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case_images: The prosthesis is first set to the appropriate maxillomandibular relationship. The neomandible is then positioned with approximately 17 mm of restorative space to the planned prosthesis.
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case_images: Set the neomandible with approximately 17 mm of prosthetic space to accommodate for restorative material, hygiene space, and height of intermediate abutments (Figure 1).
case_images: (a) Planned surgical defect with fibula and implant reconstruction. (b) Custom guide for fibula osteotomies and implant placement.
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case_images: Prosthesis positioning and indexing articulator. (a) Blue arrow: positioning attachment with access channels. The positioning attachment precisely indexes to the mandibular prosthesis. Red arrow: vertical struts maintain the maxillomandibular relationship. Orange arrow: predictive screw holes for the reconstruction plate. (b) The planned prosthesis precisely indexes to the positioning attachment of the upper member. The vertical struts and design of the upper member maintain the maxillomandibular relationship and ensure the correct orientation of the prosthesis in relation to the neomandible. (c) Access channels on the positioning attachment facilitate the pick-up.
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case_images: Design the extraoral dental prosthesis positioning and indexing articulator (Figure 3).
case_images: Fibula with custom guide for planned osteotomies and implants prior to pedicle division.
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case_images: Fibula and implant construct placed into the defect model, the lower member of the articulator prior to pedicle division. Fixation screws are placed in the predictive screw holes but not completely tightened at this stage. In this case, the left anterior implant was aborted due to the planned position being clinically too close to the osteotomy site.
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case_images: Fit the fibula with implant construct to the defect model, the lower member of the extraoral prosthesis positioning and indexing articulator (Figure 5).
case_images: (a) Articulator with the prosthesis "snapped in" to positioning index of the upper member. (b) Access channels of the positioning attachment enable access to the screw channels of the temporary cylinders.
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case_images: Seat the immediate prosthesis into the positioning attachment of the upper member with a "snap in" effect to ensure correct positioning of the dental prosthesis (Figure 6).
case_images: Reverse scan bodies at time of surgery.
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case_images: Fully tighten the reconstruction plate screws and remove the prosthesis for finishing and polishing (Figure 7).
case_images: (a) Parachute sutures are placed underneath the prosthesis for closure. The skin paddle of the fibula free flap is present anteriorly. (b) Immediate prosthesis in occlusion. No occlusal adjustments were necessary intraoperatively or subsequently.
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case_images: (a) Post-operative panoramic imaging. The positioning and bone height of the neomandible, surgical hardware, and implant placement are verified to be consistent with the pre-surgical plan. (b) A heat map of the occlusion of the immediate prosthesis to the maxilla demonstrates a balanced occlusion. No occlusal adjustments were necessary.
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case_images: Take post-operative imaging at the first clinic follow-up to verify positioning and bone height of the neomandible, surgical hardware, and implant placement (Figure 9).
case_images: Delivery of the final prosthesis 3 months after the date of surgery. The esthetics and occlusion of the final prosthesis are consistent with the patient's pre-surgical dentition. Soft tissue integration of the flap is appreciated. Patients may be referred to Dermatology for hair removal at this stage.
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