Dental Tribune Middle East & Africa

Dental Tribune Middle East & Africa Edition | May - June 2013 7 the planned resection. They create a well-defined osteotomy plane. Generally, harvesting of the bone flap (e.g. fibula) is carried out simultaneously through a second team. Harvesting the fibula is performed after exposing the bone in the conventional manner, then fixating the osteotomy templates to the bone with screws. The template as a surgical guide defines the osteotomies which can be performed exactly in the predefined lines. The individual reconstruction plate can be fixed to the fibula with the flap still perfused on the leg which reduces the time of ischemia. After harvesting the microvascular fibula graft, the surgeon positions the transplant into the bony defect of the mandible. The microvascular anastomosis is then performed to the neck vessels. Postoperative 3D cone-beam imaging allows the fusion of pre- and postoperative data and is later used for the planning of the dental implants. Case presentation In August 2010, a 30-year-old female patient was admitted to our department with a histopathological proven chondroblastic osteosarcoma of the left anterior mandible. The clinical and radiological staging including CT-scans of the head and neck area, thorax and abdomen were able to confirm the absence of second malignancies or metastasis. We discussed the patient in our interdisciplinary tumour-board and came to the consensus, that the primary radical resection of the tumour is the treatment of choice. The patient was taken to the OR and the tumour was radically resected including the soft tissue of the chin with the bone resection margins being between the teeth 36-43, and reconstructed temporarily with a UniLock 2.4-mm reconstruction plate (Synthes, Oberdorf, Switzerland) and temporarily dressings awaiting the final histopathological result. The result revealed tumour bilateral invasion of the bony margins, so that a total resection of the tooth-bearing mandible has to be performed. The following histopathological result then revealed clear resection margins. As the first reconstruction step, the missing soft tissue of the chin was reconstructed with a microsurgical myocutaneous free latissimus dorsi transplant. After a 2 years disease-free period, the second step of the reconstruction was performed utilising the CAD/CAM planning technique. A CT-scan was acquired of the head and neck area as a re-staging diagnostic measure and to determine the current bone situation as a basis for the planning. In the planning session it was defined to use the left fibula and segment it into 5 segments to mimic the mandible arch. The operation was performed in two teams, the osteomyocutaneous fibula flap was harvested and osteotomised according to the pre-surgical plan using the osteotomy templates, the pre-bent 2.0 reconstruction plate was fixated to the fibula before ligating the vessels and then the flap was transferred as the neo-mandible to the head of the patient and fixation was finished with screws to the bilateral ascending ramus (Synthes, Oberdorf, Switzerland). The anastomosis was performed to the right facial vessels, the skin island was used to reconstruct the tissues of the floor of the mouth (Figure 1). After the operation, the patient was transferred to the immediate care unite and was then finally discharged from the hospital 10 days after surgery. Following the reconstruction operation, some minor surgical procedures were carried out to optimise the appearance of the chin and realize the dental rehabilitation using implants. A removable denture anchored on an individual bar based on 6 implants (diameter of 4.1 mm and the length of 11.5 mm (BEGO Implant Systems, Bremen, Germany)) was finished 9 months after the reconstruction procedure (Figure 2). Conclusion A good functional rehabilitation and the best possible aesthetic result after reconstruction of extensive jaw defects are of great importance for the patient. The method of virtual planning of jaw resection and reconstruction, which is introduced here, leads reliably to predictable reconstruction results and simplifies the operation process considerably. We have applied this procedure since April 2011 up to now with 52 patients successfully and have established this as a routine workflow in our department. References 1. National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology: Head and Neck Cancers . National Comprehensive Cancer Network; 2009. Version 2.2009. 2 Sutton DN, Brown JS, Rogers SN, Vaughan ED, Woolgar JA. The prognostic implications of the surgical margin in oral squamous cell carcinoma. Int J Oral Maxillofac Surg. 2003 Feb;32(1):30-4. 3 Pohlenz P, Klatt J, Schön G, Blessmann M, Li L, Schmelzle R. Microvascular free flaps in head and neck surgery: complications and outcome of 1000 flaps. Int J Oral Maxillofac Surg. 2012 Jun;41(6):739-43. 4 Lutz BS, Wei FC. Microsurgical workhorse flaps in head and neck reconstruction. Clin Plast Surg. 2005 Jul;32(3):421-30, vii. Review. 5 Hoffman GR, Islam S, Eisenberg RL. Microvascular reconstruction of the mouth, face and jaws. Oromandibular reconstruction - free fibula flap. Aust Dent J. 2012 Sep;57(3):379-87. 6 Wei FC, Seah CS, Tsai YC, Liu SJ, Tsai MS. Fibula osteoseptocutaneous flap for reconstruction of composite mandibular defects. Plast Reconstr Surg. 1994 Feb;93(2):294-304; discussion 305-6. 7 López-Arcas JM, Arias J, Del Castillo JL, Burgueño M, Navarro I, Morán MJ, Chamorro M, Martorell V. The fibula osteomyocutaneous flap for mandible reconstruction: a 15-year experience. J Oral Maxillofac Surg. 2010 Oct;68(10):2377-84. Editorial Note: Full list of references is available from author/editor. E) Intraoral situation with individual bar in place C) Clinical findings after insertion of healing caps A) Appearance of the patient after correction of the soft tissue flap B) Radiological findings after implant insertion F) ) Appearance with the removable denture D) Intraoral situation with individual bar in place ” See FILLING, page 6 Contact Information University Medical Center of Hamburg- Eppendorf Department of Oral and Maxillofacial Surgery Head: Prof. Dr. Dr. M. Heiland Martinistraße 52 20246 Hamburg - Germany Contact Prof. dr. dr. 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