Watanabe et al.

Int Chin J Dent 2005; 5: 91-95.

Functional and esthetic reconstruction for a patient withmandibular osteosarcoma: A clinical report
Ikuya Watanabe, DDS, PhD,a Jorge A. Gonzalez, DDS, MS,b Ronald D. Woody, DDS,MS,b and Sterling R. Schow, DMDc
abc

Department of Biomaterials Science, Graduate Prosthodontics, and Department of Oral & Maxillofacial
Surgery/Pharmacology, Baylor College of Dentistry, Texas A&M University System Health Science Center,Dallas, TX, USA
This clinical report describes a functional and esthetic treatment using an implant-supported fixed detachable
prosthesis for a patient who underwent resection and skeletal reconstruction due to mandibular osteosarcoma. A
four-stage protocol was used that included resection and rigid fixation with a reconstruction plate, autogenous
bone graft, placement of osseointegrated implants, and prosthetic restoration. The patient required a second
resection because of the positive margin of the first resection. An autogenous bone graft was placed after thenegative margin of the second resection was confirmed. Six months after the iliac crest bone graft, five implants
were placed in the defective areas of the mandible. These implants were restored with a fixed detachable
denture fabricated with a cast gold alloy framework. This functional and esthetic prosthesis has performed
favorably without any problems for one and a half year. (Int Chin J Dent 2005; 5: 91-95.)
Key Words: esthetics, function, osteosarcoma, reconstruction.

Introduction
Osteosarcoma is a rare and aggressive malignant bone tumor that occurs more frequently in young patients.
Approximately 6-10% of all osteosarcoma arises in the maxillofacial region.1-3 The main modality treatment forosteosarcoma is surgical resection with a wide margin to prevent recurrence.4,5

Subsequent skeletal

reconstruction and oral rehabilitation are important to maintain oral functions such as mastication, deglutitionand phonation.6 Reconstruction at the time of resection is commonly advocated to provide a favorable esthetic
and functional result.7 In a previous report,8 a staged protocol was suggested for treatment and oral rehabilitationof patients with aggressive primary tumors of the jaws, especially in young children. The protocol consisted offour steps: 1) en bloc resection of the tumor and immediate placement of a rigid reconstruction plate across themandibular defect; 2) skeletal continuity restored with an autogenous bone graft; 3) placement of osseointegrated
implants; and 4) prosthetic restoration. This clinical report describes the functional and esthetic reconstructionof an adult patient with mandibular osteosarcoma using a four-stage treatment protocol.

Clinical Report
A 31-year-old female patient was diagnosed with osteosarcoma of a fibro-osseous lesion of the right mandible(Fig. 1). Mandibular resection and placement of a reconstruction plate was carried out in the patient’s mouth(Fig. 2). Since the surgical pathology examination of the right mandibular partial resection indicated a central
osteosarcoma with extension to the proximal bony margin, a further resection was required to achieve a negative
resection margin. Fig. 3 shows the postoperative panoramic radiograph after mandibular resectioning. Threemonths after the resection and rigid fixation, an iliac crest bone graft (approx. 30x10x8 mm in size) was placed
to repair the mandibular large resection defect. Figs. 4 and 5 present the frontal and occlusal views of thepatient’s mouth six months after the autogenous bone graft. Before the surgery for the implant placement tookplace, a surgical guide was fabricated on the master cast mounted on a semi-adjustable articulator. Five implants

91

Watanabe et al.

Int Chin J Dent 2005; 5: 91-95.

(OSSEOTITE Ø3.75x13 mm; Ø3.75x10 mm, 3i Implant Innovation Inc., Palm Beach Gardens, FL, USA) werethen placed in the grafted area. An AlloDerm (LifeCell Corp., Branchburg, NJ, USA) graft was also placedaround the implants to create the crest of the ridge during the secondary surgery (Fig. 6). Fig. 7 shows theimplant abutments ready for fabrication of the definitive fixed detachable prosthesis in the patient’s mandible. Atemporary partial denture was not used until the definitive prosthesis was placed. The metal framework for theimplant-supported superstructure (Fig. 8) was first fabricated with cast gold alloy (Ney-Oro 60, Degussa-Ney
Inc., Bloomfield, CT, USA) and gold cylinders. After the passive fit of the cast metal frameworks and wax
dentures with artificial teeth (Trubyte IPN 30º, Dentsply, York, PA, USA) that match the maxillary posterior
teeth was verified intraorally, the final fixed detachable dentures were fabricated according to conventional
methods (Fig. 9). The definitive fixed detachable prosthesis was finally fixed with retaining screws in thepatient’s mouth (Fig. 10). The right maxillary premolar was also restored with a single stand implant andporcelain-fused-to-metal (PFM) crown. The definitive prostheses provided a group function occlusal scheme.
The patient was satisfied with these functional and esthetic prostheses, which have performed favorably for one
year without any visible radiographic bone resorption (Fig. 11).

Fig. 1. Preoperative panoramic radiograph. Right first premolar shows periapical radiolucency.

Fig. 3. Postoperative panoramic radiograph after mandibular resections.

92

Watanabe et al.

Int Chin J Dent 2005; 5: 91-95.

Fig. 2. Resection and placement ofreconstruction plate.

Fig. 4. Frontal view with large mandibular
defect.

Fig. 5. Occlusal view of the patient’s mandible.

Fig. 6. AlloDerm graft during secondary
surgery of the implant.

