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ET AL
A 2-Stage Reconstruction of the Jaw Using Vascularized Bone and Secondary Alveolar Ridge Augmentation With Particulate Cancellous Bone and Marrow Hideto Saijo, DDS, PhD,* Madoka Sugiyama, DDS,† Yuki Kanno, DDS,‡ Kazumi Ohkubo, DDS,§ Kazuto Hoshi, MD, PhD,¶ and Tsuyoshi Takato, MD, PhDk
n the stomatognathic region, resection of a large area of the maxilla/mandible jawbone due to removal of an oral tumor or for other reasons results in the loss of not only the facial form, but also the occlusal relationship. As a result, problems occur with masticatory function, causing striking deterioration in quality of life for the patient. In such cases, the ideal approach is to graft bone to the appropriate site to create an esthetically acceptable facial form and restore the occlusal relationship, and then to implement prosthetic measures using dental implants. However, the reconstructed jaw significantly alters the intermaxillary
I
*Lecturer, Department of Oral-Maxillofacial Surgery, Dentistry and Orthodontics, The University of Tokyo Hospital, Tokyo, Japan. †Assistant Professor, Department of Oral-Maxillofacial Surgery, Dentistry and Orthodontics, The University of Tokyo Hospital, Tokyo, Japan. ‡Assistant Professor, Department of Oral-Maxillofacial Surgery, Dentistry and Orthodontics, The University of Tokyo Hospital, Tokyo, Japan. §Lecturer, Department of Oral-Maxillofacial Surgery, Dentistry and Orthodontics, The University of Tokyo Hospital, Tokyo, Japan. ¶Associate Professor, Department of Oral-Maxillofacial Surgery, Dentistry and Orthodontics, The University of Tokyo Hospital, Tokyo, Japan. kProfessor, Department of Oral-Maxillofacial Surgery, Dentistry and Orthodontics, The University of Tokyo Hospital, Tokyo, Japan.
Reprint requests and correspondence to: Hideto Saijo, DDS, PhD, Department of Oral-Maxillofacial Surgery, Dentistry and Orthodontics, The University of Tokyo Hospital, 7-3-1, Hongo, Bunkyo-ku, Tokyo 113-8655, Japan, Phone: 81-3-5800-8669, Fax: 81-3-5800-6832, E-mail: [email protected] ISSN 1056-6163/16/02502-302 Implant Dentistry Volume 25 Number 2 Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved. DOI: 10.1097/ID.0000000000000394
Purpose: To present the novel technique for reconstruction of the jaw, that facilitates occlusal restoration using dental implants, in cases with wide bony defects from tumor resection. Materials and Methods: After alveolar ridge is augmented using titanium mesh tray and particulate cancellous bone and marrow (PCBM) from iliac bone on reconstructed bone, by way of improvement of maxillomandibular relationship for dental implants. Results: This 2-stage surgery underwent successfully in 3 cases. After 2-stage surgery and occlusal reconstruction using dental implant,
the patients experienced no complications, and received satisfaction with results functionally and aesthetically. Conclusions: Our results suggest that, in cases where bone defect is over a wide area, in addition to vascularized bone grafts, secondary alveolar ridge augmentation using a titanium mesh tray and PCBM on grafted bone can provide satisfactory occlusion further to improvement of facial form. (Implant Dent 2016;25:302–306) Key Words: jawbone reconstruction, titanium mesh tray, dental implant
relationship in many cases, creating an imbalance between the jaws, and even if jaw continuity is reconstructed through vascularized bone grafts, it can often be difficult to embed dental implants and restore occlusion. This is because it is difficult to reconstruct a complex jaw form in a single stage, even using ilium, scapula, or fibula. With regard to cases like this, along with correction of the form using bone grafts, secondary reconstruction of the alveolar part of the jaw is necessary.1 In the cases described here, in which reconstruction was achieved by
grafting vascularized free bone after resection of a tumor, the authors reconstructed the jaw bone using a titanium mesh tray and grafts of particulate cancellous bone and marrow (PCBM), with the aim of restoring facial form and occlusion. We then used dental implants to restore occlusion function and enhance esthetic aspects. We describe herein these cases and their outcomes.
