{"id":4254,"date":"2020-01-01T09:10:06","date_gmt":"2020-01-01T08:10:06","guid":{"rendered":"https:\/\/bedentalexpert.com\/implanted-supported-mandibular-rehabilitation-on-microvascularized-perone-graft-use-of-computer-guided-surgery\/"},"modified":"2023-12-14T12:22:57","modified_gmt":"2023-12-14T11:22:57","slug":"implanted-supported-mandibular-rehabilitation-on-microvascularized-perone-graft-use-of-computer-guided-surgery","status":"publish","type":"post","link":"https:\/\/bedentalexpert.com\/en\/implanted-supported-mandibular-rehabilitation-on-microvascularized-perone-graft-use-of-computer-guided-surgery\/","title":{"rendered":"Implanted-supported mandibular rehabilitation on microvascularized perone graft. Use of computer-guided surgery."},"content":{"rendered":"

SUMMARY:<\/h3>\n

Introduction:<\/strong> In the treatment of patients affected by malignant tumors of the oral cavity, the surgery combines resection and immediate reconstruction in order to preserve the functions that concentrate the oral cavity (phonation, swallowing, chewing, aesthetic). The use of microvascularized flaps is a common practice in these patients to replenish dried tissues. Dental rehabilitation of these patients is often very complex, and the use of guided implantological surgery systems avoids many of the problems that occur in these patients.<\/p>\n

Clinical case:<\/strong> Patient undergoing hemi-mandibulectomy without reconstruction and adjuvant treatment with radiation therapy who is referred for reconstruction. Initially, a microvascularized fibula flap is practiced that provides bone and soft parts. It is then rehabilitated with a hybrid prosthesis on implants, which are placed by a mucous-supported surgical splint after planning with the FacilitateTM tool.<\/p>\n

Discussion:<\/strong> the microvascularized crank hant is the workhorse in the oncology patient’s mandibular reconstruction. Its main disadvantage is the difficulty for the placement of dental implants and their subsequent rehabilitation. The use of guiding implantological surgery allows to ignore many of these problems.<\/p>\n

Conclusions:<\/strong> The reconstruction of the oral cavity cancer patient by means of microvascularized grafts, and its subsequent dental rehabilitation with osteointegrated implants allows to offer the patient an acceptable quality of life.<\/p>\n

INTRODUCTION:<\/h3>\n

In recent decades, advances in the treatment of maxillary tumor conditions have allowed us to treat and even cure patients who were previously considered untreatable. In this way, today it is as important to resection of tumors as the immediate reconstruction of the defects created, which allows to offer our patients the sufficient quality of life and continue to perform the functions of the structures removed. In the field of bone reconstruction of the facial skeleton, we must take into account that both jaw and maxilla are the carriers of the tooth pieces and consequently the preservation of chewing function should also be the target of our surgical treatment. The placement of implant-supported prostheses on the reconstructed bones offers these patients a definitive solution for the recovery of chewing function in addition to helping to improve other sequelae such as lip support.<\/p>\n

The microvascularized fibula flap has been one of the main options for this bone and dental rehabilitation. The flap was initially described by Taylor and Gilbert in the late 1970s and used by Hidalgo in 1989 for the re-construction of the jaw. Since then, its use has become widespread, thanks mainly to its versatility in offering great bone length.<\/p>\n

Its disadvantage to dental rehabilitation is that it is complicated to precisely insert the implants in situations where, after resection, the occlusal relationship has been lost and the morphology of the reconstructed bone is noticeably different from the original jaw. In this way, many implants inserted into it cannot then be properly rehabilitated (Figure 1<\/strong>),and many rehabilitations are complex and lead to unfunctional tooth occlusions.<\/p>\n

Currently guided implantological surgery systems allow you to plan and place implants virtually on a computed tomography (CT) scan that doubles the patient’s bone anatomy. Using a computer support, a splint is developed that is supported on the patient’s tissues during surgery, will indicate the precise position of each implant in a way that matches the planned situation. It also allows us to sketch what the definitive prosthesis will be by ignoring malocclusion problems and un rehabilitated implants.<\/p>\n

\"\"Figure 1.<\/strong> Incomplete oral rehabilitation on microvascularized graft. unhab rehabilitated implants.<\/p>\n

