Surgeons at the University of Washington (UW) used 3-D computerized design and implant-bone integration technology to rebuild an upper jaw and hard palate both in a single day. The 15-hour procedure, known as an immediate reconstruction and rehabilitation, was performed on May 16 at the UW Medical Center.
“Only a few centers worldwide offer this service,” said Dr. Jeffrey Rubenstein of the UW School of Dentistry, who performed the final step of the surgery. The procedure used osseointegration and relied on advanced computer modeling that enabled the surgeons to precisely design a new set of teeth and supporting bone and tissue for an ideal fit.
Marvin Downs, 56, of Tumwater, Wash, had almost all of his maxilla and teeth removed in 2003 during oral cancer surgery. Lacking an upper jaw and hard palate, he could not speak intelligibly or swallow food or liquid without having it spill from his nose and sinuses.
Downs was being treated at the VA Medical Center in San Francisco, where a specialist had fashioned an obturator to give him upper teeth, cover the 2-cm hole in his palate, and improve his speech. But with only one remaining molar to anchor it, the denture could not be stabilized and grew more uncomfortable, and adjustments did not work.
In 2010, Downs was referred to Rubenstein, who determined that there was little hope for improvement with further adjustments or conventional treatment. Rubenstein then consulted with Dr. Thomas Dodson of the UW School of Dentistry and Dr. Neal Futran of the UW School of Medicine to explore a better and more permanent solution.
Typically, patients would receive grafts from the leg’s fibula to reconstruct the missing portions of the jaw. After the grafts and accompanying tissue and blood supply were allowed to heal for several months, titanium dental implants could be installed in the jaw to anchor new teeth.
In the new procedure, Futran and Dodson embedded the implants in the fibula last July. On May 16, Futran harvested the portion of the fibula with its embedded implants, each with surrounding tissue and blood supply. Using a virtually planned, prefabricated cutting guide, the straight fibula was cut into 3 pieces that then were arranged to mimic the shape of the upper jaw.
Rubenstein affixed acrylic teeth to the bone grafts, and Dodson and Futran transferred the whole complex into Downs’ mouth. Futran also harvested muscle and skin to seal the hole in the hard palate. In a single day, Downs had a restored upper jaw, a hard palate, and a full set of upper teeth.
“The huge potential advantage is the patient will have [functioning teeth] immediately as opposed to going through a year-long, multistage procedure,” said Futran. “Granted, he has had a previous step, but this still has far more potential for full rehabilitation in a meaningful way.”
Conventionally, implants are placed and the dental prosthesis is fitted to the best available bone, but it might not be the best solution in terms of function or appearance, Dodson said. But this new method virtually designs and fabricates an ideal process, with the implant and graft placement designed to fit the best prosthetic result, he added.
The team planned the case throughout the course of a year, making extensive use of virtual design software. Rubenstein prepared the prosthesis prototype, which was scanned and fabricated via a CAD/CAM manufacturing process by a firm in North Carolina. The firm also produced a drilling template for positioning the implants.
Futran performed the May 16 surgery to harvest the bone for the graft and partition it with specially prepared cutting guides based on the virtual planning. He then installed the graft in Downs’ mouth and connected it to the blood vessels in the neck. Dodson and Futran then stabilized the graft after Rubenstein connected the new teeth to the implants.
The biggest risk was failure of the blood supply to the new bone structure, which could lead the graft to fail. Other risks included the failure of the implants to integrate and having the prosthesis fit poorly. The researchers, though, believed they could recover from these risks if these outcomes did occur.
With the surgery, Downs should be able to speak clearly and eat and swallow normally, with a much better fitting and more stable set of teeth. The researchers also don’t expect Downs to have any sensory impairment in smell or taste after the procedure.
“The most challenging aspect is situating the bone and securing it to the remaining maxilla without interfering with the blood supply, sealing the palate defect, and creating an adequate tunnel for the blood vessels from the [bone graft] to reach the neck,” Futran said. “We are working in a tight space and it all has to fit just right to be successful.”
Futran and other members of the UW Medicine team oversaw Downs’ initial recovery, and the patient is now at home recovering slowly but satisfactorily. Downs will require monitoring and adjustment of his new teeth or repairs if any are damaged, Rubenstein said.
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