TECHNIQUE In performing reconstruction using vascularized bone grafts, computed tomography (CT) images are taken in
Copyright Ó 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
SAIJO
ET AL
the usual manner. Data from these CT images are then transferred using Digital Imaging and Communications in Medicine, the bone tissue is visualized, and the resulting 3-dimensional shape data are output as a file in the standard template library (STL) format. Using the STL data, a 3D computer-aided design 3-dimensional design system is applied to create a 3-dimensional stereo model,2,3 using an ink-jet powder lamination device (Z406 System 3D Printer; DICO, The Z Corporation, Rock Hill, SC), with gypsum (ZP140 Powder; DICO) serving as the base material. The resulting model is then used to envision the form of the patient’s original jaw bone, the site of the graft is specified, and the titanium mesh plate is prebent. In the surgery, an incision is made from either inside or outside the oral cavity, and separation is performed over a broad area. After a trial fitting of the titanium mesh plate, which has been adjusted to the clarified reconstructed bone before the surgery, the plate is secured at the intended site using screws. After the plate has been secured, harvested PCBM bone chips are densely grafted into the cavity between the mesh tray and reconstructed bone. After the graft has been completed, the mucoperiosteal flap is sufficiently incised with a relaxation incision, and the wound is closed. After bone regeneration has been confirmed on CT after 5 to 7 months, surgery is performed to remove the mesh tray and embed dental implants.
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Fig. 1. A, 3D-CT findings at the time of the initial visit. He had undergone segmental resection of the right mandible because of treating primary intraosseous squamous cell carcinoma. B, Intraoral findings at the time of the initial visit. Oral mucosa is covered with a rectus abdominis musculocutaneous flap.
Fig. 2. A, This 3D-CT finding was the first operation in our hospital. Reconstructive surgery was performed on the mandible using a free fibula flap, for the purpose of improving facial deformity and occlusion. B, Nine months later for the first operation in our hospital. Right mandibular plasty was performed using PCBM harvested from posterior ilium and a mesh plate.
CASES Case 1
The patient was a 35-year-old man who had undergone segmental resection of the right mandible at a certain hospital 2 years earlier to treat primary intraosseous squamous cell carcinoma found in the right mandible. Reconstruction with a rectus abdominis musculocutaneous flap was also performed to correct tissue loss, with postoperative radiation of 50 Gy. At the time of initial diagnosis, the right buccal region was slightly
Fig. 3. A, Seven months after that, the mesh plate was surgically removed. 3D-CT finding was after mesh tray removal. The bone formation was good condition. B, After secondary implant surgery, debulking of the surrounding skin flap was performed, and an attachment denture was created with a Dolder bar used as the retaining device, to restore occlusion. The oral findings at the time of implant denture installation. C, Panoramic x-ray findings after installation of the superstructure. Seventeen months after installation of the superstructure, the patient demonstrated satisfactory recovery of functional occlusion.
Copyright Ó 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
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recessed compared with the healthy side; with the tooth alignment on the healthy side shifting toward the affected side together with the residual bone chips, resulting in abnormal occlusion (Fig. 1, A and B). Reconstructive surgery was performed on the mandible using a free fibula flap, for the purpose of improving facial deformity and occlusion. Nine months later, right mandibular plasty was performed using PCBM harvested from posterior ilium and a mesh plate (Fig. 2, A and B). Seven months after that, the mesh plate was surgically removed, and an implant fixture was surgically embedded. After secondary implant surgery, debulking of the surrounding skin flap was performed, and an attachment denture was created with a Dolder bar used as the retaining device, to restore occlusion. Seventeen months after installation of the superstructure, the patient demonstrated satisfactory recovery of functional occlusion (Fig. 3, A–C).
SAIJO
ET AL
Fig. 4. A, 3D-CT at the time of the initial visit. He had undergone a hemimandibulectomy, right neck dissection, and immediate reconstruction using a free scapular flap at another hospital. B, Oral findings showed free-end spaces beyond the maxillary right first premolar and mandibular right canine, covered by a thick skin flap.
fixation of the implanted fixture. Six months after installation of the implant, oral vestibuloplasty was performed on the vestibule of the mouth, which had narrowed, using skin grafted from the inguinal region. Subsequently, a superstructure was installed in a secondary operation.
