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ORIGINAL RESEARCH  
Year : 2011  |  Volume : 22  |  Issue : 5  |  Page : 644-648
Survival of dental implants in native and grafted bone in irradiated head and neck cancer patients: A retrospective analysis


1 Private Practitioner, Seattle WA, USA
2 Department of Periodontics, Mayo Clinic, Rochester, MN, USA
3 Department of Prosthodontics, Mayo Clinic, Rochester, MN, USA
4 Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA

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Date of Submission04-Aug-2010
Date of Decision12-Nov-2010
Date of Acceptance23-Jul-2011
Date of Web Publication7-Mar-2012
 

   Abstract 

Aim: To study the long-term survival of dental implants placed in native or grafted bone in irradiated bone in subjects who had received radiation for head and neck cancer.
Materials and Methods: A retrospective chart review was conducted for all patients who received dental implants following radiation treatment for head and neck cancer between May 1, 1987 and July 1, 2008. Only patients irradiated with a radiation dose of 50 Gy or greater and those who received dental implants in the irradiated field after head and neck radiation were included in the study. The associations between implant survival and patient/implant characteristics were estimated by fitting univariate marginal Cox proportional hazards models.
Results: A total of 48 patients who had prior head and neck radiation had 271 dental implants placed during May 1987-July 2008. There was no statistically significant difference between implant failure in native and grafted bone (P=0.76). Survival of implants in grafted bone was 82.3% and 98.1% in maxilla and mandible, respectively, after 3 years. Survival of implants in native bone in maxilla and mandible was 79.8% and 100%, respectively, after 3 years. For implants placed in the native bone, there was a higher likelihood of failure in the maxilla compared to the mandible and there was also a tendency for implants placed in the posterior region to fail compared to those placed in the anterior region.
Conclusion: There was no significant difference in survival when implants were placed in native or grafted bone in irradiated head and neck cancer patients. For implants placed in native bone, survival was significantly influenced by the location of the implant (maxilla or mandible, anterior or posterior).

Keywords: Bone graft, implant survival, mucositis, osseointegration, radiotherapy

How to cite this article:
Buddula A, Assad DA, Salinas TJ, Garces YI. Survival of dental implants in native and grafted bone in irradiated head and neck cancer patients: A retrospective analysis. Indian J Dent Res 2011;22:644-8

How to cite this URL:
Buddula A, Assad DA, Salinas TJ, Garces YI. Survival of dental implants in native and grafted bone in irradiated head and neck cancer patients: A retrospective analysis. Indian J Dent Res [serial online] 2011 [cited 2019 Jun 24];22:644-8. Available from: http://www.ijdr.in/text.asp?2011/22/5/644/93449
Advanced squamous cell cancers of the head and neck are commonly treated with a combination of modalities such as surgery, radiation and/or chemotherapy. Each modality presents with its associated risks, side effects and benefits. Commonly, surgical treatment results in loss of vital structures or anatomical deformities, [1] while the short- and long-term side effects of radiation therapy can result in mucositis, xerostomia, periodontal attachment loss, dental caries, trismus and osteoradionecrosis. [2]

Dental implants have a vital role to play in the rehabilitation of head and neck cancer patients. Dental implants improve the quality of life by allowing bone-anchored reconstruction of tumor defects, proper retention of removable prostheses and reducing the overloading of vulnerable soft tissues. [3]

The regeneration of bone defects of the jaws using vascularized tissue grafts has become a reliable procedure during the last several decades. Dental implants can be placed either in native bone or in grafted bone depending on the extent of the defect and restorative treatment plan. Bone grafts typically used for reconstruction include iliac crest, [4] scapula, femur and fibula. [5] Regardless of whether the dental implants are placed in native or grafted bone, radiation exposure may cause a delay in wound healing and potentially also affect osseointegration.

Head and neck radiation can result in damage to the osteoclasts and reduce proliferation of bone marrow, collagen and blood vessels. [6] Radiotherapy also causes endarteritis that leads to hypoxia, hypocellularity and hypovascularity which compromises bone healing. [6] The extent of changes also depends upon dose, field and type of radiation treatment. [7] All these can lead to reduced remodeling and reduced viability which potentially affects osseointegration of dental implants.

There are limited data available about the long-term success of dental implants placed in patients with head and neck cancer who had received radiation therapy. Furthermore, there is much variation amongst these data, in the success rate reported. Success rate as high as 99% in the mandible was reported by Keller et al., [8] in patients who had received radiotherapy, whereas rates as low as 70% were reported by Ryu et al.[9] A similar variation is seen in implants placed in the maxilla. The reported success rates vary from as high as 100% [10] to as low as 40%. [11]

There are very few studies that compared the survival of implants in native or grafted bone in irradiated head and neck cancer patients. To the authors' knowledge, this is the first study to discuss survival in native or grafted bone. Most of the studies available in literature discuss survival in radiated fibula flaps. [12].[13].[14] The primary aim of this study was to analyze survival of dental implants in native or grafted vascularized and non-vascularized bone in irradiated head and neck cancer patients.


