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

SMILES SPOTLIGHT in the LEADERS IN NORTH TEXAS DENTISTRY CREATING UNFORGETTABLE SMILES 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 | 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.