Currently, 2 years has elapsed since the surgery and the course of progress is satisfactory (Fig. 5, A–D). Case 3
The patient was a 58-year-old man who had undergone resection of a maxillary pleomorphic adenoma in
Case 2
The patient was a 39-year-old man who had undergone a hemimandibulectomy, right neck dissection, and immediate reconstruction using a free scapular flap at another hospital, for right mandibular gingival carcinoma (T4N1M0, stage IV-A). Facial findings showed bulging of the right mandible, which was the reconstructed jaw, on the buccal side, whereas oral findings showed freeend spaces beyond the maxillary right first premolar and mandibular right canine, covered by a thick skin flap (Fig. 4, A and B). Osteotomy of the reconstructed jaw and debulking of the skin flap were performed with the aim of improving occlusion and facial appearance. Eleven months later, reconstruction of the mandible was performed using a titanium mesh plate and PCBM harvested from the posterior ilium, using the reconstructed jaw that had been formed as the nucleus of the reconstruction. Five months after bone grafting, the titanium mesh plate was removed and an implant was embedded. The state of bone formation was satisfactory, as was the initial
Fig. 5. A, 3D-CT showed that reconstruction of the mandible was performed using a titanium mesh plate and PCBM harvested from the posterior ilium, using the reconstructed jaw that had been formed as the nucleus of the reconstruction. B, Five months after bone grafting, the titanium mesh plate was removed and an implant was embedded. The state of bone formation was satisfactory, as was the initial fixation of the implanted fixture. C, Panoramic radiography showed after installation of the superstructure. D, Oral findings showed after the superstructure installation.
Copyright Ó 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
SAIJO
ET AL
Fig. 6. 3D-CT showed that the alveolar ridge and the oral vestibule were absent from the reconstructed mandible at the initial visit.
Fig. 7. The mesh plate is prebent using a 3D sculpted model, after which a simulation is performed.
Fig. 8. 3D-CT showed that PCBM harvested from posterior iliac crest were grafted, and the incision was closed. Approximately 5 months after the bone graft, CT images showed satisfactory bone formation.
the otolaryngology Department. of another hospital approximately 10 years earlier. After approximately 7 years, local recurrence had been
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Fig. 9. A, An attachment denture was created using the Dolder bar as the retaining device, to restore occlusion. B, This figure showed off the oral cavity during denture installation.
observed and the patient underwent maxillary bone tumor resection and immediate reconstruction using vascularized free fibula and a skin flap from the forearm. Based on facial findings from the initial visit, there was a sense of midface recess. Oral findings indicated that the alveolar ridge and the oral vestibule were absent from the reconstructed mandible. A denture had been installed in the maxilla, however, the compatibility was extremely poor (Fig. 6). In addition to the reconstructed fibula being posterior to the mandible, the height and width were insufficient to support an implant. The plan for the surgical procedure was to secure a titanium mesh plate as the nucleus of the fibula that had been grafted as the reconstruction bone, and to position it in the anterior direction at the earliest possible opportunity (Fig. 7). An incision was made from inside the oral cavity, and a titanium plate was secured to the reconstructed bone. After that, PCBM harvested from posterior iliac crest were grafted, and the incision was closed. Approximately 5 months after the bone graft, CT images showed satisfactory bone formation (Fig. 8). Five months postoperatively, the mesh tray was removed, and the implant fixture was embedded. Bone formation was found to be satisfactory, as was the initial fixation of the implant. Three months after installation of the implant, oral vestibuloplasty was performed. Subsequently, a healing abutment was installed in a secondary operation. An attachment denture was created using a Dolder bar as the
retaining device, to restore occlusion. Currently, 4 years have elapsed since surgery, and the course of progress is satisfactory (Fig. 9, A and B).
