Journal of Oral Implantology TOTAL MANDIBULAR RECONSTRUCTION AND REHABILITATION: A CASE REPORT --Manuscript Draft-Manuscript Number:

AAID-JOI-D-13-00141R1

Full Title:

TOTAL MANDIBULAR RECONSTRUCTION AND REHABILITATION: A CASE REPORT

Short Title:

TOTAL MANDIBULAR RECONSTRUCTION AND REHABILITATION

Article Type:

Clinical Case Letter

Keywords:

Functional Mandibular reconstruction, Total Mandibular reconstruction, Complete mandibular reconstruction, Vascularised free fibular grafts, implant supported overdenture

Corresponding Author:

Shantanu S Jambhekar, BDS ,MDS TPCT Terna Dental College,Nerul, Navi Mumbai Mumbai, Maharashtra INDIA

Corresponding Author Secondary Information: Corresponding Author's Institution:

TPCT Terna Dental College,Nerul, Navi Mumbai

Corresponding Author's Secondary Institution: First Author:

Shantanu S Jambhekar, BDS ,MDS

First Author Secondary Information: Order of Authors:

Shantanu S Jambhekar, BDS ,MDS Mohit G Kheur, BDS,MDS Satyajit Dandagi, BDS,MDS Jay D Matani, BDS,MDS Sumit Sethi, BDS,MDS Supriya M Kheur, BDS,MDS

Order of Authors Secondary Information: Abstract:

Rehabilitation of mandibular discontinuity defects is a complex procedure and involves an interdisciplinary team involvement of a maxillofacial surgeon, restorative dentist, speech therapist, psychologist and other allied health science specialists. A partial or complete mandibulectomy is the routine surgical treatment of choice for patients diagnosed with malignant oral lesions involving the mandible. Oral rehabilitation of patients with mandibular discontinuity defects is a challenge for both the surgeon and the dentist. The surgeon has the vital responsibility to perform surgery so as to minimize the impairment of function, speech and esthetics. Advances in microvascular surgery have provided the surgeon with methods to repair the partially resected mandible with vital bone grafts. However, reconstruction of the bony defect alone does not guarantee an adequate foundation for successful conventional prosthetic rehabilitation. Osseointegrated implants placed into the microvascularized grafted bone offer an opportunity for improved function and patient satisfaction and have become the treatment of choice. In recent years many reports of jaw reconstruction using free vascularized flaps have been published.However, the literature does not report any total reconstruction of the mandible using a vascularised free fibula graft followed by prosthodontic rehabilitation. The following case report presents the prosthetic rehabilitation of a totally mandible reconstructed with a vascular free fibular graft using an implant-supported overdenture.

Response to Reviewers:

Reviewer #4: -Missed better illustrate the surgical part of implant placement. -There was an implant (center) that was not used for rehabilitation, describe why.

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-At line 155, it is described that was used but in shortened arch, but in figure 9:11 there is a prosthesis extending to the second molar contradicting shortened arch. -In the discussion, could discuss more about the rate of success of implants in the region of area cancer, discuss more about the complexity of this type of patient rehabilitation in according to the literature Response to the Reviewer: The photographs for the surgical implant placement are not that clear. Explanations regarding1. Reason for not utilizing one of the implants -Line 129 2. The shortened dental arch-Line 156 3.Discussion about the rate of success of implants in the region of area cancer-Line 174 4. the complexity of this type of patient rehabilitation have been added in the revised manuscript-Line 139 Reviewer #2: This article is very interesting and well done. I think the treatment is clearly excellent and the article should be published. However, I would like to see the conclusion developed a little more--perhaps including that just because a fibular graft fails once it doesn't mean that they can't ultimately succeed. It would also be nice to have a better description of the difference in appearance and function for this patient before and after treatment Response to the Reviewer: Conclusion section has been elaborated more-Line 208. Also a short paragraph on the follow up observations have been added-Line 190. To better describe the difference in appearance after treatment additional Figure 14 has been added- Line 201.