Fig. 7. Implant abutments placed in thepatient’s mandible.

Fig. 8. Cast gold alloy framework tried-in.

Fig. 9. Definitive fixed detachable prosthesis.

Fig. 10. Fixed detachable prosthesis placedin the patient’s mouth.

93

Watanabe et al.

Int Chin J Dent 2005; 5: 91-95.

Fig. 11.

Postoperative panoramic radiographs after the restoration.

Discussion
A mandibular resection caused by aggressive malignant tumors can lead to malfunction of mastication,
deglutition and/or phonation due to a combination of defects including bone, oral mucosa, muscles and teeth with asignificant decrease in the quality of life. Functional and esthetic rehabilitation is therefore necessary for thosepatients who need mandibular resections. In this clinical case, a patient diagnosed with odontogenic osteosarcoma
underwent large mandibular resectioning. The total treatment plan for this patient followed a staged protocol
introduced in a previous report.8 The advantages of using a protocol in steps compared to protocols for immediate
reconstruction (occurring at the same time as placement of a bone graft and immobilization with maxillomandibularfixation)9 are: 1) the rigid internal fixation technique allows the surgeon to accomplish the resection, align thesegments, stabilize the jaw, and maintain the occlusion and facial esthetics without performing an immediate bonegraft; and 2) this strategy also allows the surgeon to obtain definitive pathologic analysis of the resection margins
before harvesting and placing an autogenous bone graft. Since the surgical pathology examination in this caseindicated a positive margin of the first resection after the rigid reconstructive fixation was conducted, a further
resection was required with wide margins. Before proceeding to the second stage, it was important to prevent
recurrence of the osteosarcoma by confirming that none of the resection margins were positive in terms ofmalignant cells. In the second stage, the autogenous iliac bone graft was placed in the defective area. Six months
later, the third stage of treatment was carried out when the osseointegrated implants were placed. At this stage, theAlloDerm graft,10 which provides support, strength and elasticity to the mucosa, was placed at the area of the crestof ridge (Fig. 6). The final stage of treatment was prosthetic restoration in which a definitive fixed detachable
prosthesis was fabricated for the esthetic requirements and functional rehabilitation. Due to the large mandibular
defect from resectioning, the metal framework as well as the definitive prosthesis possessed adequate verticalheight to maintain the vertical dimension of occlusion (Figs. 8-10). The fabrication of prostheses with ideal
anatomical shapes (adequate bucco-lingal width, alveolar arch and contour) is also important to assist deglutitionand phonation. This functional and esthetic prosthesis has performed favorably without any problems for one
and a half year. After the patient was successfully treated using the staged protocol for resection, reconstruction
and oral rehabilitation, follow-up appointments to monitor the recurrence of osteosarcoma and the prostheses’
function will continue.

94

Watanabe et al.

Int Chin J Dent 2005; 5: 91-95.

Acknowledgment
Editorial assistance by Mrs. Jeanne Santa Cruz is appreciated.

References
1. Tanzawa H, Uchiyama S, Sato K. Statistical observation of osteosarcoma of the maxillofacial region in Japan. Analysis of 114
Japanese cases reported between 1930 and 1989. Oral Surg Oral Med Oral Pathol 1991; 72: 444-8.
2. Vege DS, Borges AM, Aggrawal K, Balasubramaniam G, Parikh DM, Bhaser B. Osteosarcoma of the craniofacial bones. A
clinico-pathological study. J Craniomaxillofac Surg 1991; 19: 90-3.
3. Delgado R, Maafs E, Alfeiran A, et al. Osteosarcoma of the jaw. Head Neck 1994; 16: 246-52.
4. Martin JW, Chambers MS, Lemon JC, Toth BB, Helfrick JF. Prosthodontic and surgical considerations for pediatric patientsrequiring maxillectomy. Pediatr Dent 1995; 17: 116-21.
5. Tanaka N, Murata A, Yamaguchi A, Kohama G. Clinical features and management of oral and maxillofacial tumors inchildren. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999; 88: 11-5.
6. Linsen S, Niederhagen B, Braumann B, Koeck B. Functional and esthetic rehabilitation after mandibular resection in a childusing a tooth/implant-supported distraction device: A clinical report. Int J Oral Maxillofac Implants 2004; 19: 603-8.
7. Lavertu P, Wanamaker JR, Bold EL, Yetman RJ. The AO system for primary mandibular reconstruction. Am J Surg 1994;168: 503-7.
8. Troulis MJ, Williams WB, Kaban LB. Staged protocol for resection, skeletal reconstruction, and oral rehabilitation of children
with jaw tumors. J Oral Maxillofac Surg 2004; 62: 335-43.
9. Lello GE. Intraoral reconstruction of mandibular defects after tumor resection. J Oral Maxillofac Surg 1986; 44: 864-70.
10. Fowler EB, Breault LG. Ridge augmentation with a folded acellular dermal matrix allograft: a case report. J Contemp Dent
Pract 2001; 2: 31-40.

Reprint request to:
Dr. Ikuya Watanabe
Department of Biomaterials Science, Baylor College of Dentistry
Texas A&M University System Health Science Center
3302 Gaston Ave., Dallas, TX 75246, USA
Fax: +1-214-370-7001 E-mail: iwatanabe@bcd.tamhsc.edu
Received October 1, 2005. Revised November 4, 2005. Accepted November 7, 2005.
Copyright ©2005 by the Editorial Council of the International Chinese Journal of Dentistry.

95