The Application of Virtual Planning and Navigation Devices for Mandible Reconstruction and Immediate Dental Implantation

Abstract

Routine reconstruction of subtotal defects of the mandible and orthopedic rehabilitation supported by dental implants is achieved by means of detailed planning and lasts over a year. This article shows the outcomes of single-stage surgical treatment and immediate orthopedic rehabilitation performed with the help of preoperative virtual computer simulation. 3D investigation of pathological and donor sites, virtual simulation of tumor resection, positioning of the dental implants into fibula, virtual flap bending and transfer, virtual bending of fixing reconstruction plates, and fabrication of navigation templates and bridge prosthesis supported by dental implants were done preoperatively. The surgery included tumor resection, insertion of dental implants into fibula, elevation of fibula osteocutaneous free flap, rigid fixation within recipient site, and immediate loading by bridge orthopedic device. On 10-month follow-up, functional and esthetic results were asses as reasonable. Radiography showed dental implants to be integrated and positioned appropriately. We found that successful rehabilitation of the patients with extensive defects of the jaws could be achieved by ablative tumor resection, dental implants insertion prior to flap elevation guided by navigation templates, further osteotomy, modeling of the flap based on navigation template, flap transfer, and rigid fixation within recipient site by prebended plates, with application of prefabricated prosthesis.

Keywords: dental implants; free fibula transfer; navigation guide; virtual planning.

Fig. 1

(a) No facial asymmetry noted. (b) The lesion in oral cavity.

Fig. 2

(a) Preoperative radiological picture: OPG. (b) Preoperative radiological picture: 3D CT scan. The area of bone destruction (arrow).

Fig. 3

(a) Fixed bridge prosthesis on mandible, fabricated after achieving of impression from healthy maxillae. (b) For Peer Review Scanned fixed bridge prosthesis on mandible. (c) The area of affection of mandible. (d) Postresection defect of the mandible. (e) Determination of the donor site on fibula bone. (f) Determination the osteotomy lines for the best adaptation to mandibular defect. (g) Positioning of the bone graft within mandibular defect. (h) Scanned fixed bridge prosthesis is positioning on the bone graft on the mandible. (i) The sites for reference implants are determined. (j) Positioning of the reference implants on bone graft. (k) Fixing of the graft reconstruction plate is adapted to the form of the mandible and the sites for the fixing. (l) Determination of angulation and distance between of dental implants.

Fig. 4

(a) Fabrication of navigation templates: standard tray for external fixation of mandibular fractures. (b) Fabrication of navigation templates: fabrication of template for dental implants positioning. (c) Fabrication of navigation templates: fabrication of template for fibula bone osteotomy.

Fig. 5

Preoperative prebending of fixing reconstructive plate.

Fig. 6

(a) Surgical approach via labio-buccal flap elevation. (b) Excised tumor. (c) Application of navigation template for dental implants placement. (d) Application of navigation template for bone osteotomy. (e) Formed transplant of the mandible comprising dental implants prior to perineal artery and vein transfer. (f) The graft is positioned and fixed within recipient site and micro vascular anastomosis created. (g) Application of abutments and forming of soft tissue around it, wound closure.

Fig. 7

(a–c) Orthopedic rehabilitation in early postoperative period.

Fig. 8

Postoperative radiology: OPG.

Fig. 9

Reconstructive plate was replaced by miniplates.

Fig. 10

(a) Facial appearance of the patient: before surgery. (b) Facial appearance of the patient: with new mandible (a year after surgery).