DISCUSSION In oral surgery, obvious functional and esthetic impairments can arise if a large portion of the jaw is resected.1 Numerous reports4 have indicated that when a large part of the jaw is missing, vascularized free bone grafts offer an effective means to accomplish the recovery of form and function. However, when only vascularized free bone is used, only the continuity of the jaw bone is maintained, and this does not produce sufficient recovery in terms of esthetics and function in many cases. In cases where substantial jaw reconstruction is performed, severely negative effects on facial form can arise, and in many cases, the balance of the intermaxillary relationship is lost, making it difficult to embed implants directly in the reconstructed bone.5,6 In cases where this happens, reconstruction of the alveolar bone is needed that takes the relational positioning of the upper and lower jaws into consideration. Treatment planning that includes facial form is indispensable when this treatment approach is used.7 Currently, when a large portion of the jaw bone is missing, the most commonly used approach is to perform a vascularized bone graft using ilium, scapula, or fibula. This approach is satisfactory in terms of maintaining continuity of the jaw and avoiding deformation of the facial planes. However, even if jaw continuity is
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reconstructed as a result of the vascularized bone graft, embedding implants and restoring occlusion can be difficult in many cases. This is because, regardless of whether ilium, scapula, or fibula is used, reconstructing complex jaw forms in a single stage is difficult. As a result, using vascularized bone and a durable mesh tray can not only avoid pressure on the grafted bone from the surrounding tissue, but the PCBM that was grafted between the mesh tray and the vascularized bone serves as a platform. The PCBM can be expected to promote bone reconstruction, creating the so-called “in situ tissue engineering” effect.8,9 One other feature of this method is that a preformed tray is reworked over a 3-dimensional stereo model, and prebending is performed. The preformed tray used for the mandible is used as the titanium mesh tray, and numerous reports describe the application of this tray.10–12 Currently, no customized titanium mesh trays are available on the market, and the only recourse is to use an existing product or rework a sheet-shaped mesh tray. Consequently, by adjusting the plate before the surgery, not only is it possible to decide on a graft site that takes recovery of esthetic form and occlusion function into consideration but also the time required for surgery can be shortened. Jaw bone reconstruction using a mesh tray provides satisfactory compatibility between the tray and bone graft bed, because the tray is adjusted before surgery. This reduces the time required for surgery, and is also thought to enable a reconstructed alveolar ridge
SAIJO
with the ideal configuration for implant therapy. The aim of this approach is to improve occlusion and to further enhance facial form, and involves secondary alveolar bone reconstruction using a mesh tray and PCBM, with grafted vascularized bone serving as the nucleus, and dental implants being embedded to enable satisfactory occlusion and improved facial form.
CONCLUSIONS Our results suggest that, in cases where bone is missing over a wide area, as in the cases described here, in addition to vascularized bone grafts, bone grafts using a titanium mesh tray and PCBM with vascularized bone serving as the nucleus can be performed, providing satisfactory occlusion and improved facial form.
DISCLOSURE The authors claim to have no financial interest, either directly or indirectly, in the products or information listed in the article.
REFERENCES 1. Dumbach J, Rodemer H, Spitzer WJ, et al. Mandibular reconstruction with cancellous bone, hydroxylapatite and titanium mesh. J Craniomaxillofac Surg. 1994;22:151–155. 2. Saijo H, Kanno Y, Mori Y, et al. A novel method for designing and fabricating custom-made artificial bones. Int J Oral Maxillofac Surg. 2001;40:955–960. 3. Saijo H, Kanno Y, Mori Y, et al. A bone harvesting method involving a surgical
ET AL
template prepared using a three-dimensional model. Asian J Oral Maxillofac Surg. 2010;22:20–22. 4. Rana M, Warraich R, Kokemüller H: Reconstruction of mandibular defectsdclinical retrospective research over a 10-year period. Head Neck Oncol. 2011;3:23–30. 5. Lekholm U, Wannfors K, Isaksson S, et al. Oral implants in combination with bone grafts. A 3-year retrospective multicenter study using the Brånemark implant system. Int J Oral Maxillofac Surg. 1999;28:181–187. 6. Wells MD. Mandibular reconstruction using vascularized bone grafts. J Oral Maxillofac Surg. 1996;54:883–888. 7. Tideman H, Samman N, Cheung LK. Functional reconstruction of the mandible: A modified titanium mesh system, Int J Oral Maxillofac Surg. 1998;27:339–345. 8. Iino M, Fukuda M, Nagai H, et al: Evaluation of 15 mandibular reconstructions with Dumbach Titan Mesh-System and particulate cancellous bone and marrow harvested from bilateral posterior ilia. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2009;107:1–8. 9. Sugiyama M, Saijo H, Hoshi K, et al: Secondary repair of an oblique facial cleft with an absorbable mesh tray and particulate cancellous bone and marrow. Oral Sci Int. 2012;9:63–66. 10. Iino M, Shimizu H, Kasahara H, et al. Alveolar ridge augmentation using autogenous iliac cancellous bone graft combined with Micro-Titanium Augmentation Mesh and subsequent dental implant insertion. Asian J Oral Maxillofac Surg. 2000;12:187–194. 11. Ito T, Soga K, Maekawa N. Application of a new type of titanium porosity plate in oral surgery. Int J Oral Surg. 1978; 7:323–326. 12. Gongloff RK, Cole M, Whitlowet W, et al. Titanium mesh and particulate cancellous bone and marrow graft to augment maxillary alveolar ridge. Int J Oral Maxillofac Surg. 1986;15:263–268.
