Advances in technology have allowed for faster and more accurate fabrications of immediate provisional teeth placed on immediate implants. While immediate loading of implants has been performed for many years in the native jawbone, only recently have we performed immediate loading of immediate implants placed during major jaw reconstruction. Traditional techniques require two or more weeks for laboratory fabrication. With digital planning and 3D printing, a provisional prosthesis can be generated within 24 hours.
A 57-year-old patient developed an ulcerative mass in her left retromolar trigone (Fig. 1). The biopsy revealed moderately differentiated squamous cell carcinoma. A CT scan showed osseous erosion indicating invasion into the mandible. I decided to perform a segmental mandibulectomy, neck dissection and reconstruction with a microvascular fibula flap. The patient was concerned about the anticipated loss of her two molars, in addition to the second premolar previously removed; therefore, she was planned for immediate implants in the fibula with immediate loading of provisional teeth.
A presurgical workup included a cone-beam CT of the mandible and an optical scan of the upper and lower dentition. A CT scan of the fibulas was obtained for virtual surgical planning. The plan included a fibula graft positioned above the inferior border of the mandible, but with adequate restorative space for the prosthesis. Three implants were planned for these two molars because postoperative radiation was scheduled (Fig. 2). A prosthesis was created in Blue Sky Plan software (Fig. 3) and 3D printed using NextDent MFH resin (Fig. 4). An additional model was created of the mandible defect with an occlusal splint to position the prosthesis in proper occlusion (Fig. 5). The entire construct was pieced together to verify accurate fit of all components (Fig. 6).
In the operating room, the specimen was removed using cutting guides on the mandible to make osteotomies in the planned positions. Frozen sections of soft tissue and marrow showed clear margins (Fig. 7). The left fibula was harvested with the peroneal artery and veins. Because of the oral soft-tissue defect, a skin paddle was harvested with the fibula. While still perfusing on the leg, the fibula was shaped to fit the defect and three implants were placed in a guided fashion. Straight multiunit abutments and temporary cylinders were placed on the implants. The prefabricated milled plate was fixated on the model with the fibula and prosthesis in place (Fig. 8). The temporary cylinders were picked up in the prosthesis with Luxatemp, and final shaping of the intaglio surface was performed to create a convex cleansable surface. Palaseal was painted on the prosthesis and cured.
The fibula vessels were ligated, and the graft was transferred to the head and neck region. The fibula was inset into the mandibular defect using the milled plate and screws. The dental prosthesis was seated on the implants and hand tightened. The skin paddle was sutured to close the oral soft-tissue defect (Fig. 9). Revascularization of the flap was performed by anastomosing the peroneal vessels to the facial artery and common facial vein. Final occlusion was checked to verify the prosthesis was out of occlusion (Fig. 10).
Virtual surgical planning and point-of-care 3D printing can expedite treatment with predictable results. Immediate implants and provisionalization have previously been performed only for benign disease because of the extra time required to fabricate a prosthesis with traditional methods. Digital design and point-of-care 3D printing eliminates this delay and allows malignant disease to be restored with immediate teeth. However, case selection is critical, because not all patients will be candidates for this surgery.