Immediate Dental Implant Placement (IDIP) in Maxillary Reconstruction: An Expedited Workflow for the Oncologic Patient
Leslie Kim1, Thais Polanco1, Evan Rosen2, Luke Poveromo1, Ian Ganly3, Jay Boyle3, Marc Cohen3, Jonas A Nelson1, Evan Matros1, Robert J Allen, Jr.1
1Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, 2Dental Oncology and Maxillofacial Prosthetics, Baptist Health South Florida, Miami, Florida, 3Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
Background: Maxillary reconstruction is a complex undertaking characterized by a difficult surgical site, multiple tissue deficits, and high patient morbidity. Traditional methods relied on bulky myocutaneous flaps to fill the volume deficit and an obturator for functional reconstruction, but this method proved unstable over time. We developed a reconstructive workflow to address these shortcomings, improve functional and aesthetic outcomes, and decrease patient morbidity. This workflow relies on an enhanced understanding of midface and fibula anatomy, and improved imaging, reconstructive, and manufacturing technologies. Critical aspects of this workflow include virtual surgical planning, computer-aided design/manufacturing, and immediate dental implant placement (IDIP). Workflow: One to two weeks prior to surgery, the reconstructive surgeon, ablative surgeon, and dental oncologist have a virtual multidisciplinary meeting. The ablative surgeon maps resection margins based on high-fidelity, three-dimensional reconstructions of the tumor. Based on this anticipated defect, the reconstructive surgeon and dental oncologist plan optimal osteotomy and dental implant locations, taking into account perforator location, fibula shape, and cortical bone availability. Cutting guides, occlusion-based guides, and reconstruction bars and plates are fabricated based on the operative plan. Intraoperatively, the pedicle is tunneled to facial artery to spare the patient a large neck dissection scar. Three to six weeks after surgery, we perform a vestibuloplasty to expose the underlying implants and exchange the healing abutments for definitive, implant-accommodating abutments. One to three days afterward, a temporary dental prosthesis is placed. At the conclusion of radiotherapy, the temporary prosthesis is exchanged for a final prosthesis.
Methods: A retrospective review of a prospectively maintained database identified eight patients who underwent maxillary reconstruction with immediate dental implants from 2017-2021. Six patients achieved either an interim or final prosthesis; two patients are too early in the reconstructive process to progress to dental prosthetic placement at the time of writing. No patients experienced delays in oncologic treatment, all patients with prostheses achieved excellent aesthetic and functional results, and no implants or flaps were lost.
Conclusions: Although maxillary reconstruction remains challenging, the development of new technologies such as VSP, CAD/CAM, and an improved understanding of midface and fibula anatomy have allowed reconstructive surgeons to achieve better functional and aesthetic outcomes with lower patient morbidity. Here, we demonstrate that an expedited maxillary reconstruction workflow can be safely accomplished in oncologic patients with promising and effective early results.
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