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Article File

TOTAL MANDIBULAR RECONSTRUCTION AND REHABILITATION: A CASE REPORT Shantanu S Jambhekar (corresponding author), BDS , MDS; Mohit G Kheur, BDS, MDS; Satyajit Dandagi, BDS, MDS; Jay D Matani, BDS, MDS; Sumit Sethi, BDS, MDS; Supriya M Kheur, BDS, MDS

Contributors 1. Dr. Shantanu S Jambhekar BDS, MDS ITI Scholar, Department of Reconstructive Sciences (Division of Prosthodontics) University of Connecticut, School of Dental Medicine, Farmington, CT, USA And Lecturer, Dept of Prosthodontics, Terna Dental College, Nerul, Navi Mumbai. 2. Dr. Mohit G Kheur BDS, MDS Professor and PG Guide, Dept of Prosthodontics, M A Rangoonwala College of Dental Sciences and Research Centre, Pune 3. Dr. Satyajit Dandagi BDS, MDS Professor, Dept of Oral and Maxillofacial Surgery 4. Dr. Jay Matani BDS, MDS Dept of Prosthodontics, M A Rangoonwala College of Dental Sciences and Research Centre, Pune 5. Dr. Sumit Sethi BDS, MDS Reader, Bhojai Dental College and Hospital, Tehsil Baddi, Himachal Pradesh 6. Dr. Supriya Kheur BDS, MDS Dept of Oral Pathology, D Y Patil Dental College and Research Centre, Pimpri, Pune. Reader, Dept of Prosthodontics, Bhojai Dental College and Hospital, Tehsil Baddi, Himachal Pradesh, India Department(s) and institution(s) : Department of Prosthodontics, M A Rangoonwala College of Dental Sciences and Research Centre,Pune.

Corresponding contributor: Dr. Shantanu S Jambhekar BDS, MDS 1603,Datta Tower Dr. Walimbe Marg Opp. Mumbai Veternary College Parel Village Mumbai, Maharashtra 400012 INDIA +1 8609655163 / + 91 989 269 3994 [email protected]

Total number of pages: 10 Total number of photographs: 14

Word counts For abstract: 212 words For the text: 2209 words Source(s) of support: Nil Presentation at a meeting: 59th The Greater New York Academy of Prosthodontics Annual Scientific Meeting (As a Poster ) Organisation: GNYAP Conflicting Interest :Nil

Place: New York, USA

Date: 6th -7th December 2013

ABSTRACT Rehabilitation of mandibular discontinuity defects is a complex procedure and involves an interdisciplinary team involvement of a maxillofacial surgeon, restorative dentist, speech therapist, psychologist and other allied health science specialists. A partial or complete mandibulectomy is the routine surgical treatment of choice for patients diagnosed with malignant oral lesions involving the mandible. Oral rehabilitation of patients with mandibular discontinuity defects is a challenge for both the surgeon and the dentist. The surgeon has the vital responsibility to perform surgery so as to minimize the impairment of function, speech and esthetics. Advances in microvascular surgery have provided the surgeon with methods to repair the partially resected mandible with vital bone grafts. However, reconstruction of the bony defect alone does not guarantee an adequate foundation for successful conventional prosthetic rehabilitation. Osseointegrated implants placed into the microvascularized grafted bone offer an opportunity for improved function and patient satisfaction and have become the treatment of choice. In recent years many reports of jaw reconstruction using free vascularized flaps have been published. However, the literature does not report any total reconstruction of the mandible using a vascularized free fibula graft followed by prosthodontic rehabilitation. The following case report presents the prosthetic rehabilitation of a totally mandible reconstructed with a vascular free fibular graft using an implant-supported overdenture. Key words: Functional Mandibular reconstruction, Total Mandibular reconstruction, complete mandibular reconstruction, vascularized free fibular grafts, implant supported overdenture

INTRODUCTION Treatment of mandibular discontinuity defects is a great clinical challenge.1-3Partial or complete mandibulectomy is the surgical treatment of choice for patients diagnosed with malignant oral lesions involving the mandible The use of microvascular grafts to minimize the impairment of function, speech, esthetics is the mainstay of modern surgical approach of the reconstructive team. Advances in microvascular surgery have provided the surgeon with methods to repair the partially resected mandible with vital bone grafts. Vascularized bone is used for the secondary reconstructions with large defect, where soft tissue is inadequate, or where the recipient bed has been compromised by radiation, chronic infection, or previous surgery. Often, however, reconstruction of the bony defect alone does not guarantee an adequate foundation for successful conventional prosthetic rehabilitation. Osseointegrated implants placed into the microvascularized grafted bone offer an opportunity for improved function and patient satisfaction and have become the preferred treatment modality. 4-6 A variety of donor sites have been used for this purpose, including the iliac crest, radius, scapula, and fibula.7-10However, currently the microvascular free fibula flap represents a versatile reconstruction method after mandibularablation.3 The free fibular microvascular flap was one of the earliest osseous free flaps with successful application in large bony defects.11-14 Hidalgo was the first to report the use of a fibula vascularized flap for mandibular reconstruction with 100% osseous survival in a series of 13patients.15

