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SURGICAL ONCOLOGY AND RECONSTRUCTION
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Computer-Aided Rehabilitation of MaxillaryOncological Defects Using ZygomaticImplants: A Defect-Based Classification
eived
partme
ogna, I
*---
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z---
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kFull PrDrs Pel
Addres
xillofac
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Gerardo Pellegrino, DDS,* Achille Tarsitano, MD,y Francesco Basile, DDS,zAngelo Pizzigallo, MD,x and Claudio Marchetti, MD, DDSk
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Purpose: A complete maxillectomy for neoplastic lesions leads to serious oral dysfunction. Zygomatic
implants for fixed bridge support are considered beneficial for maxillary defects after tumor resection.
Materials andMethods: This clinical study examined the management of patients with different maxil-
lary defect types who underwent delayed rehabilitation using zygomatic implants and immediate pros-thetic loading. Virtual preoperative planning and intraoperative navigation were performed in all cases.
Results: Five patients were treated with this newmethod. The total number of zygomatic implants posi-tioned was 17. Four patients had immediate loading of a fixed prosthesis and 1 had delayed loading. One
patient had 1 failed implant.
Conclusion: The use of preoperative virtual surgical planning and an intraoperative navigation system
allows the surgeon to achieve safer implant positioning in a complex anatomic site. A systematic bone
defect classification was created and a specific treatment protocol is proposed for each type of defect.
� 2015 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg -:1.e1-1.e11, 2015
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Oncologic bone resection for neoplastic lesions
involving the maxilla leads to serious oral dysfunction
with respect to speaking, swallowing, chewing, and
quality of life.1 Defect classification systems enable cli-
nicians to choose the type of rehabilitation and deter-
mine a functional prognosis.1 Since the publication ofthe study by Ohngren,2 many classification schemes
have been proposed to describe the anatomic bound-
aries of maxillectomy defects.1-3
A complete maxillectomy produces complex de-
fects of the alveolar bone, palate, paranasal sinuses,
and orbital floor.4 Loss of these anatomic structures
has relevant functional and esthetic consequences.
Reconstruction of this region should 1) preventany communication between the oral cavity and
the nasopharynx, 2) reconstruct the palatal surface,
from the Oral and Maxillofacial Surgery Division,
nt of Biomedical and Neuromotor Sciences, University of
taly.
.
.
.
.
ofessor.
legrino and Tarsitano contributed equally to this research.
s correspondence and reprint requests to Dr Tarsitano:
ial Surgery Unit, S Orsola-Malpighi Hospital, Department
1.e1
FLA 5.4.0 DTD � YJOMS56955_proof � 22
and 3) achieve facial symmetry and good facial
morphology.5
Several surgical reconstruction options exist,
including nonvascularized grafts, local flaps, and
microsurgical reconstruction with bone or soft tis-
sues.6 However, in many cases, dental implants havebeen used to obtain functional restoration throughme-
chanical retention of dental prostheses.7
Implant placement and subsequent prosthetic reha-
bilitation are often difficult to obtain after maxillec-
tomy because of a lack of bone alveolar tissue and
gingiva.7 Dental implants can be considered a viable
restorative option only when the basal maxillary
bone is preserved.8
Zygomatic implants are used to rehabilitate patients
with insufficient bone volume for ‘‘traditional’’ dental
of Biomedical and Neuromotor Sciences, Alma Mater Studiorum
University of Bologna, Via S Vitale 59, 40125 Bologna, Italy Q3;
e-mail: achille.tarsitano2@unibo.it; achilletarsitano@gmail.com
Received May 28 2015
Accepted August 31 2015
� 2015 American Association of Oral and Maxillofacial Surgeons
0278-2391/15/01265-3
http://dx.doi.org/10.1016/j.joms.2015.08.020
September 2015 � 8:11 pm � CE AH
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1.e2 COMPUTER-AIDED MAXILLARY DEFECT REHABILITATION Q1
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implants.7-13 These implants are inserted into the
zygomatic bone when alveolar bone is deficient after
maxillectomy.7,14,15 However, the application of
zygomatic implants in reconstructive surgery is often
associated with various problems, including
deficiencies of bone tissue and the presence of a
reconstructive soft tissue flap.7
In this clinical study, the authors examined the man-agement of patients with different maxillary defect
types who underwent delayed rehabilitation using
zygomatic implants and immediate prosthetic loading.
