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Case Reports
. 2023 Mar 9;59(3):535.
doi: 10.3390/medicina59030535.

MRONJ of the Mandible-From Decortication to a Complex Jaw Reconstruction Using a CAD/CAM-Guided Bilateral Scapula Flap

Robin Kasper  1 , Mario Scheurer  1 , Sebastian Pietzka  1   2 , Andreas Sakkas  1   2 , Alexander Schramm  1   2 , Frank Wilde  1   2 , Marcel Ebeling  1
Affiliations
Case Reports

MRONJ of the Mandible-From Decortication to a Complex Jaw Reconstruction Using a CAD/CAM-Guided Bilateral Scapula Flap

Robin Kasper et al. Medicina (Kaunas). .

Abstract

Medication-related osteonecrosis of the jaw (MRONJ) has been an integral part of the maxillofacial patient population for some time. The therapeutic concept ranges from conservative approaches over less extended decortications to major jaw resections, which can result in a considerable loss of quality of life. Based on three case reports, this paper presents the long-term history of patients with MRONJ of the mandible, whose disease ultimately resulted in partial or total mandibular resection and subsequent multisegmental reconstruction using a microvascular anastomosed bone flap. Furthermore, a suitable alternative for complex mandibular reconstruction is demonstrated when using a free fibula flap is not possible. The options are limited, particularly when multisegmental restoration of mandibular continuity is required. One case presents a mandible reconstruction using a CAD/CAM-guided bilateral scapular free flap (CAD/CAM = Computer-Aided Design and Manufacturing), which has not been described for this purpose before. Due to the complexity, computer-assisted surgery and patient-specific implants seem reasonable, which is why a special focus was applied to this topic.

Keywords: CAD/CAM; MRONJ; PSI; free flap; mandibular reconstruction.

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Conflict of interest statement

The authors declare no conflict of interest.

Figures

Figure 1
Figure 1
Dental X-ray after mandibular box resection and protective osteosynthesis, July 2014.
Figure 2
Figure 2
Dental X-ray after mandibular continuity resection and osteosynthesis with a patient-specific plate, August 2018.
Figure 3
Figure 3
CAD/CAM-guided planning of partial mandibular resection and primary bony reconstruction using free scapular flaps from both sides: (a) resected mandible indicated in red; (b) reconstructed mandible using three segments from the right (yellow and purple) and left scapula (green), patient-specific plate with an artificial joint on the right side indicated in blue, red arrows indicate the screw positions; (c) posterior view on the bone harvested from the left scapula (green, 1 segment) and the right scapula (yellow and purple, 2 segments) with surgical guides.
Figure 3
Figure 3
CAD/CAM-guided planning of partial mandibular resection and primary bony reconstruction using free scapular flaps from both sides: (a) resected mandible indicated in red; (b) reconstructed mandible using three segments from the right (yellow and purple) and left scapula (green), patient-specific plate with an artificial joint on the right side indicated in blue, red arrows indicate the screw positions; (c) posterior view on the bone harvested from the left scapula (green, 1 segment) and the right scapula (yellow and purple, 2 segments) with surgical guides.
Figure 4
Figure 4
(a–c) shows the 3D reconstruction of the postoperative CT scan after resection and reconstruction of the mandible using free scapular flaps from both sides as virtually planned. The patient-specific implant is indicated in blue (along with the upper teeth).
Figure 4
Figure 4
(a–c) shows the 3D reconstruction of the postoperative CT scan after resection and reconstruction of the mandible using free scapular flaps from both sides as virtually planned. The patient-specific implant is indicated in blue (along with the upper teeth).
Figure 5
Figure 5
Dental X-ray at the time of admission with extended MRONJ of the left anterior mandible and ongoing intraoral fistulation, January 2020.
Figure 6
Figure 6
CAD/CAM-guided planning of the resection and reconstruction of the mandible using a free fibular flap: (a) planned postoperative situation after resection and reconstruction with three fibula segments and patient-specific plate; (b) cutting-/drill-guides for resection of the mandible (red) and pre-drilling of the holes for fixation of the patient-specific reconstruction plate (c) patient’s right fibula with colored osteotomy segments for the planned reconstruction of the mandible; surgical guides for osteotomy of the fibula.
Figure 7
Figure 7
Dental X-ray after mandibular resection and primary bony reconstruction using a free fibular flap, April 2020.
Figure 8
Figure 8
Dental X-ray after implantation of four endosseous implants in the neo-mandible for dental rehabilitation and extraction of the upper first incisor on the right, August 2021.
Figure 9
Figure 9
CT reconstruction of the midface and mandible shows a massive periost reaction due to MRONJ of the mandible.
Figure 10
Figure 10
Dental X-ray after total mandibular resection and reconstruction with a fibular free flap. Fractured hand-bent plate in the right anterior region and supporting reconstruction plate on the basal rim of the neo-mandible.
Figure 11
Figure 11
Dental X-ray after removal of the osteolytic destructed lateral right and anterior fibula segment and following re-osteosynthesis due to chronic inflammation.
See this image and copyright information in PMC

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