Ameloblastoma: Digital Workflow Key to Restoring Hemimaxillectomy Patient

Katya Archambault, DMD

A 32-year-old healthy man, referred by his general dentist, presented with mild numbing sensation symptoms on the left aspect of his maxilla. Four months before the referral, when the patient had no symptoms, a panoramic radiograph revealed the splaying of teeth. Possibly because of the superimposition of radiopaque structures, this went unnoticed. Upon the author's clinical examination, a CBCT revealed a well-defined, multilocular radiolucent lesion present between teeth Nos. 13 and 14. The general behavior of the lesion was rather aggressive. Biopsy results confirmed ameloblastoma, a common benign tumor of the jaws that requires marginal resection due to its high recurrence rate. A treatment plan with the surgical and restorative team was presented to the patient. The treatment would begin with a hemimaxillectomy with secured margins and mucocutaneous fibula graft with implant placement at the time of resection. After 6 months of healing, the second-stage surgery would follow with the insertion of a 3D-printed long-term temporary restoration. Several months later, after occlusion changes and complete healing, the final prosthesis would be inserted. The case was completed in 12 months using a digital workflow plan (DEXIS, dexis.com) that involved the use of intraoral scanning, virtual surgical planning (VSP) software, advanced imaging, exocad software, 3D printing, and more.

· Massive surgical intervention requires fluid communication with the entire surgical and prosthetic rehabilitation team. The morbidity of the procedures can be very high in patients with benign aggressive tumors.

· Reliable state-of-the-art oral and maxillofacial reconstruction is needed to create a predictable, esthetic, and functional outcome. Use of the latest technologies helps ensure that patient needs are met.

· In an extreme case like this, which involves the synergy of the medical and dental team, the digital workflow is crucial to a successful outcome for the patient and the entire team.

Katya Archambault, DMD
Board-Certified Oral and Maxillofacial Radiologist, Private Practice, La Jolla, California; Adjunct Faculty, Departments of Otolaryngology and Plastic Surgery, University of California San Diego; Diplomate, American Board of Oral and Maxillofacial Radiology

The author thanks the UCSD Head & Neck Surgical team and Plastics Surgical team Drs. Ryan Orosco and Frederic Kolb; Dr. Thanos Kristallis, oral and maxillofacial prosthodontist at UCSD, and M. Jordan Reiss, Senior Director, Global Sales & Clinician Professional Development, DEXIS.

Figures and Images

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Fig 1. Preoperative, maximum intercuspation of the patient’s existing dentition at initial consultation.

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Fig 2. Preoperative panoramic radiograph taken by the referring dentist a few months prior to the patient being seen in the author’s clinic.

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Fig 3. Periapical radiograph from the referring dentist days before the patient was seen in the author’s clinic. Note the multilocular lesion between teeth Nos. 13 and 14.

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Fig 4. CBCT panoramic upper arch curved reconstruction using DTX Studio™ Clinic (DEXIS) software. On the right is the reconstructed panoramic image.

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Fig 5. Panoramic upper arch curved reconstruction using DTX Studio Clinic (20 mm). Note severe opacification of the left maxillary sinus. The right maxillary sinus demonstrated a mucous retention pseudocyst, a radiographic finding with no clinical significance. Mandibular nerve tracing was done using the “Magic assistant” automatic feature on DTX Studio Clinic.

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Fig 6. Panoramic reconstruction and cross-sectional views of the left maxilla in the area of the lesion (CBCT volume rendering and axial view).

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Fig 7. A DTX Studio Clinic custom slice of the lesion, which extended from the alveolar crestal ridge to the floor on the left maxillary sinus. The entity was splaying the roots of teeth Nos. 13 and 14 and displacing the left maxillary sinus floor superiorly.

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Fig 8. VSP surgical resection treatment plan and replacement by the mucocutaneous fibula graft. This simulated surgical procedure called for maxilla reconstruction using fibula-free flap, planned with patient-specific data, left fibula to left neck, vessels coming off the posterior of the reconstruction, and plating along the lateral fibula surface.

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Fig 9. Exocad (exocad) virtual reconstruction. A 3D-printed (SprintRay) interim restoration will be made 3 months after the surgery to provide teeth and re-establish function while the healing process is completed.

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Fig 10. Surgical day. Resected part of the maxilla with safety margins and clearance from pathology is shown.

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Fig 11. Post-resection panoramic radiograph. Note fixation of surgical plates with the fibula graft and dental implants (Paltop, Keystone Dental Group).

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Fig 12. Intraoral view 3 months post-resection. At this appointment, the second-stage surgery and insertion of the 3D-printed interim prosthesis will take place.

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Fig 13. Insertion of the final prosthesis. A 3D-printed interim prosthesis was used to re-establish function while the healing process was completed.

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Fig 14. Close-up view of patient’s smile with final prosthesis inserted.