Mandibular resection and reconstruction in the management of extensive ameloblastoma.

PURPOSE: To present our experience with the management of 31 extensive mandibular ameloblastomas treated with segmental mandibulectomy, reconstruction with free fibula or iliac crest flap, and rehabilitation with immediate or delayed endosteal dental implants. PATIENTS AND METHODS: The study sample comprised 31 patients with histologically confirmed mandibular ameloblastomas. Primary ameloblastomas were treated in 23 patients, and recurrent ameloblastomas affected 8 patients. Mandibular defect sizes ranged from 3.5 to 12.5 cm (mean, 5.6 cm). A free fibula osseous or osteocutaneous flap was used 17 times for reconstruction; in the remaining 14, a free iliac crest osseous or osteomuscular flap was chosen. Dental implants were positioned in 25 patients; implant procedures were performed simultaneously with reconstruction in 21 cases. RESULTS: All flaps were transplanted successfully, and no major complication occurred postoperatively. Final histologic examinations showed 27 multicystic and 4 unicystic ameloblastomas. Free margins were achieved in all patients. The duration of follow-up was 18 to 120 months (mean, 53.6 months). No patient showed clinical or radiologic signs of recurrence. The dental implant success rate was 100%. CONCLUSIONS: Segmental mandibular resection followed by immediate defect reconstruction with bone-containing free flaps with immediate dental implant placement should be considered as the treatment of choice for extensive mandibular ameloblastomas.

Rehabilitation with dental implants in microvascular iliac graft after solid ameloblastoma resection: a case report.

PURPOSE: Ameloblastoma is a true odontogenic tumor that is most frequently found in clinical practice. Osseous resection with clear margins is the recommended treatment followed by bone reconstruction, such as a vascularized graft. The use of osseointegrated dental implants for rehabilitation is advisable, as it allows the recovery of the masticatory function. MATERIALS AND METHODS: This case report includes 1 subject, a patient who presented with a large ameloblastoma treated by resection, a microvascular iliac graft, and dental implants. RESULTS: After 6 months of regular control, the patient exhibited perfect healing of both the soft tissues and bone graft. At the time of this report, the patient had undergone 36 months of clinical and radiographic follow-up and had not exhibited any sign of osseous loss, implant mobility, or tumor recurrence. CONCLUSIONS: The outcome of this case indicates that a microvascular graft and subsequent dental implantation is a good treatment plan that aids in a quick functional rehabilitation in ameloblastoma patients.

Replacement of mandibular posterior teeth with implants in a postmandibular resection case: a case report.

This case report describes the prosthetic rehabilitation of a patient who was treated for ameloblastoma by segmental resection of the mandible. Because of the size of the defect it was decided to use a healing obturator to facilitate bone formation in the defect. At the end of 3 months, bone formation had led to complete obliteration of the defect with an almost complete fill to the crest of the ridge. The next phase of the treatment was prosthetic rehabilitation. The patient preferred a fixed replacement of teeth as opposed to a removable option. The final treatment plan was an implant-supported fixed prosthesis that was progressively loaded.

Implant mandibular rehabilitation postoncologic segmental resection: a clinical report.

In cases of reconstruction of a discontinuity defect of the mandible, the surgeon has a major responsibility to maximize function as well as cosmetics and to preserve quality of life, restoring mastication, speech, and appearance. Treatment of mandibular discontinuity defects is a complex process and, among other methods, includes the use of free vascularized flaps. A variety of donor sites have been used for this purpose, including the iliac crest, radius, scapula, and fibula.At this time, the iliac crest free flap represents a versatile reconstruction method after mandibular ablation. This article reports a clinical case using the iliac crest free flap for comprehensive reconstruction of discontinuity defects in the mandible after resections of an aggressive odontogenic tumor. The immediate implant positioning reduced the number of surgical procedures and the rehabilitation time.

Complete oral rehabilitation of a postresection ameloblastoma patient: a clinical case report.