Some of the documented advantages of using free fibular microvascular flaps are a)

Its ability to provide the largest bone length that allows reconstructing even after

complete jaw resections.1,2,7 b)

The quality of fibular bone transfer and its rich periosteal blood supply makes it

very safe and useful for mandibular reconstruction. The nature of the fibular blood supply allows precise graft shaping by multiple osteotomies using a prefabricated template. c)

The fibular flap is considered one of the ideal flaps for large mandibular defects

and is superior to the iliac crest grafts especially in older patients.1,2 d)

It allows mandibular reconstruction without transferring a large bulk of soft tissue

as is required in the iliac crest vascularized flap. e)

The postoperative morbidity after fibula free flap reconstruction is relatively

low.1,7,14 f)

In addition, the fibula provides adequate amount of bone width and height to support

osseointegrated implants that support the functional reconstruction via overdenture or fixed reconstruction.2

In recent years many reports of jaw reconstruction using free vascularized flaps have been published. However, the literature does not report any total reconstruction of the mandible using a vascularized free fibula graft followed by prosthetic rehabilitation. There are a number of unique clinical problems encountered during such prosthetic rehabilitation. The authors have encountered these problems during the jaw relation registration and the overdenture trial stage. The following case report presents the prosthetic rehabilitation of a totally mandible reconstructed with a vascular free fibular graft using an implant-supported overdenture.

CASE REPORT A twenty four year old female patient reported to the Dept of Oral and Maxillofacial Surgery with a history of mandibular nerve neuroma treated with mandibular resection followed by reconstruction with a fibular graft about 3 years ago. Radiographic examination revealed a failed reconstruction. [Figure 1] The patient had no systemic disease and all routine investigations were normal. MANAGEMENT: Planning of the prosthodontic rehabilitation prior to mandibular reconstruction has been suggested as to play a vital role for a successful dental reconstruction.4 The case was planned for resection of the failed fibular flap followed by simultaneous reconstruction with a free fibular vascularized osteocutaneous flap. Since the mandibular reconstruction was performed secondarily (i.e., following failure of a previous reconstruction), the contours were established using a normal maxillo-mandibular relationships. A wax rim supported by a record base was utilized as a stent in order to establish the contours of the reconstructed fibula. Once the contour and length were established, the graft was then fashioned into the shape of the mandible by judiciously placed osteotomies and bone wedge resection, care was taken to meticulously preserve the periosteum. The osteotomies were performed sequentially and were maintained in position with a titanium miniplate system [(2 -mm four- hole plate with gap and 2 X 10mmscrews) Orthomax, India] [Figure 2]

The reconstructed fibula was then oriented in place of the mandible and anastomoses with vessels was done. The panoramic radiograph showed well integrated fibula flap after 6 months. [Figure 3] Implant placement was planned in the reconstructed area. After adequate healing for about 8 months from the initial reconstructive surgery, dental implants were inserted secondarily to allow a more accurate implant positioning according to the prosthodontic needs. Care was taken during incision, flap elevation and implant site preparation to avoid damaging the vascular pedicle of the fibula flap. Four implants were placed into the reconstructed mandible under local anesthesia (Three implants Uniti D5.3 X L10 and one Uniti D4.3XL 10) (Equinox, Medical technologies, B.V, Ziest, Holland) Primary stability of all implants achieved was achieved and verified by Periotest (Medizintechnik Gulden e.K, Modataul, Germany).All implants were allowed to integrate for a period of 4months before second stage surgery. The healing period was asymptomatic. After four months, second stage surgery for implant exposure was performed along with skin graft harvested from the medial aspect of the thigh. An acrylic stent relined with tissue conditioner was used to stabilize the tissues using Titanium bone plating screws (1.5X6mm) [Orthomax, India].1 However this graft failed to take up due to a postoperative infection and an additional vestibuloplasty was performed to allow increase in attached gingiva to provide an adequate amount of keratinized mucosa around the implants so as to allow maintenance procedures.

