Free flap reconstruction and implant-based dental rehabilitation in oral cancer patients
Authors:   , Lodders Johannes Nicolaas 
Published: October 2023

Chapter 2 retrospectively investigated postoperative complications (POC) in patients who had undergone primary free flap reconstructions after surgical treatment of oral cancer.
Surgical complications occurred in 32% of the patients and systemic complications occurred in 8% of the patients. Prolonged anaesthesia time and red cell transfusion were associated with systemic complications and prolonged hospital stay, respectively. Although both variables are difficult to modify, these may create awareness during the postoperative course and may be informative in the preoperative phase for patient selection and during the informed consent process.

Chapter 3 gives an estimation of the occurrence of symptomatic venous thromboembolism (VTE) in 233 surgical oral cancer patients. Despite almost all patients (97%) were classified as having the highest risk for VTE, the occurrence of VTE in surgical oral cancer patients seems to be rare, if thromboprophylaxis is used (overall incidence: 0.4 %). We could not recommend the use of routine thromboprophylaxis as there was no control group without thromboprophylaxis. Therefore, thromboprophylaxis could be advocated in patients with obvious and serious risk factors.

Chapter 4 focused on POCs in patients who had undergone reconstruction of segmental mandibular defects with free fibula flaps after surgical ablation of oral cancer.

During the first year, POCs occurred in 47 patients (54.7%). Twenty-eight patients (32.6%) had surgical complications, 10 patients (11.6%) had systemic complications and 9 patients (10.5%) had surgical and systemic complications. Active smoking, mandibular reconstruction in the symphyseal region, and TNM anatomic stage group>II were associated with surgical complications. Age>60 years and a Charlson Comorbidity Index (CCI)>2 were identified as predictive factors for systemic complications.

With exemption of smoking habits, most variables are relatively unchangeable and its clinical value is mostly informative regarding risk stratification and it may be helpful during the informed consent process and for selecting surgical patients.

In Chapter 5 a retrospective study is described on head and neck cancer patients who had undergone implant-based dental rehabilitation after jaw reconstruction with a fibula free flap.

In total, 161 dental implants were placed secondarily in 44 fibula free flaps. The implant survival was significantly different in irradiated fibula free flaps (55%) compared to the implant survival in non-irradiated fibula free flaps (96%). Implant-based dental rehabilitation was started 45 times in 42 patients, out of 150 patients. Three patients underwent a second attempt after the initial fibula graft was lost. In 37 patients dental rehabilitation was completed of whom 29 eventually functioned satisfactory.

Irradiation of the fibula free flap and cigarette smoking seemed to be significant predictors for dental implant failure and attainment of functional dental rehabilitation. Having both risk factors simultaneously may be associated with an extreme high risk for dental implant failure and necrosis of the fibula free flap.

Chapter 6 evaluated the effect of implant-based dental rehabilitation on the health-related quality of life (HRQoL) in head and neck cancer patients who had undergone reconstruction with a fibula free flap.

HRQoL was evaluated with the EORTC QLQ-C30 and EORTC QLQ-H&N 35 in 19 patients who had undergone implant-based dental rehabilitation and 38 patients who had not.

HRQoL did not seem to substantially change after completing implant-based dental rehabilitation compared to baseline values, as weight loss was the only domain that reached significance in the within-subject analysis. When the mean changes of all the EORTC QLQ-C30 and EORTC QLQ-H&N35 scores were analysed in both groups, no significant differences could be found in the course of HRQoL for those who had undergone implant-based dental rehabilitation compared to those who had not.

Patients should be preoperatively informed regarding this finding to have realistic expectations regarding the outcomes of this additional treatment.