Conventional ameloblastomas are rare, benign, epithelial odontogenic tumors that tend to grow slowly in the mandible or maxilla, but are locally invasive and can be highly destructive of the surrounding dental anatomy. Aggressive resection is the most effective method of eliminating the tumors, but treatment can further contribute to patient deformity and malfunction. Ameloblastomas also have a high rate of recurrence, which significantly diminishes 8 years after resection, but still requires vigilant clinical monitoring. This case report describes the complete oral rehabilitation of a postresection ameloblastoma patient with a mandibular reconstruction plate and partial edentulism. An autogenous graft was taken from the patient's iliac crest, shaped to fit the defect, and attached with bone screws. After graft incorporation, dental implants were successfully placed into the augmented ridge and restored with a fixed partial denture. There was no evidence of tumor recurrence during the 10 months of treatment or 8 years of subsequent clinical monitoring.

Esthetic and functional reconstruction of the posttumoral interrupted mandible with double-barrel fibular free flap graft: rationale for a microsurgical and prosthodontic approach.

Reconstruction after substantial osseous, cutaneous, and muscular tissue loss following a mandibular resection is a challenge. The use of a fibular free flap is an outstanding, but delicate, treatment option. These grafts, using the double-barrel technique, can achieve an almost complete reconstruction of the mandibular defect. The challenge posed by these treatments is to achieve an end result that is both functional and esthetically pleasing-an endeavor that requires a defined prosthetic plan prior to complete microsurgical reconstruction. Using a detailed clinical case, this article discusses the importance of planning the mandible reconstruction with double-barrel fibular graft in view of an implant-supported fixed partial denture. Immediate implant loading was even possible in this case. This approach allows improvement of the final esthetic and functional result of such a complex rehabilitation. Maxillofacial reconstructive surgery should seek to establish a near-as-normal anatomic situation that will allow a permanent implant rehabilitation that is both esthetic and durable.

Rehabilitation of recurrent unicystic ameloblastoma using distraction osteogenesis and dental implants.

Ameloblastoma is a true neoplasm of odontogenic epithelial origin. Surgical resection of the ameloblastoma is well-documented and an accepted treatment modality. Vertical distraction of the alveolar process is an efficient method for augmentation. This method of providing additional bone and soft tissue for implant placement is becoming more common. This clinical report describes the use of distraction osteogenesis and fixed implant supported prosthesis to treat a post-surgical alveolar defect as a result of the resection of a unicystic ameloblastoma in the anterior mandibular region. As a result of alveolar distraction a segment of mature bone was transported vertically in order to lengthen the crest, for better implant anchorage. Further clinical and experimental studies of the technique with long-term follow-up are needed, to confirm bone and implant stability, as it relates to alveolar height.

Clinical case report: a multidisciplinary solution to a complex restorative problem and a macro-esthetic dilemma.

The restoration of facial harmony and establishment of a functional occlusion can pose unique problems in the treatment of complex dentoskeletal malformations. The advantages offered by the conjoint treatment planning, proper treatment sequencing, and the cooperation of various dental providers can create the best solutions for complex problems in patients. This case presentation demonstrates the interdisciplinary approach used by implant and restorative dentists, oral and maxillofacial surgeons, and orthodontists in a case that required "thinking outside the box" for optimal functional and esthetic solutions.

Oral rehabilitation with osseointegrated implants in oncologic patients.

PURPOSE: The esthetic and functional rehabilitation of oncologic patients subjected to major resection surgery constitutes one of the greatest challenges for the head and neck surgeon. Immediate bone reconstruction with microsurgical free tissue transfer and dental implants has constituted a genuine revolution in the management of such patients. MATERIALS AND METHODS: We present a series of 111 oncologic patients, involving a total of 706 implants, who underwent reconstruction with pedicled or free microsurgical flaps. RESULTS: The osseointegration success rate was 92.9%, with a global failure rate (malpositioning or failed osseointegration or loading) of 15%. Failure particularly affected the group of irradiated patients and those subjected to lateral osseomyocutaneous trapezial pedicled flap reconstruction. Excellent results were obtained with the fibular and iliac crest free flaps and osseointegrated dental implants. CONCLUSIONS: The difficulties of prosthetic rehabilitation are discussed, along with the individualized solutions applied, the repercussions on the temporomandibular joint, and the management protocol adopted by our service.