Copyright Ó 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
A 2-STAGE RECONSTRUCTION
SAIJO
ET AL
A 2-Stage Reconstruction of the Jaw Using Vascularized Bone and Secondary Alveolar Ridge Augmentation With Particulate Cancellous Bone and Marrow Hideto Saijo, DDS, PhD,* Madoka Sugiyama, DDS,† Yuki Kanno, DDS,‡ Kazumi Ohkubo, DDS,§ Kazuto Hoshi, MD, PhD,¶ and Tsuyoshi Takato, MD, PhDk
n the stomatognathic region, resection of a large area of the maxilla/mandible jawbone due to removal of an oral tumor or for other reasons results in the loss of not only the facial form, but also the occlusal relationship. As a result, problems occur with masticatory function, causing striking deterioration in quality of life for the patient. In such cases, the ideal approach is to graft bone to the appropriate site to create an esthetically acceptable facial form and restore the occlusal relationship, and then to implement prosthetic measures using dental implants. However, the reconstructed jaw significantly alters the intermaxillary
I
*Lecturer, Department of Oral-Maxillofacial Surgery, Dentistry and Orthodontics, The University of Tokyo Hospital, Tokyo, Japan. †Assistant Professor, Department of Oral-Maxillofacial Surgery, Dentistry and Orthodontics, The University of Tokyo Hospital, Tokyo, Japan. ‡Assistant Professor, Department of Oral-Maxillofacial Surgery, Dentistry and Orthodontics, The University of Tokyo Hospital, Tokyo, Japan. §Lecturer, Department of Oral-Maxillofacial Surgery, Dentistry and Orthodontics, The University of Tokyo Hospital, Tokyo, Japan. ¶Associate Professor, Department of Oral-Maxillofacial Surgery, Dentistry and Orthodontics, The University of Tokyo Hospital, Tokyo, Japan. kProfessor, Department of Oral-Maxillofacial Surgery, Dentistry and Orthodontics, The University of Tokyo Hospital, Tokyo, Japan.
