Case Report 7

(Modular System)

Resection of Huge Tumours


Denture abutments may be riveted to reconstruction plates for mandibular reconstruction, in patients with very advanced tumours, and may be used in association with flap surgery.

This technique obviates the need for an osseous component in repair, and reduces surgical trauma.

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Rivet Gun Modular Abutment with Rivets


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Riveted Abutment Combination with Endosseous Implant


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Denture Abutment Denture Prostheses




Case Summary

1. Disease free @ 55 months (January 2001)

2. Major Surgical Technique - but no osseous component required.

3. Simple pedicled muscle only flap required to effect primary reconstruction.

4. Surgery time - 8 hours surgery time..<

5. Post operative intensive care required - 18 hours.

6. Reduction in morbidity - initial salvage the implant is illustrated in this case

7. Excellent. function.

8. Normal speech and swallowing.

9. Significant Cost Savings for Purchasers of Health Care.



Complication

This patient had excellent overdenture function for three years, despite skin perforation of the plate secondary to post operative irradiation. The plate was trimmed and covered with a local flap, but he later developed a methicillin resistant staphylococcus (MRSA) infection and lost his implant at 40 months post surgery. Following loss of the plate he was able to wear a trimmed implant retained lower denture, based in the mandibular remnant, with minimal problems with function.



Comment

Although prognosis was initially poor, this patient has survived a massive resection, with excellent function and quality of life. Loosening and loss of the plate might have been prevented by increasing the length and mechanical anchorage of the plate, and/or by placing the plate either on the lingual (tongue) aspect of the mandible or on the alveolar crest (see below).



Discussion

It is advocated that customised riveted dental abutment systems can be used in conjunction with a reconstruction plate in mandibular reconstruction without an osseous component. This technique converts a very difficult and potentially dangerous multistaged reconstruction into a more simple single staged procedure with almost immediate replacement of the dentition.

One persisting problem related to the use of reconstruction plates in the mandible is related to ulceration of the laterally placed (buccal) plate. This complication occurs usually after 2 years with formation of a fistula which may be simply closed with a local flap (Peckitt). According to Raveh (see Reference) plate ulceration and fistula formation be obviated by placement of the plate on the lingual side of the mandible. Another option which we suggest is to place the plate on the alveolar crest; this would serve as a denture abutment and could be used as a denture abutment system.


Click image to view Single Stage Reconstruction of Mandible


Whilst caution is required in the interpretation of this outcome, further research and development is advocated as a matter of priority, at a national and international level, in view of the potential of this solution to mandibular reconstruction. This evaluation must take place in conjunction with reappraisal of the general principles of reconstructive surgery, and the potential for outcome enhancement with engineering assisted surgery techniques. Associations with more accurate planning, and the potential for the elimination of human error, must be identified and incorporated into clinical practice within the framework of Clinical Governance.



Conclusion

The use of a riveted modular denture abutment system is possible with minimal reconstructive surgical trauma. Modification of the technique outlined above is required with placement of the reconstruction plate in an alternative location e.g. on the alveolar crest.

There are advantages for:

The patient (less trauma / early ambulation / early discharge / early rehabilitation)
The provider hospital (efficient use of resources / less dependency on intensive care / single stage reconstruction / early discharge)
The purchaser (cost reduction / single surgery)




Further research and development is advocated

Disease free at 55 months

Compromised Aesthetics (Predicted)

Oral feeding

Good Quality of Life