Pediatric mandibular reconstruction after benign tumor ablation using a vascularized fibular flap.

This study evaluated the aesthetic and functional outcomes of vascularized fibular flaps used for pediatric mandibular reconstruction. Six pediatric patients ranging in age from 12 to 15 years underwent mandibular reconstruction using a vascularized fibula flap with a skin paddle, after benign tumor ablation. All of the flap transfers were successful, and there were no complications. Panorex radiographs showed good bone union in all patients. The flap conferred adequate support for dental rehabilitation. The mean follow-up was 24.2 months. The aesthetic and functional outcomes were normal. No patient had recurrence. A vascularized fibular flap is a very reliable method for reconstructing the pediatric mandible after benign tumor ablation.

Reconstruction of 10 major mandibular defects using bioimplants containing BMP-7.

PURPOSE: The limitations and morbidity associated with autogenous bone grafting have driven the search for predictable bone substitutes and bioimplants. A novel method of reconstruction was tested in this case series. MATERIALS AND METHODS: Ten patients with major mandibular defects following resection of biopsy-proven ameloblastoma lesions or osteomyelitis of the mandibular body or ramus were included in this study. The resection defects were spanned with rigid reconstruction plates to hold the remaining mandibular segments in the correct position. The defects were filled with a bioimplant containing bone morphogenetic protein-7 (BMP-7) in a demineralized bone matrix (DBM) suspended in a reverse-phase medium to effect sustained BMP delivery. RESULTS: The postoperative course for all 10 patients was uneventful. Radiographic evidence of mandibular bone formation was found in all cases. At the end of 1 year, functional and esthetic reconstruction of the mandible was complete. CONCLUSION: Bioimplants containing BMP-7 in DBM suspended in a reverse phase medium were successful in restoring major mandibular defects in nonirradiated beds in this series of 10 patients.

Rehabilitation of a marginal mandibulectomy patient using a modified neutral zone technique: a case report.

Anterior edentulous areas usually display unusual soft tissue configurations and compromised bone support in patients with marginal mandibulectomy. There are several treatment modalities for these patients. A removable partial denture may be the treatment of choice. Maximum stability of the partial denture base for mandibulectomy patients may be accomplished by the application of the neutral zone concept, which helps providing stability to the base. This case report describes the fabrication of a removable partial denture for a patient with marginal mandibulectomy using a modified neutral zone technique.

Recreating the original contour in tumor deformed mandibles for plate adapting.

Use of stereolithographic models of the resection areas in mandibular tumor surgery allows for preoperative adapting of resection plates, and shortening operating time. Adapting reconstruction plates along the deformed resection contour, however, recreates the existing, unfavorable contour. The computer-aided procedure that generates the stereolithographic model, nevertheless, allows for digital manipulation of the data, to reestablish the required contour. Here are two cases that benefited from this simple method.

Early functional loading in the fully edentulous mandible after mandibular resection and reconstruction due to an ameloblastoma: case report.

BACKGROUND: Immediate or early functional loading of implants in fully edentulous mandibles can enhance patient comfort and the ability to masticate within a few days after implant placement. Recently there has been evidence that this method of restoring edentulous mandibles is predictable. PURPOSE: The goal of this case report is to present the treatment of a patient diagnosed with a large ameloblastoma in the mandible. After removal of the tumor and mandibular reconstruction, the patient had complete anesthesia in the right mandible, with an alveolar ridge deformity. METHODS: Two years after removal of an ameloblastoma in the right mandibluar sextant, five implants were installed between the mental foramina. One implant was installed for safety reasons in the event one of the others was lost. This implant remains buried. A denture was used as a drilling guide. Abutments were attached to the implants, and impression copings were fixed to the abutments. The denture was used for the "pickup" impression. Flaps were sutured, maintaining exposure of the abutments. In the laboratory, gold cylinders were heat cured to the tissue side of the denture. The cylinders were attached to the cast with laboratory screws. The gold cylinders were heat cured to the intaglio side of the denture. Five days after implant placement, the nonmetal reinforced acrylic denture was fixed to the implants with laboratory screws. The bridge is removed annually, and the implants are examined for mobility and periapical radiographs are taken. RESULTS: The patient has worn the prosthesis for 2.5 years without loss of implants and without breakage of the nonmetal reinforced denture. At 2.5 years the implants are stable, implant sites demonstrate stable crestal bone, and the patient is eating comfortably and without limitations. CONCLUSION: Early functional loading of implants in the edentulous mandible may offer patients the option of wearing implant-supported prosthesis immediately or shortly after implant insertion.

