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Application of stereolithography in mandibular reconstruction following  resection of ameloblastoma case report
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Application of stereolithography in mandibular reconstruction following resection of ameloblastoma case report


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  • 1. ISSN 1807-5274 Rev. Clín. Pesq. Odontol., Curitiba, v. 4, n. 2, p. 101-105, maio/ago. 2008 ©Revista de Clínica e Pesquisa Odontológica APPLICATION OF STEREOLITHOGRAPHY IN MANDIBULAR RECONSTRUCTION FOLLOWING RESECTION OF AMELOBLASTOMA: case report Aplicação da estereolitografia na reconstrução mandibular após ressecção de ameloblastoma: relato de caso Camila Lopes Cardoso1, Etiene de Andrade Munhoz2, Eduardo Dias Ribeiro3, José Bonifácio de Souza Neto4, Eduardo Sant’Ana5, Osny Ferreira Júnior61 DDS, MSc student, Department of Stomatology, Bauru Dental School, University of São Paulo, Bauru, SP - Brazil.2 DDS, MSc, PhD student, Department of Stomatology, Bauru Dental School, University of São Paulo, Bauru, SP - Brazil.3 DDS, Oral and Maxillofacial Surgeon, Bauru Dental School, University of São Paulo, Bauru, SP - Brazil, e-mail: DDS,Oral and Maxillofacial Surgeon, Bauru, SP - Brazil.5 DDS, PhD, Oral and Maxillofacial surgeon, Department of Stomatology Bauru Dental School, University of São Paulo, Bauru, SP - Brazil.6 DDS, PhD, Professor, Department of Stomatology, Bauru Dental School, University of São Paulo, Bauru, SP - Brazil. Abstract A 32-year-old female patient complaining about swelling in the right side of the mandible was referred to our Institution. Clinical exam showed erythema and crepitation during palpation in the region. CT showed a multilocular lesion involving the angle, ramus and part of the right body of the mandible. Incisional biopsy confirmed the diagnosis of ameloblastoma. The surgical treatment performed was partial resection with safety margin and reconstruction with titanium plaques. The reported case describes, in details, the application of stereolithography for presurgical planning of mandibular reconstruction following resection of ameloblastoma. Keywords: Stereolithography; Mandibular reconstruction; Rapid prototyping; Ameloblastoma. Resumo Paciente de 32 anos, sexo feminino, com queixa de aumento de volume no lado direito da face, foi indicada para nossa instituição. Ao exame clínico, apresentou tumoração no lado direito do corpo mandibular, eritema e crepitação à palpação da região. TC revelou lesão Rev Clín Pesq Odontol. 2008 maio/ago;4(2):101-105
  • 2. 102 Cardoso CL, Munhoz EA de, Ribeiro ED, Souza Neto JB de, Sant’Ana E, Ferreira Júnior O. multilocular comprometendo o ângulo, ramo e parte do corpo mandibular direito. O exame microscópico da lesão apresentou diagnóstico de ameloblastoma. O tratamento cirúrgico foi ressecção parcial da mandíbula com margens de segurança e reconstrução com placa de titânio. Descreve-se o planejamento cirúrgico da reconstrução mandibular, utilizando a estereolitografia no planejamento. Palavras-chave: Estereolitografia; Reconstrução mandibular; Prototipagem rápida; AmeloblastomaCASE REPORT Design). With the aid of a CAM (Computer Aided Manufacturing) system, and specific equipment, A 32-year-old white female patient the physical model was built. The equipmentcomplaining of swelling on the right side of the consists of a tank filled with acrylic resin, epoxyface was referred to our institution. Extraoral or vinyl, constituted by monomers, photo-examination revealed a slight asymmetry on the initiators and additives. The model is built on aright side of the mandible. The patient reported mobile platform situated immediately below thesuppuration in the region of mandibular molars. surface of this tank.Erythema and crepitation during palpation in the The computer sends to the platform theregion were found on clinical examination. The first layer of the virtual model to be polymerized.CT showed 4 cm in diameter multilocular When this layer is hit by the laser, photo-initiatorsradiolucent lesion, compromising