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Zurich Open Repository andArchiveUniversity of ZurichMain LibraryStrickhofstrasse 39CH-8057 Zurichwww.zora.uzh.ch
Year: 2016
Implant-prosthetic rehabilitation after radiation treatment in head and neckcancer patients: a case-series report of outcome
Cotic, Jasna ; Jamsek, Jure ; Kuhar, Milan ; Hren, Natasa Ihan ; Kansky, Andrej ; Özcan, Mutlu ;Jevnikar, Peter
DOI: https://doi.org/10.1515/raon-2016-0005
Posted at the Zurich Open Repository and Archive, University of ZurichZORA URL: https://doi.org/10.5167/uzh-135081Journal ArticleAccepted Version
Originally published at:Cotic, Jasna; Jamsek, Jure; Kuhar, Milan; Hren, Natasa Ihan; Kansky, Andrej; Özcan, Mutlu; Jevnikar,Peter (2016). Implant-prosthetic rehabilitation after radiation treatment in head and neck cancer patients:a case-series report of outcome. Radiology and Oncology:1-7.DOI: https://doi.org/10.1515/raon-2016-0005
1
Implant-prostheticrehabilitationafterradiationtreatmentinheadandneckcancerpatients:
acase-seriesreportofoutcome
JasnaCotič1,JureJamšek1,MilanKuhar1,2,NatašaIhanHren3,4,MutluÖzcan5,Peter
Jevnikar1,2
1DepartmentofProsthodontics,FacultyofMedicine,UniversityofLjubljana,Slovenia
2DepartmentofProsthodontics,UniversityMedicalCentreLjubljana,Slovenia
3DepartmentofMaxillofacialandOralSurgery,FacultyofMedicine,UniversityofLjubljana,
Slovenia
4DepartmentofMaxillofacialandOralSurgery,UniversityMedicalCentreLjubljana,Slovenia
5UniversityofZürich,DentalMaterialsUnit,CenterforDentalandOralMedicine,Clinicfor
FixedandRemovableProsthodonticsandDentalMaterialsScience,Switzerland
Correspondenceto:
PeterJevnikar,DepartmentofProsthodontics,Hrvatskitrg6,1000Ljubljana,Slovenia.
Phone:015224242;E-mail:[email protected]
2
ABSTRACT
Introduction
Sloveniahasahighburdenofheadandneckcancer.Patientsaremostlytreatedwith
surgeryfollowedbyradiationtherapy.Advancedsurgicalandprosthodontictechniqueshave
expandedtherehabilitationoptions.Theaimofthestudywastoreviewtheoutcomeof
implant-prosthetictreatmentafterradiationtherapy.
Materialsandmethods:
20irradiatedheadandneckcancerpatientswhoreceivedaremovableimplant-supported
dentureattheUniversityMedicalCentreLjubljanawereincludedinthestudy.Kaplan-Meier
survivalanalysis,Coxproportionalhazardmodelsandlogisticregressionwereusedtoassess
theimplantsurvivalandsuccessrate.
Results:
20patientshad100implantsinserted.Theestimatedsurvivalratewas96%after1yearand
87%after5years.Failuresweremostlyobservedbeforeloading(91.2%).Implantsinserted
inthetransplantedboneweresignificantlymorelikelytofail.Outof89implantssupporting
thedentures,79implants(88.7%)weresuccessful,meaningthattheywerefunctionally
loadedandexhibitednopain,radiolucencyorprogressiveboneloss.Prosthetictreatment
wassignificanlylesssuccessfulinolderpatients.Theattachmentsystemandthenumberof
thedenturedidnothaveastatisticallysignificantinfluenceonthesuccessrate.
Conclusions:
Implant-supporteddenturesprovedtobeareliabletreatmentmodalityafterheadandneck
cancersurgeryandradiationtherapy.Possibleearlyfailuresshouldbecommunicatedwith
thepatients.
3
KEYWORDS
headandneckcancer,radiationtherapy,dentalimplants,implant-supporteddentures
4
Izidimplantatno-protetičnerehabilitacijepoobsevanjuzaradirakaglaveinvratu
POVZETEK
Uvod:
VSlovenijijevisokapojavnostrakaglaveinvratu.Zdravljenjenajpogostejevključuje
kombinacijokirurškeobravnaveinobsevanja.Možnostikasnejšeprotetičnerehabilitacijeso
izboljšaneobuporabisodobnihkirurškihtehnikinzobnihvsadkov.Namenprispevkaje
prikazatiizidimplantatno-protetičneoskrbeobsevanihpacientovnaUniverzitetnem
kliničnemcentruLjubljana.