CLASSIC CASE:<\/h3>\n

We present the case of a 54-year-old patient who had undergone hemimandibulectomy for developing bone-length triplar triptyl epidermoid carcinoma with bone extension. At first, no reconstruction of the removed area was performed and the defect was blocked by stitching the tongue to the cheek mucosa after removal of the left jaw body. Cervical functional dissection was also performed and postoperative radiation therapy was indicated.<\/p>\n

Three years after the intervention the patient was free of disease, although he had very poor quality of life. It depended on a gastrostomy for its nutrition, with severe alteration of its fonatory, chewing and swallowing functions. In these conditions he was referred to the Oral and Maxilofacial Surgery Service to improve his clinical situation (Figure 2<\/strong>).<\/p>\n

\"\"Figure 2.<\/strong> orthopantomography showing the state in which the patient arrived at our consultation after mandibulectomy segmented by epidermoid carcinoma of the jaw gum<\/p>\n

At first, bone reconstruction was performed with a microvascularized crannge of fibula (fixed with a reconstruction plate) that improved facial symmetry and fonatory and swallowing functions, allowing the gastrostomy to be removed (Figure 3<\/strong>). However, the patient continued to feed on a soft diet, so rehabilitation of chewing function was considered.<\/p>\n

\"\"Figure 3.<\/strong> image of the scanner after mandibular reconstruction with microvascularized perone graft.<\/p>\n

Since the patient had mandibular edentulism, a complete prosthesis was developed, which was very poorly tolerated due to support and retention problems related to the complex anatomy of the area. Thus, the only possibility to achieve a satisfactory chewing function was the manufacture of an implant-supported prosthesis, placing the bindings in both the healthy jaw and the fibula segment.<\/p>\n

It was an unfavourable anatomical situation, made worse by the presence of a titanium plate with many screws that was complicated to remove, so it was decided to carry out a guided implantological surgery procedure.<\/p>\n

To do this, a radiopaca splint was developed on a patient model. A scanner was requested which was processed by and on the company Materialise (Leuven, Belgium) using SimPlantTM’s FacilitateTM tool (Leuven, Belgium) seven implants 4 mm in diameter and different Osseospeed lengths (Astratech, Sweden). Of these, three were placed on the native hemijaw and four on the fibula, for the manufacture of a screwed hybrid prosthesis. Given the good adaptation of the radiological splint to the patient’s mandibular rim, a mucosoportated surgical splint (Figure 4-8<\/strong>) was performed.<\/p>\n

\"\"Figure 4.<\/strong> image of the radiological splint designed for virtual surgery.<\/p>\n

\"mandibularFigure 5.<\/strong> implants planned on jaw scanner using the FacilitatetM simplant tool.<\/p>\n

\"mandibularFigure 6.<\/strong> Surgical splint. Detail of the placement of the implants avoiding the screws of the osteosynthesis plate.<\/p>\n

\"\"Figure 7.<\/strong> Surgical splint for guided surgery (surgiguide, simPlantFacilitatetM)<\/p>\n

\"\"Figure 8.<\/strong> Mucoportated splint positioned in the oral cavity.<\/p>\n

The surgery went uncomplicated. The seven planned implants were placed and the closure plugs were placed. After three months, the implants were discovered by checking their osteointegration and transepitizing plugs were placed (Figure 9<\/strong>). Three weeks later the prosthetic phase began, taking individual bucket prints, an implant-supported hybrid prosthesis was developed. The seven implants could be rehabilitated (Figure 10, 11<\/strong>).<\/p>\n

\"\"Figure 9.<\/strong> properly placed and integrated implants six months after insertion.<\/p>\n

\"mandibularFigure 10.<\/strong> Individual bucket and work model detail<\/p>\n

\"mandibularFigure 11.<\/strong> orthopantomography showing the correct adaptation of the hybrid prosthesis placed on the implants.<\/p>\n

As regards the antagonistic arch and taking advantage of the remaining teeth, a mixed metalporcellane prosthesis was performed in the anterior sector with attaches to support a skeletal and rehabilitate the posterior sector maxilla.<\/p>\n

