Prosthetically Driven Maxillofacial Reconstruction with Vascularized Fibula Free Flap and Simultaneous Dental Rehabilitation. Jaw in a Day Concept: 10-year review

Vascularized osseous free tissue transfer has become the gold standard for the reconstruction of complex maxillofacial defects. The integration of virtual surgical planning and 3D prosthetic design led to the development of the Jaw in a Day concept. This concept revolutionized the management for patients undergoing resection and reconstructive surgery. This approach allows for a predictable single stage resection, reconstruction, and immediate dental rehabilitation with implant supported prosthesis. For the patient, this offers an enhanced recovery, superior aesthetics, and accelerated functional rehabilitation. Since its introduction, Jaw in a Day has been adopted at multiple institutions around the world. The purpose of this manuscript is to provide an in-depth review of our series of fibula free flap reconstructions with immediate dental rehabilitation using virtual surgical planning technologies. This review also incorporates the concept as it relates to malignant pathologies undergoing adjuvant radiation therapy and its influence on prosthetic rehabilitation, which has yet to be described in the literature. Retrospective medical record review was performed in all patients undergoing maxillofacial resection and reconstruction with fibular free flap and immediate dental rehabilitation by single ablative surgeon between 2011 and 2023. Analysis and descriptive statistics were performed on available data. Records were reviewed for demographics, location and type of pathology, size of resection defect, and adjuvant radiation therapy. Our clinical algorithm was outlined based on this experience. At our institution, we have performed reconstruction with microvascular fibula free flap and simultaneous prosthetic rehabilitation for 37 patients. The mean age of the population was 43 years (range 21 to 83 years) with 19 males and 18 females. The histopathologic diagnoses included in this review were as follows: Ameloblastoma (23), Squamous Cell Carcinoma (5), Ossifying Fibroma (3), Odontogenic Keratocyst (2), Myxoma (1), Adenoid Cystic Carcinoma (1), Rhabdomyosarcoma (1), and Atrio-venous malformation (1). Eighty-three percent of the cases were mandibular reconstructions (31/37) and 16% were maxillary reconstructions (6/37). Mean length of follow up was 22.9 months (Range 2 to 144 months). Three patients underwent post-surgical adjuvant radiation therapy. A total of 160 implant fixtures were placed with a success rate for implants placed of 97.5% (156/160). Four implants required removal due to failed osseointegration or associated inflammatory response leading to failure. Of the implants with successful osseointegration with the fibula, all but 3 were loaded to support the final fixed prosthesis, demonstrating a 98.1% utilization rate. Six patients required removal of hardware due to plate exposure. We experienced 3 delayed flap failures, 2 of which were associated with large maxillary defect reconstructions. The 3 patients that underwent adjuvant radiation therapy have been followed for an average of 9.3 months with no complications. Our study demonstrates a 92% success rate for patients undergoing microvascular fibula free flap reconstruction and immediate prosthetic rehabilitation. This success rate is comparable to the accepted success rate of 95% for fibula free flap maxillofacial reconstruction and reported 92.6% success rate for when implants were placed at the time of surgery. Through our experience, we have refined our approach to develop algorithms for both benign and malignant resections including patients who require adjuvant radiation. The Jaw in a Day algorithm has allowed us to offer patients a superior functional, aesthetic, and psychological recovery based on precise virtual surgical planning and prosthetic design.