Metodeinmateriali:
Vštudijismopreveriliizidzdravljenja20pacientovpokirurškioskrbiinobsevanjuzaradi
rakaglaveinvratu,kismojihoskrbelizimplantatnopodprtimiprotezami.Preživetjein
uspešnostzobnihvsadkovsmostatističnoovrednotilizmetodoKaplan-Meier,Coxovimi
modelisorazmernihtveganjinlogističnoregresijo.
Rezultati:
20pacientovjeskupnoprejelo100zobnihvsadkov.Ocenjenastopnjapreživetjavsadkovje
bila96%po1letuin87%po5letih.Doodpovedivsadkovjevečinomaprišlopred
obremenitvijo(91.2%).Vsadkivpresajenikostisoimelistatističnoznačilnoslabšepreživetje.
Izmed89obremenjenihvsadkovjihjebilo79(88.7%)uspešnih,karjepomenilo
funkcionalnouporaboprotezinodsotnostbolečinalinapredujočeizgubekostnine.Opazili
smostatističnoznačilnoslabšanjeuspehaznapredujočostarostjo,medtemkoizbor
protetičnegasidrainštevilovsadkovpodprotezoinnauspehrehabilitacijenistaimela
statističnoznačilnegavpliva.
Zaključki:
5
Implantatnopodprteprotezesozanesljivnačinprotetičneoskrbepoobsevanjuzaradiraka
glaveinvratu.Pacientejepotrebnoseznanitizmožnostjozgodnjeodpovedivsadkov.
6
INTRODUCTION
Sloveniaisamongthecountrieswiththehighestincidenceoforalandoropharyngealcancer
(deCamargoCancela,2010and2012).Inapopulatonof2millionpeople,approximately450
casesarediagnosedperyear(CancerinSlovenia2011,2015).Mosttumorsareregionally
advancedandthepatientsaretreatedwithradicalresectionandreconstructionfollowedby
radiationtreatment(CancerinSlovenia2011,2015).Afterwards,patientsexperience
profoundchangesintheoralanatomy,functionandfacialappearance.Radiationtreatment
causesirreversibledamagetobothhardandsofttissuesbycreatingahypoxic,hypocellular
andhypovascularenvironmentwhichimpedeswoundhealingandcreatesariskfor
osteoradionecrosis(Marx,1983).Aprotocolinvolvinghyperbaricoxygentreatment(HBO)
wasproposedasamethodtoenhancewoundhealingbyincreasingthetissueoxygenation
(Larsen,1997).
Followingtheradicalprocedurestoeradicatecancer,thegreatestproblemsperceivedby
irradiatedpatientsareswallowing,mouthopening,xerostomiaandcompromisedaeshetics
(Fierz,2013).Prosthodontictreatmentisadvocatedtoregainlostoralfunctions,enhance
thephysicalappearanceandenablethepatienttotakepartinnormaldailyactivitieswith
greaterconfidence.However,comprehensiveprosthetictreatmentafterheadandneck
cancerischallenging,time-consumingandcostly.Therefore,only40%ofsuchpatientsare
treatedfollowingthepostsurgicalprostheticprotocol.Amongthem,70%receivedentures
supportedbytheresidualteethandboneand30%receiveimplant-supporteddentures
(Brauner,2010).Edentulouspatientswithheadandneckcancerafterradiationtherapyare
anespeciallyvulnerablesubgroup.Radiationtreatmentsequelaepersistthroughoutthe
patient’slifetimeandinthepast,radiationtherapyusedtobeanabsolutecontraindication
7
toplacingofdentalimplants(Carini,2012).Treatmentoptionshavethereforebeenlimited
toconventionalcompletedenturesornoprostheticrehabilitationatall.
