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8. Implants in Irradiated Tissues John Beumer III, DDS, MS Division of Advanced Prosthodontics, Biomaterials and Hospital Dentistry  UCLA School of Dentistry All rights reserved.  This program of instruction is covered by copyright ©.  No part of this program of instruction may be reproduced, recorded, or transmitted, by any means, electronic, digital, photographic, mechanical, etc., or by any information storage or retrieval system, without prior permission of the authors .
Implants in Irradiated Tissues Table of Contents ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Osseointegration Osteoblasts Non-collagenous matrix Mineral deposition Collagen matrix Success requires primary implant anchorage and immobilization, the formation of a clot between the surface of the implant and the osteotomy site, release of growth factors, angiogenesis and migration of osteoprogenitor cells to and deposition of bone on the surface of the implant and in the osteotomy site.
Osseointegrated Implants ,[object Object],[object Object]
Radiation effects ,[object Object],[object Object],[object Object],[object Object],Root surface Marrow Trabecular bone ,[object Object],[object Object],[object Object]
Radiation effects ,[object Object],[object Object],[object Object],Root surface Marrow Trabecular bone ,[object Object],[object Object],[object Object],These tissue changes lead to:
Why are these changes important? ,[object Object],[object Object],[object Object],[object Object],[object Object],Root surface Marrow Trabecular bone
Continued osteolytic activity ,[object Object]
[object Object],[object Object],[object Object],[object Object],Preradiation Postradiation
[object Object],[object Object],[object Object],Postradiation
[object Object],Remodeling apparatus – Osteolytic Activity It was reduced and repaired as shown with eventual healing.  An implant assisted overlay denture was later fabricated and used successfully by the patient.
The tissue changes are dose dependent and the dose depends in part upon: ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],The mode of therapy will determine the dose delivered to these regions and dose is the best predictor of long term success and the risk of ORN.
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Changing methods of radiation delivery Source:  www.beaumonthospital.com Source:  www.beaumonthospital.com ,[object Object],This technique uses multiple radiation beams of non-uniform intensities. The beams are modulated to the required intensity maps for delivering highly conformal doses of radiation to the treatment targets, while limiting dose normal tissue structures.
IMRT dosimetry diagrams ,[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],Chemora diation Consequences (particularly with CRT): The biologically equivalent dose (BED) is  raised leading to more short  term and long term side effects (mucositis, fibrosis, trismus,  velopharyngeal incompetence, osteoradionecrosis etc). Source:  www.beaumonthospital.com Source:  www.beaumonthospital.com
Implants in Irradiated Tissues ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Risk vs Reward Edentulous Maxillectomy Patients ,[object Object],[object Object],[object Object],[object Object]
Masticatory Performance Maxillectomy N=5   (‘0’ score if not able to chew) % performance *p<0.01 Garret et al, 2008
Masticatory Performance Maxillectomy N=5   (‘0’ score if not able to chew) % performance *p<0.01 * * Garret et al, 2008; Garrett et al, 2009
Tongue-Mandible Defects Reconstructed with Free Flaps   Patients with dentition on the unresected side ,[object Object],[object Object],[object Object],[object Object]
Masticatory Performance Fibula free flaps - Mandible   ( dentate patients) % performance (“0” if unable to attempt test; n=15) Garrett et al, 2005
Tongue-Mandible Defects Reconstructed with Free Flaps -  Edentulous Patients ,[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],Tongue-Mandible Defects Reconstructed with Free Flaps -  Edentulous Patients Note: The patient must masticate on the sensate unresected side.
Facial Prostheses – Quality of retention Quality of life ,[object Object],[object Object],[object Object],[object Object]
Facial Prostheses - Retention During Daily Activities   * * * Chang et al, 2005
Frequency of Wear Facial Prostheses * Chang et al, 2005
Implants in Irradiated Tissues ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Implants in Irradiated Tissues ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Implants in Irradiated Tissues ,[object Object],[object Object],[object Object],[object Object]
Methods – Histomorphometric Calculations ,[object Object],The histometry calculation yielded volume and boundary fractions for the implant, bone and soft tissue components. Weinlander et al, 2006
Bone contact area in control specimens Weinlander et al, 2006
Bone contact area in irradiated tissue Weinlander et al, 2006
Dosage of Radiation Therapy Administered ,[object Object],[object Object],[object Object],[object Object],A rabbit tibia model was used in this study.  The rat tibia were exposed to equivalents of  the following doses and implants were placed 3 months following completion of radiation treatments.  Polyfluorochrome labeling was performed three months after implant placement and the animals sacrificed 2 days later, Nishimura et al,1996
Results ,[object Object],Normal  5800 cGy Three months after implant placement the tissue samples were harvested and were evaluated with light and fluorescent microscopy.  Fluorochrome labeling documented a steady decrease in biologic activity at the higher doses.  Nishimura et al, 1996
Results ,[object Object],Irradiated bone At lower doses irradiated specimens had more woven bone at the bone implant interface than did the normal specimens  at the time of sacrifice. Nishimura et al, 1996
Additional animal studies (summaries) ,[object Object],[object Object],[object Object]
Summary of tissue changes affecting osseointegration   based on animal studies ,[object Object],[object Object],[object Object]
Summary of tissue changes affecting osseointegration based on animal studies ,[object Object],[object Object]
[object Object],[object Object],[object Object],Animal studies have yet to be reported assessing the impact of chemoradiation on osseointegration.
