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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 16  |  Issue : 1  |  Page : 212-215

Defect reconstruction in oral squamous cell carcinoma patient using novel patient-specific polyether ether ketone implant: Report of a case


Department of Oral and Maxillofacial Surgery, Sharad Pawar Dental College and Hospital, Datta Meghe Institute of Medical Sciences (Deemed to be University), Wardha, Maharashtra, India

Date of Submission28-Nov-2020
Date of Decision20-Jan-2021
Date of Acceptance15-Feb-2021
Date of Web Publication29-Jul-2021

Correspondence Address:
Dr. Aishwarya Gupta
Department of Oral and Maxillofacial Surgery, Sharad Pawar Dental College and Hospital, Datta Meghe Institute of Medical Sciences (Deemed to be University), Wardha - 442 004, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdmimsu.jdmimsu_415_20

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  Abstract 


Oral squamous cell cancer comprises of one-third of carcinomas of the maxillofacial region. The principle of treatment involves the resection of the lesion with safe surgical margins. However, the rehabilitation of resected soft and hard tissues remains a challenging aspect for the maxillofacial surgeons. In the past few years, the alternatives for maxillofacial rehabilitation have been transmogrified. The profoundness of functional and esthetic significance of the face has led to evolving concepts in the field of reconstruction. With the emerging trends and search for a better reconstruction modality, a novel, biocompatible, and nonmetallic material that is polyether ether ketone (PEEK) was introduced that has shown to have good success rates in the past few years. However, its utility in the reconstruction of mandibular segmental defect is yet to be studied extensively. This case presents our success in reconstructing a mandibular segmental defect in an operated case of oral squamous cell carcinoma using a patient-specific PEEK implant with a follow-up period of 2 years.

Keywords: Esthetic reconstruction, hard-tissue rehabilitation, oral squamous cell carcinoma, patient-specific implant, polyether ether ketone


How to cite this article:
Gupta A, Bhola N, Kambala R. Defect reconstruction in oral squamous cell carcinoma patient using novel patient-specific polyether ether ketone implant: Report of a case. J Datta Meghe Inst Med Sci Univ 2021;16:212-5

How to cite this URL:
Gupta A, Bhola N, Kambala R. Defect reconstruction in oral squamous cell carcinoma patient using novel patient-specific polyether ether ketone implant: Report of a case. J Datta Meghe Inst Med Sci Univ [serial online] 2021 [cited 2021 Sep 16];16:212-5. Available from: http://www.journaldmims.com/text.asp?2021/16/1/212/322637




  Introduction Top


Oral squamous cell carcinoma (OSCC) is the sixth most common cancer in the world and the third most common in the Indian subcontinent with an increasing burden of one million newly diagnosed cases every year.[1] To reinstate a near-normal state, various reconstructive options to correct the created discontinuity defect have been proposed in the literature. These are regional flaps, local flaps, and free osseo fascio myocutaneous graft transfer. However, all of them have the drawback of donor site morbidity and prolong hospital stay of patient and limitation in the esthetic outcome. With the advent of the suboptimal esthetic outcome, custom-made implant has been introduced in head and neck surgery which enables the surgeon to reconstruct such defect with no donor site morbidity, less operating time, and optimal esthetics. The durability, biocompatibility and excellent resistance to aggressive sterilization makes it different from other material. The versatility of PEEK has encroached spinal cage to spinal rods, disc replacements, and joint replacements.[2] PEEK formulations have been established involving hydroxyapatite additive to counteract infection and surface grafted polymer to improve lubrication.[2] Polyether ether ketone (PEEK) a material due to its durability, biocompatibility, and excellent resistance to repeated sterilization makes it a polymer of choice. A variety of material marketed for implant fabrication namely PEEK, polymethyl acrylate, and titanium. In the present case, we are elaborating reconstruction of a defect in an operated patient of OSCC using patient-specific PEEK implant.


