Art-7-Zhou
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ORAL REHABILITATION www.stomaeduj.com
A MULTIDISCIPLINARY APPROACH FOR THE REHABILITATION
Case Report
OF A PATIENT WITH CHONDROSARCOMA:
PROSTHETICALLY-DRIVEN DIGITAL WORKFLOW FOR
MAXILLARY RECONSTRUCTION AND IMPLANT TREATMENT
Yanjun Ge1a , Danni Guo1b , Xiaofeng Shan2c , Lei Zhang2d , Ruifang Lu3e , Pan Shaoxia1f , Yongsheng Zhou1g*
1
Department of Prosthodontics, Peking University School and Hospital of Stomatology & National Center of Stomatology & National Clinical
Research Center for Oral Diseases & National Engineering Laboratory for Digital and Material Technology of Stomatology & Beijing Key
Laboratory of Digital Stomatology & Research Center of Engineering and Technology for Computerized Dentistry Ministry of Health & NMPA
Key Laboratory for Dental Materials, Beijing 100081, China
2
Department of Oral-Maxillofacial Surgery, Peking University School and Hospital of Stomatology & National Center of Stomatology &
National Clinical Research Center for Oral Diseases & National Engineering Laboratory for Digital and Material Technology of Stomatology,
Beijing 100081, China
3
Department of Periodontology, Peking University School and Hospital of Stomatology & National Center of Stomatology & National Clinical
Research Center for Oral Diseases & National Engineering Laboratory for Digital and Material Technology of Stomatology & Beijing Key
Laboratory of Digital Stomatology & Research Center of Engineering and Technology for Computerized Dentistry Ministry of Health & NMPA
Key Laboratory for Dental Materials, Beijing 100081, China
a
DDS, PhD; e-mail: yanjun_ge@163.com; ORCIDiD: https://orcid.org/0000-0003-2853-8657
b
DDS ; e-mail: gdnsunshine@163.com; ORCIDiD: https://orcid.org/0000-0001-8190-0972
c
DDS, PhD; e-mail: kqsxf@263.net; ORCIDiD: https://orcid.org/0000-0002-2126-8052
d
DDS, PhD ; e-mail: zhlei_doctor@sina.com; ORCIDiD: https://orcid.org/0000-0001-8251-6032
e
DDS, PhD; e-mail: kqrflu@bjmu.edu.cn; ORCIDiD: https://orcid.org/0000-0002-9581-508X
f
DDS, PhD; e-mail: panshaoxia@vip.163.com; ORCID: https://orcid.org/0000-0002-3808-9499
g
DDS, PhD, Professor and Head; e-mail: kqzhouysh@hsc.pku.edu.cn; ORCID: https://orcid.org/0000-0002-4332-0878
https://doi.org/10.25241/stomaeduj.2021.8(3).art.7
ABSTRACT
Aim To describe a comprehensive digital therapy oriented towards the final restoration for treating an oral
maxillofacial defect caused by maxillary chondrosarcoma.
Summary The prosthetically-driven multidisciplinary approach was applied to achieve perfectly functional-
aesthetic reconstruction for a male patient with maxillary chondrosarcoma. The complete tumor resection
was ensured by the design of virtual osteotomy and surgical guide plate. A reverse engineering technique
was used to reconstruct the bone defect in the maxillary aesthetic area, which offered reference for a three-
dimensional printing guide plate to shape and fix the free vascularized iliac bone flap. On the solid basis of
previous treatment, the implant placement was performed under the guidance of the prosthetic-driven
implant plate. Vestibular extension and tissue graft were performed to increase keratinized gingiva width to
improve implant-supported fixed prosthesis effect.
Key learning points 1. A multidisciplinary approach including maxillofacial surgery, prosthodontic and
periodontal treatment can provide better esthetic and functional results for complex rehabilitation of a patient
with oral maxillofacial defect. 2. Predictability of maxillary reconstruction and implant restoration can be
increased with prosthetic-driven treatment plan. 3. Applying preoperative virtual design and personalized guide
plate is beneficial to achieve an ideal outline of reconstructed upper jaw. 4. Obtaining comprehensive aesthetic
parameters of the expected restoration is one of the key principles of upper anterior teeth rehabilitation. 5.
Digital technology provides an opportunity for consistency between the primary treatment design and the
final restoration outcome.
KEYWORDS
Digital; Surgical guide; Implant supported restoration; Oral-maxillofacial defect; Multidisciplinary approach
OPEN ACCESS This is an Open Access article under the CC BY-NC 4.0 license.
