Page 37 - Read Online

Page 2 of 14 Grewal et al. Plast Aesthet Res 2021;8:37 https://dx.doi.org/10.20517/2347-9264.2021.43

INTRODUCTION
Historically, maxillomandibular ablation and reconstruction include a series of intensive procedures aimed
at removing lesions of either the maxilla or mandible and then reconstructing the jaws to appropriate form
and function. This dental rehabilitation post-fibula free flap reconstruction was staged and took months to
years to yield the final product, if completed at all. The defects in the meantime are often disfiguring,
affecting their facial appearance and their ability and desire to perform daily functions such as eat, smile, or
communicate. Such a complex operation requires not only assembly of and coordination between multiple
surgical teams, but also meticulous selection of the patient candidate and precise planning of each step of
the surgical workflow. Restoration of function is often dependent on reconstruction of the occlusion.
Precision is of utmost importance since patients with native teeth can detect differences as low as 8 to 10
microns.

Often several additional procedures were required to debulk scar tissue and allow for sufficient healing of
the fibula-mandible or fibula-maxilla bony union. Only once the flap was healed were dental implants (DIs)
placed into the fibula for eventual delivery of a dental prosthesis. DIs heal by osseointegration which
typically requires 3-4 months before they can be loaded with a dental prosthesis. Therefore, appropriate
form and function for a patient, by means of dental prostheses, were not delivered until the graft had been
fully integrated and the DIs integrated into the fibula graft, typically 6-9 months in total. Radiation therapy
can delay this even further.

However, maxillofacial reconstruction via microvascular free flaps have seen tremendous progress in the
past decade since the advent of the “Jaw in a Day” (JIAD) procedure. “Jaw in a Day” represents the process
of a single operation which includes: ablation of maxillary or mandibular lesion, immediate reconstruction
with a microvascular free flap, immediate DI placement into the graft, and immediate delivery of dental
prosthesis. In 2013, an interdisciplinary team of surgeons described harnessing the breakthrough technology
of virtual surgical planning to achieve dental rehabilitation to the reconstructed mandible with a fibula free
flap simultaneously in four patients .
[1]

[2]
In 2016, an additional institution reported on three patients in whom they used this same technique . Both
reported on patients with benign masses of the mandible and maxilla that required no further radiation
therapy post-surgery that might have affected osseointegration. Since then, several other institutions have
described their successes in fibular-mandible and fibular-maxilla reconstruction, although in albeit a smaller
number of patients . These studies emphasize the both the feasibility and room for expanded application
[1-8]
of such techniques, which carries the potential to leverage technology to reduce the burden of surgery on a
vulnerable patient population.

Virtual surgical planning (VSP) improves three-dimensional accuracy of the reconstruction and provides
detailed calculations and spatial configurations needed to ensure successful fit of the graft, and occlusion of
the reconstructed jaw. It allows for specific measurements of the patient’s maxilla or mandible and fibulas to
a print custom reconstruction plate and surgical cutting guide unique to each patient’s specific osteotomies.
Utilizing VSP reduces both human error and surgical time, making JIAD possible at the utmost benefit to
patients.

PROTOCOL
Successful “Jaw in a Day” surgery requires extensive planning and preparation with an experienced
multidisciplinary team. Briefly, once an appropriate patient has been identified and the team assembled, a
virtual surgical planning session is held to plan all aspects of the resection and reconstruction, and establish