Advancedsurgicalsurgicalandprosthodontictechniques,suchas3Dplanningandguided
implantsurgery,haveexpandedthetreatmentoptions(Schiegnitz,2014).Inadditionto
conventionalball-andbar-retaineddentures,newattachmentshavebeenintroducedto
clinicalpractice.Locatorattachmentiscommonlyusedinremovableimplant
prosthodontics.Itisaself-aligningsystemwithrelativelysimplemaintenancerequirements
(Andreiotelli,2010).Locatoris,however,anon-rigidtypeofattachmentanddoesnot
completelyrelievethestressfromtheunderlyingmucosa.Toaddressthisissue,technically
moreadvancedsystemofprefabricateddoublecrownsonimplantshasbeenintroduced
(May,2002).TheSynConesystem(Dentsply,Germany)isindicatedinunfavourable
resectionareas,wherecompletelyrigidconstructionsarenecessaryduetotheanatomical
constraints.BothLocatorandSynconesystemsarecommonlyusedattheUniversityMedical
CentreLjubljana,Slovenia.Theseattachmentsystemshaveexpandedthetreatment
possibilitiesfortherehabilitationofheadandneckcancerpatients,whichisalwaysa
collaborativeworkbetweenoralsurgeonsandprosthodontists.
Theaimofthestudywastoreviewtheoutcomeoftheimplant-prostheticrehabilitationof
irradiatedpatientsperformedattheUniversityMedicalCentreLjubljana.
8
MATERIALSANDMETHODS
Aretrospectivechartreviewwasperformedforthepatientswhoweretreatedjointlybythe
DepartmentoforalandmaxillofacialsurgeryandtheDepartmentofprosthodonticsatthe
UniversityMedicalCentreLjubljanainthetimeperiodfrom2008to2014.Onlypatientswho
underwentresectionofmalignanttumourswithasubsequentradiationtreatmentand
receivedremovableimplant-supporteddentureswereincludedinthestudy.Therecorded
dataincludedpatientgenderanddateofbirth,smokingstatusatthetimeofprosthetic
rehabilitation,cancertype,surgicalmanagement,dateanddoseofradiationtreatment,
administrationofhyperbaricoxygentreatment(HBO),timingtoimplantsurgeryandto
functionalloading,treatedjaw,typeofimplantbed,numberofimplantssupportingthe
dentures,implantsystemandthedentureattachmentsystemused.AtUniversityMedical
CentreLjubljana,HBOisprovidedaccordingtotheprotocolsuggestedbyMarxandLarsen
(Marx1983,Larsen1997).Patientsarescheduledfor20sessionsbeforeand10sessions
aftertheimplantinsertion,respectively.Each90-minutesessionconsistsofexposureto
100%oxygenon2.5ATA(1.5bar)withthreebreaksduringwhichpatientsbreathenormal
air.
Theimplantswereassessedforsurvivalandsuccessusingtheguidelinesproposedbyvan
Steenbergheetal(1997).Thesurvivalcriteriaincludedosseointegrationandpresenceinthe
mouth.Tobeconsideredsuccessful,theimplanthadtobefunctionallyloaded,immobile,
withoutpersistentpainorinflammationoftheperiimplanttissueandwithoutprogressive
bonelossevidentfromradiographsandprobingdepthatyearlyrecall.
Thesurvivaltimewasmeasuredfromthedateoftheimplantinsertiontothedateofthe
implantfailureorthelastcontroloftheimplant.
9
Thepresentseriesconsistedof20patients(11menand9women)withamedianageof57.6
years(range46.7to77.2years)atthetimeoftheimplantinsertion.17patients(85%)hada
historyofsquamouscellcarcinoma.Mucoepidermoid,adenoidcysticandorigoignota
metastaticcancerwerediagnosedin1patienteach.Themostcommonsitesofprimary
cancerwerethetongueandthefloorofthemouth(6patientseach),followedbypharynx
andmaxilla(2patientseach).Mandible,tonsilla,larynxandorigoignotametastasesin
lymphnodeswereencounteredinonepatienteach.Asegmentalresectionofthemandible
wasperformedin8patients.Inonepatient,thetumorresectioninthemaxillaresultedinan
oronasalcommunication.Aftersurgery,allpatientsweresubjectedtotheradiationtherapy,
withreporteddosesrangingfrom54to66Gy.
Reconstructionwithboneandsofttissuegraftswasaccomplishedin3patients.Intwocases
thefibulargraftwasusedtoreconstructthemandible.Inonepatientthemaxillawas
reconstructedwiththeiliaccrestbonegraft.
