Hemisection of mandibular right side: how to proceed with this case?

What was the reason for the hemi-mandibularectomy? What type of reconstruction? Any radiation? Need more info. Are you working with a maxillofacial prostdontist or the reconstructing surgeon?

I agree with the upper two comments, but if we try to advice and there is no contraindication of implant insertion (like radiotherapy), the overdenture with magnetic attachment may be a good choice because it can be used with short implant and has a stress release effect and this consider as a protection for the weak reconsitructed part of mandible from trauma and high lateral components of masticatory forces The magnetic retained overdenturs usually indicated for maxlllofacial prosthesis

. I would begin with partial denture, because of uncertainty this clinical situation and severe bone deficiency.

I'd feel better if it was a free tibial flap. If it were me I would show the case to a university based program with experience in placing implants in grafted bone.How about a course of hyperbaric oxygen to increase the blood supply? I would be very careful to open up the plate and graft to the oral flora, you don'twant to lose it.How about submitting case to Dental XP,or asking Pikos or Sclar?

Honestly that ridge concerns me. I've worked with many hemi-mandibulectomy cases and the ridge is much more significant after grafting than this one. How about taking out 23,24 placing implants there and making a implant retainer RPD on locator abutments? The restoration will be very retentive and be tissue borne to reduce pressure in the area if the graft. Also the fulcrum is further forward away from the TMJ area and the angle of the mandible.

Never met an oral surgeon trying to perform prosthetic rehabilitation himself (no offense). Usually this is the part for my colleagues and me (we discuss similar cases on Head and Neck Cancer Boards in our Miami hospitals). There are multiple ways to restore this patient, but this is the task for Maxillofacial Prosthodontist. I agree that it should be started with partial RPD, and later evaluated for maybe overdenture (that probably I won`t agree) or overlay denture. Why do you want HBO? If the patient didn`t receive and RT? Neither Pikos or Sclar will help you ( I`m Sclar`s research fellow). What you need- is a team with the Max- fac. Prosthodontist who will be able to restore this patient.

Are you really going to be placing the prosthesis in this case? You have a long way to go, before you can even consider placing implants. I would love to see the Pre- op X-ray. How did this benign entity get so large? The only way to obtain any vertical bone at your intended implant site is either with a vascular graft or some space maintenance device. I have had good luck with trans facial approaches using small superior border plates and bone harvested from a reamed femur( ala inter medullary rod technique RIA(Stryker). One pass gives you a cup of bone and the second pass gives you almost two cups. Be aware of the FACT that the most this patient will ever get, best case scenario, is a mini- hybrid denture. You will not be able to restore tooth per implant. Expectations should be limited. You are attempting to replace half of his lower jaw. Please involve a boarded prosthodontist, in cases such as these! Bvinci

This needs a team approach- FULL STOP

I agree with Stephen Travis . I'm a gp with experience in implants but you need to know where to stop.Team approach.

This patient should be placed in orthodontic appliances. Super eruption is inevitable. Bvinci

Can someone please comment on what appears to be a pathological fracture propagating through the lower wisdom tooth.

Dear colleagues, there`s no fracture, bilateral natural shadow. Orthodontics and extrusion of the teeth are way far ahead for this patient. Why nobody talks about bringing another Prosthodontist to the discussion? In a mean time the best option for this patient will be a lower overlay denture.

Dear Dr. Olga, super eruption happens every time, in that an appropriate secondary graft and ultimately implants could be 3 years down the road and if you read closely, several of us suggested bringing in a prosthodontist. Bvinci

Dear Dr Olga that is the airway no such thing as a "bilateral natural shadow" you can see the soft palate in the shadow and my very first comment was maxillofacial prostodontist I agree with baker k Vinci

I know this is a slightly off subject", but for those that suggest the condyle has to be in a specific location ( ie. positioning splints or equilibration) has any true merit, take a look at the condylar position in this case. Not sure why the cystic defects were left in the ramus. Maybe it is just artifact? Removal of the coronoid process and stripping g of the temporalis, may have helped to avoid the less than perfect position. As long as there is no tumor left behind, I would not fret. I have seen joints function perfectly with the " head " completely out of the fossa, or unrepaired . My point is; we are adaptive creatures and there is very little scientific correlative between occlusion and the temporal mandibular joint. Bv

RIA is a synthes product, by the way. Bvinci

There still appears to be a continuity defect despite prior grafting. I would strongly consider another bone grafting procedure prior to implant placement, even with the recon plate present.

Interesting studies in the November journal of Oral and Maxillofacial Surgery, regarding the resorption rates of iliac crest grafts and a very clever way to place your implants trans facially, in a tent pole fashion. I have used this technique a number of times, but found myself hamstrung when preserving the nerve in large cases such as the one you present. I would suspect the nerve was sacrificed in this case. One suggestion, transracial placement of implants requires a very small guide and while this study suggest using iliac crest, I would strongly suggest the "RIA" technique. I hope this helps. Our American journal really is a very good resource for the active OMFS. Bvinci. Vinci Oral and Facial Surgery. Baton Rouge , La.

I see two options in this case, neither of which is executable outside an OMFS hospital unit: 1. A microsurgical fibular flap (a split part of the fibula is detached with adjacent muscles, and after corresponding blood vessels (a. and v.) are identified, they are reconnected inside the mouth with branches of the facial artery and vein. The fibular block is ostheosynthesized to the remaining bone. After 3-4 months, better make an X-ray scintygraphy (with isotopes), to check bone vitality of the transplanted graft. If it is positive- place your implants as in natural bone. 2.Dr George Sandor (a hungarian OMFS surgeon, who lives and at present works in Finland and runs a genetic and growth factors research lab) has adopted a technique of insulating patients stem cells . He cultivates them outside the patient for 30-40 days prior surgery. After that a stereolitographic model is made of the resected lower jaw. A hydroxiapatite block is shaped corresponding to the defect. The HA block is inserted in the stem cells and and PDGF growth factors rich environment. The HA block is implanted under a big patient`s muscle (m.pectoralis). After 4 months time and positive scintigraphy test with isotopes, the HA block is removed with portion of the surrounding muscle and its corresponding a. and v. and implanted in the recipient site. Recipient site blood vessels are identified (branches of the facial a. and v.). 4 months post op dental implants are placed. Sandor reported a short 3 year follow up of 12 cases with a success rate exceeding 85 %