Management of an anterior defect with a removable partial denture supported by implants and residual teeth: a case report.

The treatment of a patient with a major defect in the anterior region of the mandible is described. A large part of the anterior dental arch and underlying mandibular bone was involved in the defect. A removable partial denture supported by implants as well as residual teeth was used to restore the defect. Compared with a traditional removable partial denture, which was used by the patient for several years as an interim prosthesis, the application of implants resulted in improved functional comfort and stability.

Osseointegration and nerve transposition after mandibular resection to treat an ameloblastoma: a case report.

This case report demonstrates the use of osseointegrated implants to replace the mandibular left second premolar and first and second molars removed during a surgical resection of a walnut-sized ameloblastoma. The first-stage surgery was performed 2 years after the oncologic surgery, and it was necessary to laterally reposition the inferior alveolar nerve prior to placement of implants. The patient has been restored to full dental function. There was no occurrence of paresthesia at any time. The treatment plan and the treatment were a collaboration of an oral surgeon, a periodontist, and a restorative dentist, located in Sweden, the United States, and Italy, respectively, and is an indication of what can be accomplished to the benefit of the patient when teamwork is exercised.

Prosthodontic treatment for patients with large mandibular defects; porous hydroxyapatite grafts.

It is difficult for both prosthodontists and their patients with large marginal defects to achieve a satisfactory prosthodontic result, because retention, support, and stability of the prosthesis are limited and recovery of esthetics is unsatisfactory owing to large mandibular defects. Alveolar ridge augmentation therapy is performed to compensate for such problems. We have experienced a good prognosis of prosthodontic treatment for over 10 years in two patients with large marginal defects of the partially edentulous mandible, who had undergone grafting of porous hydroxyapatite blocks to their bone defects. It has been reported that porous hydroxyapatite blocks are unsuitable for edentulous patients, because the mucosa covering the hydroxyapatite block is too thin and delicate to support dentures. We, therefore, designed the denture to prevent concentration of occlusal stress on the mucosa. In both of these two cases, we achieved recovery of occlusal function and esthetics by affixing denture to the large marginally resected defect augmented with a graft of porous hydroxyapatite block.

Comparison of obturator prosthesis fabricated using different techniques and its effect on the management of a hemipalatomaxillectomy patient.

Odontogenic tumours involving the maxilla or mandible are usually treated with surgical resection. To prevent recurrence, extensive surgical intervention might be carried out leaving the patient with anatomical defects. However, rehabilitation of such patients with an obturator can improve function, facial form and social acceptance. In this case, we have evaluated the different designs and techniques of fabrication of an obturator prosthesis used for the rehabilitation of a hemipalatomaxillectomy patient. A 40-year-old man presented with a loose fitting obturator prosthesis. He had undergone hemipalatomaxillectomy for the treatment of an ameloblastoma 2 years earlier and had been using an obturator prosthesis since then. Hollow-bulb obturator prostheses were fabricated using two different methods, the lost salt and open lid techniques. The obturator prosthesis fabricated with the lost salt technique weighed less than the patient's old obturator. But the obturator fabricated using the open lid technique did not only considerably reduce the weight of the prosthesis but also improved health, function, aesthetics, phonetics and quality of life in this hemipalatomaxillectomy patient.