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06.03.2016

Surgical team rebuilds man's jaw, palate in rare procedure

Dentistry, Medicine specialists use computer-aided design, bone-implanted titanium to aid one-time cancer patient

By Steve Steinberg  |  HSNewsBeat  |  Updated 9:30 AM, 06.03.2016

Posted in: Healthcare

  • (Click arrows for slide show). Surgeons reconstruct Marvin Downs' jaw and hard palate at UW Medical Center on May 16, 2016. Note: Graphic images follow. Leila Gray
  • (Click arrows for slide show.) Surgeons at UW Medical Center remove a graft of titanium-embedded bone from the patient's leg; the graft was fashioned into an upper jaw. Leila Gray
  • (Click arrows for slide show.) With the reconstructed upper jaw, a new denture can be firmly anchored to the embedded implants. Grafted muscle and skin sealed the hole in the patient’s palate. Courtesy of Thomas Dodson
  • (Click arrows for slide show). Illustrations are posted pre-surgery to help surgeons follow procedural steps in reconstructing patient Marvin Downs' upper jaw. Leila Gray
[Editors' note: Graphic images below and in slide show, above.]

A team of University of Washington surgeons have rebuilt a patient’s upper jaw and hard palate in a rare procedure that employed three-dimensional computerized design and implant-bone integration technology.

Drs. Thomas Dodson and Jeffrey Rubenstein of the School of Dentistry and Neal Futran of the School of Medicine performed the 15-hour procedure, called an immediate reconstruction and rehabilitation, May 16 at UW Medical Center.

It is unlikely that the surgery has been performed before in the Pacific Northwest, Rubenstein said. “Only a few centers worldwide offer this service.” 

The procedure makes significant use of osseointegration, the process by which living bone grows around and bonds to a titanium implant. It also relies on advanced computer modeling that allowed the surgeons to precisely design a dental prosthesis and supporting bone and tissue for an ideal fit.  The patient, Marvin Downs, 56, of Tumwater, Wash., had almost all of his upper jaw and upper teeth removed in 2003 during surgery for oral cancer. Lacking an upper jaw and hard palate, Downs could not speak intelligibly or swallow food or liquid without having it spill from his nose and sinuses.

A specialist at the Veterans Affairs Medical Center in San Francisco, where Downs was then being treated, fashioned an obturator – a kind of denture similar to an orthodontic retainer – that gave Downs upper teeth, covered the 2-centimeter hole in his palate and improved his speech. However, with only one remaining molar to anchor it, the denture lacked stability and grew more uncomfortable over time.

In 2010, Downs was referred to Rubenstein, a maxillofacial prosthodontist, who consulted with Futran and Dodson to determine whether a better, more permanent solution might be pursued.

Conventionally, such a patient receives bone grafts from the fibula, the long bone in the lower leg. The grafts are used to reconstruct the missing portions of upper or lower jaw, Dodson said. After the grafts and their accompanying tissue and blood supply are allowed to heal for several months, titanium dental implants can be installed in the jaw to anchor new teeth. The teeth might also be installed at that time, or later if healing is slow. 
Osseointegration
(Click to enlarge.) The titanium dental shelves were inserted against the patient's fibula in July 2015.
illustration of the titanium implants that were attached to the patient's fibula bone
In this case, though, Futran and Dodson embedded the implant anchors in Downs' fibula last July by following a treatment plan conceived by Rubenstein. During the May 16 procedure, Futran harvested the section of fibula with its imbedded implants, each with surrounding tissue and blood supply. Using a virtually planned, prefabricated cutting guide, the straight fibula was cut into three pieces that were reoriented to conform to the shape of the upper jaw.

Futran and Dodson anchored a set of all-acrylic teeth to the three bone segments and then transferred the entire complex into patient’s mouth. Futran also harvested muscle and skin to seal the hole in the hard palate. In one day, Downs had a restored upper jaw, hard palate, and upper teeth.  A new set of teeth with a metal substructure will be fabricated after the bone graft heals and is deemed stable, which will take several months, Rubenstein said.
 
“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.” 

In one day, Downs had a restored upper jaw, hard palate, and upper teeth.  A new denture will be fabricated after the bone graft heals and is deemed stable, which will take several months, Rubenstein said. 
Obturator
Before the new procedure, the patient used an obturator – a removable denture that also sealed the hole in his palate. But with only one remaining molar to anchor the device, its fit and stability were major issues.
picture of the patient's removable dental prosthesis used before this procedure
“The huge potential advantage is the patient will have [functioning teeth] immediately as opposed to going through a yearlong, multistage procedure,” Futran said. “Granted, he has had a previous step, but this still has far more potential for full rehabilitation in a meaningful way.”

The medical team planned its approach with 3D Systems of Littleton, Colorado, which provided the virtual design software. Rubenstein prepared the prosthesis prototype, which was scanned and fabricated via a computer-aided design and manufacturing process by Sculpture Studios of Raleigh-Durham, North Carolina.

After several virtual planning sessions, the firm produced a drilling template for positioning the implants. 

The biggest risk of the surgery would be failure of the blood supply to the new bone structure, which could lead the graft to fail, Dodson said. Other risks would be failure of the implants to integrate or a poor fit for the prosthesis.

However, he said, “I think we can recover from these risks.” With the surgery, Downs should be able to speak clearly and eat and swallow normally, with a much better-fitting, more stable denture. Dodson also said he did not expect Downs to have any postoperative impairment to senses of smell or taste.

Downs is recovering slowly but satisfactorily at home, his doctors said. He will require monitoring and adjustment of his new teeth and repairs if any of the teeth are damaged.

Futran is professor and chair of otolaryngology-head and neck surgery in the UW School of Medicine. Dodson is professor and chair of oral and maxillofacial surgery in the UW School of Dentistry, and Rubenstein directs the school’s maxillofacial prosthetic service. He is one of about 250 maxillofacial rehabilitation specialists in the United States.

Media contact:  Steve Steinberg, UW School of Dentistry, 206.616.0827, ss55@uw.edu
Tagged with: reconstructive surgery, cancer, oral surgery, dentistry, otolaryngology, head & neck surgery
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