   Materials and Methods Top


A retrospective chart review was conducted of all patients who received dental implants following radiation treatment for head and neck cancer at the Mayo Clinic, Rochester, MN, between May 1, 1987 and July 1, 2008. Mayo Clinic Institutional Review Board gave approval for the study. According to Minnesota state laws, any patient who had denied access of their medical records for research purposes was not included. Data were collected from patients' medical records. Only patients irradiated with a dose of 50 Gy or greater and those who received dental implants in the field after head and neck radiation were included in the study. The abstracted data included patient gender, diagnosis of cancer, date of initial radiation, radiation dose received, timing and sequence to dental surgery. For each implant, the abstracted data included date and age at implant placement, anatomic location, width and length of dental implant, time lapse between radiation and implant placement and whether the implant was placed in native bone or grafted bone. Type of grafted bone in which implant was placed was also recorded. Survival of each implant was documented by its presence or absence in the oral cavity at the time of data collection. Implant failure was defined as its loss or explantation. The patients' records were followed until the last follow-up in the clinic, and duration of follow-up was calculated from the time of placement to the date of failure or date of last follow-up. The Kaplan-Meier method was used to estimate the implant survival following placement in native or grafted bone.


   Results Top


A total of 48 patients who had prior head and neck radiation had 271 dental implants placed between May 1987 and July 2008. The number of implants placed in each patient ranged from 1 to 27; 46 had one placement date (1-14 implants placed per patient), 1 patient had two placement dates (8 total implants), and 1 patient had three placement dates (27 total implants). The most frequent number of implants placed was 5, which occurred in 21 (44%) patients. There was no statistically significant difference between implant failure in native and grafted bone (P=0.76).

Twenty-nine of the 48 subjects were males and the mean age at the time of the first implant was 60.2 years [Table 1]. The median time interval between radiation and first implant placement was 3.4 years. The most common histologic tumor types identified were squamous cell carcinoma (43 of 48 patients), adenoid cystic carcinoma (3 of 48), basal cell carcinoma (1 of 48) and unknown primary head and neck carcinoma (1 of 48). Mean radiation dose received was 60.7 Gy with a range of 50.2-67.50 Gy. [Table 2] summarizes the implant characteristics.
Table 1: Summary of patient characteristics

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Table 2: Summary of implant characteristics

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[Table 3] and [Table 4] and [Figure 1] summarize implant survival in grafted bone. A total of 59 implants were placed in grafted bone. Seven implants were placed in the maxilla and 52 in the mandible. Survival of implants in grafted bone was 82.3% and 98.1% in maxilla and mandible, respectively, after 3 years [Figure 2] and [Figure 3]. No statistically significant association of radiation dosage or time span between radiation and placement with implant failure in grafted bone was identified. There was no statistically significant association between length of implant, surface roughness, implant location (anterior or posterior) and survival when implants were placed in grafted bone. However, statistically significant association was noted between diameter of implant and its survival. Implants with a diameter of 3.75 mm or less had lower survival compared to the ones with a diameter of 4 or 5 mm (P=0.033).
Figure 1: Kaplan-Meier curves for implant survival in native or grafted bone

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Figure 2: Kaplan-Meier curves for implant survival in native or grafted bone in maxilla

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Figure 3: Kaplan-Meier curves for implant survival in native or grafted bone in mandible

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Table 3: Summary of implant survival placed in grafted bone by factors of interest

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Table 4: Summary of the patient/implant characteristics evaluated for an association with implant failure in grafted bone

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[Table 5] and [Table 6] and [Figure 1] summarize implant survival in native bone. A total of 212 implants were placed in native bone. Implants placed in the maxilla had a higher likelihood of failure compared to the ones placed in the mandible (P=0.010) [Figure 2] and[Figure 3]. Survival of implants in native bone in maxilla and mandible was 79.8% and 100%, respectively, after 3 years. Similarly, implants placed in the posterior region were more likely to fail compared to the ones placed in the anterior region (P=0.062). No statistically significant association of radiation dosage or time span between radiation and placement with implant failure in native bone was identified. There was no statistically significant association between length or diameter of implant and its survival in native bone.
Table 5: Summary of implant survival in native bone by the factors of interest

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Table 6: Summary of the patient/implant characteristics evaluated for an association with implant failure in native bone

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   Discussion Top


Dental implant failure in patients receiving head and neck radiation is primarily a result of hard and soft tissue changes. Head and neck radiation brings about irreversible changes to the blood vessels and bone forming cells, thus affecting bone turnover. [6] Osseointegration of dental implants can be compromised as a result of changes brought about by radiation therapy. The aim of the study was to compare survival of dental implants placed in native or grafted bone in head and neck cancer patients.

