North Texas Dentistry Volume 7 Issue 3 NTD 2017 ISSUE 3 DE | Page 12

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Complex Jaw Reconstruction to Restore
Normal Mandibular Form for
Dental Rehabilitation of Patient with
Osteoradionecrosis
by Fayette Williams, DDS, MD, FACS
Reconstruction of jaw defects is not considered complete
until the dentition has been restored. For complex cases of
jaw reconstruction, dental rehabilitation becomes even
more challenging. The quantity, quality, and location of bone
makes dental implants impossible for many patients. Since
dental implants are ideally placed based on restorative
goals, jaw reconstruction should also be performed keeping
the final dental restorations in mind.
Traditional treatment of severe osteoradionecrosis involves
resection of the diseased mandible and immediate vascu-
larized bone reconstruction. Unfortunately this usually leads
to the loss of multiple teeth. The fibula is the most common
bone used for this reconstruction. Dental rehabilitation is
made difficult by the relatively short height of the fibula com-
pared to a mandible. This often results in a large occlusal
step between the native mandible and the fibula graft. Most
patients also suffer from a delay in their dental rehabilitation
because implants are usually placed six months or more
after the initial reconstructive surgery. The two problems of
delayed implant placement and deficient vertical graft height
are addressed in this case.
12 NORTH TEXAS DENTISTRY | www.northtexasdentistry.com
This patient is a healthy 58-year-old male with a history of
throat cancer treated successfully with radiation 5 years ago.
A symptomatic right mandibular molar was later removed and
he developed osteoradionecrosis. He failed conservative
therapy including bone debridements and hyperbaric oxygen
therapy. The patient eventually developed a painful patho-
logic fracture of his right mandible before being referred to
this author. Initial examination revealed an open intraoral
wound along the right posterior mandible with exposed bone
and pain on manipulation of the bone segments. A cone
beam CT scan revealed a large bone defect from prior de-
bridements and a subtle fracture with evidence of fibrous
malunion. There was an open wound over the fracture site
with exposed bone.
The patient underwent resection of his necrotic bone with im-
mediate reconstruction using a fibula free flap. This vascu-
larized bone allows placement of immediate dental implants.
While the bone is healing in its new position, the implants are
integrating at the same time.
1
Figure 1 shows the preoperative panorex with necrotic bone
on the right mandible and a pathologic fracture.