Received: 17 June 2023 Accepted: 9 November 2023

DOI: 10.1111/jopr.13800

TECHNIQUE

Dental prosthesis extraoral indexing and pick-up technique for

mandibular full arch immediate rehabilitation in fibula free flap
reconstruction

Sasha J. Betz DDS, MS1 Daniel A. Hammer DDS, FACS1

Michael R. Andersen DDS, MS, FACP2

1
Oral and Maxillofacial Surgery, Naval Medical Abstract
Center, San Diego, California, USA
Same-day ablative and reconstructive surgeries for the treatment of head and neck
2
Oral and Maxillofacial Prosthodontics, Naval pathologies are gaining in popularity with the recognition that single-day surgeries
Medical Center, San Diego, California, USA
reduce morbidity and increase quality of life. Implant-borne prosthetics on the donor
graft provide immediate dental reconstruction. This report describes a novel tech-
Correspondence
Sasha J. Betz, DDS, MS, Oral and Maxillofacial nique for extraoral pickup of a full arch immediate prosthesis from the donor site free
Surgery, Naval Medical Center, San Diego, CA, flap. This technique minimizes intraoperative occlusal adjustments, saves intraoperative
USA.
time, prevents undesirable “rolling” of a fibula segment, and immediately rehabilitates
Email: [email protected]
patients with dental prosthetics.

KEYWORDS
digital planning, fibula free flap, jaw in a day, mandibular reconstruction, reconstructive surgery, virtual
surgical planning

Reconstruction of the mandible after pathology or trauma fabrication of stereolithic models, osteotomy guides, implant
is necessary as the bony mandible and its dentition play a guides, occlusal splints, and immediate dental prostheses in
role in facial form and esthetics, speech, nutritional intake, four cases of benign gnathic pathology.3 The dental implants,
and breathing.1,2 Vascularized tissue grafts are often pre- abutments, and prosthesis were placed onto the fibula prior
ferred to non-vascularized corticocancellous bone grafts for to division of the vascular pedicle, and an occlusal splint was
anatomically complex defects requiring hard and soft tissue used to facilitate placement of the prosthesis intraorally and
reconstruction.1 Of these, the fibula free flap is the gold stan- maintain the maxillomandibular relationships.3
dard due to adequate length and bicortical bone stock, long Since the initial JIAD publication, the procedure has been
pedicle, availability of skin and muscle to address soft tis- gaining in popularity.4,5 Critical to the success of same-day
sue defects, and ability to operate in a two-team approach.2 dental rehabilitation is an accurate and reproducible pick
Dental implants placed into the fibula free flap allow for up technique. The goals of a successful technique include
dental reconstruction of patients with mandibular trauma or the establishment of satisfactory occlusion of the imme-
pathology.1–3 diate prosthesis and minimal intraoperative adjustments.
In early reports, dental implants placed into vascularized Both intraoral and extraoral techniques are described in the
mandibular bone grafts were allowed several months for literature.2,5–8 Qaisi et al. described the inset of the fibula and
osseous integration before uncovering and delivery of a den- prosthesis to a defect model at the leg and intraoral adjust-
tal prosthesis.2 In 2013, head and neck reconstructive surgery ments to fit the adjacent mandible and opposing dentition
was revolutionized with the first description of a same-day using an occlusal splint, similar to Levine et al.6 Williams
virtual guided resection, fibula reconstruction, and fibula- et al. described a “floating prosthesis” that indexed to the
borne implant-retained dental prosthesis delivery.3 Termed remaining teeth on the defect model, allowing for pickup
“Jaw in a Day” (JIAD) surgery, virtual planning facilitated the of the implant copings prior to division of the fibula free

This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction in any medium,
provided the original work is properly cited and is not used for commercial purposes.
Published 2023. This article is a U.S. Government work and is in the public domain in the USA. Journal of Prosthodontics published by Wiley Periodicals LLC on behalf of American
College of Prosthodontists.

J. Prosthodont. 2025;34:101–106. wileyonlinelibrary.com/journal/jopr 101

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102 BETZ ET AL.