angle, ramus trigger a localized reaction that fosters theand part of the right body of the mandible, formation of a polymeric chain between thedelimited by moderately irregular margins. monomer’s molecules dispersed in the resin and Aspiratory punch and incisional biopsy were solidification takes place.carried out for microscopic examination. The An elevator dives the platform in themicroscopic diagnosis was compatible with liquid polymer bath and the laser beam creates theameloblastoma, following a follicular microscopic second layer of solid polymer on top of the firstpattern. layer. The numerical control of the machine A partial resection of the mandible in the positions this platform on the surface of the resinarea affected by the lesion was planned with adequate and galvanometric mirrors directs the laser beamsafety margins. A prototype or model of the area to to the portion of resin corresponding to this firstbe reconstructed was chosen, through the layer. The process is repeated successively untilstereolithography method (rapid prototyping type). the prototype is complete. Once ready the solid In order to obtain models through this model is removed from the liquid polymer bathtechnique the helicoidal computerized tomograph and washed. The supports are removed and theshould obtain reformatted axial cuts of about 1,0 model is placed in an ultraviolet radiation oven tomm in thickness to reproduce precisely all the undergo a complete polymerization.details captured. After the image is captured, With the model in hands, precisefollowing the prototype manufacturer’s measurements were obtained, which wererequirements, specific programs generate a virtual transferred to the patient with extreme precision.three-dimensional model which is utilized in the Therefore, it provided a tactile perception of thereal model reconstruction process. lesion. Modeling and adaptation of the In the case at issue, the program used reconstruction plaque, in the 2.7mm system, werewas the 3D CAD system (Computer Aided performed from the model (Figure 1). Rev Clín Pesq Odontol. 2008 maio/ago;4(2):101-105
  • 3. Application of stereolithography in mandibular reconstruction following resection of ameloblastoma 103FIGURE 1 - Plaque modelling and adaptation Resection of the lesion with safety marginswas performed and the previously molded FIGURE 3 - Final computerized tomographyreconstruction plaque was installed (Figure 2 e 3). DISCUSSION Ameloblastoma is classified as a benign odontogenic tumor, although its behavior is similar to that of true neoplasia, for being locally invasive, aggressive and leads to a radical treatment planning, since the conservative ones has recurrence reports (1, 2). The prognosis of the solid pattern is obscure; thus, the treatment of choice is generally radical. Due to the relapsing potential, in the face of great resections, the patients seek a treatment with functional and aesthetic results. Hence, the planning requires new technologies in the reconstruction techniques. Technological advances in image collection, through more and more developed plans such as helicoidal computerized tomography,FIGURE 2 - Installation of premolded plaque have allowed the creation of a prototype or model construction technology, in a reduced time, known as Rapid Prototyping (RP). It is a process of organs and objects reproduction by scanning the area to be prototyped, usually through a computerized tomography or magnetic resonance exams. Rev Clín Pesq Odontol. 2008 maio/ago;4(2):101-105