Reprint requests and correspondence to: Hideto Saijo, DDS, PhD, Department of Oral-Maxillofacial Surgery, Dentistry and Orthodontics, The University of Tokyo Hospital, 7-3-1, Hongo, Bunkyo-ku, Tokyo 113-8655, Japan, Phone: 81-3-5800-8669, Fax: 81-3-5800-6832, E-mail: [email protected] ISSN 1056-6163/16/02502-302 Implant Dentistry Volume 25 Number 2 Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved. DOI: 10.1097/ID.0000000000000394
Purpose: To present the novel technique for reconstruction of the jaw, that facilitates occlusal restoration using dental implants, in cases with wide bony defects from tumor resection. Materials and Methods: After alveolar ridge is augmented using titanium mesh tray and particulate cancellous bone and marrow (PCBM) from iliac bone on reconstructed bone, by way of improvement of maxillomandibular relationship for dental implants. Results: This 2-stage surgery underwent successfully in 3 cases. After 2-stage surgery and occlusal reconstruction using dental implant,
the patients experienced no complications, and received satisfaction with results functionally and aesthetically. Conclusions: Our results suggest that, in cases where bone defect is over a wide area, in addition to vascularized bone grafts, secondary alveolar ridge augmentation using a titanium mesh tray and PCBM on grafted bone can provide satisfactory occlusion further to improvement of facial form. (Implant Dent 2016;25:302–306) Key Words: jawbone reconstruction, titanium mesh tray, dental implant
relationship in many cases, creating an imbalance between the jaws, and even if jaw continuity is reconstructed through vascularized bone grafts, it can often be difficult to embed dental implants and restore occlusion. This is because it is difficult to reconstruct a complex jaw form in a single stage, even using ilium, scapula, or fibula. With regard to cases like this, along with correction of the form using bone grafts, secondary reconstruction of the alveolar part of the jaw is necessary.1 In the cases described here, in which reconstruction was achieved by
grafting vascularized free bone after resection of a tumor, the authors reconstructed the jaw bone using a titanium mesh tray and grafts of particulate cancellous bone and marrow (PCBM), with the aim of restoring facial form and occlusion. We then used dental implants to restore occlusion function and enhance esthetic aspects. We describe herein these cases and their outcomes.
TECHNIQUE In performing reconstruction using vascularized bone grafts, computed tomography (CT) images are taken in
Copyright Ó 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
SAIJO
ET AL
the usual manner. Data from these CT images are then transferred using Digital Imaging and Communications in Medicine, the bone tissue is visualized, and the resulting 3-dimensional shape data are output as a file in the standard template library (STL) format. Using the STL data, a 3D computer-aided design 3-dimensional design system is applied to create a 3-dimensional stereo model,2,3 using an ink-jet powder lamination device (Z406 System 3D Printer; DICO, The Z Corporation, Rock Hill, SC), with gypsum (ZP140 Powder; DICO) serving as the base material. The resulting model is then used to envision the form of the patient’s original jaw bone, the site of the graft is specified, and the titanium mesh plate is prebent. In the surgery, an incision is made from either inside or outside the oral cavity, and separation is performed over a broad area. After a trial fitting of the titanium mesh plate, which has been adjusted to the clarified reconstructed bone before the surgery, the plate is secured at the intended site using screws. After the plate has been secured, harvested PCBM bone chips are densely grafted into the cavity between the mesh tray and reconstructed bone. After the graft has been completed, the mucoperiosteal flap is sufficiently incised with a relaxation incision, and the wound is closed. After bone regeneration has been confirmed on CT after 5 to 7 months, surgery is performed to remove the mesh tray and embed dental implants.
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Fig. 1. A, 3D-CT findings at the time of the initial visit. He had undergone segmental resection of the right mandible because of treating primary intraosseous squamous cell carcinoma. B, Intraoral findings at the time of the initial visit. Oral mucosa is covered with a rectus abdominis musculocutaneous flap.
Fig. 2. A, This 3D-CT finding was the first operation in our hospital. Reconstructive surgery was performed on the mandible using a free fibula flap, for the purpose of improving facial deformity and occlusion. B, Nine months later for the first operation in our hospital. Right mandibular plasty was performed using PCBM harvested from posterior ilium and a mesh plate.
CASES Case 1
The patient was a 35-year-old man who had undergone segmental resection of the right mandible at a certain hospital 2 years earlier to treat primary intraosseous squamous cell carcinoma found in the right mandible. Reconstruction with a rectus abdominis musculocutaneous flap was also performed to correct tissue loss, with postoperative radiation of 50 Gy. At the time of initial diagnosis, the right buccal region was slightly
Fig. 3. A, Seven months after that, the mesh plate was surgically removed. 3D-CT finding was after mesh tray removal. The bone formation was good condition. B, After secondary implant surgery, debulking of the surrounding skin flap was performed, and an attachment denture was created with a Dolder bar used as the retaining device, to restore occlusion. The oral findings at the time of implant denture installation. C, Panoramic x-ray findings after installation of the superstructure. Seventeen months after installation of the superstructure, the patient demonstrated satisfactory recovery of functional occlusion.