Anticipated outcomes in humans based on animal studies ,[object Object],[object Object]
Anticipated outcomes in humans based on animal studies ,[object Object],[object Object]
Anticipated outcomes in humans based on animal studies ,[object Object],[object Object]
Human studies ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Implants in irradiated mandible ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],*HBO was not used
Implants in irradiated mandible ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Implants in irradiated mandible ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],*HBO was not used
Implants in the irradiated maxilla ,[object Object],[object Object],[object Object],* Without HBO
Implants in edentulous maxillectomy patients ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Failures in the irradiated group  tend to be late, after the implants have been loaded. Roumanas et al, 1997
Implants in nonirradiated tissues Craniofacial sites * ,[object Object],Implant  Pts  Implants  Implants  Implants  Implants  Survival sites  placed  uncovered  buried  failed  rates (%) Auricular  35  111  97  8  5  94 Nasal  16 Piriform  27  25  0  5  80 Glabella  2  2  0  2  0 Orbital  9  28  25  2  7  70 Overall  60  172  153  10  21  85
Implants in irradiated tissues Craniofacial sites* ,[object Object],Implant  Pts  Implants  Implants  Implants  Implants  Survival sites  placed  uncovered  buried  failed  rates (%) Auricular  2  6  6  0  0  100 Nasal  4  Piriform  8  6  0  1  83 Glabella  2  2  0  2  0 Orbital  6  19  15  0  11  27 Overall  12  35  29  0  14  52 Failures in the irradiated group  tend to be late, after the implants have been loaded .
Implants in the Irradiated Supraorbital Rim ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],This patient received more than 6000 cGy to the implant sites Case report Flange exposure Eventually led to loss of implants
Implant failures – Irradiated sites Auricular defects ,[object Object],[object Object]
Risk of osteoradionecrosis Esser et al, 1997 .   In this retrospective analysis, 2 patients out 60 (3.4%),  developed osteoradionecrosis, both in the mandible.  All patients received 6000 cGy  with CRT postoperatively via opposed mandibular fields.
Risk of osteoradionecrosis ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Osteoradionecrosis  Case report Three years after implant placement the patient developed an infection associated with left posterior implant. This patient received 6600 cGy for a squamous carcinoma of the lateral tongue.  Three  years later implants were placed. Eventually, the patient developed an osteoradionecrosis, a pathologic fracture of the mandible and subsequently the mandible was resected.
Osteoradionecrosis - Mastoid ,[object Object],[object Object]
Implants in irradiated mandible ,[object Object],[object Object],[object Object],[object Object],[object Object]
Impact of HBO ,[object Object],[object Object],[object Object],[object Object]
Impact of HBO ,[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],The use of hyperbaric oxygen can be justified only on the basis of improving success rates. Impact of HBO - Maxilla
Time from irradiation ,[object Object],[object Object],[object Object]
Implants in Irradiated Tissues ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Implants in Irradiated Tissues ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Implants in the irradiated mandible ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Implants in the irradiated edentulous mandible ,[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],Implants in the irradiated mandible
Implants irradiated maxillary sites ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Implants - Irradiated craniofacial sites ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
CRT - Implants in irradiated patients vs implants in the radiation field ,[object Object],[object Object],Implants can be placed in the anterior mandible and anterior maxilla  in such patients and  the success will be equivalent to normal non irradiated patients
CRT - Implants in irradiated patients vs implants in the radiation field ,[object Object]
Radiation delivery factors - IMRT 3 fields   5 fields   7 fields ,[object Object],[object Object]
Irradiation of Existing Implants - Backscatter ,[object Object],These implants were irradiated 2 years following placement. Note the exposure of the implant flanges.