  Case Report Top


We report the case of a systemically healthy, 41-year-old, male, tobacco chewer presented to the emergency department with a history of chronic, painful nonhealing ulcer over the lower left molar region for 4 months approximately. Intraoral examination revealed lesion over the left gingivobuccal sulcus involving premolar to molar region with an ulceroinfiltrative growth of size 3 cm × 1 cm approximately, with bilateral submandibular lymphadenopathy making the lesion T4aN2cM0 histopathological report suggestive of micro-invasive squamous cell carcinoma. A contrast-enhanced computed tomography (CECT) scan of the head was done to determine the extension of the lesion [Figure 1]a. The lesion was causing erosive destruction of the body of the mandible on the left side and symphysis region [Figure 2]a, [Figure 2]b, [Figure 2]c.
Figure 1: (a) The computed tomographic scan showing extension of the carcinomatous lesion. (b and c) Marking on the model showing the amount of resection to be done

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Figure 2: (a and b) The resection followed by reconstruction of the surgical defect using polyether ether ketone implant. (c) Orthopantamograph showing the surgical defect and reconstruction plate after 2-month follow-up

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Considering the clinico-radio-histological diagnosis and the extent of bone erosion, segmental resection of the lesion and modified radical neck dissection (MRND) were planned. We opted to reconstruct such a vast defect using a pectoralis major myocutaneous flap (PMMC) and a patient-specific PEEK implant. Then, the PEEK implant was fabricated using digital imaging and communications in medicine images in computer-aided design/computer-aided manufacturing software.

A mock surgery defining the limits of the resection was performed and a mirror image of the contralateral mandible was superimposed on the defect [Figure 1]b and [Figure 1]c. Further, this was then used to fabricate a Patient specific implant (PSI) using stereolithography. A single-piece PEEK implant was fabricated which was sterilized preoperatively. Segmental mandibulectomy was done from the right premolar to the left mandibular angle. PEEK implant used to reconstruct the hard-tissue defect and soft-tissue reconstruction was done using a PMMC flap. The implant was adapted to the bone, afixed using titanium plates and screws (angle to angle reconstruction plate with 13 screws of 10 mm × 2.5 mm each) [Figure 2]a and [Figure 2]b. The patient recovered well postoperatively without any complications. The patient underwent 30 fractions of radiotherapy postoperative radiotherapy. The patient was kept on a 6-month follow-up for 2 years without any signs of infection, implant fracture, recurrence, or any other complications [Figure 2]c.


  Discussion Top


The clinical and radiographic assessment of primary lesion decides the degree of mandibular invasion which helps to decide the treatment plan for the patient. The treatment plan comprises of surgical resection, neck dissection, and reconstruction with suitable flap. Surgical resection can be of marginal or segmental type. Marginal mandibulectomy is performed such as the slice of bone can be split off in one piece bearing the undisturbed cancer off as on a bone platter, while segmental refers to en bloc resection of bone.[3] However, segmental mandibulectomy severely damages the patient's esthetic contour and oral function and tremendously affects the patient's psychological status and social behavior. Brown et al. in 2016 proposed a classification for mandibular defect and reconstruction options for same.[4] Reconstructive surgery for complex maxillofacial defects is an enigma for most of the skilled surgeons.[5] Regional flaps, local flaps, free graft transfer, reconstruction using titanium implants, and PEEK have been described in the literature.[6],[7] For reconstruction of defect of small dimensions with noncomplex shapes, autologous bone grafts are a good reconstructive option. Larger defects (>4 cm), however, require free tissue transfer,[4] causing augmented morbidity of the donor site, inadequate amount of donor material, and bone resorption. The use of alloplastic material such as titanium has the disadvantage of radiation scattering effect during postoperative radiotherapy and intraoperative adjustments.[8]

PEEK is a polyaromatic linear polymer having exceptional combination of strength, stiffness, biocompatibility, environmental resistance, and durability.[9],[10] It was first developed in 1978 and established its use in aircrafts and turbine blades.[11] In vitro use of implants to reconstruct the spine and in orthopedic surgery has also been reported in the late 90s.[11]