TheKaplan-Meiermethodwasutilizedtoestimatetheimplantsurvivalrate.Theassociation
betweenthesurvivalandthepotentialprognosticfactorswasanalyzedbyfittingunivariate
Coxproportionalhazardsmodels.Theassociationbetweenthepotentialprognosticfactors
andimplantsuccesswasanalyzedwithunivariatelogisticregressionmodels.TheHolm-
Bonferronimethodwasusedtoaccountformultiplecomparisonsandthelevelof
significancewassettoα=0.05.Statisticalanalyseswereconductedwiththestatistical
softwarepackageR[R].
10
RESULTS
AspresentedinTable1,100implantsof3differentimplantsystemswereincludedinthe
study:18AstraTechimplants(Dentsply,Mannheim,Germany),22Straumannimplants
(InstitutStraumannAG,Basel,Switzerland)and60Ankylosimplants(Dentsply,Mannheim,
Germany).28implantswereinsertedinthemaxillaand72inthemandible.92implants
wereinsertedinnativeboneand8intransplantedbone.Themediantimebetweentheend
oftheradiationtherapyandtheimplantsurgerywas3.8years(range1.1to38.1years).
ProphylacticantibiotictherapywasprescribedtoallpatientsandHBOwasadministeredto
16patients.Osteoradionecrosiswasnotobservedinthisstudy.Allimplantswereinsertedin
edentulousjaws,with5patientsreceivingimplantsinbothjaws,14onlyinthemandible
and1onlyinthemaxilla.12patientswerenon-smokersand8patientsweresmokersatthe
timeoftheprostheticrehabilitation.Atwo-stageimplantinsertionprotocolwasusedinall
cases.Themedianhealingperiodbetweentheimplantinsertionandfunctionalloadingwas
15.1months(range4.3to54.3months).AsshowninTable2,threedifferentattachment
systemsforimplant-supporteddentureswereused:39Locatorattachments(ZestAnchors,
Escondido,USA)(Figure1),40prefabricatedconicalcrowns(SynCone,DentsplyFriadent,
Mannheim,Germany)(Figure2),and10customdesignedbar-clipsystems.
Medianfollowupafterimplantinsertionwas61.9months(range1.4to90.2months).
TheKaplan-Meierestimated1-and5-yearcumulativeimplantsurvivalrateswere96%(95%
confidenceinterval:92.2%-99.9%)and87.0%(95%confidenceinterval:80.4-94.2%).The
survivalcurveisshownonFigure3.Duringtheexaminationperiod,threepatientsdied.Time
ofthese14implants'serviceinthemouthwas,aswithotherimplants,registeredfromthe
dateoftheimplantinsertiontothedateofthelastfollow-upexamination.
Themediantimeoffailurewas19.1months(range1.4to48.5months)afterimplantation.
11
Thecrudesurvivalrateinoursamplewas88%,as12implantsin5patientsfailed.Datafor
alltheimplantsandforthesubgroupsofsurvivedandfailedimplantsaredescribedinTable
1.Primaryimplantfailureduringthehealingperiodbeforefunctionalloadingwasrecorded
in11implants(91.2%).Thecausesofimplantremovalinoursamplewereincomplete
osseointegration(4),persistentpain(4),andperiimplantitiswithrecurrentsofttissue
hyperplasia(3).Theonlyimplantthatwaslostafterfunctionalloading(secondaryimplant
failure)wasincludedinabar-supporteddentureandhadtoberemovedbecauseof
periimplantitis.
ResultsoftheanalysiswiththeCoxregressionmodelsispresentedinTable2.Thesurvived
andfailedimplantswerecomparableconsideringthepatient’sgender,ageandsmoking
status,thetimeelapsedbetweentheradiationtherapyandtheimplantsurgery,thejawof
theimplantinsertionandtheadministrationofHBO.Theresultsforthebonetypeindicated
thattheimplantsinsertedinthetransplantedbonewerestatisticallysignificantlymorelikely
tofailthanthoseinsertedinthenativebone.Theinfluenceoftheimplantsystemonthe
survivalcouldnotbeanalyzedbecauseoftheinsufficientnumberoffailureeventsamong
thethreegroups.
