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an intraoperative workflow with an emphasis on efficiency and patient safety [Figure 1].

General considerations: patient population, team assembly, & financial plan
Patient population
Patients with benign jaw disease localized to the maxilla or mandible who are motivated to have immediate
dental tooth replacement have the most to be gained from this procedure. The ideal JIAD candidate patient
is one with benign disease such as an odontogenic keratocyst (OKC), ameloblastoma, odontogenic
myxoma, or medication-related osteonecrosis of the jaw (MRONJ), a stable existing occlusion, and high
post-operative expectations. Additionally, good oral hygiene and intact dentition is a must; this procedure is
less successful in recreating dentition or occlusion already lost to disease. Patients with oncologic disease
processes that require post-operative radiation are less favorable as radiation can damage bone
mineralization, reducing osteointegration of the implants. However, several centers have expanded the
[4]
application to patients with malignancies, without increased rate of complications .

Once a patient has been selected, a multidisciplinary team with clearly defined roles is established. The team
consists of an ablative surgeon, a microvascular trained reconstructive surgeon [either Otolaryngology -
Head and Neck Surgery, Oral and Maxillofacial Surgeon (OMS), or Plastic Surgeon], and an appropriately
trained prosthodontist, usually a maxillofacial prosthodontist. The surgeons are responsible for ablation of
the disease, harvesting and inset of a vascularized free flap, and closure of the head and neck incisions. An
OMS assists with the ablation and inset, and completes the implant placement. Finally, a prosthodontist
designs the prosthesis, loads the prosthesis to the DIs, and oversees postoperative modifications to ensure
proper occlusion and function of the maxillary and mandibular teeth. Regarding the post-operative oral
rehabilitation and functional occlusion, a dedicated prosthodontist is critical to procedural success.
Practitioners must be aware of the length, complexity and multidisciplinary nature of the operation; they
should be willing to undertake the significant risks of a time intensive surgical procedure and should be
experts in their respective fields.

This procedure can be a significant financial burden to the patient. Often times, as medical insurance does
not cover dental rehabilitation, the patient will incur most of the dental related expenses which may include
the placement of DIs and almost always includes the cost of the provisional and definitive prostheses. The
cost of the implants themselves can be bundled with hospital materials management. However, the costs of
the provisional acrylic prosthesis, all related components, and the definitive prosthesis of zirconia or
porcelain can still approach tens of thousands of dollars. While fees may vary per geographic region, these
fees are comparable to traditional prosthetic work that requires precious materials and high laboratory fees.
The patient should be counselled as to a feasible financial plan for affording the operation and dental
treatment options.

Preoperative preparation
Ablation and reconstruction
Before proceeding with the operation, the team will need to evaluate the location and extent of the patient’s
pathology as well as the condition of their existing dentition. The patient will also need a lower extremity
CT angiogram to evaluate patency of the peroneal vessels and adequate three-vessel run-off to determine
the best candidate leg for graft harvest.

Prosthodontist consult
Data collection
The prosthodontist will obtain intraoral and extraoral preliminary photos for documentation and
evaluation purposes. Either an intraoral scan or a conventional impression is taken to produce a digital or