Three years have passed and the prostheses remain installed and in use. Tooth occlusion is correct and the patient has normalized chewing function by being able to eat a normal diet (Figure 12<\/strong>).<\/p>\n

\"\"Figure 12.<\/strong> Detail of the prosthesis placed in the oral cavity.<\/p>\n

\n

The lack of saliva related to radiation therapy is an additional problem that makes it difficult to manage bolus, and has been treated with symptomatic measures (abundant water intake, salivary substitutes, gum…). Another objective of the reconstruction was the contribution of soft parts to achieve adequate lingual mobility and promote swallowing and phonation.<\/p>\n<\/div>\n

\n

DISCUSSION:<\/h3>\n

The development of reconstructive facial skeleton surgery in recent decades has greatly improved the quality of life of cancer patients. Being able to eat a normal diet depends directly on good chewing and swallowing function. The use of microvascularized flaps and the development of implantology have greatly helped to achieve these goals.<\/p>\n

With regard to the flaps used, fibula has been shown to be the most versatile in bone reconstruction. Its main advantages are: its length, which allows to reconstruct defects of up to 25 cm, the possibility of molding it performing multiple osteotomies, and the minimum morbidity of the donor area. Its indications would include, among others, mandibular reconstruction associated with significant intraoral soft tissue defects, reconstruction of sinfisary, subtotal or total mandibular defects, branch and condyle reconstructions, and reconstruction of posterior maxillary defects.<\/p>\n

Its greatest disadvantage is the low height of the bone obtained that hinders functional rehabilitation with osteointegrated implants 12, and which must also be placed deferred due to incompatibility with the amount of osteosynthesis material that is required to fix osteotomies. In any case, whenever we have 10 mm bone height and 5 mm in width, rehabilitation with implants will be possible if these are placed precisely.<\/p>\n

As already mentioned, the ultimate goal of bone reconstruction is the placement of implants on these vascularized grafts for the rehabilitation of chewing function. The main problem that implantology on flaps has posed has been the precision in placing the implants on the flap to achieve a correct emergency of prosthetic attachments and ultimately good occlusion. In this sense, it is not uncommon that many of the implants placed cannot be then rehabilitated (Figure 1<\/strong>).<\/p>\n

Guided implantological surgery systems have come to remedy many of these problems. Virtual planning allows you to:<\/p>\n

    \n
  1. Place the implants where the radiological quality of the bone is optimal by precisely adjusting the length and width of the implants.<\/li>\n
  2. Plan the emergence of prosthetic attachments so that the implants placed are rehabilitable.<\/li>\n
  3. Avoid the need to remove osteosynthesis material when placing the implants, if possible, where there are no screws and also avoiding osteotomy lines.<\/li>\n
  4. Perform minimally invasive surgeries without the need to deperiost the grafted bone.<\/li>\n
  5. Plan immediate prostheses that can be placed in the postoperative by improving the function and adaptation of soft tissues<\/li>\n<\/ol>\n

    Guided surgery requires:<\/p>\n

      \n
    1. an imaging test, CT scan, that allows us to accurately assess the jaw or jaw bone for virtual implant placement.<\/li>\n
    2. proper computer support, planning program, which in our case has been the Facilitate tool for Materialise Dental’s SimPlant program.<\/li>\n
    3. a stereolithographic splint that translates scanner planning information into the actual patient.<\/li>\n<\/ol>\n

      In this sequence of needs we must take into account that:<\/p>\n

        \n
      1. Before referring the patient to the radiological cabinet, we must decide on the type of support for the surgical splint. If we are going to perform surgery without flap, which is ideal, the patient should perform the CT with a radiological splint, baryta. For the splint to be useful, it must be precisely adjusted to the patient’s mucosa and stable so that the thickness of this mucosa can be inferred and the planning is correct in terms of the diameter and length of the implants. This is often complicated in cases of complete jaw reconstructions. In case it is impossible to adapt the radiological splint to the mucosa (very common in reconstructed patients with bone profile alteration and distortion of soft parts) the surgical splint will be bone-supported. If the patient is a carrier of tooth pieces in the arch to be reconstructed, we can opt for a dentary support. In all other cases where the radiological splint adapts well to the mucosa, that support will be chosen for the final surgical splint.<\/li>\n
      2. As for the planning program it is necessary to know its characteristics well to be able to exploit all the tools and advantages it offers.<\/li>\n
      3. Finally, as far as the surgical splint is concerned, it must be borne in mind that, if we add the height of the splint to that of the bushings through which the implants are placed, there is a distance to the bone that requires the cutters to be of great length, usually between 18 and 25 mm. This can complicate surgery if we are acting on the jaw region especially in cancer patients who frequently have limited oral opening as a sequel to the intervention and radiation therapy.<\/li>\n<\/ol>\n

