Abstract
Introduction:
Restoration of dental rehabilitation is the ultimate goal of functional jaw reconstruction, which is called “occlusion-driven jaw reconstruction”, whereas fibular mandibular reconstruction (FMR) in the Asian population fails to adequately provide adequate bone volume for subsequent dental implantation. This study proposed a preoperative occlusion-driven design of FMR and compared the peri-implant bone thickness in fibular-reconstructed mandibles with or without preoperative occlusion-driven design.
Methods:
The patients underwent FMR and following dental implantation were reviewed, consisting of 10 cases with preoperative occlusion-driven design of free fibular flap (FFF) as the experimental group and the other 12 cases as the control group. A total of 82 endosseous implants were radiographically evaluated and the cross-sectional buccal, lingual, and bottom distances between implant and fibula were calculated.
Results:
The lingual bone thickness at the crown third of the peri-implant in the premolar region and at the middle third of the peri-implant in the molar region was 2.36±0.36 and 4.90±0.43 mm in the experimental group, significantly greater than 1.57±0.15 and 3.73±0.32 mm in the control group, respectively (P=0.04, P=0.032). The bone thickness at the root of the peri-implant in the experimental group was significantly greater than that in the control group (P=0.007). Specifically, the anterior and premolar regions in the experimental group were 4.31±0.24 and 4.29±0.30 mm, significantly greater than 3.21±0.40 and 4.16±0.30 mm in the control group, respectively (P=0.019 and P=0.009). No significant difference was found in the buccal bone thickness at the crown, middle, and root third of the peri-implant between the experimental and control groups.
Conclusions:
On the basis of the results of limited cases, this study demonstrated preoperative occlusion-driven design of the intended fibula segment for implant placement could provide adequate bone volume for endosseous implants, contributing to maximize successful osseointegration and minimize complications for FMR patients.
Key Words: CBCT, dental implantation, fibula free flap, mandibular reconstruction, occlusion-driven design
When reconstructing mandibular segmental defects using vascularized free fibular flaps (FFF), both of the facial symmetry and occlusal rehabilitation are taken into account by craniomaxillofacial surgeons. Recently, the development of computer-aided surgery (CAS) has greatly enhanced the precision of fibular mandibular reconstruction (FMR); however, achieving satisfactory dental rehabilitation with osseointegrated implants in fibular-reconstructed mandibles remains a major clinical challenge.1,2
Restoration of dental occlusion and oral rehabilitation is the ultimate goal of functional jaw reconstruction, which is called “occlusion-driven jaw reconstruction”. The occlusion-driven FMR following by implant-retained prothesis should restore the height of the alveolar ridge to avoid the imbalance of crown-to-root ratio so as to reduce the occurrence of peri-implant inflammation.2 Although FMR in most Asian population, particularly females, fails to adequately provide bone volume for subsequent dental implantation. It was reported that only 4.2% and 21.1% of fibulas possessed bone height suitable for inserting dental implants in females and males, respectively.3 In addition, the radiographic investigation categorized the cross-sectional morphology of transplanted fibulas into 2 types: pointed and non-pointed, with the former being too narrow to support implants.4 Nevertheless, the fibula exhibited significant variability in height and width, both within individual segments and between segments from the same patient. The cross-sectional shape of fibulae varies along its length, and certain regions may simultaneously meet the height and width requirements for dental implantation.5,6 Therefore, preoperative imaging and planning are critical to account for fibular anatomical variations and proper region for implant placement.
Advances in digital 3D software allow for preoperative assessments of 3D skeletal models and detailed anatomical variations.7 In our previous research, with preoperative design of FFF cases, we measured the height, width, and shape of the proximal, middle, and distal segments of the fibula in Chinese adults, as well as the corresponding dimensions in the anterior, premolar, and molar regions of the mandible.8 This enabled us to assess the morphologic compatibility between different fibular segments and mandibular regions. Building on these findings, we applied this preoperative occlusion-driven design of FFF to FMR cases.9 In the current study, we retrospectively analyzed these FMR cases undergoing subsequent dental implantation, measuring peri-implant bone volume in comparison to cases without preoperative occlusion-driven design.
MATERIALS AND METHODS
Ethics Statements
The study was approved by the Ethics Committee of the School of Stomatology, Nanjing Medical University, China (PJ2020-119-001), and written informed consent was obtained from all patients.
Patients and Data Collection
The patients who underwent FFF for mandibular reconstruction and following dental implant rehabilitation at the department of Oral and Maxillofacial Surgery, affiliated to Stomatological Hospital of Nanjing Medical University from September 2020 to January 2024 were reviewed in this study. To concretize the preoperative occlusion-driven design of FFF, our previous study suggested that the middle and distal regions of the fibula were suitable for FMR in the anterior tooth area, whereas the proximal region of the fibula was more appropriate for FMR in the premolar and molar regions (Fig. 1). Among all reviewed cases, the patients received preoperative occlusion-driven design of FFF were selected as the experimental group, and the other patients were selected as the control group.
