SMILES
SPOTLIGHT
in the
LEADERS IN NORTH TEXAS DENTISTRY
CREATING UNFORGETTABLE SMILES
Treatment of jaw tumors most often involves resection of significant
portions of bone. The functional and cosmetic consequences can be
devastating without adequate reconstruction. Traditional reconstructive
techniques involve multiple operations over 1-2 years before the
dentition can be restored. Historically, bone grafting for large segmental
jaw defects can have a success rate of only 70% and often require
additional grafting. For devastating defects following tumor removal,
vascularized bone grafting has become increasingly predictable with a
95% success rate by most studies. Vascularized bone also allows for
the immediate placement of dental implants. Combining these
advantages with modern 3D virtual surgery planning, it is possible to
remove a tumor, reconstruct the defect with vascularized bone, place
dental implants, and attach an immediate provisional prosthesis. We are
now able to take patients “from tumor to teeth” all in a single operation.
PREOP PANOREX
PLANNING
TOTAL JAW RECONSTRUCTION
A healthy 47-year-old male presented with a biopsy-proven ameloblastoma
of the mandible. The mass extended from the left second premolar to the right
first premolar. Slight bony expansion was noted on the lingual aspect of the
mandible. Traditional treatment would involve a staged approach of resecting
the mandible tumor with 1cm margins and placing a bone plate to span the
defect. After 3 months of healing, the wound would be re-opened and an iliac
crest bone graft would be placed. This graft would heal for 6 months before
implants could be placed. Implants in this type of bone often require 6 months
before osseointegration can be assessed. Soft tissue refinements are often
needed as well.
For this patient, we chose to remove his tumor and reconstruct both the
mandible and his dentition in one operation. A cone beam CT scan of his
maxilla and mandible was obtained. Using 3D virtual surgical planning with
Medical Modeling, Inc. (Golden, CO), cutting guides were made to remove
the tumor with at least 1cm margins. A computer-modeled virtual
reconstruction was performed to plan the location of mandibular osteotomies
for tumor removal, proper shaping of the fibula bone to fit the defect, and
precise placement of dental implants. A custom reconstruction plate was
fabricated to fit the planned fibula graft to the mandible. A 3D model with
planned implant locations was printed to allow creation of a provisional
denture to be converted to a fixed hybrid.
In the operating room under general anesthesia, the mandible was removed
from 1st molar to 1st molar, while the 2nd molars were preserved to maintain
the vertical dimension. The left fibula was harvested from the leg but remained
temporarily attached via the peroneal artery and vein to maintain blood flow
while shaping the bone and placement of implants. Our guided surgery stent
was then used to place implants as well as make osteotomies in the fibula
for shaping. The reconstruction plate was attached to fibula while the X