Featured Case 01/22: JAW TUMOR AND RECONSTRUCTION

Patient:

Isidro is a 63-year-old male.

The problem:

• Isidro is a 63-year-old male referred by his primary MD to assess and treat a tumor of the lower jaw.
• He complained of pain and swelling in his left jaw for weeks.

Patient History:

• He was originally seen by his dentist years ago and told to remove his left impacted mandibular (lower jaw) wisdom tooth #32.
• He admittedly procrastinated on that recommendation until he felt pain and noticed the swelling of his jaw.
• His primary doctor performed a CAT scan which noted a tumor associated with impacted tooth #32.
• He was also noted to have a suspicious lesion on the skin below his left ear.
• He experienced significant anxiety and apprehension over this shocking news.
• After researching numerous surgeons, he and his wife chose to see Dr. Gilbert on the recommendation of his primary MD.

Pertinent Information:

• Approximately 85% of our population does not have room for their wisdom teeth.
• When malpositioned and unable to erupt into their proper place, they are referred to as “impacted”.
• Impacted teeth have a high probability of causing infections, damage to other teeth, gum problems, and the development of cysts and jaw tumors.
• When possible, it is recommended to be screened by a dentist between the ages of 14 and 18 to determine if the wisdom teeth are impacted or not.
• If they are impacted, removing them before they are problematic in the 14 to 18-year-old age group is optimal, as risks are lowest and healing is best in this age group.
• The risks of both surgery and the consequence of inaction are greater in the adult population.
• In Isidro’s case, he developed a tumor associated with his lower left impacted wisdom tooth that was destructive to his jaw.

Procedures:

• Proper diagnosis was obtained by performing biopsies of the jaw lesion and the skin lesion as an outpatient at Inland Institute Surgery Center.
• The jaw lesion was diagnosed as a Keratocystic Odontogenic Tumor which, although benign, can be invasive and destructive.
• The skin lesion was diagnosed as a basal cell carcinoma which has a low chance of spread or metastasis.
• Patients with both Keratocystic Odontogenic Tumors and Basal cell Carcinomas have been associated with Nevoid Basal Cell Carcinoma Syndrome.
• Isidro did not have any other manifestations of this syndrome.
• Jaw cysts of this nature have a high chance of recurrence (30-50%) with simple removal (enucleation and curettage).
• Isidro was scheduled for resection of that portion of the jaw to gain healthy margins and reduce the chances of recurrence.
• The highly involved nature of the cyst with the sensory nerve of the lower jaw (inferior alveolar nerve) would require nerve reconstruction.
• Surgery planning was performed by virtual computerized software before entering the operating room.

• The planning included the fabrication of a guide to isolate and “free” the nerve from the bone and confines of the tumor.
• A guide was also fabricated to position a prefabricated reconstruction titanium plate for the jaw.
• These highly accurate guides facilitated minimally invasive surgery that allowed excellent execution of the surgical plan for tumor removal and jaw and nerve reconstruction.

• The jaw bone was reconstructed utilizing a combination of the patient's own hip bone, bone marrow, stem cells (cells with the potential to differentiate into new tissue), and bone morphogenic protein (a naturally occurring but synthesized bone inductor).
• The nerve was transected in one location to deliver it out of the bone and reconstructed utilizing a donor nerve conduit and microsurgery.
• The skin basal cell carcinoma was fully excised and repaired with a plastic closure.

Treatment Course:

• The surgeries were performed as a single intervention at our regional hospital as an inpatient requiring a 2-day stay.
• Isidro progressed very well in recovery and was followed very closely by our office.
• He healed uneventfully and went on to resume his work and family life.
• He disappeared after a year of follow-up and eventually came in to see us 2 years later with a new tooth infection.
• This time, we were able to remove the offending tooth before an even bigger infection developed.
• We also had the wonderful opportunity to assess reconstruction and function.
• We noted excellent bone regeneration and maturation despite the new tooth infection.
• He was also noted to have a very good sensory function of the reconstructed nerve with a good sensation to his lower lip and chin.
• His wife noted that his family could not tell if he ever had surgery as he looked and functioned as he did before.
• The surgical incisions healed very cosmetically.