FIGURE 1.
Schematics of preoperative occlusion-driven design for fibular mandibular reconstruction.
All cases were performed with dental implantation at least 6 months after FMR and received CBCT (NewTom VGi) examination. The CBCT images were acquired at 80 kV and 10 mA, with scanning layer volume of 0.25 mm. The obtained digital imaging and communication in medicine (DICOM) data of CBCT after implantation were imported into software SIMPLANT Pro 17.01 (Materialize) for the following peri-implant bone volume measurement.
Protocol for the Analysis of Measurements
The middle sagittal sectional slide of the implant was chosen for measuring the peri-implant bone volume by the distance calculation model of the SIMPLANT Pro 17.01 software. The crown, middle, root thirds of the buccal and lingual bone thickness of each implant were measured, as well as the distance between the implant bottom and the fibular inferior border (Fig. 2). Two independent analysts (D.M. and Z.W.) performed the measurements of the above 7 sites of peri-implant bone thickness 3 times and took the average.
FIGURE 2.
Selected cross-sectional landmarks for bone thickness calculation of peri-implant in fibular-reconstructed mandible.
In this study, dental implants of varying diameters and lengths were utilized across different regions. In the anterior area, implant diameters included 3.5, 4.0, 4.3, and 4.5 mm. Similarly, the premolar area featured implants with diameters of 4.0, 4.3, 4.5, and 5.0 mm, whereas the molar area used implants of 4.0, 4.3, 4.5, and 5.0 mm. Implant lengths varied across 5 options: 8, 10, 11, 11.5, and 13 mm. To minimize the potential bias produced by variations in implant dimensions during comparative analysis, standardized reference implants were selected for data normalization. Specifically, 4.0×10 mm (diameter×length) implants were used as the standard for the anterior region, whereas 4.5×10 mm implants served as the reference for both the premolar and molar regions.
Statistical Analysis
Data were expressed as the mean ± SD and statistically analyzed with SPSS 23.0 software (SPSS Inc). The difference of demographic and clinical data of the experimental and control groups was evaluated using a 1-way analysis of variance (ANOVA) and t test. The differences of peri-implant bone volume at the same measuring sites between experimental and control groups and differences among the anterior, premolar, and molar regions within each group were evaluated using generalized estimating equations (GEE). Statistical significance was set at P<0.05.
RESULTS
Demographic and Clinical Characteristics
A total of 116 FMR cases were reviewed and 22 (18.97%) patients underwent dental implantation, with 10 cases in the experimental group and 12 cases in the control group (Fig. 3). The FFF of all cases survived. The postoperative follow-up time was more than 6 months, and no obvious complications were found in the donor/recipient area. The representative case of the experimental group is shown in Figure 4. The demographic and clinical characteristics of the enrolled patients in both groups were summarized in Supplementary Table 1, Supplemental Digital Content 1, http://links.lww.com/SCS/J762. In the experimental group, 36 implants were evaluated, distributing as follows: 12 in the anterior region, 9 in the premolar region, and 15 in the molar region. In the control group, 46 implants were assessed, comprising 15 in the anterior region, 15 in the premolar region, and 16 in the molar region. No statistically significant differences were observed in clinical variables such as sex, age, or implant locations between 2 groups.
FIGURE 3.
Study flow chart of included cases.
FIGURE 4.
The representative case of the experimental group undergoing preoperative occlusion-driven design for fibular mandibular reconstruction. (A) Preoperative occlusion relationship; (B) preoperative 3D reconstruction; (C) preoperative occlusion-driven design of fibular segmentation; (D) simulation of dental implantation in fibular-reconstructed mandible; (E) dental implantation in fibular-reconstructed mandible; (F) postoperative occlusion relationship; (G) completion of implant-retained rehabilitation.
In the premolar and molar regions, all cases of experimental group showed a normal occlusion relationship between maxillae and mandible after completion of implant-supported rehabilitation (Fig. 5A), whereas 3 cases in control group presented with a reverse occlusion relationship (Fig. 5B). In the anterior mandibular region, in comparison to experimental group, 4 implants of control group positioned more towards the buccal side in the transplanted fibular segment to get a normal occlusion relationship (Fig. 5C and D).
FIGURE 5.
Occlusion relationship of implant-supported rehabilitation in experimental group (A) and control group (B) in the molar region; implants inclination in experimental group (C) and control group (D) in the anterior region.
Buccal Bone Thickness of the Peri-Implant
As shown in Supplementary Table 2, Supplemental Digital Content 2, http://links.lww.com/SCS/J763，3, Supplemental Digital Content 3, http://links.lww.com/SCS/J764 and 4, Supplemental Digital Content 4, http://links.lww.com/SCS/J765, no significant difference was found in the buccal bone volume at the crown, middle, and root third of the peri-implant between experimental and control groups.