Clinical outcomes were assessed for implant failure
and prosthetic loading.
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Rehabilitative Protocol
During the preparation of this article, it became
clear that none of the classifications addressed maxil-
lary restoration using zygomatic implants. A system-
atic bone defect classification was considered and a
specific treatment protocol is proposed for each type
of defect.Patientswere categorized into 3 classes according to
the site of the defect, the size of the defect, and resid-
ual masticatory function. Class I was defined as bilat-
eral maxillectomy. Class II was defined as unilateral
maxillectomy. In this class, 3 subclasses were identi-
fied according to the dental status of the unresected
side: Class IIA included patients with dentition or par-
tial dentition in the contralateral maxilla. Class IIBincluded patients without dentition in the residual
maxilla. Class IIC included patients without dentition
in the healthy maxilla with atrophied alveolar bone.
Class III included patients whose anterior maxilla (pre-
maxilla) was resected.
FIGURE 1. Class I defect restored using a total pr
Pellegrino et al. Computer-Aided Maxillary Defect Rehabilitation. J Oral
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For patients in Class I, the treatment provided
4 zygomatic implants (2 for each zygoma; Fig 1). For
those in Class IIA, rehabilitation was achieved through
the insertion of 1 or 2 zygomatic implants on the re-
sected side and 1 zygomatic implant on the unresected
side. This implant was inserted in the contralateral
zygomatic bone with a trajectory passing above the
dental roots and below the nose (Fig 2). For those inClass IIB, 2 zygomatic implants were inserted on the
resected side and traditional implants were inserted
in the alveolar bone of the healthy maxilla (Fig 3). If
the healthy side did not have sufficient alveolar bone
height, then 2 zygomatic implants were inserted in
this site instead of traditional implants (Class IIC;
Fig 4).
For patients in Class III, the treatment provided 4zygomatic implants for the edentulous patient (Fig 5).
Otherwise, the use of standard implants or a dental-
supported prosthesis was contemplated.
Materials and Methods
From October 2013 through April 2014, 5 patientswith maxillary defects owing to resections of neo-
plasms were recruited. The hospital’s institutional re-
view board approved this study protocol. Written
informed consent was obtained from each patient
and the study protocol conformed to the ethical guide-
lines of the World Medical Association Declaration of
Helsinki—Ethical Principles for Medical Research
Involving Human Subjects.Patients were scheduled for treatment based on the
extent of resection and residual bone. Clinical proce-
dures were performed according to the specific treat-
ment protocol proposed for each type of defect. In
4 patients, zygomatic implant positioning was delayed
osthesis supported by 4 zygomatic implants.
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FIGURE 2. Class IIA defect restored using a partial prosthesis supported by 2 zygomatic implants on the resected side and 1 zygomaticimplant positioned in the contralateral maxilla.
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PELLEGRINO ET AL 1.e3
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with respect to themaxillary resection. All patients un-
derwent rehabilitation using zygomatic implants
(Southern Implants, Irene, South Africa). Zygomatic
implant length ranged from 27.5 to 52.5mm accordingto the residual anatomy after resection.
VIRTUAL PLANNING
Each patient in the study underwent preoperative
computed tomographic (CT) scanning of the maxillo-
facial region. Digital Imaging and Communications in
Medicine (DICOM) data extracted from the CT scan
were imported into simulation software (SimPlantO&O; Dentsply Implants, Leuven, Belgium) for prelim-
inary planning. This plan allowed the surgical team to
simulate implant placement on a 3-dimensional (3D)
FIGURE 3. Class IIB defect restored using a full-arch prosthesis supportemaxilla.
Pellegrino et al. Computer-Aided Maxillary Defect Rehabilitation. J Oral
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model. While considering theanatomic structures
and the bone resection performed, the surgical team
interactively simulated the position and the length of
the implant in each plane. Once the implant was posi-tioned, its angulation could be modified and its dimen-
sions adapted to obtain a better 3D position (Fig 6).