Peer-Reviewed Article
Citation: Ge Y, Guo D, Shan X, Zhang L, Lu R, Shaoxia P, Zhou Y. A multidisciplinary approach for the rehabilitation of a patient with chondrosarcoma:
prosthetically-driven digital workflow for maxillary reconstruction and implant treatment. Stoma Edu J. 2021;8(3): 207-215
Received: September 25, 2021; Revised: September 27, 2021; Accepted: September 29, 2021; Published: September 30, 2021
*Corresponding author: Prof. Yongsheng Zhou, DDS, PhD, Head; Department of Prosthodontics, Peking University School and Hospital of Stomatology,
No. 22 Zhongguancun South Avenue, Haidian District, Beijing 100081, P.R. China;
Tel.: +8610- 82195370; Fax: +8610-62173402; e-mail: kqzhouysh@hsc.pku.edu.cn
Copyright: © 2020 the Editorial Council for the Stomatology Edu Journal.
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1. INTRODUCTION In this article, a maxillary chondrosarcoma case is
Case Reports reported to propose a multidisciplinary approach
Tumors, trauma or congenital factors mostly lead to an and prosthetically-driven digital workflow for the
oral-maxillofacial defect. The maxillary defect, especially oral-maxillofacial rehabilitation.
in the anterior teeth area, has a serious impact on
patients from both physiological and psychological 2. CASE PRESENTATION
aspects, including bite, pronunciation and aesthetic
functions [1,2]. Therefore, as a complex functional A 46-year-old male patient required examination
and aesthetic reconstruction, the multidisciplinary and treatment with the chief complaint of a mass
approach is urgently needed to make a comprehensive on the front of the maxillary and accompanied by
diagnosis and optimal treatment plan, which may loose upper anterior teeth for several months, and
consist in periodontal, prosthodontic, maxillofacial he had no relevant medical history. The general
and implant treatment [3]. examination showed no abnormalities. The patient
Conventional rehabilitation workflow for patients visited the Department of Prosthodontics, Peking
with oral cancer completes the following steps in University School and Hospital of Stomatology in
sequence [4]. Surgery is performed to remove the February 2018.
affected area. The bone defect is reconstructed There was a tough mass with a diameter of about
with a bone flap or prosthesis. When feasible, the 3 cm and smooth surface on the labial side of the
implant and fixed restoration are used to improve maxilla central and lateral incisors (Fig. 1). The
the effect. Obviously, there are disadvantages vestibular sulcus was swollen without bleeding
of the conventional workflow to be optimized. and tenderness. Intraoral examination revealed
Discontinuous procedures are difficult to ensure tooth space among upper anterior teeth, which
the treatment consistency. The diagnosis and were I degree loose and drifted towards the mesial
treatment standards of different specialties are direction. Deep overjet and overbite were shown
diversified and rely heavily on their experience. In on anterior teeth. The first and second right maxilla
summary, the complex treatment process reduces premolars were missing. The relative position of the
the predictability of the rehabilitation [5]. upper and lower jaws was basically normal. This
The development of digital technology provides a patient had lots of dental calculus and poor oral
variety of means for the optimization of the oral- hygiene. The contour of the nasal base and upper
maxillofacial defect treatment, such as virtual lip was obviously raised, the skin color of the lesion
surgery, personalized model made by rapid looking normal. There were no abnormalities in the
prototyping technique, static plate or dynamic region of the neurological lymph nodes and bilateral
navigation-guided surgery [6]. The application of temporomandibular joint.
the novel digital technology can achieve higher Cone beam computed tomography (CBCT) showed
time efficiency and better quality of outcomes one circular area in the maxilla with reduced bone
for prosthetic treatment [7]. The implant guide density and unclear boundaries closely adhering
plate significantly reduces the error of implant to the anterior teeth. The range of this lesion was
surgery [8]. Precious registration of multi-source about 5cmX4cmX3cm, in which spot and flake-
data can realize virtual aesthetic design before like calcification were visible. The radiographic film
surgery. Most of the current scientific evidence of revealed neither root canal treatment nor peri-apical
applying digital technique for oral-maxillofacial resorption of upper anterior teeth (Fig. 2).
rehabilitation focuses on mandible reconstruction According to the clinical and radiographic
and shaping of vascularized fibular flap [5,9-12]. examination, multidisciplinary experts consulted
Literature on maxillary reconstruction in aesthetic and gave a comprehensive diagnosis and sequential
high-risk area rehabilitated with a free vascularized treatment plan. Firstly, the systematic periodontal
iliac bone flap assisted by digital technique was rare. treatment was performed by the periodontist.