AspresentedinTable3,89implantswereobservedafterfunctionalloading.79ofthose
implants(88.7%)weresuccessful,meaningthattheywerefunctionallyloadedandexhibited
nopain,radiolucencyorprogressivebonelossevidentfromradiographsandprobingdepth
atyearlyrecall.Regardlessoftheappropriateosseointegration,prostheticrehabilitationof
10implants(11.2%)infourpatients(20%)didnothaveafavourableoutcome.Twopatients
with4implantsexperienceddifficultiesinadaptingtodenturesanddidnotwearthemon
regularbasis.Inaddition,twofurtherimplantswereconsideredunsuccessfulbecauseof
persistentsofttissuediscomfortreportedbythepatients.AsshowninTable3,higher
12
patientagewasastatisticallysignificantpredictorforthelackofsuccess.Gender,smoking
status,healingtimeafterimplantinsertion,thenumberofimplantssupportingthedenture,
theprostheticsystem,jaw,bonetypeandadministeredHBOdidnothaveastatistically
significanteffectonthesuccessrateofloadedimplantsinthissampleofirradiatedpatients.
13
DISCUSSION
Ithasbeenshowninthisstudythattheimplant-supporteddentureisareliabletreatment
modalityfortheheadandneckcancerpatientsthatundergoradiationtherapy.When
specialsurgicalandprosthodonticprotocolsareconductedappropriately,dentalimplants
greatlyenhancethestabilityofthedenturesandimprovethefacialcontours.Accordingto
thecurrentguidelines,veryfewabsolutecontraindicationsexistforusingdentalimplantsin
medicallycompromisedpatients(Diz,2013).Radiationtherapyintheheadandneckregion
isnolongeracontraindication,asthereisagrowingnumberofreportsthatahigh
osseointegrationrateandapredictabletreatmentoutcomecanbeexpected(Ihde,2009,
Tanaka,2013).Whenconsideringtheprosthodonticrehabilitationoptions,thesocio-
economicstatusofthepatientsshouldbeevaluatedcarefully.Asheadandneckcanceris
connectedwithsmokingandalcoholoverconsumption,similarproblemscanpersistafter
theinitialcancertreatment,jeopardizingtheimplant-prostheticrehabilitationoutcome.
Inthiscaseseriesofirradiatedpatients,theimplantfailureswererareandmostlyconfined
tothehealingperiod.Thepredominantlyearlyimplantlossisinaccordancewiththe
findingsofLinsenetal(2012).Extendedhealingtimeshouldthereforebeallowedafter
implantationandimmediateloadingprotocolsarenotadvised(Diz,2013).
TheKaplan-Meierestimated1-and5-yearcumulativeimplantsurvivalrateswere96%and
87%.ThisisinaccordancewithBuddulaetal(2012)reportingimplantsurvivalratesof98.9%
and89.9%after1and5yearsandYeritetal(2006)reportinga95%and91%survivalafter2
and5years,respectively.Duetothesmallnumberoffailedimplants,detailedstatistical
analysisofprognosticfactorsforimplantfailureisoftennotpossibleorlackspower.Itis
thereforedifficulttodrawmeaningfulconclusionsfromtheresultsofsinglestudiesalone.In
thisstudy,somelimitedinsightcouldbeobtainedregardingthesurvivalofimplants.There
14
wasastatisticallysignificanthigherfailurerateinthetransplantedbone.Thereduced
survivalofimplantsinthetransplantedbonemaybeexplainedbydifferencesinbone
quality,bonevolume,andrevascularizationcomparedtothenativebone(Schiegnitz,2014).
OurfindingsareinagreementwithYeritetal(2006),wherelowersurvivalwasalsoreported
forthetransplantedbone.Incontrast,Buddulaetal(2012)reportednodifferencebetween
implantsurvivalinthenativeandtransplantedbone.Theyalsoreportednodifferencein
survivalbetweengendersandconsideringthetimespanbetweenradiationtreatmentand
implantinsertion,whichisinaccordancewiththisstudy.Theirfindingofthestatistically
significanthigherhazardratioforimplantsintheupperjawcouldnotbeconfirmedinthis
study.Whiletheriskforimplantfailureisknowntobeslightlygreaterinsmokingpatients
(DeLuca2006),thesmokingstatuswasnotadetectablepredictorfortheimplantsurvivalin
thisstudy.ThiswasalsotrueforHBO,whichiscommonlyusedattheUniversityMedical
CentreLjubljanafortheheadandneckcancerpatientsrequiringsurgery.Generally,thereis
noagreementontheHBOefficacyandvalue(Spiegelberg,2010).