In 3 cases, an intraoperative navigation system was
used to control implant positioning. In 2 of these
cases, CT data were imported into the navigation sys-
tem software (ImplaNav, BresMedical, Ingleburn,
Australia). A dental-supported reference tool for the
passive tracking navigation system was used to con-nect the patient’s position with the navigation system
in real time. In 1 case, an active tracking navigation sys-
tem was used for the intraoperative navigation guide.
d by 2 zygomatic implants and standard implants in the unresected
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FIGURE 4. Class IIC defect restored using a total prosthesis supported by 2 zygomatic implants on the resected side and standard zygomaticimplants in the atrophied contralateral maxilla.
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1.e4 COMPUTER-AIDED MAXILLARY DEFECT REHABILITATION
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In this case, an active tracker was placed on the cra-nial skeleton.
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SURGICAL PROCEDURE
A full-thickness flap was performed in all cases to
obtain zygomatic bone exposure. Implant drilling
was performed using a straight or angled handle. Thefixtures were placed with the handle at 30 rpm at a
maximum torque of 50 N-cm or manually.
Zygomatic implants were used when in contact
with the skin flap. This kind of zygomatic implant
has a machined surface rather than spires in the third
coronal portion of the fixture (Fig 7). Figure 8 shows
the design of the implant. Standard zygomatic im-
plants were inserted to maintain contact with theoral gingiva and mucosa.
FIGURE 5. Class III defect restored using a pros
Pellegrino et al. Computer-Aided Maxillary Defect Rehabilitation. J Oral
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In these cases in which implant placement was per-
formed under a navigation guide, during surgery, there
was constant visualization of the drill trajectory in the
3D-reconstructed CT image and in the sagittal, coro-
nal, and axial views (Fig 9).Deviation from the planned position was detected
immediately, and precise implant placement was
achieved. Postoperative radiographic evaluation
confirmed the placement and angulation of the
implant in the remaining zygomatic bone.
PROSTHETIC PROCEDURE
In 4 of the 5 cases, right or angled conical abutments
were mounted before suturing and not removed. At
the time of surgery after the suture pickup, transferswere positioned and splinted with flow composite
thesis supported by 4 zygomatic implants.
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FIGURE 6. Virtual implant positioning in a Class IIA defect case. The angulation of the implants can be adjusted according to the final pros-thetic position and their dimensions can be adapted in the 3-dimensional model. The patient underwent a left maxillectomy for oral squamouscell carcinoma. Q8The defect was initially restored using a temporalis muscle flap.
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or resin. An impression was taken with a polyetherimpression material (Impregum Penta, 3M ESPE, St
Paul, MN) using a custom-made tray, reproducing the
dental arch, placed in occlusion. Within 72 hours, a
screw-retained fixed bridge was delivered (Fig 10).
A new definitive prosthesis could be placed after a
3-month follow-up if the prosthetist deemed it neces-
sary. The definitive prosthesis could be a fixed
bridge or an overdenture-retaining bar to facilitateoral hygiene.
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FOLLOW-UP
After 3 months, the prosthesis was unscrewed and
implant stability was tested. Implant stability, pain,
FIGURE 7. Intraoperative image
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and inflammation of the peri-implant soft tissue werethe parameters assessed. The same clinical outcomes
were evaluated at each subsequent assessment at 6,
12, and 18 months. Postoperative radiographs (ortho-
pantomogram and lateral head radiograph) were taken
immediately after surgery, after 6 and 12 months, and
then once every year (Figs 11, 12).
QUALITY-OF-LIFE ASSESSMENT
The Oral Health-Related Quality of Life Question-
naire (OHRQOL) is ‘‘a multidimensional construct
that reflects (among other things) people’s comfort
when eating, sleeping, and engaging in social inter-
action; their self-esteem; and their satisfaction with
showing implant positioning.
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FIGURE 8. Zygomatic implant design.
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1.e6 COMPUTER-AIDED MAXILLARY DEFECT REHABILITATION
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respect to their oral health.’’16 The OHRQOL is
associated with functional factors, psychological fac-tors, social factors, and experience of pain or
discomfort.17
OH-14 QOL questionnaires were administered to
each patient. A high score indicates low functional
ability. The questionnaire was administered preopera-
FIGURE 9. Intraoperative implant positioning control using a navigationof the planned site and the angulation of the implant during the insertion.