Figure 2. Pre-operative panoramic radiograph indicating the maxilla
with reduced bone density and unclear boundaries lesion close to the
Figure 1. A maxillary tumor with a diameter of about 3 cm and smooth anterior teeth. Neither root canal treatment nor peri-apical resorption
surface on the labial side of the upper anterior teeth. of upper anterior teeth were noted.
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The oral and maxillofacial surgeons would remove
Case Reports
the maxillary tumor and reconstruct the maxilla
for implant restoration. Free gingival grafts would
be performed where required. Subsequently,
implant-supported fixed partial denture would be
accomplished.
The current condition, treatment plan, cost and
prognosis were communicated in detail to the
patient. Signed informed consent, with the aid
of digital technique, virtual surgical planning
(VSP) and rapid prototyping technology (RP) were
applied for maxillary chondrosarcoma resection and
reconstruction. The free vascularized iliac bone graft
Figure 3. (a)
surgery was performed. The CT dataset of maxillofacial
and iliac were used to simulate the osteotomy
operation and construct a three-dimensional
maxillary defect model through reverse engineering
software. Based on digital design, surgical guide
plates and personalized models were made to assist
in the osteotomy operation and flap fixation (Fig. 3).
A full-thickness flap was raised through intraoral
incision under general anesthesia. The tooth-
supported maxillary surgical guide was completed
in place. According to the preoperative design,
the maxillary lesion was excised (Fig. 4). Taking
pathology analysis and examination together, the
results confirmed the diagnosis of well-differentiated
chondrosarcoma. According to the pathological
Figure 3. (b)
results of frozen sections, there wereas no tumor
cells at the margin. The free vascularized iliac bone
flap was prepared and shaped under the guidance
of the personalized plate and maxillary model. The
bone flap was adequately positioned at the maxillary
defect area and firmly fixed by titanium nails and
plate. A vascular anastomosis was completed under
the microscope for the successful reconstruction
(Fig. 5). One week, three months and twelve months
after surgery, a clinical examination was performed at
each follow-up visit. Panoramic radiograph and CBCT
showed no recurrence (Fig. 6).
After healing, plaster models were made from primary
Figure 3. (c)
impressions. A characteristic occlusal rim was made
to record the maxillo-mandibular relationship and
key aesthetic parameters with radiopaque material.
The Digital Imaging and Communications in Medicine
(DICOM) data from CBCT and model scanning data
were registered accurately. Based on the aesthetic
principle, the expected restoration and implant
treatment were virtually designed (Fig. 7). An implant
surgical guide supported by natural teeth and lateral
retention nails was made through the RP technique.
A full-thickness flap was raised under local anesthesia
(Primacaine adrenaline 1:100,000, Dentaires Pierre
Rolland), and four implants(15,13 NobelActive® RP, Figure 3. (d)
11,21 NobelActive® NP, Institut Nobel Biocare AG) were Figure 3. Virtual surgical planning (VSP) and rapid prototyping
inserted with the guidance of the template (Fig. 8). technology (RP) applying for maxillary chondrosarcoma resection
Before suturing, the healing screws were connected and reconstruction. (a) Virtual osteotomy operation was performed
using digital technique. (b) 3D printed surgical plate for radical
to the implant. Ten days after surgery, the sutures resection of maxillary chondrosarcoma. (c) The iliac CT data were
were removed. The examination revealed a favorable used to simulate maxillary defect reconstruction. (d) A guide plate
healing process of the implant and soft tissue. for free vascularized iliac bone graft surgery.
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Case Reports
Figure 4. (b)
Figure 4. (a)
Figure 4. Resection of maxillary chondrosarcoma with the
guidance of tooth-supported surgical guide. (a) The surgical
guide plate was in place. (b) The maxillary lesion was excised as
pre-operative design. (c) The maxillary defect after maxillofacial
surgery.
Figure 5. Maxillary reconstruction with vascularized iliac bone
flap graft surgery. (a) Preparation of free vascularized iliac bone flap.
(b) Shaping and fixation of flap with the personalized 3D printed
model as reference. (c) The bone flap was adequately positioned at
the maxillary defect area and firmly fixed. (d) Completion of vascular
anastomosis. Figure 4. (c)
Figure 5. (a) Figure 5. (b)
Figure 5. (c) Figure 5. (d)
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-Case Reports
Figure 6. Panoramic radiograph showed adequate bone for
implant placement.