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304
A 2-STAGE RECONSTRUCTION
recessed compared with the healthy side; with the tooth alignment on the healthy side shifting toward the affected side together with the residual bone chips, resulting in abnormal occlusion (Fig. 1, A and B). Reconstructive surgery was performed on the mandible using a free fibula flap, for the purpose of improving facial deformity and occlusion. Nine months later, right mandibular plasty was performed using PCBM harvested from posterior ilium and a mesh plate (Fig. 2, A and B). Seven months after that, the mesh plate was surgically removed, and an implant fixture was surgically embedded. After secondary implant surgery, debulking of the surrounding skin flap was performed, and an attachment denture was created with a Dolder bar used as the retaining device, to restore occlusion. Seventeen months after installation of the superstructure, the patient demonstrated satisfactory recovery of functional occlusion (Fig. 3, A–C).
SAIJO
ET AL
Fig. 4. A, 3D-CT at the time of the initial visit. He had undergone a hemimandibulectomy, right neck dissection, and immediate reconstruction using a free scapular flap at another hospital. B, Oral findings showed free-end spaces beyond the maxillary right first premolar and mandibular right canine, covered by a thick skin flap.
fixation of the implanted fixture. Six months after installation of the implant, oral vestibuloplasty was performed on the vestibule of the mouth, which had narrowed, using skin grafted from the inguinal region. Subsequently, a superstructure was installed in a secondary operation.
Currently, 2 years has elapsed since the surgery and the course of progress is satisfactory (Fig. 5, A–D). Case 3
The patient was a 58-year-old man who had undergone resection of a maxillary pleomorphic adenoma in
Case 2
The patient was a 39-year-old man who had undergone a hemimandibulectomy, right neck dissection, and immediate reconstruction using a free scapular flap at another hospital, for right mandibular gingival carcinoma (T4N1M0, stage IV-A). Facial findings showed bulging of the right mandible, which was the reconstructed jaw, on the buccal side, whereas oral findings showed freeend spaces beyond the maxillary right first premolar and mandibular right canine, covered by a thick skin flap (Fig. 4, A and B). Osteotomy of the reconstructed jaw and debulking of the skin flap were performed with the aim of improving occlusion and facial appearance. Eleven months later, reconstruction of the mandible was performed using a titanium mesh plate and PCBM harvested from the posterior ilium, using the reconstructed jaw that had been formed as the nucleus of the reconstruction. Five months after bone grafting, the titanium mesh plate was removed and an implant was embedded. The state of bone formation was satisfactory, as was the initial
Fig. 5. A, 3D-CT showed that reconstruction of the mandible was performed using a titanium mesh plate and PCBM harvested from the posterior ilium, using the reconstructed jaw that had been formed as the nucleus of the reconstruction. B, Five months after bone grafting, the titanium mesh plate was removed and an implant was embedded. The state of bone formation was satisfactory, as was the initial fixation of the implanted fixture. C, Panoramic radiography showed after installation of the superstructure. D, Oral findings showed after the superstructure installation.
Copyright Ó 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
SAIJO
ET AL
Fig. 6. 3D-CT showed that the alveolar ridge and the oral vestibule were absent from the reconstructed mandible at the initial visit.
Fig. 7. The mesh plate is prebent using a 3D sculpted model, after which a simulation is performed.
Fig. 8. 3D-CT showed that PCBM harvested from posterior iliac crest were grafted, and the incision was closed. Approximately 5 months after the bone graft, CT images showed satisfactory bone formation.
the otolaryngology Department. of another hospital approximately 10 years earlier. After approximately 7 years, local recurrence had been
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305
Fig. 9. A, An attachment denture was created using the Dolder bar as the retaining device, to restore occlusion. B, This figure showed off the oral cavity during denture installation.
