Clinical Outcome of Jaw-in-a-Day Total Maxillofacial Reconstruction

Reconstruction of large maxillary and mandibular defects following ablative surgery has posed a challenge to the head and neck surgeon due to the high functional and aesthetic demands requiring precise three-dimensional reconstruction. Previous issues with maxillofacial reconstruction have included poor facial contour, unfavorable orthognathic relationships, and inability to provide adequate dental rehabilitation. The advent of the fibula flap along with (3D) facial analysis and virtual surgical simulation has revolutionized surgical interventions of the head and neck. Recent reports on the long-term success of dental implants in fibula reconstructions have made dental rehabilitation a reality. However, the loading and restoration of these implants are usually delayed prior to final prosthodontic rehabilitation leading to adverse functional, aesthetic and psychological effects. Rohner et al. has documented the success of a two-stage surgery of fibula harvest and dental implant placement (Stage 1) followed by ablative surgery, inset and immediate loading with a dental prosthesis (Stage 2) ⁽²⁾; this procedure is a two stage process that involves a 10 week delay between each surgery and will leave the patient edentulous. At our institution, computer aided surgery and CAD/CAM technologies have enabled us to virtually plan complex surgery and have afforded our group the opportunity of providing a “Jaw in a Day”⁽¹⁾.   This technique is a one stage complete surgery including ablation, free flap, implant, and prosthetic reconstruction.

 A retrospective chart review was conducted for all patients who received immediate dental implants with a dental prosthesis in a fibular free flap following mandibular resection due to benign tumors. “Jaw in a Day”procedures were completed at two of our affiliated hospitals (Bellevue Hospital Center and NYU Langone Medical Center) from January 2011 to January 2015.  We looked at success rate of flaps, implants, and prosthesis.  We also looked at primary and long term complications. 

Of the 8 patients who underwent the above procedure, a total of 35 immediate implants were placed along with a fixed prosthesis.  Patients received maxillary/mandibular resection, fibula free flap reconstruction with immediate implant and dental prosthesis placement. All patients treated were diagnosed with benign mandibular (7) and maxillary (1) tumors, including ameloblastoma (6), odontogenic myxoma (1), and AV malformation (1). Of the 35 implants placed, 1 implant failed and was removed. The cumulative survival of fibular-free flaps was 100%. The cumulative implant success rate was 97%. Complications included soft tissue peri-mplantitis (2), plate exposure (2), and (1) prosthesis that did not adequately fit.  The follow-up of the 8 patients was from January 2011 to January 2015.

Single-stage maxillofacial reconstruction with virtual surgical planning has greatly impacted the field of maxillofacial reconstruction allowing for precision and accuracy while improving patient’s function and quality of life.  The above study shows its feasibility and low complication rates.   Immediate implant and dental prosthesis placement has helped reduce the time for dental prosthetic rehabilitation and avoid the traditional 3- to 6-month delay period. Reconstruction with a MVFFF and immediate dental rehabilitation has revolutionized the treatment of benign tumor following ablative surgery.

References:

1. Hirsch D, Garfein E, Christensen A, Weimer K, Saadeh P, Levine J.  Use of computer-aided design and computer-aided manufacturing to produce orthognathically ideal surgical outcomes:  A paradigm shift in head and neck reconstruction.  J Oral Maxillofac Surg.2009;67:2115-22.

2. Rohner D, Bucher P, Kunz C, Hammer B, Schenk RK, Prein J. Treatment of severe atrophy of the maxilla with the prefabricated free vascularized fibula flap. Clin. Oral Impl. Res. 13, 2002; 44-52.