Case Report 2

(Single Stage Reconstruction Mandible)

The Mandibular Bridge

Customised Armature riveted to Reconstruction Plate Denture Abutments: Nobel Bio-Care SDCB116


Oral rehabilitation complete @ 24 days post operation



1 year







Complications

Ulceration of a prominent rivet head through the skin occurred at 24 months. It is advocated that this complication may be prevented by placing the reconstruction plate on the lingual (tongue) aspect of the mandible, and by the incorporation of low profile rivet head designs.



Solutions

The small skin perforation was simply repaired with a local rotation flap. It is to be noted that similar ulceration related to repairs using complex composite flaps of bone muscle and skin result in infection and necrosis of bone with partial or complete loss of the repair. This may imply that there are added safety margins in the use of customised implants and further research and development is advocated.



3 years

simple closure of fistula

Free of complications until 5 years

At 5 years ulceration of the THORP plate occurred over the angle of the lower jaw on the right side, over an area of the plate screwed to the mandible. This was associated with a major infection requiring surgical drainage.



Case Summary

1. Tumour free @ 5 years (July 2001)
2. Atraumatic Surgical Technique - increased margins of safety.
3. No second donor surgical site required to effect primary reconstruction.
4. Surgery time - only 5 hours in the operating theatre.
5. No post operative intensive care required.
6. Earlier rehabilitation of dentition.
7. Reduction in morbidity - simple salvage the implant is illustrated in this case
8. Implant aesthetics and function excellent up to 5 years.
9. Normal speech and swallowing.
10. Significant Cost Savings for Purchasers of Health Care.
11. Second fistula related to position of THORP plate @ 5 years.
12. Drainage of facial abscess.



Conclusions

It is advocated that stereolithography and customised implant techniques have converted a very difficult and potentially dangerous multistaged reconstruction into a simple single staged procedure.

Complications in this case were related to ulceration of the laterally (buccally) positioned reconstruction plate and not to the exposed titanium jaw in the mouth. If this technique is to have long term success in mandibular reconstruction, positioning of the reconstruction plate must be in a location which does not produce a pressure effect on the adjacent skin.



Potential Solution

We therefore advocate that that the reconstruction plate should be positioned on the top of the alveolar crest :-

Exposed Customised Mandibular Implant Bridge



Fixation of the plate to the mandible and titanium prosthesis is proposed using a transmandibular fixation pin/screw devices. The reconstruction plate also serves as an attachment mechanism for an overdenture.