to fibrosis of the masticatory muscles due to surgery, the tumor itself, radiotherapy, or a combination of these factors [20]. Unfortunately, proposing implant rehabilitation for patients with irreducible trismus, which restricts the insertion of necessary tools for both implants and prostheses, remains unfeasible.

On the other hand, the cost of the procedure presents a significant barrier. Numerous studies have shown an increased risk of head and neck cancer in socio-economically disadvantaged populations [21,22]. However, in many countries, oral health remains a lower priority and is often viewed more as an individual responsibility rather than a social one. In France, for example, social security covers the cost of two mandibular implants and four maxillary implants in the context of oncological treatment, but the prosthetic part—often a substantial cost—remains the responsibility of the patient. This financial burden means that many patients from underprivileged backgrounds are still unable to afford implant rehabilitation. In our

survey, 61 % of surgeons identified the high cost as a barrier to implant rehabilitation for their patients. Interestingly, some studies have shown that secondary implantation tends to be more expensive than primary implantation, primarily due to the higher number of surgical procedures involved in secondary implantation [23].

Moreover, one of the most significant challenges is the need for close collaboration between multiple teams throughout the entire process, from implantation to the fitting and adjustment of the prosthesis. While some reconstruction teams perform their own implantations, others rely on dentists or oral surgeons to carry out this task. For primary implantations, this often requires high availability from these specialists, given the tight scheduling constraints associated with oncology surgeries. In our study, 85 % of centers enlisted dental or oral surgeons to perform implant placements, while 31 % of reconstructive surgeons indicated they could handle the implants themselves. This coordination is more seamless in hospitals with in-house dental care centers, where prosthesis design is typically carried out in the reconstruction center. However, in 47 % of cases, prosthetic design can also involve dentists from the center's network. The lack of a reliable network of practitioners for implant placement and prosthetics, as well as insufficiently trained practitioners within reconstruction teams, were cited by surgeons as significant barriers to implant rehabilitation for patients.

Additionally, when considering primary implantation of free bone flaps, a critical challenge lies in the precise placement of implants during reconstructive surgery. This process demands specialized expertise from the surgeon and often entails a learning curve during the early stage. A study by Smolka et al. highlighted a significant contrast between the high rate of successful osseointegration and the notably lower rate of functional restoration. This discrepancy was largely attributed to challenges such as implant misplacement [24]. These findings emphasize the importance of accurate implant placement for ensuring durable and functional prosthetic outcomes. In our study, all surgeons who had performed primary implantation on free bone flaps utilized surgical guides, either systematically or occasionally, to ensure precise implant positioning. In contrast, half of the surgeons performing secondary implantations did not use surgical guides, as secondary implantation can often be carried out under local anaesthetia, allowing for better assessment of occlusal landmarks. While experience plays a significant role, several studies have demonstrated that guided surgery surpasses freehand surgery in terms of precision and outcome [25]. Various types of guides are utilized in implant surgery: static guides, such as conventional surgical guides made from transparent resin to assist with the drilling
sequence and implant placement, and dynamic guides, which pro-
vide real-time tracking of bone drilling and implant placement
through three-dimensional (3D) software. Ochandiano et al. recom-
mend combining these approaches in oncological patients, who often
present anatomical distortions [26].

Despite these challenges, primary implantation offers several sig-
nificant advantages. These include earlier patient rehabilitation and a
higher rehabilitation rate for implanted patients [7]. Our previous
systematic review showed a mean delay before rehabilitation of 5.3
months in the primary implantation group, compared to 20.4 months
in the secondary implantation group [7]. In contrast, secondary
implantation can lead to delays that extend for several years, with
patients often adjusting to their situation. These delays are especially
concerning in a population with potentially limited life expectancy.
Schoen et al. demonstrated that implant-retained lower dentures can
substantially improve the quality of life related to oral functioning
and denture satisfaction in head and neck cancer patients [2]. Addi-
tionally, the comparative study by Allen et al. found no significant dif-
ferences in postoperative complications between primary and
secondary implantation, nor in the time required to initiate adjuvant
radiotherapy [27].

Regarding other barriers to implantation, 28 % of surgeons cited the increased risk of recurrence during the first two years as an obstacle. Korfage et al., in their 14-year follow-up study, reported an 8 % implant loss rate (27 out of 318) in irradiated patients attributed to tumor recurrence [28]. In our opinion, this should not delay rehabilitation. For patients with limited survival, prioritizing quality of life is crucial. The FDI Word Dental Federation recognizes the role of oral health in overall well-being, stating that masticatory function plays a significant role in both nutrition and the physical and mental health of patients [29]. Finally, 22 % of surgeons considered the increased operating time to be a limitation for primary implantation. Several studies estimate this additional time to be about one hour, without increasing the risk of flap failure [7,9]. Eventually, implantation of free bone flaps is the most effective solution for rehabilitating patients who have undergone reconstruction for oral cavity cancer. However, its implementation remains limited, even in expert centers performing a high volume of free flaps annually. Organizational and financial constraints, along with the technical challenges posed by frequent adjuvant radiotherapy, significantly hinder its widespread use. Nevertheless, all surgeons surveyed in this study expressed strong support for increasing the number of rehabilitated patients following oncological surgery and demonstrated a willingness to participate in a larger prospective multicenter study on this subject.

Declaration of competing interest

The authors declare to have no conflict of interest regarding this
manuscript.

CRediT authorship contribution statement

Sophie Dugast: Writing – review & editing, Writing – original draft, Methodology, Investigation, Formal analysis, Conceptualization. Leonor Guilmault: Validation, Methodology, Conceptualization. Isabelle Bouhier: Methodology, Formal analysis, Data curation, Conceptualization. Olivier Airaudo: Writing – review & editing, Validation, Investigation, Data curation. Julie Longis: Writing – review & editing, Validation, Supervision. Helios Bertin: Writing – review & editing, Writing – original draft, Formal analysis, Data curation.

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