PMC8548147_01
Initial findings. (a) Intraoral view shows a raised mass over the left buccal vestibular area. (b) Extraoral view shows slight facial asymmetry. (c) Panoramic radiograph reveals multilocular radiolucent lesion over the anterior and left mandible.
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The intraoral examination revealed a raised mass in the left mandibular buccal vestibular area extending to the labial area without secretory discharge. The color and appearance of the surrounding mucosa were normal. The teeth in this area also have no obvious periodontal pockets (Figure 1(a)). The neurological examination was normal, and there were no swollen and palpable lymph nodes in the neck (Figure 1(b)). The biopsy and pathology reports confirmed that the lesion was consistent with ameloblastoma (Figure 1(c)).
Mandible reconstruction. (a) A soft liner was used as the obturator material after two marsupializations. (b) The tumor size decreased on the left side but remained unchanged in the anterior area. (c) The 3D model was used to simulate the scope of the resection. (d) The free fibular flap was positioned. (e) The flap was fixed with the prebent metal bone band.
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Soft liner was applied immediately as the obturator materials, and regular visits were arranged to monitor the changes of tumor size and to adjust the obturator (Figure 2(a)). It took a total of 12 months to reduce the size of the lesion and confirm the scope of the tumor (Figure 2(b)). And then, the 3D printing transferred from CT files/images was applied to create a solid model, and the actual scope of the resection could be simulated before surgery (Figure 2(c)). Soft tissue defects in the mouth were also reconstructed with free flaps (Figures 2(d) and 2(e)).
The soft and hard tissues had healed completely and ready for reconstruction. (a, b) Intraoral view. Teeth 46 and 47 were temporarily kept for maintaining vertical support. (c) Panoramic radiograph after segmental mandibulectomy and fibular free flap.
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At this point, the soft and hard tissues had healed completely and were ready for reconstruction (Figure 3).
Teeth 46 and 47 were extracted after staged approach implant placement. Cross-bite and lack of restoration space over right side were observed. (a, b) Extraoral view shows narrow maxillary arch and large buccal corridor. (c) Lack of restoration space over lower right posterior area. (d) Panoramic film after staged approach implant placement.
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Finally, teeth 46 and 47 were extracted (Figure 4).
(a) Leveling and alignment after extraction of tooth 17 to create space. (b) Placement of the rapid palatal expander. (c) Posterior segmental osteotomy in the right maxilla. (d) Complete maxillary arch expansion. (e) Correction of the transverse jaw deficiency, with increased restoration space.
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In the beginning, tooth 17 was extracted and followed by leveling and alignment to create space (Figure 5(a)). After rapid palatal expander (RPE) placement (Figure 5(b)), the right maxillary posterior segmental osteotomy (PSO) (Figure 5(c)), right mandibular alveoloplasty, and extraction of tooth 48 were performed in the same operation to achieve proper interocclusal relationship and gain enough restoration space over right posterior region. Alveoloplasty also increased restoration space (Figures 5(d) and 5(e)).
Completed dental reconstruction. (a-c) Final insertion of zirconia implant-supported fixed partial dentures and ideal occlusal plane and occlusion. (d, e) Smooth and symmetrical dental arches. (f) Photograph showing improved asymmetry of face. (g) Radiograph of the final mandible and dental reconstruction.
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After postoperative treatment was completed, the upper and lower jaws presented smooth and symmetrical dental arches, dental function was restored, and the patient's face showed improved symmetry (Figure 6).