Within the experimental group, significant differences were observed between the anterior and molar regions (P=0.008) and between the premolar and molar regions at the crown third of the peri-implant (P<0.001). Within the control group, significant differences were noted between the anterior and premolar regions (P=0.012) and between the anterior and molar regions (P=0.011) (Supplementary Table 2, Supplemental Digital Content 2, http://links.lww.com/SCS/J763).
As shown in Supplementary Table 4, Supplemental Digital Content 4, http://links.lww.com/SCS/J765, significant differences were observed between the anterior and premolar regions (P<0.001) at the root third of the peri-implant within the experimental group. Although within the control group, significant differences were noted between the anterior and molar regions (P=0.01).
Lingual Bone Thickness of the Peri-Implant
As shown in Supplementary Table 5, Supplemental Digital Content 5, http://links.lww.com/SCS/J766 and 6, Supplemental Digital Content 6, http://links.lww.com/SCS/J767, the lingual bone volume at the crown third of the peri-implant in the premolar region and at the middle third of the peri-implant in the molar region was 2.36±0.36 and 4.90±0.43 mm in experimental group, significantly greater than 1.57±0.15 and 3.73±0.32 mm in control group, respectively (P=0.04, P=0.032).
Within the control group, significant differences were found between the anterior and premolar regions (P=0.001) and between the anterior and molar regions (P=0.03) at the crown and middle third of the peri-implant, as well as between the premolar and molar regions (P=0.047) at the middle third of the peri-implant.
As shown in Supplementary Table 7, Supplemental Digital Content 7, http://links.lww.com/SCS/J768, no significant difference was found in the lingual bone volume at the root third of the peri-implant between experimental and control groups. However, within the experimental group, a significant difference was observed between the anterior and molar regions (P=0.004).
Bone Thickness at the Root of the Peri-Implant
As shown in Supplementary Table 8, Supplemental Digital Content 8, http://links.lww.com/SCS/J769, the bone thickness at the root of the peri-implant in the experimental group was significantly greater than that in the control group (P=0.007). Specifically, the anterior and premolar regions in the experimental group were 4.31±0.24 and 4.29±0.30 mm, respectively, significantly greater than 3.21±0.40 and 4.16±0.30 mm in the control group (P=0.019 and P=0.009, respectively). No significant differences were found across different regions within either experimental or control groups.
All cases of the experimental group utilized dental implants with a length no more less than 10 mm, whereas short implants of 8 mm were more common in the control group. In addition, regardless of whether free bone grafting was used, the dental implants in the experimental group were all within the cortical bone of a single segment and did not penetrate the lower cortical bone of the fibula, whereas in the control group, 2 cases with a total of 5 dental implants penetrated the double-layer cortical bone of the fibula (Fig. 6).
FIGURE 6.
Completion of implant-retained rehabilitation with or without free bone grafting in the experimental group (A and B) and the control group (C and D).
DISCUSSION
The occlusion-driven FMR could enhance the outcomes of oral rehabilitation.2,6,10–12 Sukato et al11 introduced an advanced prosthodontic technique of implant-borne articulation splint ensuring the fibula grafts and implants in a restorable position for subsequent dental implants insetting. Choi et al12 found the additional application of patient-specific occlusion-based positioning guide could obtain ideal occlusal relationship and mandibular contour in patients undergoing FMR, in comparison to single fibular cutting guide. Therefore, the occlusion-driven FMR could achieve both the aesthetic and functional outcomes of dental restoration.
The thickness and bone mineral density (BMD) of the fibular cortical bone were considered as important indicators for determining the initial stability and long-term survival rates of implants, respectively.13,14 The superior cortex density was significantly higher for the fibula than the native mandible and the changing trend of fibular BMD after jaw reconstruction was <10% absorption rate in 75.9% of fibular jaw reconstruction patients 6 months postoperatively.6,14 Hence, the thickness of peri-implant in fibular cortical bone may influence the success rate of implant denture restorations. In addition, when dental implants are subjected to functional loading, mechanical stress is predominantly concentrated in the cortical bone surrounding the implant neck. As the implant diameter increases, the contact area between the implant and the bone expands, allowing the load to be distributed over a larger surface area of the bone tissue. This results in a reduction in stress at the bone-implant interface in the cervical region, thereby enhancing the implant’s support and retention capabilities, slowing bone resorption, and improving the overall success rate of the implant.15 Therefore, under the premise of ensuring adequate volume of the buccal and lingual bone walls, it is advisable to select implants with larger diameters whenever possible. In this study, the experimental group utilized implants with diameters exceeding 4 mm, whereas the control group included many implants with diameter of 3.5 mm. In the experimental group, the distances between the crown aspect of the premolar implants and the lingual bone wall, as well as the middle and root aspect of the molar implants and the lingual bone wall, were significantly greater than that of the control group. Meanwhile, no significant difference was found in buccal bone volume of the peri-implant between 2 groups. All these results suggested more bone volume in the buccolingual dimension in cases of the experimental group, which could allow for better distribution of mechanical stress of postoperative prosthetic rehabilitation and recovery of masticatory function.