        In any case the concordance between the simulated planning and the actual result after surgery in cases where we attend all these premises is very high, with position differences less than 1 mm. All this allows, in these very complex cases, to rehabilitate all implants and achieve acceptable occlusions. In addition, thanks to the stability of the implant-supported prostheses, the complications posed by the soft parts could be avoided, without the need for complex retouching of the flap or the patient’s mucosa (thinnings of the skin palette, vestigoplasties,…).<\/p>\n

        As for the prognosis of these implants, there are authors who insist that microvascularized bony flaps statistically accept implants better than normal alveolar bone due to their large vascularity.<\/p>\n

        Finally, the prosthetic solution should be individualized on a case-by-case basis based on the number of implants that can be placed, the biomechanical situation of the chewing system, the dentition of the antagonist arch, the sensory deficits of the patient and their oral hygiene. At free ends we will routinely use fixed ceramo-metallic prostheses, while in complete reconstructions we must assess that fixed prostheses require a greater number of implants, a more complex occlusal fit and thorough hygiene. This is often a greater satisfaction for the patient although it is a more expensive treatment.<\/p>\n<\/div>\n

        \n

        CONCLUSIONS:<\/h3>\n

        As a final conclusion of this work we must say that, although healing remains our priority objective, the development of microsurgical techniques and osteointegrated implantology has ostensibly improved the integral treatment of cancer patients. Therefore, we want to highlight the real possibility that we have to offer patients undergoing jawed bone resections and reconstructed with bone flaps, a dental rehabilitation with implant-supported prosthesis and \/ or implantorretened, which will improve their facial harmony and their quality of life. The satisfaction rate with this type of treatment is very high since what most of them demand after surgery and radiation therapy, is the possibility of having teeth again and chewing normally.<\/p>\n<\/div>\n

        \n

        AUTHORS:<\/h3>\n
        \n

        Cebri\u00e1n-Carretero, Jos\u00e9 Luis<\/strong>. Doctor of Medicine. Specialist in Oral and Maxilofacial Surgery. Degree in Dentistry. La Paz University Hospital in Madrid. Private practice.<\/p>\n

        Gonz\u00e1lez Mart\u00edn-Moro, Javier<\/strong>. Bachelor of Medicine. Specialist in Oral and Maxilofacial Surgery. Degree in Dentistry. La Paz University Hospital in Madrid. Private practice.<\/p>\n

        Sobrino del Riego, Jos\u00e9 Andr\u00e9s<\/strong>. Bachelor of Medicine. Specialist in General Surgery. Degree in Dentistry. Private practice.<\/p>\n

        Demar\u00eda Mart\u00ednez, Gaston<\/strong>. Bachelor of Medicine. Specialist in Oral and Maxilofacial Surgery. Degree in Dentistry. Private practice.<\/p>\n

        Chamorro Pons, Manuel<\/strong>. Doctor of Medicine. Specialist in Oral and Maxilofacial Surgery. Head of service of Oral and Maxilofacial Surgery of Sanitas Madrid hospitals.<\/p>\n

        Indexed in:<\/strong>
        \n– IME
        \n– IBECS
        \n– LATINDEX
        \n– GOOGLE ACADEMIC<\/p>\n

        Correspondence:<\/strong>
        \nJos\u00e9 Luis Cebri\u00e1n Carretero
        \nOral Surgery Service and Maxillofacial Hospital University La Paz.
        \nPaseo de la Castellana, 261. 28046 Madrid
        \njlcebrian@clinicalaluz.es
        \nTel: 91 727 73 36<\/p>\n<\/div>\n<\/div>\n","protected":false},"excerpt":{"rendered":"

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