When tumors emerge in the jaw, surgeons typically implement a fibula free flap. They replace the section of jawbone and soft tissue where the tumor is located with a portion of the fibula. It’s a complicated reconstructive process completed in stages over a year or more.
But doctors at New York University’s Langone Medical Center have come up with a quicker option, trademarked as Jaw in a Day. Using computer-aided, 3-D surgery simulation, oral and maxillofacial surgeons plan the procedure to fit a dental prosthesis with laboratory-produced teeth that align with the patient’s natural teeth, all with near perfection.
Patients undergoing fibula free flap wake up with missing teeth. With Jaw in a Day, that section of fibula is outfitted with dental posts and prosthetic teeth, even while the bone is still receiving blood flow in the patient’s leg.
The piece of fibula is then taken from the leg and placed in the gap created by the removal of the tumor-covered jawbone, where it will fuse with the remaining bone and give the patient normal function. The patient wakes up with temporary prosthetic teeth that are replaced with permanent ones 6 to 12 months later.
“NYU Langone has performed eight procedures, and we expect the program will continue to grow,” said Dr. Jamie Levine, a plastic and reconstructive microsurgeon and chief of microsurgery at NYU Langone. He also was on the first Jaw in a Day surgery team. “We’ve made significant improvements in the technology since we’ve started, working closely with 3D Systems, that allow for extremely accurate placement and outcomes.
Based in Colorado, 3D Systems works with NYU Langone and the University of Mississippi Medical Center (UMMC) to generate images included in a virtual surgical plan that is very specific to each Jaw in a Day patient. The JPS Health Network in Fort Worth, Texas, has performed the procedure as well.
Patients who don’t get surgery will have trouble chewing and increasingly suffer pain and bone tissue destruction. Tumors can grow so large that patients will lose jaw function. Faces can become swollen and disfigured, and airways can be affected.
Jaw in a Day surgery can last up to 12 hours. The surgical team begins by completely removing the tumor and affected portion of jawbone. Then, the team cuts into one of the patient’s legs to expose the fibula, which isn’t needed to support a person’s weight and will heal itself.
Surgeons use the digital plan to place dental posts in the fibula while the bone is still inside the leg and receiving blood. Prosthetic teeth that have been shaded to match the patient’s own teeth are placed on the posts.
“A millimeter too high or low can make a difference,” said Dr. Mohammed Qaisi, assistant professor in the department of oral and maxillofacial surgery in the UMMC School of Dentistry. “Everything is planned to the smallest detail. We’re so specific with our technology that we can fit each cuspid and molar on the fibula before it’s placed in the jaw.”
Once the section of fibula with the posts and teeth has been moved to the jaw, the surgeons use a microscope and hair-thin needles to connect blood vessels so the new bone and tissue will have good blood supply. They also make sure the bone fits with the adjacent bone and the teeth fit with the adjacent and opposing teeth.
During the subsequent intensive care, nurses check the jawbone every hour to ensure good blood flow and that no clots have formed. Patients go home in 7 to 10 days and are closely monitored over the following 4 months. Doctors perform a CT scan at 4 months to make sure the bone has fully fused. But the surgery’s success depends just as equally on its preparation.
“You have to see that end result digitally, before the procedure is done,” said Dr. Harold Kolodney, a maxillofacial prosthodontist, professor of dentistry at the UMMC School of Dentistry, and professor of oral oncology at the UMMC department of otolaryngology and communicative sciences in the School of Medicine. “During the procedure, someone is working on the patient’s leg at the same time that someone is working in his oral cavity.”
Insurance generally covers the tumor removal and jaw replacement. However, it doesn’t cover implantation of the dental posts and prosthetic teeth because it is considered cosmetic. Patients must come up with about $10,000 for the implants and teeth or go without them.
“This is not cosmetic,” Qaisi said. “They have no choice but to lose part of their jaw.”
“It would be harder to go for 6 months to a year without having some of your front teeth,” Kolodney said. “This surgery immediately gives them teeth on an interim basis.”
“Anything that disfigures our face has an enormous impact on our lives,” said Fayette Williams, DDS, MD, of the JPS Health Network. “Tumors of the face strike at our identity. What if you couldn’t smile? What if people couldn’t understand you when you spoke? This is about quality of life.”
“I was in the hospital for 11 days and was back at work three weeks after that,” said Stacy Bledsoe, a patient at the JPS Health Network who was diagnosed with ameloblastoma. “I feel great.”
“There have been days that I’ve thought about the what-ifs,” said Jacob Reeves, who suffered from an ameloblastoma tumor removed by Qaisi and his team. “But I’m really happy that I took this path.”