Implantosseointegrationandsurvivaldataprovidevaluableinformationaboutthesuccess
oftheimplanttherapy.Nevertheless,thefinaljudgementoftheimplant-prosthetictherapy
shouldbemadeaccordingthothedentureperformanceintheoralcavity.Successful
implantsenablethepatientstousethedenturesanddonotcauseanypersistent
discomfort.Toachieveafavorableclinicaloutcome,itiscrucialtodesignaviableprosthetic
planearlyintherehabilitationprocess.Headandneckcancerpatientspresentseverely
alteredandunfavourabletissueconditions,makingitchallengingtomodelrehabilitation
usingtheoptimaltop-downapproach.Thefragilemucosa,xerostomia,limitedmouth
openingandjawdeviationsareadditionalfactorstoconsider.Thepossiblelocations,
15
angulationsandimplantdimensionsmightnotbeidealandshouldbediscussedthoroughly
betweentheoralsurgeonandtheprosthodontist.
Theoptimalnumberofimplantsshouldbecarefullydecided.Thereisatendencytoinsertas
fewimplantsaspossibleinoncologicalpatients,tofacilitatebonehealing.Ontheother
handagreaternumberisoftenrequiredtodesignrigid,implant-borneprosthetic
constructions(Diz,2013).Moreimplantsalsoallowmoreflexibilityinprosthetictreatment
planning.Moreover,ifsomeimplantsarelost,implantdenturescanbesuccessfullyrepaired
andwornbythepatients.Itiscurrentlythoughtthatthenumberofimplantsisnotcritical
forthesuccessoftheprosthetictreatment(Roccuzzo,2012),butlong-termclinicalstudies
arelacking.Inthepresentstudythenumberofimplantssupportingthedentureswasnota
detectablefactorinthesuccessrateoftheprosthodonticrehabilitation.Similarly,neither
wasthetreatedjaworthehealingtime,whichexceeded4monthsinallimplants.
Theloadedimplantsalsoexhibitedsimilarsuccessratesregardlessofthedenture
attachmentsystemused.Whilethebar-supportingimplantsexperiencedlesssuccess,the
differencesincomparisontotheLocatorattachmentsandSynConesystemswerenot
significant.
Additionalsystemicandpatient-relatedfactorsmightplayanimportantroleinimplant
prostheticrehabilitation.Inthiscaseseriesofirradiatedpatients,advancedageshoweda
negativeprognosticvaluefortherehabilitationsuccess,butnotforimplantsurvival.Oneof
thepossiblelimitationsofthisstudywasthatthedataonsystemicdiseasesandalcohol
consumptionwhichmightnegativelyaffectimplantperformancewerenotincluded.After
completionoftheimplant-prostheticrehabilitation,itisofutmostimportancetoenrolthe
patientinanappropriatesupportiveprogram,withregularrecalls,cancerscreeningand
maintenanceoftheperi-implantconditions.Therecallprogramshouldmeettheindividual
16
needsofthepatientsaccordingtotheoverallriskprofile.Somepatientsshouldberecalled
every3months,whileothersmayneedtobecheckedonceperyear(Lang2015).
Thisstudyhasshownthatfavorablerehabilitationresultscanbeobtainedwithimplant-
prosthetictreatmentinirradiatedpatients.Withpropercollaborationbetweenexperienced
surgeonsandprosthodontists,thistreatmentmodalitycanberegardedaviableoptionfor
oralrehabilitationafterheadandneckcancer.
17
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TABLES
Table1
Summaryoftheimplantsurvivalaccordingtothefactorsofinterest.
Parameter Allimplants
(n=100)
Survivedimplants
(n=88)
Failedimplants
(n=12)
Patient’smedianageat
implantinsertioninyears
(range)
58.3
(46.7-77.2)
61.5
(46.7-77.2)
57.9
(46.7-77.2)
Mediantimeinterval
betweenradiation
treatmentandimplant
insertioninyears
(range)
3.8
(1.1-38.1)
3.2
(1.1-38.1)
5.2
(2.4-12.8)
Patient’sgender
• Female,n(%)
• Male,n(%)
40(40%)
60(60%)
32(36%)
56(64%)
8(67%)
4(33%)
Smoking
• No,n(%)
• Yes,n(%)
66(66%)
34(34%)
57(65%)
31(35%)
9(75%)
3(25%)
Implantsystem
• Astra,n(%)
• Straumann,n(%)
• Ankylos,n(%)
18(18%)
22(22%)
60(60%)
18(20%)
17(20%)
53(60%)
0(0%)
5(42%)
7(58%)
Jaw
• Lower,n(%)
• Upper,n(%)
72(72%)
28(28%)
63(72%)
25(28%)
9(75%)
3(25%)
Bone
• Native,n(%)
• Transplanted,n(%)
92(92%)
8(8%)
85(97%)
3(3%)
7(58%)
5(42%)
HBOadministred
• No,n(%)
• Yes,n(%)
19(19%)
81(81%)
14(16%)
74(84%)
5(42%)
7(58%)
21
Table2
Predictorsoftheimplantfailure.