Implants were placed simultaneous with tumor resection and reconstruction of this large body-symphyseal defect with a fibula free flap.  The patient received 6000 cGy post operatively.  Irradiation of existing implants- Backscatter
Several months later and just after delivery of the tissue bar, the tissues on the labial surfaces of the implants dehisced and the bone overlying the implants sequestrated leading to loss of the implants. Irradiation of existing implants- Backscatter
Following loss of the implants,  the mucosa recovered the area.  The graft remained viable and mandibular continuity was maintained. Irradiation of existing implants- Backscatter
Irradiation of Existing Implants ,[object Object],[object Object],[object Object],[object Object]
Irradiation of Existing Implants ,[object Object],[object Object]
Irradiation of Existing Implants ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Irradiation of Existing Implants ,[object Object],[object Object],[object Object],[object Object],[object Object]
Irradiation of Existing Implants ,[object Object],[object Object],[object Object],[object Object],[object Object]
Irradiation of Existing Implants ,[object Object],[object Object],[object Object],[object Object],[object Object]
Irradiation of Existing Implants ,[object Object],[object Object],[object Object],[object Object],[object Object]
Irradiation of Existing Implants ,[object Object],[object Object],[object Object],[object Object],[object Object]
Irradiation of Existing Implants ,[object Object],[object Object],[object Object],[object Object],[object Object]
Placement of implants in patients to receive postoperative radiation. ,[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object]
Risk of osteoradionecrosis ,[object Object],[object Object]
Nano-enhanced and genetically engineered implant surfaces Probably not. Anchorage is mechanical as opposed to biologic. The macro-surface topography, the quality of bone and the skill of the surgeon are the most critical factors.  Will these phenomenon be  clinically significant in the irradiated patient? ,[object Object]
[object Object],[object Object],[object Object],This patient is 16 years of age.  He received 3600 cGy of radiation when he was 4 years of age for treatment of  a rhabdomyosarcoma.
[object Object],[object Object],[object Object],Are these patients candidates for implants? Yes!  If t dose is below 4000 cGy.
Early Radiation to the Enamel Organ  Implant supported fixed partial denture ,[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object]
Coming soon ,[object Object],[object Object],[object Object]
References ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
References ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
References ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
References ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
References ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
The End Thank you for your kind attention

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8.implant in irradiated patients

  • 1. 8. Implants in Irradiated Tissues John Beumer III, DDS, MS Division of Advanced Prosthodontics, Biomaterials and Hospital Dentistry UCLA School of Dentistry All rights reserved. This program of instruction is covered by copyright ©. No part of this program of instruction may be reproduced, recorded, or transmitted, by any means, electronic, digital, photographic, mechanical, etc., or by any information storage or retrieval system, without prior permission of the authors .
  • 2.
  • 3. Osseointegration Osteoblasts Non-collagenous matrix Mineral deposition Collagen matrix Success requires primary implant anchorage and immobilization, the formation of a clot between the surface of the implant and the osteotomy site, release of growth factors, angiogenesis and migration of osteoprogenitor cells to and deposition of bone on the surface of the implant and in the osteotomy site.
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  • 18. Masticatory Performance Maxillectomy N=5 (‘0’ score if not able to chew) % performance *p<0.01 Garret et al, 2008
  • 19. Masticatory Performance Maxillectomy N=5 (‘0’ score if not able to chew) % performance *p<0.01 * * Garret et al, 2008; Garrett et al, 2009
  • 20.
  • 21. Masticatory Performance Fibula free flaps - Mandible ( dentate patients) % performance (“0” if unable to attempt test; n=15) Garrett et al, 2005
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  • 25. Facial Prostheses - Retention During Daily Activities * * * Chang et al, 2005
  • 26. Frequency of Wear Facial Prostheses * Chang et al, 2005
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  • 31. Bone contact area in control specimens Weinlander et al, 2006
  • 32. Bone contact area in irradiated tissue Weinlander et al, 2006
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  • 54. Risk of osteoradionecrosis Esser et al, 1997 . In this retrospective analysis, 2 patients out 60 (3.4%), developed osteoradionecrosis, both in the mandible. All patients received 6000 cGy with CRT postoperatively via opposed mandibular fields.
  • 55.
  • 56. Osteoradionecrosis Case report Three years after implant placement the patient developed an infection associated with left posterior implant. This patient received 6600 cGy for a squamous carcinoma of the lateral tongue. Three years later implants were placed. Eventually, the patient developed an osteoradionecrosis, a pathologic fracture of the mandible and subsequently the mandible was resected.
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  • 74. Implants were placed simultaneous with tumor resection and reconstruction of this large body-symphyseal defect with a fibula free flap. The patient received 6000 cGy post operatively. Irradiation of existing implants- Backscatter
  • 75. Several months later and just after delivery of the tissue bar, the tissues on the labial surfaces of the implants dehisced and the bone overlying the implants sequestrated leading to loss of the implants. Irradiation of existing implants- Backscatter
  • 76. Following loss of the implants, the mucosa recovered the area. The graft remained viable and mandibular continuity was maintained. Irradiation of existing implants- Backscatter
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  • 100. The End Thank you for your kind attention

Editor's Notes

  1. Dental Management of the Irradiated Patient
  2. Among the 46 subjects we had 14 subjects who complete all the treatment procedure and data collection. The mean masticatory performance prior the surgery on the defect side was 22.6% and 38.6% on the non-defect side, then decreased to 7.8% and 25.3% postsurgically. Restoration with the conventional prosthesis significantly improved performance to 20% on the defect side and 32% on the non-defect side. Following treatment with the implant-supported prosthesis masticatory performance improved significantly to 31.4% on the defect side and 39.5% on the non-defect side. At the entry level the MP was 22and38% very low