Figure 8. (a)
Figure 8. (b)
Figure 7. (a)
Figure 8. (c)
Figure 8. (d)
Figure 7. (b) Figure 8. A restoration-oriented digital workflow for implant
surgery. (a) Implant treatment was virtually designed using precious
Figure 7. A prosthetically-driven virtual design for implant registered dataset. (b) Implant surgical guide was made by rapid
placement. (a) Registration of multi-source data. (b) Implant type prototyping technology. (c) The implant guide plate was stabilized
and position were virtually designed according to the optimal through transverse retention nails and residual teeth. (d) Optimal
restoration. implant placement under the guidance of the plate.
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Case Reports
Figure 9. (a)
Figure 11. Temporary resin restoration milled with a 5-axis CNC machine.
Four months after surgery, the implants showed
good osseointegration. Further intraoral examination
showed less keratinized gingiva on the buccal side of
the right upper jaw. Vestibular extension and tissue
graft were performed to increase keratinized gingiva
width. During the second-stage operation, the 4mm
buccal keratinized gingival was retained through
apically repositioned flap surgery (Fig. 9). The screws
Figure 9. (b)
were unscrewed, and the healing abutments were
connected to the implants (Fig. 10).
Communicating with the patient, the final restoration
was screw-retained zirconia base with labial porcelain
fixed bridge. For the upper jaw, an open-tray splint
implant impression was taken with a polyether material
(Impregum Penta, 3M ESPE GmbH). A conventional
impression of the opposing jaw was taken with
alginate material (Alginoplast, Heraeus Kulzer GmbH).
Temporary resin restoration was milled with a 5-axis CNC
machine. Trying in the temporary restoration, passive
fit and appropriate upper lip fullness were achieved
(Fig. 11). Referred to the pupil line and smile line, minus
adjustment of the denture was performed on the
Figure 9. (c) restoration to obtain coordinated midline and incisal
curve. After three months, the patient did not express
Figure 9. Tissue graft to increase width of the keratinized discomfort. The maxillo-mandibular relationship was re-
gingiva. (a) A deficiency of the keratinized gingiva on the buccal
side of the right upper jaw. (b) Performance of vestibular extension
determined and transferred to the articulator by face-
and tissue graft. (c) The second-stage operation and apically bow. The final zirconium restoration was made with the
repositioned flap surgery. reference of the temporary restoration. At delivery, the
interproximal contact points were assessed for a strong
contact using dental floss. Occlusal contact points were
checked for light occlusal contacts without lateral
occlusal disturbance (Arti‐Fol shimstock foil, Dr. Jean
Bausch GmbH & Co.). With a small amount of modified
occlusal contact, the patient showed high satisfaction
for the effect and comfort (Fig. 12). The panoramic
radiograph showed good marginal adaptation of final
restoration (Fig. 13). Twelve months after delivery, the
follow-up examination revealed restoration in good
condition. Oral hygiene maintenance and regular
Figure 10. Panoramic radiograph after osseointegration of implants. recheck were instructed (Fig. 14).
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Figure 13. Panoramic radiograph after final restoration showed passive fit.
Figure 12. (a)
Figure 14. (a)
Figure 12. (b)
Figure 12. (c)
Figure 14. (b)
Figure 14. Twelve months after delivery. (a) Restoration in good
condition (b) Well maintained oral hygiene.
3. DISCUSSION
In this case, the patient was diagnosed with maxillary
Figure 12. (d) chondrosarcoma, which is a rare malignant neoplasm
[13]. Chondrosarcoma(CHS) usually occurs in the pelvis,
chest wall, and scapula. Maxillary chondrosarcoma is
more common in men, average age range from 35
to 45 years old [14]. Maxillary chondrosarcoma may
originate from the embryonic cartilage precursors
of turbinate and nasal septum. According to the
characteristics of the cells under the microscope,
this patient is pathologically diagnosed as highly
Figure 12. (e) differentiated chondrosarcoma, classified as Grade I.
Figure 12. Perfect functional-aesthetic reconstruction with final The 5-year survival rate for patients with grade I is 89%,
implant supported fixed partial denture. (a) Occlusal view. (b) Centric
occlusion-right. (c) Centric occlusion-left. (d) The color and contour of according to WHO data [13,15]. Therefore, it is necessary
the restoration are consistent with adjacent teeth. (e) The gingival end to provide complete treatment and a rehabilitation
of the bridge is in harmony with the soft tissue. plan for this patient to improve his survival life quality.