Parameter Hazardratio
(95%confidenceinterval)
p
Patient’sageatimplant
insertioninyears
1.05
(0.99-1.12)
1.0000
Timeintervalbetween
theradiationtreatment
andtheimplant
insertioninyears
0.99
(0.92-1.07)
1.0000
Femalegender 2.74
(0.82-9.10)
1.0000
Smoker 0.72
(0.19-2.66)
1.0000
Lowerjaw 0.84
(0.23-3.09)
1.0000
Transplantedbone 12.37
(3.87-39.56)
0.0003
HBOadministered
0.31
(0.10-0.98)
0.4753
22
Table3
Summaryoftheloadedimplants’successaccordingtothefactorsofinterest.
Parameter Allloaded
implants
(n=89)
Successfulloaded
implants
(n=79)
Unsuccessful
loaded
implants
(n=10)
Medianpatient’sageat
prostheticrehabilitation
inyears
(range)
59.1
(49.3-79.2)
58.9
(49.3-67.9)
71.7
(59.1-79.2)
Medianhealingtime
aftertheimplant
insertioninmonths
(range)
15.1
(4.3-54.4)
15.2
(4.3-54.4)
13.0
(4.3-24.6)
Patient’sgender
• Female,n(%)
• Male,n(%)
33(37%)
56(63%)
25(32%)
54(68%)
8(80%)
2(20%)
Smoking
• No,n(%)
• Yes,n(%)
57(64%)
32(36%)
49(62%)
30(38%)
8(80%)
2(20%)
Mediannumberofthe
implantssupportingthe
denture
(range)
4(2-5)
4(2-5)
4
Implantdenturesystem
• Bar,n(%)
• Locator,n(%)
• SynCone,n(%)
10(11%)
39(44%)
40(45%)
6(8%)
37(47%)
36(45%)
4(40%)
2(20%)
4(40%)
Jaw
• Upper,n(%)
• Lower,n(%)
25(28%)
64(72%)
21(27%)
58(73%)
4(40%)
6(60%)
Bone
• Native,n(%)
• Transplanted,n
(%)
86(97%)
3(3%)
76(96%)
3(4%)
10(100%)
0(0%)
HBOadministred
• Yes
• No
75(84%)
14(16%)
65(82%)
14(18%)
10(100%)
0(0%)
23
Table4
Predictorsoftheloadedimplants’success.
Parameter Oddsratiofortheloadedimplants’success
(95%confidenceinterval)
p
Patient’sageatprosthetic
rehabilitation
0.66
(0.49-0.80)
0.0075
Healingtimeafterthe
implantinsertion
1.09
(0.53-2.73)
1.0000
Malegender 8.64
(1.99-60.09)
0.1456
Smoker 2.44
(0.57-16.95)
1.0000
Numberoftheimplants
supportingthedenture
0.78
(0.24-1.94)
1.0000
Dentureattachmentsystem
• Locatorvsbar
• SynConevsbar
• SynConevsLocator
12.33
(1.98-104.98)
6.00
(1.15-32.68)
0.48
(0.06-2.65)
0.1456
0.4416
1.0000
Upperjaw
0.54
(0.14-2.30)
1.0000
24
Figures
Figure1
Aclinicalsituationofapatientwiththesegmentalresectionoftheleftmandiblebodydueto
cancer,asvisibleontheradiograph(a).Thepatientreceivedanimplant-supportedlower
denture(b),wheretheretentionwasbasedontheLocatorconcept(c).
b
c
a
25
Figure2
Aclinicalsituationofapatientrehabilitatedafteroropharyngealcarcinoma.Segmental
resectionoftheleftmandiblebodyisvisibleontheradiograph(a).Thepatientreceived
implant-supportedlowerandupperdentureswithretentionbasedontheSynConedouble
crownconcept(b).
a
b
26
Figure3
TheKaplan-Meiercurveforthesurvivaloftheimplants.95%confidenceintervalsand
censoreddataareincludedontheplot.