Treatment of extensive tumors of the jaws by hemimandibuloectomy with simultaniouse reconstruction of the mandible, arthroplasty of temporomandibular joint, orthopedic rehabilitation supported by dental implants

Abstract

Background. Reconstruction of subtotal and total defects of maxillofacial region after ablative tumor surgery is a challenging task of reconstructive surgery. The “golden rule” is maintaining of radicalism of ablative surgery as well as appropriate surgical reconstruction and prosthodontic rehabilitation, that allows patient return to normal life. Wherein reconstructive procedure is focusing on restoring of mandibular continuity by the means of different flaps and grafts, while prosthodontic rehabilitation is performing after some period of time (usually around year) by the means of removable and non-removable prosthodontic devices. Non-removable device requiring dental implants insertion into grafted material followed by period of osteointegration, that is requiring some time as well. However, within this period of time one could observe significant soft tissue deformity.The objective is to improve the outcomes of surgical reconstruction of extensive defects of the mandible and to carry out rapid prosthodontic rehabilitation supported by dental implants by application of 3D preoperative planning and navigation devices.Clinical case. Forty-nine years-old female patient with recurrent ameloblastoma, that affects vertical and horizontal ramus of the mandible. Within virtual preoperative planning one performed: resection of the mandible associated with exarticulation of condylar head, virtual plate bending according to contours of the mandible (that were determined by application of “mirror” function of virtual planning software), arthroplasty of temporomandibular joint, determination of donor site on fibula bone, osteotomy of fibula free flap, positioning of dental implants, transferring of composite flap and it’s fixation by reconstructive plate. According to acquiring data one performed fabrication of patient specific navigation guides for both fibula flap segmentation and dental implants positioning. Surgical procedure included single-step tumor ablation and exarticulation of condylar head, reconstruction of defect by the means of osseo-myo-cutaneous fibula free flap, that was pre-implanted by dental implants, total joint reconstruction by titanium condylar head and polypropylene fossa, fixation of the flap and condylar head in recipient site by the means of prebended reconstructive plate, as well as insertion of non-removable bridge prosthodontic device. Postoperative result was asses clinically and radiologically. No significant postoperative complications occurred. Restoration of facial contours, mouth opening, I class occlusion, as well as adequate meal and speech were detected. Postoperative radiological investigation revealed adequate positioning of dental implants within neo-mandible, as well as positioning of artificial joint.Conclusion. In cases of extensive tumors of the jaws single-step ablative surgical procedure, reconstruction of missing anatomical structures of the jaws and simultaneous prosthodontic rehabilitation allows to prevent possible deformities of the soft tissues and due to rapid restoration of vital functions has great impact to quality of patient’s life. Adequacy of performing procedures could be reached by implementation of virtual preoperative planning and fabrication of patient-specific surgical guides.