Sufficient bone volume in the vertical dimension provided better conditions for the selection of implant length, thereby enhancing the long-term success rate of implantation.13 A 3-year follow-up study on post-implantation outcomes demonstrated that the probability of peri-implant bone resorption and implant failure significantly increased when the crown-to-root ratio exceeded 3.16 As the height of fibula was only 1.3 to 1.5 mm, folded fibular flap or secondary distraction osteogenesis after single-segment FFF transplantation was utilized to increase the vertical height of reconstructed mandible.2,17–19 Compared with reconstruction using only single-segment FFF, the length of endosseous implants in distracted fibular mandible increased by 0.66 to 2.06 mm.19 In this study, the implant lengths utilized in the experimental group were no less than 10 mm, whereas in the control group, short implants of 8 mm were more prevalent. Furthermore, the distance between the implant apex and the basal bone wall in the anterior and premolar regions was significantly greater in the experimental group. These findings indicated that FMR conducted in the experimental group, based on preoperative occlusion-driven design of FFF, achieved greater vertical bone height, thereby facilitating the selection of longer endosseous implants. Besides, as implant-supported restoration after FMR did not necessitate the placement of dental implants corresponding to the exact number of missing teeth, preoperative occlusion-driven planning to position the fibular segments with optimal height in regions most favorable for implant placement could facilitate implant-retained rehabilitation. This approach could mitigate complications associated with distraction osteogenesis, such as fibular segment fracture, lingual displacement of the fibular segment, and wound dehiscence, thereby reducing treatment duration and costs.19
Previous study proved that FMR followed by immediate or delayed placement of osseointegrated implants was an ideal and predictable treatment modality for patients with mandibular benign tumor, presenting with better masticatory function, improved quality of life, and less psychological consequences.20 However, the proportion of dental implant-supported rehabilitation in FMR patients was relatively low.21 In our series, only 18.97% of all FMR cases received dental implantation, all of which were delayed implant placement at least 6 months postoperatively. Most of MFR patients refused the dental implantation owing to heavy psychological burden associated with several times of surgical operations, and high cost of implant-supported prothesis. In contrast, some cases of malignant tumors posed difficulties for secondary dental implantation because of postoperative radiotherapy. It was reported that failure of already rehabilitated implants almost always occurs in irradiated patients.22 The FMR cases with postoperative radiotherapy were not recommended for dental implantation in our department, although some studies suggested a waiting period between irradiation and implant placement could warrant the implant viability.23,24
As a retrospective analysis, this study had certain limitations. Firstly, the sample size of patients who underwent dental implantation after FMR was relatively small. Secondly, the study’s retrospective nature and variability of different dental implants may affect the consistency and resolution of measurements. Furthermore, there was no comprehensive evaluation such as comparison of masticatory function and long-term implant stability after the completion of prosthetic restoration, which was the confirmative evidence for the advantage of occlusion-driven FMR. Therefore, this study was essentially a radiographic analysis providing foundational data and reference value for future investigation.
CONCLUSIONS
Building upon the findings of limited cases, this study conducted a radiographic comparison of peri-implant bone volume in free fibular flap with or without preoperative occlusion-driven mandible reconstruction. Results from this study suggested that preoperative planning of the intended fibula segment for implant placement provided adequate bone height and width for endosseous implants, which could be leveraged to maximize successful osseointegration and minimize complications for FMR patients.
Supplementary Material
Footnotes
D.M., J.C., and H.Z. contributed equally to this article.
Y.D. and Y.W. designed the study and performed the drafting article. D.M., H.Z., J.C., and Z.W. collected the data. Y.B. and Y.Y. were responsible for the data analyses. L.W. and H.Y. made critical revision of the article.
The work was supported in part by the National Natural Science Foundation of China (Grant No. 81800936) and the Jiangsu Province Capability Improvement Project through Science, Technology and Education-Jiangsu Provincial Research Hospital Cultivation Unit (YJXYYJSDW4), Jiangsu Provincial Medical Innovation Center (CXZX202227) and by the Project Funded by Jiangsu Provincial Commission of Health and Family Planning, Nanjing, China (BJ18035) and Nanjing Specific Program of Health and Technology Development, Nanjing, China (YKK23295).
The authors report no conflicts of interest.
Supplemental Digital Content is available for this article. Direct URL citations are provided in the HTML and PDF versions of this article on the journal’s website, www.jcraniofacialsurgery.com.
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