It is mechanically strong, nonallergenic, and nonmagnetic and does not undergo exothermic reactions.[10] It has good biocompatibility and is radiolucent. The patient-specific implants fabricated using PEEK can be easily trimmed intraoperatively and provide permanent long-term results.[10] It can withstand repeated autoclave sterilizations.[2] The modulus of elasticity is 3–4 GPa and the elasticity of PEEK (GPa – 8.3, MPa – 139) is analogous to that of cortical bone (GPa – 17.7, MPa – 133).[6],[11] The infection rates with the use of PEEK implants were noted to be 8.3%, which was comparable with other alloplastic material.[5] Some authors suggested the complications such as hematoma formation, fracture of implant, allergic reactions, and implant exposure.[10] The disadvantage of PEEK is its high manufacturing cost.

Current research has also investigated the biotribology of PEEK composites as bearing material and flexible implants for joint arthroplasty.[12] Fillers of carbon and glass are firstly added for improvement of stiffness and strength for the material. The carbon-fiber-reinforced PEEK biomaterial is currently used as an implant for joint replacement and spine fusion.[11] PEEK implants are nowadays one of the most interesting materials for research purposes as it has highly versatile implications for reconstructive surgeries for continuity defects in the oral and maxillofacial region arising due to trauma, cysts and tumors, malignancies, and any another pathology requiring reconstruction of hard tissue.[13],[14],[15],[16],[17],[18],[19],[20]


  Conclusion Top


The custom-made implant of PEEK material is a good option for the reconstruction of discontinuity defects of the maxillofacial skeleton. It helps in the restoration of the function with minimal disturbances of the esthetics and prevents donor site morbidity. The surgical resection of the mandible has a devastating effect on the esthetics and function of the patient which led to poor quality of life postoperatively, in order to enhance the surgical outcome functionally and esthetically, PEEK implants can be considered.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Genden EM, Ferlito A, Silver CE, Takes RP, Suárez C, Owen RP, et al. Contemporary management of cancer of the oral cavity. Eur Arch Otorhinolaryngol 2010;267:1001-17.  Back to cited text no. 1
    
2.
Rahmitasari F, Ishida Y, Kurahashi K, Matsuda T, Watanabe M, Ichikawa T. PEEK with reinforced materials and modifications for dental implant applications. Dent J 2017;5:35.  Back to cited text no. 2
    
3.
Rao LP, Shukla M, Sharma V, Pandey M. Mandibular conservation in oral cancer. Surg Oncol 2012;21:109-18.  Back to cited text no. 3
    
4.
Brown JS, Barry C, Ho M, Shaw R. A new classification for mandibular defects after oncological resection. Lancet Oncol 2016;17:e23-30.  Back to cited text no. 4
    
5.
Järvinen S, Suojanen J, Kormi E, Wilkman T, Kiukkonen A, Leikola J, et al. The use of patient specific polyetheretherketone implants for reconstruction of maxillofacial deformities. J Craniomaxillofac Surg 2019;47:1072-6.  Back to cited text no. 5
    
6.
Rudman K, Hoekzema C, Rhee J. Computer-assisted innovations in craniofacial surgery. Facial Plast Surg 2011;27:358-65.  Back to cited text no. 6
    
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Scolozzi, P. Maxillofacial reconstruction using polyetheretherketone patient-specific implants by “Mirroring” computational planning. Aesth Plast Surg 2012;36:660-5.  Back to cited text no. 7
    
8.
Joonas T, Mikko B, Heikki M, Pekka V, Jami R. Scattering of therapeutic radiation in the presence of craniofacial bone reconstruction materials. J Appl Clin Med Phys 2019;20;119-126. [doi: 10.1002/acm2.12776].  Back to cited text no. 8
    
9.
Kim MM, Boahene KD, Byrne PJ. Use of customized polyetheretherketone (PEEK) implants in the reconstruction of complex maxillofacial defects. Arch Facial Plast Surg 2009;11:53-7.  Back to cited text no. 9
    
