Immediate Dental Implant Placement (IDIP) In Maxillary Reconstruction - An Expedited Workflow For The Oncologic Patient
Luke P. Poveromo, MD1, Leslie N. Kim, MD2, Thais O. Polanco, MD2, Evan Rosen, DMD3, Ian Ganly, MD, PhD2, Jay O. Boyle, MD2, Marc A. Cohen, MD, MPH2, Jonas A. Nelson, MD, MPH2, Evan Matros, MD, MMSc, MPH2, Robert J. Allen, Jr., MD2.
1NewYork-Presbyterian Weill Cornell Medical Center, New York, NY, USA, 2Memorial Sloan Kettering Cancer Center, New York, NY, USA, 3Baptist Health South Florida, Miami, FL, USA.
Purpose: Maxillary reconstruction is a complex undertaking characterized by a difficult surgical site, multiple tissue deficits, and high patient morbidity. Prior to the advent of virtual surgical planning (VSP) and computer-aided design/manufacturing (CAD/CAM), bony reconstruction was inaccurate and inefficient. Thus, most reconstructive surgeons defaulted to bulky myocutaneous flaps in conjunction with obturators. We propose a reconstructive workflow to address these shortcomings, improve functional and aesthetic outcomes, and decrease patient morbidity.Methods: A reconstructive workflow was developed to address these shortcomings, improve functional and aesthetic outcomes, and decrease patient morbidity. One to two weeks prior to surgery, the reconstructive surgeon, ablative surgeon, and dental oncologist hold a virtual multidisciplinary meeting. The ablative surgeon maps resection margins based on high-fidelity, three-dimensional reconstructions of the tumor. Using the anticipated defect, the reconstructive surgeon and dental oncologist coordinate optimal osteotomy and dental implant locations, considering perforator location, fibula shape, and cortical bone availability. Cutting guides, occlusion-based guides, and reconstruction plates are fabricated based upon the virtual surgical plan. Three to six weeks after surgery, the underlying implants are exposed with a vestibuloplasty to facilitate the exchange of 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 final prosthesis. A retrospective review of a prospectively maintained database identified eleven patients who underwent maxillary reconstruction with immediate dental implants from 2017-2021.Results: Seven patients achieved either an interim or final prosthesis; four patients were too early in the reconstructive process to progress to dental prosthetic placement. No patients experienced delays in oncologic treatment, and all patients with prostheses achieved acceptable aesthetic and functional results. Only 1 out of the 31 implants were lost. No 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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