After adequate healing of the site the implants were uncovered and an acrylic stent was fabricated to maintain the patency of the emergence profile of the gingival formers. Straight abutments (Uniti D5.3) (Equinox Medical technologies, B.V, Ziest, Holland) were placed into the terminal implants while gingival formers were placed on the implants closer to the midline. Addition silicone putty (AFFINIS Putty super soft, Colene Whaledent, Langenau, Germany) was manipulated and adapted over the straight abutments. It was then molded to fabricate an index. The index so formed was then flasked and packed in clear self-cure acrylic resin. (DPI, India) The acrylic resin stent was stabilized intraorally by cementing the stent using GIC luting agent (GC Fuji I® Glass Ionomer Luting Cement, GC America, USA) onto the straight abutments. (Uniti Straight abutments D5.3Equinox Medical technologies, B.V, Ziest, Holland) The stent was placed to hold the labial tissues away from the implant abutments and to maintain patency of the exposed implants. [Figure 4] After a month the patient was recalled and the stent removed. The central implants were re exposed. Preliminary impression was made using a stock tray and Modeling plastic impression compound(Y-Dents impression compound; MDM Corporation, New. Delhi, India) and poured in dental stone. Open tray impression posts were placed and final impression made using Impregum Penta Medium Bodied polyether (3MESPE AG, Germany) [Figure 5] Due to the thickness of overlying soft tissue, a closed tray impression coping could not be utilized. The angulation of the medial right implant, and its proximity to its neighboring implant, precluded the utilization of long open tray impression copings. Hence it was decided to utilize only three implants for the prosthetic rehabilitation. Laboratory analogues were attached and the impression was poured to obtain the working model.

The orientation of the implants was verified intraorally using a transfer orientation jig fabricated on the master cast. [Figure 6] Considering the amount of the excessive overlying soft tissue, to obtain maximum stability of the record base during recording of jaw relations the record base was then fabricated over the jig. It was observed that the amount of closure of the reconstructed mandible was dependent on the position and tilt of the head. Thus the horizontal and vertical jaw relations varied with the amount of opening. This could be attributed to the pseudo TMJ reconstruction and lack of direct muscles attachments with the reconstructed mandible. Hence it was decided to record the jaw relation record with the head tilt (centered) with a straight gaze as that was the position the patient would assume during mastication and at rest. This facilitated development of maximum intercuspation at the particular head tilt and allowed maximum masticatory efficiency (functional efficiency) thus allowing better patient satisfaction and improving quality of life. [Figure 7] Tentative maxillo-mandibular relationship records and diagnostic arrangement of teeth were made to evaluate the amount of space for prosthetic platform fabrication. Other parameters like occlusion, esthetics and phonetics were also evaluated. It was decided to splint all the three implants with a platform to harbor the precision attachment (Ball and O-ring) for retention of the prosthesis. Using waxable bridge abutments a prosthetic platform was fabricated in Pattern resin (GC pattern rising America, USA) to splint the implants. After verifying the fit of the platform intraorally the precision attachments (ball attachments from OT cap system, castable single

spheres (Rhein 83 attachments, Bologna, Italy)were attached on top of the platform and it was cast in Nickel-Chromium alloy.(Hi-Chrom Soft7, High Dental Japan)[Figure 8] The passive fit of the framework was evaluated using radiographs. A record base was fabricated over the framework with the O -rings incorporated in order to stabilize the base and jaw relation records were made. Anatomic teeth were selected for maximum masticatory efficiency to compensate for decreased muscle action due to lack of direct muscle attachments. A shortened dental arch concept was utilized to reduce the amount of cantilever and decrease the amount of stress on the implants. The 2nd premolar tooth was omitted and replaced by a second molar. This was done to increase the surface area of the occlusal table to improve the masticatory efficiency and compensate for the lack of normal masticatory muscle attachments. [Figure 9] The try in denture was evaluated for aesthetics, phonetics and occlusion. The try in denture was then processed using injection molding technique. (BPS-Bio functional Prosthetic System, Ivoclar Vivadent, Liechtenstein)[Figure 10, 11, 12] At the time of prosthesis delivery, a panoramic radiograph was taken to check implant position and the coupling between prosthetic components. [Figure 13] The patient was instructed to eat a soft diet during the healing period of three months. Oral hygiene instructions, including the use of toothbrushes, interdental brushes, Water pik (Water Pik Inc, USA) and Chlorhexidine mouth rinse were given. Discussion:

There are several documented advantages of using free fibular microvascular flap for mandibular reconstruction.1-3, 7, 14 The literature also reports an excellent potential prognosis for implant- supported prostheses with the long-term survival and success rates of implants placed in reconstructed jaws ranging from 86-99%. 4, 16-20 Hidalgo and coworkers have reported a success rate of 100% for a series of 19 patients over a 10 year follow up.16Kramer reported a success rate of 96.1% after an observation period of 1400 days.17 Wu reported that high primary stability for implants placed into the free fibula grafts was achieved. The 1-year and 5-year cumulative survival rates of the implants were 96% and 91%, 18 The implant-supported fixed restoration is often considered the treatment of choice for patients following jaw resection/reconstruction.17 However, its fabrication requires more number of implants, and the initial treatment cost is much higher than the implant overdenture option.18, 21

The lack of keratinized mucosa, coupled with reduced labial sulcus depth and limited oral

access hinders the patient’s oral hygiene procedures. Removable implant-supported prostheses are easier for the patient to clean.22, 23 Hence an implant supported removable prosthesis was planned for the patient. The implants were splinted to minimize movement of the prosthesis during function and better distribution of forces. Over a period of 2 years the patient reported great comfort and ability to function with the prosthetic reconstruction. The patient was able to wear the prosthesis easily. The patient reported ability to eat most of the normal to near normal diet except for nuts, meats. The level of retention achieved from the attachments helped in psychological comfort which in turn had positive

impact on the patient’s confidence levels. During the follow up time period the plastic attachments had to be replaced once due to routine wear and tear. Although, following surgical failure of the first fibular graft, the fibula from other leg was utilized for the secondary reconstruction. The patient did not report or display any significant donor site disability that had effect on or would curtail any form of routine physical activity. The reconstructed mandible acted as a stable platform for tongue mobility. Thus the patient showed excellent speech quality postoperatively. Postoperatively, there was significant change in the patient’s profile, facial proportions and symmetry. (Figure 14) Over a two year follow up period, there was no detectable distortion to the outcome achieved. Radiographically the grafted bone did not show any significant change and was uniformly stable. These outcomes had a significant effect from a quality of life standpoint. Conclusion: In conclusion, the fibula free vascularized flap is a safe and reliable method for comprehensive functional and esthetic mandibular defect reconstruction. The use of the free fibular vascular flap of the second leg following failure of the first flap, led to an excellent surgical and prosthetic outcome. The protocol followed for the case had a significant impact on enhancing the patient’s quality of life.

References1. Micha Peled, Imad Abu El-Naaj, Yitzhak Lipin and Leon Ardekian, The Use Of Free Fibular Flap For Functional Mandibular Reconstruction.J Oral Maxillofac Surg. 2005 Feb; 63(2): 220-4. 2. T. L. Wong, Peter Y. P. Wat, Edmond H, N.Pow and A S. Mcmillan. Rehabilitation Of A Mandibulotomy/ Onlay/Graft-Reconstructed Mandible Using A Milled Bar And A Tooth- And Implant-Supported Removable Dental Prosthesis: A Clinical Report. J Prosthet Dent 2010; 104:1-5. 3. Mehmet Kürkcü, Mehmet Emre Benlidayı, Cem Kurtog˘Lu and Erol Kesiktas. Placement Of Implants In The Mandible Reconstructed With Free Vascularized Fibula Flap: Comparison Of 2 Cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008; 105:E36-E40 4. Hervc Reychler, Jose Iriarte Ortabe,Alain Pecheur and Veronique Brogniez. Mandibular Reconstruction with a Free Vascularized Fibula Flap and Osseointegrated Implants: A Report of Four Cases. J Oral Maxillofac Surg. 1996 Dec;54(12):1464-9. 5. Chiapasco M, Colletti G, Romeo E, Zaniboni M, Brusati R. Long-Term Results Of Mandibular Reconstruction With Autogenous Bone Grafts And Oral Implants After Tumor Resection. Clin Oral Implants Res 2008; 19:1074-80. 6. Koord Smolka, Michel Kraehenbuehl, Nicole Eggensperger, Wock Hallermann Et Al; Fibula Free Flap Reconstruction of the Mandible in Cancer Patients: Evaluation of a Combined Surgical And Prosthodontic Treatment Concept. Oral Oncology (2008) 44, 571– 581 7. Sieg P, Zieron Jo, Bierwolf S, Et Al. Defect-Related Variations in Mandibular Reconstruction Using Fibula Grafts. A Review Of 96 Cases.Br J Oral Maxillofac Surg. 2002 Aug; 40(4):322-9