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Ghavat C, Bhola N. Reconstruction of mandibular defect using patient specific peek implant – An approach to aesthetic reconstruction. Med Scie 2020;24:1261-6.  Back to cited text no. 10
    
11.
Honigmann P, Sharma N, Okolo B, Popp U, Msallem B, Thieringer FM. Patient-Specific Surgical implants made of 3D printed PEEK: Material, technology, and scope of surgical application. Biomed Res Int 2018;2018:110-22.  Back to cited text no. 11
    
12.
Kurtz SM. An overview of PEEK biomaterials. In: PEEK Biomaterials Handbook. oxford: William Andrew Publishing; 2012.  Back to cited text no. 12
    
13.
Agarwal A, Bhola N, Kambala R, Borle RM. Touch Imprint Cytology: Can It Serve as an Alternative to Frozen Section in Intraoperative Assessment of Cervical Metastasis in Oral Squamous Cell Carcinoma? J Oral Maxillofac Surg 2019;77:994-9. Available from: https://doi.org/10.1016/j.joms.2019.01.011. [Last accessed on 2020 Apr 08].  Back to cited text no. 13
    
14.
Gadbail AR, Korde S, Chaudhary MS, Sarode SC, Gondivkar SM, Dande R, et al. Ki67, CD105, and α-SMA Expression Supports Biological Distinctness of Oral Squamous Cell Carcinoma Arising in the Background of Oral Submucous Fibrosis. Asian Pac J Cancer Prev 2020;21:2067-74. Available from: https://doi.org/10.31557/APJCP.2020.21.7.2067. [Last accessed on 2020 Apr 08].  Back to cited text no. 14
    
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Karia HG, Jadhav A, Bhola N, Karia HG. Incidence of Metastatic Involvement of Carotid Sheath in Oral Squamous Cell Carcinoma-A Cross Sectional Type of Study. European Journal of Molecular and Clinical Medicine 2020;7:1185-90.  Back to cited text no. 15
    
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Nidhi S, Madhuri G. Comparative Evaluation of Immunohistochemical Expression of MT-1 MMP, TIMP-1, TGF-δ1, α-SMA in Oral Submucous Fibrosis and Oral Submucous Fibrosis with Coexisting Oral Squamous Cell Carcinoma. Eur J Molecular Clin Med 2020;7:1994-2002.  Back to cited text no. 16
    
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Patil CS, Jadhav AA. Comparison of Resection Performed by Peroral and Transoral Route on Surgical Margins in Patients with Oral Squamous Cell Carcinoma. Eur J Molecular Clin Med 2020;7:2070-8.  Back to cited text no. 17
    
18.
Alvi S, Hande A, Chaudhary M, Gawande M, Patil S, Sharma P. The Assessment of Expression of Midkine in Epithelial Dysplasia and Oral Squamous Cell Carcinoma. J Datta Meghe Inst Med Sci Univ 2019;14: 378-82. Available from: https://doi.org/10.4103/jdmimsu.jdmimsu_178_19. [Last accessed on 2020 Apr 08].  Back to cited text no. 18
    
19.
Anmol T, Sunita V, Gode C. Vimentin Expression and Its Correlation with Lymph Node Metastasis in Oral Squamous Cell Carcinoma. Int J Pharm Res 2019;11:1216-22. Available from: https://doi.org/10.31838/ijpr/2019.11.01.215. [Last accessed on 2020 Apr 08].  Back to cited text no. 19
    
20.
Bagri-Manjrekar K, Chaudhary M, Sridharan G, Tekade S, Gadbail A, Khot K. In Vivo Autofluorescence of Oral Squamous Cell Carcinoma Correlated to Cell Proliferation Rate. J Cancer Res Ther 2018;14:553-8. Available from: https://doi.org/10.4103/0973-1482.172710. [Last accessed on 2020 Apr 08].  Back to cited text no. 20
    


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