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Prosthetic-driven multidisciplinary approach is Implant restoration can effectively improve the
Case Reports an important concept for maxillofacial defect rehabilitation outcome of patients with maxillofacial
rehabilitation [5]. Radical resection of the affected defects. It is reported that the cumulative survival rate
area of maxillary chondrosarcoma is the sole way to of implants placed in bone flaps in jaw rehabilitation
achieve an optimal outcome. However, common hard can reach 93.2% [20]. It should be noted that the
and soft tissue defects after resection always make it long-term good prognosis of implant restoration is
too difficult to complete optical restoration. In this case, closely related to the dentist’s treatment as well as
under the guidance of final implant supported fixed the patient’s maintenance. A reasonable preoperative
restoration, the key parameters were formulated to design ensures a good self-cleaning for the patient.
shape the iliac bone flap, and to restore the contour Hygiene maintenance and regular review effectively
and bone mass of the maxillary defect area. Based reduce complications. The limitation of this case report
on the solid foundation, ideal implant surgery can be is that the temporary denture does not use digital
performed as the established design with the aid of a preoperative design. The application of the fully digital
digital surgical guide plate. At the same time, a plan to workflow can further ensure the guiding role of the
final restoration. The conventional workflow used in
increase the width of keratinized gingiva with palatal
this case report is a time-saving and mature method.
mucosal transplantation is made when necessary
The long-term repair effect needs to be further tracked.
[19]. Prosthetic-driven treatment can improve the
predictability of rehabilitation effect, the consistency 4. CONCLUSION
of multidisciplinary treatment standards and the
effectiveness of communication with patients. In this case, a new concept of multidisciplinary
The application of computer aided surgery (CAS) has diagnosis and treatment approach is used to complete
significantly improved the accuracy and safety of the the maxillary reconstruction and implant supported
jaw reconstruction. Based on different bone defects, fixed restoration for the maxillary chondrosarcoma
guided bone regeneration (GBR), onlay bone graft, patient. The prosthetic-driven workflow can achieve
distraction osteogenesis, or vascularized bone flap graft the consistency of complex treatment standards and
can be selected for reconstruction [17-19]. As agreed improve the predictability of the restoration. The
with the patient, the vascularized iliac bone flap was accuracy and efficiency of the treatment are improved
chosen to reconstruct his maxilla. Three common digital with digital technology.
techniques are navigation surgery, guide plate, and a CONFLICT OF INTEREST
combination of navigation and plate, which can be The authors declare no conflict of interest.
selected according to the purpose of the operation and ACKNOWLEDGMENTS
scope of the defect. In this case, using a static guide None
plate as appropriate auxiliary method to accurately AUTHOR CONTRIBUTIONS
guide osteotomy and fixation of the flap, consists three *Yanjun Ge and Danni Guo have equally contributed as first authors.
DG and YG collected data and wrote the original draft. YG, XS, LZ
key steps: obtaining registered data pre-operation, and RL performed the clinical treatment. SP and YZ lead the writing
virtual surgical planning, application of rapid prototype. and revised the manuscript.
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Yanjun GE
DDS, PhD
Department of Prosthodontics; Peking University School and Hospital of Stomatology National
Center of Stomatology; National Clinical Research Center for Oral Diseases; National Engineering
Laboratory for Digital and Material Technology of Stomatology; Beijing Key Laboratory of Digital
Stomatology Research Center of Engineering and Technology for Computerized Dentistry
Ministry of Health; NMPA Key Laboratory for Dental Materials, Beijing 100081, China
CV
Dr. Ge, DDS, has been a prosthodontist and lecturer at Peking University School and Hospital of Stomatology since 2009. As an
ITI member, he carried out a large number of implant treatments using digital technology. He is good at and responsible for
treating prosthetic patients, especially complex case treated with the multidisciplinary approach.
Questions
1. What is the average age range of male patients with maxillary chondrosarcoma?
q a. 40 to 55;
q b. 35 to 45;
q c. 25 to 36;
q d. 65 to 75.
2. Which of the following options is not a method for maxillofacial surgery to reconstruct
the maxilla?
q a. Distraction osteogenesis;
q b. Vascularized bone flap graft;
q c. GBR;
q d. Obturator.
3. Which is the digital method commonly used in computer-assisted surgery?
q a. Navigation surgery;
q b. Surgical guide plate;
q c. Virtual surgical planning;
q d. All of the above.
4. What is the retention survival rate of implants on the bone flap (jaw reconstruction)?
q a. 78.5%;
q b. 93.2%;
q c. 96.8%;
q d. 89.7%.
Stoma Edu J. 2021;8(3): 207-215 pISSN 2360-2406; eISSN 2502-0285 215