8. Moscoso Jf, Keller J, Genden E, Et Al. Vascularized Bone Flaps In Oromandibular Reconstruction. A Comparative Anatomic Study of Bone Stock from Various Donor Sites to Assess Suitability for Endosseous Dental Implants. Arch Otolaryngol Head Neck Surg. 1994 Jan; 120(1):36-43. 9. Beckers A, Schenck C, Klesper B, Et Al. Comparative Densitometric Study Of Iliac Crest And Scapula Bone In Relation To Osseous Integrated Dental Implants In Microvascular Mandibular Reconstruction. J Craniomaxillofac Surg. 1998 Apr; 26(2):75-83. 10. Nikolaos A. Papadopulos, Juergen Schaff, Robert Sader ,Laszlo Kovacs, Et Al Mandibular Reconstruction With Free Osteofasciocutaneous Fibula Flap: A 10 Years’ Experience Injury, Int. J. Care Injured (2008) 39s, S75—S82 11. Bahr W, Stoll P, Wachter R. Use of the “Double Barrel” Free Vascularized Fibula in Mandibular Reconstruction. J Oral Maxillofac Surg. 1998 Jan; 56(1):38-44. 12. Anthony JP, Foster Rd, Pogrel Ma. The Free Fibula Bone Graft for Salvaging Failed Mandibular Reconstructions. J Oral Maxillofac Surg. 1997 Dec; 55, (12), 1417-21. 13. Dalkiz M, Beydemir B, Gunaydin Y: Treatment Of A Microvascular Reconstructed Mandible Using An Implant-Supported Fixed Partial Denture: Case Report. Implant Dent. 2001; 10(2):121-5. 14. Jong Ho Lee, Myeong Jin Kim, Jong Won Kim, Mandibular Reconstruction with Free Vascularized Fibular Flap; J Craniomaxillofac Surg. 1995 Feb; 23(1):20-6 15. Hidalgo Da: Fibula Free Flap: A New Method of Mandible Reconstruction. PlastReconstr Surg. 1989 Jul; 84(1):71-9.

16. David A. Hidalgo, Andrea L. Pusic. Flap Mandibular Reconstruction: A 10-Year Follow-Up Study. Plast. Reconstr. Surg.2002 110(2): 438-449.

Written wrong format

17. Kramer FJ, Dempf R, Bremer B. Efficacy of dental implants placed into fibula-free flaps for orofacial reconstruction. Clin Oral Implants Res. 2005 Feb; 16(1):80-8. 18. Dalkiz M, Beydemir B, Gunaydin Y. Treatment Of A Microvascular Reconstructed Mandible Using An Implant-Supported Fixed Partial Denture: Case Report. Implant Dent 2001; 10:121-5. 19. Chiapasco M, Bigliori F, Autelitano L, Romeo E, Brusati R. Clinical outcome of dental implants placed in fibula free flaps used for the reconstruction of maxillo-mandibular defects following ablation for tumors or osteoradionecrosis. Clin Oral Implants Res 2006; 17: 220–8. 20. Roumanas ED, Chang TL, Beumer J. Use of osseointegrated implants in the restoration of head and neck defects. J Calif Dent Assoc 2006; 34(9):711–8. 21. Attard Nj, Zarb Ga, Laporte A. Long term Treatment Costs Associated With ImplantSupported Mandibular Prostheses in Edentulous Patients. Int J Prosthodont 2005; 18:117-23. 22. Zitzmann Nu, Marinello Cp. A Review of Clinical and Technical Considerations for Fixed and Removable Implant Prostheses in the Edentulous Mandible. Int J Prosthodont 2002; 15:6572. 23. Heydecke G, Boudrias P, Awad Ma, Dealbuquerque Rf, Lund Jp, Feine Js. Within subject Comparisions of Maxillary Fixed and Removable Implant Prostheses: Patient Satisfaction and Choice of Prosthesis. Clin Oral Implants Res 2003; 14:125-30.

Legend for Figures

Figure 1 Preoperative Orthopantograph Figure 2 Wax rim and record base used as a stent to form the horse shoe shape of the fibula Figure 3 Postoperative Orthopantograph Figure 4 Acrylic stent in situ Figure 5 Final Impression Figure 6 The verification jig on the master cast and tried intraorally Figure 7 Intercuspation at various tilts of the head Figure 8 Resin Prosthetic Platform Trial Figure 9 Arrangement of teeth Figure 10 Prosthetic platform with Rhein-83 attachments Figure 11 Final Prosthesis Figure 12 The O-ring attachments in the final prosthesis Figure 13 Postoperative Orthopantograph Figure 14 Preoperative and postoperative views showing improvement in the facial esthetics.

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Total Mandibular Reconstruction and Rehabilitation: A Case Report.

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