Pellegrino et al. Computer-Aided Maxillary Defect Rehabilitation. J Oral
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tively (T0) and after prosthetic rehabilitation at
2 weeks (T1) and 6 months (T2).
Results
Five patients received this treatment (age range,
51 to 83 yr; mean, 61.8 yr). The follow-up period
system. The navigation screen allows the surgeon to view the drilling
Maxillofac Surg 2015.
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FIGURE 10. Dental prosthesis fixed 72 hours after surgery.
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was 10 to 29 months (mean, 12 months). Four of the
5 patients had delayed implant placement withrespect to primary maxillary resection. The mean in-
terval from resection to implant positioning was
34 months (range, 29 to 61 months).
One patient had implants placed at the same time as
surgical bone resection. This patient underwent adju-
vant radiotherapy 2 months after implant insertion.
Table 1 lists the patient characteristics and the
numbers of implants positioned in each case. Accord-ing to the proposed classification, 2 patients were in
Class IIA, 1 was in Class IIC, 1 was in Class I, and 1
was in Class III. The total number of zygomatic im-
plants positioned was 17. Four patients had immediate
loading of a fixed prosthesis and 1 had delayed loading.
One patient had 1 failed implant. At approximately
8 months after loading, during a follow-up examina-
tion, unscrewing of the prosthesis was detected. Afterprosthesis removal, 1 implant had a rotation during
contra-torque shunting. The fixture was unscrewed
without local anesthesia and the prosthesis was re-
placed. No definitive prosthesis has been requested
the prosthodontist or the patient. To date, no peri-
implantitis or local inflammation has occurred.
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QUALITY-OF-LIFE ASSESSMENT
Results from the OH-14 QOL questionnaire are re-
ported using a score system. Information on QOL al-
lows the assessment of patient-reported perceptions,
thus improving the possibility of effective communica-tion between physicians and patients.18 This leads to
better knowledge of the impact of oral health on the
daily activities of the patient and an evaluation of the
clinical results obtained. The OH-14 questionnaire
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mean values at baseline and at T0, T1, and T2 are listed
in Table 2.A mean of 10 points in QOL improvement was re-
corded between the T0 and T2 assessments.
Discussion
Extensive surgery for neoplasms of the jaws often
produces serious functional, emotional, and social ef-
fects on patients.19 Currently, immediate reconstruc-
tion with local pedicled flaps or microsurgical flaps
is often performed, somewhat decreasing postopera-
tive functional impairment. However, even when
reconstruction is performed successfully, it does not
always guarantee functional restoration of mastica-tion. Soft tissue flaps, temporalis muscle flaps, and fas-
ciocutaneous free flaps do not offer the possibility of
implant insertion.
Althoughminor maxillary bone resections can be re-
paired easily, large defects often require complex reha-
bilitation.8 Some of these cases could be restored using
standard implants with long abutments anchored in
the zygoma area.20
In contrast, most extensive resections lead to com-
plete loss of the alveolar bone with the consequent
loss of support for the facial soft tissues in the lip
and cheek areas.8
Moreover, in most cases, surgery is associated with
adjuvant radiotherapy that can cause adjunctive
impairment of the elastic properties of the facial
structures.In patients in whom immediate reconstruction with
amicrosurgical bone flap after a subtotal maxillectomy
is not possible, zygomatic implants could represent
the only available option to obtain stable support for
September 2015 � 8:11 pm � CE AH
FIGURE 11. Frontal radiographic outcomes of a Class IIA defect.
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1.e8 COMPUTER-AIDED MAXILLARY DEFECT REHABILITATION
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FIGURE 12. Lateral radiographic outcomes of a Class IIA defect.
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a viable prosthesis.7,8 The specific design of zygomaticimplants allows their insertion even in cases of large
bone defects because they obtain bicortical stability
through the malar bone.6 There is agreement that
placement of a zygomatic implant is more complex
and difficult than conventional oral implant place-
ment.21 Not only the dimensions of the implants but
also the anatomic intricacies of the curved zygomatic
bone make this type of surgery a challenging proce-dure.22,23 Moreover, the presence of the orbital floor
and the limited intraoperative visibility require great
accuracy during the surgical insertion of implants.