Based on the findings from this study, there was no significant difference between survival of implants in native or grafted bone (P=0.76). To the knowledge of the authors, there are no studies that compared survival of dental implants in native and in grafted bone in subjects who had received head and neck radiation. Data, however, are available comparing survival in native or grafted bone in subjects who have no history of head and neck radiation. Sbordone et al., [15] reported a survival of 98.9% in native bone and 99.1% in grafted bone. Although this study was conducted in subjects who had no prior history of head and neck radiation, the results of the present study are comparable to the above-mentioned study in the mandible, both for grafted and native bone. However, implants placed in maxilla both in native or grafted bone had a higher chance of failure compared to the ones placed in mandible. The difference was statistically significant in native bone as opposed to grafted bone. The difference in the bone density of the maxilla and mandible could account for better results in the mandible. [16],[17],[18],[19]

The study also identified anatomic location as a risk factor for the dental implants placed in native bone in head and neck radiation patients. There was a tendency for implants placed in the posterior region to fail compared to those placed in the anterior region (P=0.010). This is in agreement with previous studies that have reported anatomic location and/or bone quality as a risk factor for failure of implants. [20],[21] But these studies were conducted in subjects who have no history of head and neck radiation. Implants placed in Type IV bone, which is present in posterior maxilla, have higher failure rates compared to implants placed in other types of bone, [21],[22] which is in agreement with the results of this study.

The study demonstrated that implants with a diameter of 3.75 mm or less had a higher likelihood of failing (P=0.022) compared to implants with a diameter of 4 or 5 mm when placed in grafted bone. The study showed that wider diameter turned implants had a higher survival compared to the narrow diameter implants. Unfortunately, there are no historical data to compare the results of this study with those of the previous studies.

There are always limitations associated with retrospective studies. Data about smoking and other systemic medical conditions could not be accounted for in all subjects during follow-up. Implant survival could not be analyzed in individual bone grafts (scapula, iliac crest and femur). It was not possible to calculate statistical association, as sufficient subjects were not present in each category. Also, from the data available, it was not possible to record whether the implants were placed in grafts with free flaps or in vascularized bone grafts. Further prospective long-term controlled studies are necessary to support the conclusion of this study.


   Conclusions Top


There was no statistically significant difference in survival of implants placed in native or grafted bone. For implants placed in native bone, there was a higher likelihood of failure when implants were placed in maxilla than those placed in mandible. Implants placed in the posterior region failed more than the ones placed in the anterior region for those placed in native bone. No association was identified between survival and location, length, type of bone and radiation dose received for implants in grafted bone. Statistically significant association was noted between diameter of implant and its survival for implants placed in grafted bone.

 
   References Top

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8.Keller EE. Placement of dental implants in the irradiated mandible; Aprotocol without adjuvant hyperbaric oxygen. J Oral MaxillofacSurg 1983:55;972-80.  Back to cited text no. 8
    
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10.Andersson G, Andreasson L, Bjelkengren G. Oral implant rehabilitation in irradiated patients without adjunctive hyperbaric oxygen. Int J Oral Maxilliofac Implants 1998;13:647-54.  Back to cited text no. 10
    
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13.Lyberg T, Ostad OA. The vascularized fibula flap for mandibular reconstruction. J CraniomaxillofacSurg 1991;19:235-42.  Back to cited text no. 13
    
14.Hayter JP, Cawood JI. Oral rehabilitation with endosteal implants and free flaps. Int J Oral Maxilliofac Implants 1996;25:248.  Back to cited text no. 14
    
15.Sbordone L, Toti P, MenchiniFabris G, Guidetti F. Implant survival in maxillary and mandibular osseous onlay grafts and native bone: A 3-year clinical and computerized tomographic follow-up. Int J Oral Maxilliofac Implants 2009;24:695-703.  Back to cited text no. 15
    
16.Schoen PJ, Reinstema H, Raghoebar GM, Vissink A, Roodenburg JL. The use of implant retained mandibular prosthesis in the oral rehabilitation of head and neck cancer patients: A review and rationale for treatment planning. Oral Oncol 2004;40:862-71.  Back to cited text no. 16
    
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18.Weischer T, Mohr C. Ten-year experience in oral implant rehabilitation of cancer patients: Treatment concept and proposed criteria for success. Int J Oral Maxillofac Implants 1999;14:521-28.  Back to cited text no. 18
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19.Kovacs AF. Clinical analysis of implant failures in oral tumor and defect patients. Clin Oral Implant Res 2000;11:494-504.  Back to cited text no. 19
    
20.Scurria MS, Morgan ZV 4 th , Guckes AD, Li S, Koch G. Prognostic variables associated with implant failure: A retrospective effectiveness study. Int J Oral Maxillofac Implants 1998;13:400-6.  Back to cited text no. 20
    
21.Taylor TD, Worthington P. Osseointegrated implant rehabilitation of the previously irradiated lower jaw. Craniomaxillofac Surg 1996;24:237-44.  Back to cited text no. 21
    
22.Buddula A, Assad DA, Salinas TJ, Garces YI, Volz JE, Weaver AL. Survival of dental implants in irradiated head and neck cancer patients: A retrospective analysis. Clin Implant Dent Relat Res 2010 *** [Epub ahead of print] ***.  Back to cited text no. 22
    

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Correspondence Address:
Aravind Buddula
Private Practitioner, Seattle WA
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9290.93449

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    Tables

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