In a first-of-its-kind for the University of Rochester Medical Center and Upstate New York, experts from four disciplines worked together to perform in one day a procedure that previously would have taken separate procedures over several months to a year.
First, Oral and Maxillofacial Surgeon Dr. Antonia Kolokythas, removed a five centimeter section of the patient’s jaw where a fast-growing tumor was discovered.
At the same time, Plastic Surgeon Dr. Gui Christiano worked on the patient’s right leg, harvesting a portion of the fibula bone and its feeding vessels. This segment of fibula bone was secured with a titanium plate to the residual jaw to replace the portion removed that contained the tumor. The blood vessels feeding the transferred bone were connected to vessels in the neck using a microscope, through a small incision in the patient’s neck.
Then, Dr. Kolokythas and Dr. Carlo Ercoli, a periodontist and prosthodontist, placed implants into the fibula bone. Dr. Ercoli placed a dental prosthesis over the implants to replace the patient’s teeth that were removed with the jaw.
“Previously, patients who have undergone this in separate surgeries would struggle with eating, speaking and a changed facial appearance for months until new bone was placed,” explained Dr. Kolokythas, chair, Oral and Maxillofacial Surgery at UR Medicine’s Eastman Institute for Oral Health. “Then, after implants are placed, it normally would take another three to four months of healing before placing permanent crowns.”
The patient—28-year old Michael Smith—told his dentist at Eastman Dental, part of URMC, he was having pain in the lower left jaw area. After conducting a clinical exam and reviewing x-rays, the dentist knew there was something suspicious.
There was thinning of the jaw bone and replacement of the bone architecture and structure by a pathologic process,” explained Dr. Sergio Kellesarian. “We started suspecting that the condition was most likely an odontogenic tumor.”
A panorex X-ray confirmed lesions were only on the one side, and a thin-cut CT scan was ordered to gain a better view of the lesions. “After interpreting the results,” Dr. Kellesarian said, “we knew the condition needed immediate evaluation by a higher level of care.”
Part of the surgical team included Oral and Maxillofacial Surgeon
Dr. Antonia Kolokythas, Periodontist and Prosthodontist
Dr. Carlo Ercoli, and Dr. David Romeo, Prosthodontist resident.
Michael was promptly referred to Dr. Kolokythas. A biopsy confirmed it was an odontogentic tumor, which always originate from tissues that grow teeth and can only be found in jaw bones.
“If they’re not treated, odontogenic tumors that are generally aggressive can be locally destructive,” explained Dr. Kolokythas, who has performed surgery on more than 200 patients with these types of tumors. “Sometimes the first symptom is facial swelling, which means the tumor is growing outside the boundary of the bone, or the first sign can be a jaw fracture.”
“There is no way of predicting who develops these tumors or when they will become problematic,” explained Dr. Kolokythas, who has published extensively on and authored textbook chapters on this subject for pediatric pathology and oral and maxillofacial surgery textbooks. “These tumors often become evident either on routine imaging or when symptoms begin.”
Plastic Surgeon Dr. Gui Christiano explains the complex
procedure to guests at a Meliora Weekend event.
While the reasons are still unknown, it appears as though the messaging gets mixed up in development because some patients end up with a tumor in the location where teeth should be and aren’t.
These tumors are almost always benign, she added, stating that only 1 or 2 percent are cancerous, or behave as cancerous by metastasizing to the lungs.
After Dr. Kolokythas explained the serious nature of his tumor to Michael, he wasn’t convinced.
“Right from the beginning, I laughed it off,” Michael recalled. “I didn’t believe I had that tumor. I was definitely in denial.” Several months passed before he eventually accepted the reality of the situation, and agreed to surgery.
Given his age, overall health status and type of jaw resection required, Michael was the ideal candidate for the one-stage procedure.
While this technique and the inherent collaboration it requires across the various specialties is being performed at select leading centers in the U.S., it is a first for the University of Rochester Medical Center. UR Medicine is the only place in Upstate New York performing this procedure, which took about 12 hours.
“We are thrilled to bring this advanced level of treatment for patients in our region,” said Dr. Kolokythas, who sees patients every day who can benefit from this procedure. “It requires collaboration between medicine and dentistry, and extensive pre-operative planning and coordination among all the team members.”
Thanks to 3-D virtual surgical planning and 3-D printing, the team was able to capture images of the tumor, jawbone, fibula and teeth to precisely measure, plan and engineer every step of the surgery beforehand.
3-D virtual planning allows for accuracy and reproducibility of the planned surgery while significantly reducing operating room time.
“In a complex procedure like this, it is mission-critical that all members of the three teams involved feel comfortable working collaboratively, with open channels of communication,” said Dr. Christiano, assistant professor, Division of Plastic Surgery. “Everybody’s role is important. Everyone needs to be at his or her best on surgery day. And we were, for Michael. I am very proud of the team we have here.”
“In line with our University motto, Meliora–or Ever Better—we are always striving to improve what we do across our mission,” said Dr. Carlo Ercoli, chair, Eastman Institute Prosthodontics Department. “Because of this approach, the patient wakes up with an already reconstructed bone and gum structure and a functional set of teeth and oral structure that dramatically and positively affects his or her quality of life.”
Dr. Kolokythas with patient Michael Smith
at a follow-up appointment.
Dr. Davide Romeo, a prosthodontic resident who designed the 3-D fabricated implant bridge, and Dr. David Schwartz, also a prosthodontic resident, worked with Dr. Ercoli during the lengthy procedure to fit and install the bridge once the fibula was in place in Michael’s jaw. Dr. David Lillian, an oral and maxillofacial surgery resident, was also present.
Because the entire reconstruction is done through the mouth, the patient awakes and, aside from initial swelling and soreness, is able to return to normal daily activities soon afterwards.
“Everyone was awesome,” said Michael, a songwriter and musician. “They were phenomenal. I thank God for Dr. K and the whole team…they are all a blessing. They were very supportive throughout the whole process. I felt that I was in really good hands.”