By Melissa Amundson, DDS, MPH
The past decade has seen tremendous growth in both hard and soft tissue reconstruction for maxillofacial surgery. The emergence of 3-D printing and online Virtual Surgical planning has improved both the quality, precision, and outcomes for defects involving dentate aspects of the maxilla and mandible. Prior to hardware customization and widely available microvascular reconstruction, patients suffering from hard tissue defects of the maxilla or mandible were left with few acceptable reconstructive options resulting in “dental cripples”. Segmental defects of the maxilla or mandible were historically very difficult to achieve a reconstructive outcome that restored functional dentition. Patient morbidity was high and quality of life outcomes were poor. The evolution of 3-D printing and virtual surgical planning has led to our current “gold standard” known as the Jaw in a Day ™.
The Jaw in a Day procedure allows for single surgery treatment and full dentate reconstruction.
For example, the benign but aggressive tumor known as ameloblastoma, has historically been a topic of surgical debate weighing surgical morbidity against surgical “cure”. Ameloblastoma does not metastasize like cancer, however, they exhibit a high recurrence rate if large surgical margins are not taken. Although they can be lethal, it is rare and is not the same biology as malignant disease. Risking recurrence, however, results in further surgery with each recurrence becoming more difficult to control from a surgical perspective. Does significant functional loss and reduced quality of life outweigh non-malignant recurrence?
Full resection can often mean a tumor defect involving half or more of the tooth bearing segments. Formally, reconstruction included step wise surgery: tumor removal followed by bone grafting followed by implant placement followed by tissue grafting and finally dental rehabilitation. Serial procedures, graft unpredictability and access to a restorative dentist created significant road blocks to proper and definitive reconstruction. The Jaw in a Day (JIAD) is performed in the following way: Preoperative surgical planning anticipating the tumor defect from removal while also planning the size of the free fibula that will be used for the hard and soft tissue defect A customized, patient specific reconstruction plate is then planned according to the bony contour of the fibula and the margins of the remaining bone after tumor removal. The implant planning is then performed. The size and location are established alongside a customized implant guide. Lastly, a custom temporary denture is planned and printed according to the anticipated position of the implants.
The procedure then proceeds with tumor removal, immediate hard tissue reconstruction (free fibula flap), dental implants and teeth. The patient emerges from surgery with a cosmetic and functional reconstruction in one procedure. Improved quality of life, patient satisfaction, reduced surgical costs and procedures are significant improvements due to this innovative surgical option. Recent publications have also demonstrated that early function on the dentate restoration does not increase implant failure rates when compared to more traditional reconstructive options. This approach is now being used in oncologic cases with great success – despite previous concerns for surveillance and possible recurrence. Literature has demonstrated no increase in recurrence rates or mortality when JIAD is used for oncologic reconstruction. Although this technique had been in use for nearly 10 years, it remains somewhat unknown and not yet widely adopted outside of academic centers.
Dr. Amundson will speak on this topic at the 2024 Florida Dental Convention on June 20-22 in Orlando. You can find more information on her courses at www.floridadentalconvention.com.