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11 Advancing Immediate Dental Rehabilitation in Free Tissue Transfer Utilizing…
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Fig. 11.4 The tooth-borne oating prosthesis joined with the dental prosthesis
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Fig. 11.5 Lateral view of the virtual prosthesis and oating guide. Note the highwater design
required for soft tissue skin paddle inset and cleansability
For full-arch dental rehabilitation, the entire maxillary or mandibular arch is
duplicated if the patient has reasonable preoperative dentition. Again, the data is
taken from an intraoral scan, preoperative CBCT data, or digitization of physical
stone models in articulation. If the patient does not have adequate dentition, then a
virtual denture is made through a denture module in the software. The prosthesis is
then smoothed and rened digitally. The digital implant abutments are again
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Fig. 11.6 The virtual implant abutments are digitally subtracted from the prosthesis using a
Boolean difference function for intraoperative pickup. Note the inferior border offset to achieve the
proper interocclusal restorative space
Fig. 11.7 Full-arch
prosthesis pickup with
contralateral arch 3D
model prior to ap
ischemia
D. Hammer et al.
subtracted from the prosthesis with a Boolean difference function for purposes of
intraoperative pickup impression (Figs.11.7, 11.8, 11.9, and 11.10). The prosthesis
is then 3D printed using biocompatible crown and bridge resin available from multiple manufacturers or milled PMMA as described above.
11 Advancing Immediate Dental Rehabilitation in Free Tissue Transfer Utilizing…
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Fig. 11.8 Complete dental arch reconstruction using a combination of the patient’s existing dentition and digitally created teeth
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Fig. 11.9 Full-arch reconstruction. The second molars were left until time of pickup. This provides a stable occlusal stop to conrm the correct vertical dimension of occlusion (VDO). The
second molars will be removed before nal inset of the prosthesis
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Fig. 11.10 Poly(methyl methacrylate) milled immediate full-arch prosthesis
D. Hammer et al.
Intraoperative Technique
A defect model, bula cutting guide, mandible or maxilla cutting guide, and custom
reconstruction plate are requested from the vendor used for the initial VSP panning
session. A preoperative t check on the defect model is performed to ensure correct
positioning of implants and prosthesis. The defect model should have predictive
holes to attach the plate and bula construct. Intraoperatively, it is imperative that
the resection and bula cutting guides are placed at the surgical sites according to
the preoperative plan. The bula cutting guide is then secured, predictive holes are
drilled, and then the guided dental implants are placed. Following these steps, the
closing osteotomies are created with a surgical saw.
The bula segments are then t into the defect model and secured to the custom
plate. Straight multiunit abutments are placed on the implants and torqued to manufacturer’s specications. Temporary copings are then placed on the multiunit abutments in preparation for attachment of the prosthesis. The tooth-borne guided
“oating prosthesis” is placed on the printed STL defect model. A pickup impression is performed, and the prosthesis is removed and converted. At that time, the ap
is divided and transferred to the head and neck. In cases where the full dental arch
is being reconstructed, the prosthesis can be picked up utilizing a 3D-printed skull
model with hinged opposing and vertical dimension of occlusion (VDO) stops
(Fig.11.11). Alternatively, the prosthesis can also be picked up intraorally. While
this can be more difcult due to the constraints of operating with limited space
within the intraoral surgical eld, the occlusion is more accurate and requires minimal nal adjustment.
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Fig. 11.11 Full-arch pickup performed at the donor site. A hinged model is used to provide opposing dentition
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Postoperative Digital Workow: Naval Medical Center Rapid
Restorative Protocol
At the time of surgery, the pre-manufactured prosthesis is converted to a xed conversion dental prosthesis by xating multiunit abutment temporary cylinders to the
dental prosthesis with autocure acrylic. After the prosthesis is disinfected and taken
to the dental laboratory for completion of the conversion, a check-cast of the multiunit abutment analog positions is poured in low-expansion type IV die stone. The
intaglio contours of the prosthesis are rounded, hygienically contoured, and polished. In addition, multiunit abutment impression scan bodies are attached to the
conversion prosthesis and scanned in the desktop scanner that provides surface scan
data of the cameo and intaglio surfaces of the prosthesis and its relationship to the
multiunit abutment platforms (Fig.11.12).
After an appropriate amount of time has elapsed as deemed by the surgeon for
restorative recall, maxillomandibular relationship records are made with an intraoral scanner after any additional occlusal adjustments are required (Fig.11.13). The
conversion prosthesis is then removed and the soft tissue is inspected for areas of
concern. Corresponding areas of the intaglio surface of the prosthesis are adjusted
and polished as appropriate, all multiunit abutments are re-torqued to manufacturer’s specications, and the conversion prosthesis is reinserted intraorally and analyzed for passivity to the multiunit abutments. A PVS wash of the intaglio of the
conversion prosthesis or nal impression using splinted impression copings and
custom tray can also be made to capture the respective soft tissue if indicated. Premanufactured verication jigs made from the surgical check cast are then luted
intraorally using autocure acrylic to verify passivity of the nal master cast. The
conversion prosthesis is then disinfected and taken to the dental laboratory, and a
nal master cast is poured in a low-expansion type IV die stone using the veried
passive conversion prosthesis or splinted impression copings with multiunit analogs. The conversion prosthesis is then scanned on a desktop scanner individually
and attached to the master cast that captures the cameo and intaglio surfaces and its
relationship to the veried master cast (Fig.11.14).
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Fig. 11.12 The scanned
STL le of the temporary
prosthesis to use for
fabrication of the nal
prosthesis
D. Hammer et al.
Fig. 11.13 Maxillomandibular relationship records of the conversion prosthesis and opposing
dentition made with an intraoral scanner
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Fig. 11.14 Desktop scan
of the conversion
prosthesis indexed to the
veried master cast
Fig. 11.15 The master
cast is then registered to
the opposing dentition in
the restorative
maxillomandibular
relationship using the
conversion prosthesis as
the constant duciary
surface
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These STL models can then be registered within the CAD software for an accurate relationship to each other, and all les are sent to the dental laboratory for
manufacture of a denitive prosthesis along with the veried stone master cast for
verication of the metal framework milling accuracy (Fig.11.15). The prosthesis
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D. Hammer et al.
design consists of a milled titanium substructure enhanced by vertical retention
grooves with a denitive suprastructure that replicates the presurgical anatomy and
occlusion if available made from zirconia or milled PMMA.A 2mm bilayer pressure form matrix occlusal guard is also fabricated to the prosthesis and delivered to
the patient upon delivery of the denitive prosthesis (Figs. 11.16 and 11.17).
Fig. 11.16 Final prosthesis
Fig. 11.17 Delivery of prosthesis 14weeks postoperatively
11 Advancing Immediate Dental Rehabilitation in Free Tissue Transfer Utilizing…
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Homecare instructions are reinforced, and the recall regimen is customized per
patient requirements. This protocol has enabled delivery of a nal dental prosthesis
in less than 4months postoperatively.
Future Directions
Currently, we strive to complete dental rehabilitation with nal prosthesis delivery
within 4months of surgery. The nal prostheses can be delivered following implant
integration torque testing. With the use of digital workow and in-house 3D printing, rapid design and fabrication can be achieved even in the time constraints of
malignancy. As technology continues to advance, the workow will continue to
simplify and improve accuracy. Thus, patients will benet from early return to function as immediate maxillofacial reconstruction becomes common practice.
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