  • 4. 104 Cardoso CL, Munhoz EA de, Ribeiro ED, Souza Neto JB de, Sant’Ana E, Ferreira Júnior O. Rapid prototyping systems emerged in 1987, REFERENCESthrough industrial engineering dominating theautomobile, consumption goods, aeronautic and naval 1. Neville BW, Damm DD, Bouquot JE. Oralindustries, pioneering the stereolithography process and maxillofacial patholog y. 2 nd ed.(SLA). Nowadays, it is well utilized in the health Philadelphia: WB Saunders; 1995.area, besides surpassing the other techniques by itsgreater precision and finishing of the model. It is 2. Regezi JA, Sciuba JJ. Patologia Bucal:widely utilized in architecture, engineering and correlações clinicopatológicas. Rio deindustrial design. In medicine, it is applied mainly in Janeiro: Guanabara Koogan; 2000.orthopedics, neurosurgery and oncology. In dentistry 3. Bouyssie JF, Bouyssie S, Sarrack P, Duran D.its application is useful in oral and maxillofacial Stereolithographic models derived from x-raysurgery, in orthognatic surgeries (model surgery) and computed tomography: reproduction accuracy.implants, and is less used in orthodontic planning, Surg Radiol Anat. 1997;19(3):193-9.analyzing the real positioning of the teeth (3, 4).Erickson investigated the opinion of surgeons on the 4. Hibi H, Sawaki Y, Ueda M. Three-use of SLA in planning, diagnosis and treatment, dimensional model simulation inwhen necessary, and found out that most of the orthognatic surgery. Int J Adult Orthodonsamples thought it useful in all indications (5). Others Orthognath Surg. 1997;12(3):226-32.authors, analyzing 40 patients with craniofacialdeformities, who underwent reconstruction surgeries 5. Erickson DM, Chance D, Schmitt S, Mathisutilizing stereolithographic models, concluded that J. An opinion survey of reported benefitsstereolithography is well indicated for planning and from the use of stereolithographic models.treatment; however, there are some limiting factors J Oral Maxillofac Surg. 1999;57(9):1040-3.such as manufacturing time and financial costs (6). 6. D’Urso PS, Atkinson RL, Laningan MW, As for anatomy precision, Barker carried Earwaker WJ, Br uce IJ, Holmes A.out a study measuring dimensions of objects and Stereolithographic (SL) biomodelling incomparing with their replicas, and obtained, as a craniofacial surger y. Br J Plast Surg.result 12% dimensional accuracy of the anatomical 1998;51(7):522-30.replicas (7). In cases of tumor treatment it has to be 7. Barker TM, Earwaker WJS, Lisle DA.taken into account the functional reestablishment Accuracy of stereolithographic models ofand the aesthetic result of facial contour; therefore, human anatomy. Australas Radiolgreat precision is needed (2, 3, 7, 8). 1994;38(2):106-11. The model can be used as a treatment anddidactic material for the parents and patient 8. Stoker NG, Mankovich NJ, Valentino D.themselves. Its role in the follow up of lesions has Stereolithographic models for surgicalbeen described for being excellent preoperative planning: preliminary report. J Oralanatomical references and serving as a parameter Maxillofac Surg. 1992;50(5):466-71.for posterior comparison (3). 9. Epply BL, Sadaore AM. Computer Hence, stereolithography is a useful way for generated patient models for recons-surgical planning of facial intra-osseous tumors, truction of cranial and facial deformities. Jproviding precision in the resection with all osseous Craniofac Surg. 1998;9(6):548-56.limits, facilitating also the adaptation of metallicprostheses, helping to preserve facial aesthetic and 10. Peckitt NS. Stereolithography and thereducing significantly the surgery and anesthesia time. manufacture of customized implants in The model also enables the surgeon to facial reconstruction a flapless surgicaldetermine the required length of the plate as well as technique. Br J Oral Maxillofac Surg.length and number of screws before surgery (8-13). 1998;36(6):481. Rev Clín Pesq Odontol. 2008 maio/ago;4(2):101-105
  • 5. Application of stereolithography in mandibular reconstruction following resection of ameloblastoma 10511. James WJ, Slabbekoorn MA, Edgin WA, Hardin, CK. Correction of congenital malar hypoplasia using stereolithography for presurgical planning. J Oral Maxillofac Surg. 1998;56(4):512-7.12. Ker nan BT, Wimsalt JA Use of a stereolithography model for accurate, preoperative adaptation of a reconstruction plate. J Oral Maxillofac Surg. 2000;58(3):349-51.13. Curcio R, Perin GL, Chilvarquer I, Borri ML, Ajzen S. Use of models in surgical predictability of oral rehabilitations. Acta Cir Bras. 2007;22(5):387-95. Recebido: 20/03/2007 Received: 03/20/2007 Aceito: 25/04/2007 Accepted: 04/25/2007 Rev Clín Pesq Odontol. 2008 maio/ago;4(2):101-105