The surgical procedure can be simplified and
facilitated using computer-assisted planning and sur-
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gery.24 A computer-based transfer of preplanned posi-tioning can be achieved using drill guides.14 However,
when applying this technique, precision depends
largely on the ability to position the drill guide accu-
rately on the underlying tissue.13,21 In contrast to the
technique using drilling templates, a computer-aided
surgical navigation approach offers constant intrao-
perative visualization of the tip of the drilling bur.
This enables the surgeon to guide the drill preciselyto control the implant axis and achieve better implant
stability. A cadaver study reported an accuracy of
1.3 � 0.8 mm in the implant versus planned posi-
tion.25 This result appears to be better than the accu-
racy achieved using drilling templates.13
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Table 1. PATIENT CHARACTERISTICS AND IMPLANT POSITIONS ACCORDING TO TYPE OF MAXILLARY DEFECT
Patient Number Age (yr) Diagnosis Class of Defect Zygomatic Implants Failure
1 56 OSCC IIA 3
2 77 OSCC IIC 4 1
3 62 ACC I 4
4 54 Mucoepidermoid carcinoma IIA 2
5 59 cleft III 4
Abbreviations: ACC, adrenocortical carcinoma; OSCC, oral squamous cell carcinoma. Q9
Pellegrino et al. Computer-Aided Maxillary Defect Rehabilitation. J Oral Maxillofac Surg 2015.
1.e10 COMPUTER-AIDED MAXILLARY DEFECT REHABILITATION
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In the authors’ experience, the use of preoperative
virtual surgical planning and an intraoperative naviga-
tion system allows the surgeon to achieve safer
implant positioning in a complex anatomic site.15
The rationale for proposing a new defect-based clas-
sification and algorithm is based on the opportunity af-
forded, using new techniques, to perform implant
insertion in extreme bone deficiency. Classificationsof maxillary bone defects described in the literature
do not consider the functional aspect of residual denti-
tion. The classification of Brown and Shaw26 considers
the size of the defect in soft and hard tissues and the
preferred method of microvascular reconstruction.
However, it does not consider rehabilitative options
when reconstruction is performed without bone-
free flaps.Jensen et al20 in 1992 described available sites for
implant placement in the facial skeleton and suggested
a viable craniofacial site classification. The authors’ new
reconstructive algorithmcouldbeconsidered a step for-
ward, although their suggestions have not been widely
adopted. Compared with the classification of Jensen
et al,20 the present classification is simpler and more
effectively considers the rehabilitative opportunities af-forded by zygomatic implants and computer-assisted
surgery for patients in whom bone reconstruction is
not performed. For each type of defect, the authors’
classification defines the number of zygomatic implants
required to optimize functional and esthetic outcomes.
To the authors’ knowledge, no previous reported
study has tested zygomatic implants in oncologic pa-
Table 2. OH-14QOLQUESTIONNAIREMEANVALUESAT PREOPERATIVE, 2-WEEK, AND 6-MONTHEVALUATIONS
T0 T1 T2
Mean value 25.5 19.4 15.5
Abbreviations: OH-14 QOL, ---; T0, preoperative; T1,2-week follow-up; T2, 6-month follow-up.
Pellegrino et al. Computer-AidedMaxillary Defect Rehabilitation. J
Oral Maxillofac Surg 2015.
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tients undergoing maxillectomy. In this study, the au-
thors tested these newly designed zygomatic
implants in various maxillary defects. This technique
appears to be a safe procedure to obtain effective reha-
bilitation after extensive maxillectomy. Early pros-
thetic loading certainly allows the patient to have
better functional outcomes and satisfactory mastica-
tory function. A fixed bridge not removable by the pa-tient for the first 3 months seems to promote
osseointegration of the implants. Prosthetic screwing
is advisable to obtain greater stability.
This use of fixed treatment does not allow for pa-
tient removal and cleaning. It can cause problems
from chronic inflammation. For this reason, the au-
thors suggest maintaining an adequate distance be-
tween the implant emergence and the prosthesis toallow the patient to perform a daily accurate cleaning.
The results of this series should be confirmed by
further studies and longer-term follow-up.
Acknowledgments
The authors thank Claudio Carboni of the University of Bolognafor his work, S.I.R. Srl (Verona, Italy), and Southern Implants (Irene,South Africa).
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