Virtual Surgical Planning (VSP) and Jaw in a Day (JIAD) for mandibular reconstruction

Case description

Patient Selection Disclaimer: Highly selective approach for low-risk patients without high volume disease - ideal for benign cases, secondary reconstructive cases, and very limited oncologic cases.
The Jaw-In-A-Day (JIAD) mandible resection with immediate dental implant placement and prosthetic restoration, is a single-stage reconstructive procedure that combines resection, reconstruction using a free flap, dental implant placement, and temporary prosthetic restoration all in one operation.
Virtual Surgical Planning (VSP) for mandibular reconstruction enables precise preoperative planning with the use of prefabricated, patient-specific cutting guides and titanium plates. Key benefits include:
- improved operative efficiency,
- decreased OR time,
- and optimized occlusion accuracy.
In this case, the neck dissection was performed for oncological reasons.

Skin paddle position is based off the preoperative perforator location which is measured from CT angiogram. The cutting guide would then be positioned accordingly.
The fibula cutting guide may not fit as well as its shifted proximally, because the fibula shape changes.
If implants are to be placed down at the leg, implant placement can also be performed prior to the proximal and distal osteotomies as this provides a longer fibula to hold on to.
Once the osteotomies are performed, the mandibular plate can be secured to the fibula down at the leg, and tried on an ablative guide to ensure it matches prior to transfer.
When the fibula is secured to the native mandible, a prefabricated occlusal guide can be used to maintain intercuspal position (ICP) as the screws are fastened, and this will maintain the patient's occlusion prior to tightening.

Proper implant angulation is essential for successful prosthetic restoration in JIAD procedures, as Buccal canting (implants angled toward the cheek) creates significant complications.
When doing mandible reconstruction, fixating the proximal, posterior segment first allows for accurate seating of the mandibular condyle prior to fixating the distal, anterior segment to achieve an ideal occlusion of the native dentition at the time of rigid fixation.
If there is extensive buccal and floor-mouth component in the soft tissue defect, these can be challenging to immediately prosthetically restore. Considerations include:
- immediate bury of the implants, or,
- bring out two separate skin paddles where implants come out between 2 skin paddles, but this does increase the case complexity.
Dental implants can be placed with fibula, but, need VSP model to confirm appropriate location.
If dental implants are placed in the oral cavity, an occlusal guide will need to be used.
In the case presented here, the implants are brought out at the interface of the skin paddle and floor-mouth mucosa to avoid post-op infection (peri-implantitis).
A temporary prosthesis was placed out of occlusal function to avoid unnecessary loading of the implants, but the permanent prosthetic will provide adequate occlusion.

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