observed and the patient underwent maxillary bone tumor resection and immediate reconstruction using vascularized free fibula and a skin flap from the forearm. Based on facial findings from the initial visit, there was a sense of midface recess. Oral findings indicated that the alveolar ridge and the oral vestibule were absent from the reconstructed mandible. A denture had been installed in the maxilla, however, the compatibility was extremely poor (Fig. 6). In addition to the reconstructed fibula being posterior to the mandible, the height and width were insufficient to support an implant. The plan for the surgical procedure was to secure a titanium mesh plate as the nucleus of the fibula that had been grafted as the reconstruction bone, and to position it in the anterior direction at the earliest possible opportunity (Fig. 7). An incision was made from inside the oral cavity, and a titanium plate was secured to the reconstructed bone. After that, PCBM harvested from posterior iliac crest were grafted, and the incision was closed. Approximately 5 months after the bone graft, CT images showed satisfactory bone formation (Fig. 8). Five months postoperatively, the mesh tray was removed, and the implant fixture was embedded. Bone formation was found to be satisfactory, as was the initial fixation of the implant. Three months after installation of the implant, oral vestibuloplasty was performed. Subsequently, a healing abutment was installed in a secondary operation. An attachment denture was created using a Dolder bar as the
retaining device, to restore occlusion. Currently, 4 years have elapsed since surgery, and the course of progress is satisfactory (Fig. 9, A and B).
DISCUSSION In oral surgery, obvious functional and esthetic impairments can arise if a large portion of the jaw is resected.1 Numerous reports4 have indicated that when a large part of the jaw is missing, vascularized free bone grafts offer an effective means to accomplish the recovery of form and function. However, when only vascularized free bone is used, only the continuity of the jaw bone is maintained, and this does not produce sufficient recovery in terms of esthetics and function in many cases. In cases where substantial jaw reconstruction is performed, severely negative effects on facial form can arise, and in many cases, the balance of the intermaxillary relationship is lost, making it difficult to embed implants directly in the reconstructed bone.5,6 In cases where this happens, reconstruction of the alveolar bone is needed that takes the relational positioning of the upper and lower jaws into consideration. Treatment planning that includes facial form is indispensable when this treatment approach is used.7 Currently, when a large portion of the jaw bone is missing, the most commonly used approach is to perform a vascularized bone graft using ilium, scapula, or fibula. This approach is satisfactory in terms of maintaining continuity of the jaw and avoiding deformation of the facial planes. However, even if jaw continuity is
Copyright Ó 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
306
A 2-STAGE RECONSTRUCTION
reconstructed as a result of the vascularized bone graft, embedding implants and restoring occlusion can be difficult in many cases. This is because, regardless of whether ilium, scapula, or fibula is used, reconstructing complex jaw forms in a single stage is difficult. As a result, using vascularized bone and a durable mesh tray can not only avoid pressure on the grafted bone from the surrounding tissue, but the PCBM that was grafted between the mesh tray and the vascularized bone serves as a platform. The PCBM can be expected to promote bone reconstruction, creating the so-called “in situ tissue engineering” effect.8,9 One other feature of this method is that a preformed tray is reworked over a 3-dimensional stereo model, and prebending is performed. The preformed tray used for the mandible is used as the titanium mesh tray, and numerous reports describe the application of this tray.10–12 Currently, no customized titanium mesh trays are available on the market, and the only recourse is to use an existing product or rework a sheet-shaped mesh tray. Consequently, by adjusting the plate before the surgery, not only is it possible to decide on a graft site that takes recovery of esthetic form and occlusion function into consideration but also the time required for surgery can be shortened. Jaw bone reconstruction using a mesh tray provides satisfactory compatibility between the tray and bone graft bed, because the tray is adjusted before surgery. This reduces the time required for surgery, and is also thought to enable a reconstructed alveolar ridge
SAIJO
with the ideal configuration for implant therapy. The aim of this approach is to improve occlusion and to further enhance facial form, and involves secondary alveolar bone reconstruction using a mesh tray and PCBM, with grafted vascularized bone serving as the nucleus, and dental implants being embedded to enable satisfactory occlusion and improved facial form.
CONCLUSIONS Our results suggest that, in cases where bone is missing over a wide area, as in the cases described here, in addition to vascularized bone grafts, bone grafts using a titanium mesh tray and PCBM with vascularized bone serving as the nucleus can be performed, providing satisfactory occlusion and improved facial form.
DISCLOSURE The authors claim to have no financial interest, either directly or indirectly, in the products or information listed in the article.
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ET AL
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