flap.5 This technique requires residual dentition and thus

would not apply in the case of a full arch defect. Patel et
al described an extraoral pickup technique using the pros-
thesis on a defect model to try-in on a stereolithic model
of the maxilla with provisional height adjustments made
intraoperatively.2 While these techniques all result in same-
day prosthesis delivery, there is potential for discrepancies in
the ideal occlusion and maintenance of the vertical dimen-
sion of occlusion as compared to the surgical plan. This may
require intraoperative occlusal adjustments to the prosthesis
which adds risk of acrylic debris in the surgical site and
increases the overall intraoperative time in an already lengthy
surgery.
This report describes a novel extraoral dental prosthesis
indexing and pick-up technique for mandibular fibula free
flap full arch reconstruction using a fully digital workflow
and a lightweight, hinged articulator. The upper member is F I G U R E 1 The prosthesis is first set to the appropriate
designed with a positioning index and vertical stops, and the maxillomandibular relationship. The neomandible is then positioned with
approximately 17 mm of restorative space to the planned prosthesis.
lower member has predictive screw holes for positioning the
fibula free flap. By leveraging a streamlined digital workflow
and this novel extraoral dental prosthesis indexing and posi-
tioning articulator, a dental prosthesis is predictably indexed
to the neomandible to maintain the predesigned occlusion
and vertical dimension of occlusion. This method minimizes
intraoperative adjustments to reduce operating room time
compared to traditional intraoral indexing techniques for full
arch immediate dental prostheses. Furthermore, the dental
prosthesis on the neomandible acts as an external fixation
device to help prevent unwanted “rolling” of a fibula segment
during fixation of the reconstruction plate.
In this case, a 28-year-old male with no significant med-
ical history was referred for evaluation and treatment of a
four-centimeter biopsy-proven conventional ameloblastoma
of the anterior mandible. After a thorough review of the risks,
options, and benefits of surgery, he elected for same-day
ablation and reconstruction via JIAD surgery.

TECHNIQUE
F I G U R E 2 (a) Planned surgical defect with fibula and implant
reconstruction. (b) Custom guide for fibula osteotomies and implant
1. Imaging placement.

Obtain CT maxillofacial, CT neck, and CTA images of the

lower extremities with 1 mm slices for pre-surgical planning 2. Digital surgical planning with a craniofacial
of the reconstruction and free flap. High-quality CBCT may plating company
also be used. Position the patient in the maxillomandibular
relationship of the final prosthetic plan during imaging. For Upload images to the software of a craniofacial plating com-
edentulous patients, use a dual scan technique with occlusal pany that partners with a full-service dental laboratory for
rims or an existing denture for planning the prosthetic teeth digital planning with the surgical and restorative team such
at the appropriate maxillomandibular relationship.7 as IPS (KLS Martin, Jacksonville, FL) or VSP (Stryker,
Capture the existing dentition and restorative maxillo- Kalamazoo, MI).
mandibular relationship with intraoral or laboratory scans In the virtual surgical planning session, ensure the align-
of stone models from physical intraoral impressions. If the ment of the intraoral scan STL images to the CBCT or CT
patient is edentulous, use occlusion rims or an existing imaging for maintenance of maxillomandibular relationships
denture to facilitate appropriate maxillomandibular records. and improved surface fidelity of the dentition.
Design the prosthesis from the pre-existing dentition or Position the prosthesis in the planned maxillomandibu-
with CAD-CAM software. lar relationship to commence planning in a “crown down”
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EXTRAORAL PICK-UP FOR MANDIBULAR RECONSTRUCTION 103

F I G U R E 3 Prosthesis positioning and indexing articulator. (a) Blue arrow: positioning attachment with access channels. The positioning attachment
precisely indexes to the mandibular prosthesis. Red arrow: vertical struts maintain the maxillomandibular relationship. Orange arrow: predictive screw holes
for the reconstruction plate. (b) The planned prosthesis precisely indexes to the positioning attachment of the upper member. The vertical struts and design of
the upper member maintain the maxillomandibular relationship and ensure the correct orientation of the prosthesis in relation to the neomandible. (c) Access
channels on the positioning attachment facilitate the pick-up.

approach. Set the neomandible with approximately 17 mm from the dental laboratory with a biocompatible ceramic
of prosthetic space to accommodate for restorative mate- nanohybrid photopolymer (Rodin Sculpture; PacDent, Brea,
rial, hygiene space, and height of intermediate abutments CA).
(Figure 1).
Plan the implant position into the fibula according to prin-
ciples of full arch implant dental restoration planning with 3. Intraoperative techniques
extra consideration to vertical prosthetic requirements for soft
tissue and hygiene space (Figure 2). After the surgical team performs the fibula osteotomies and
Design the extraoral dental prosthesis positioning and placement of implants (Figure 4), place straight intermediate
indexing articulator (Figure 3). On the upper member, create abutments on the dental implants and torque to manufacture
vertical struts to maintain the maxillomandibular relation- specifications.
ship and a positioning attachment to allow for an intimate Fit the fibula with implant construct to the defect model,
and reproducible alignment of the full arch dental prosthesis. the lower member of the extraoral prosthesis positioning and
Design hinges that translate the orientation of the upper mem- indexing articulator (Figure 5). Adapt custom reconstruction
ber in the sagittal plane to the lower member. Make access plates to the fibula and leave fixation screws incompletely
channels on the positioning attachment to facilitate accessi- tightened until the prosthesis is picked up to the temporary
bility to the screw channels after prosthesis pickup with a cylinders with a dual cure methacrylate-based acrylic resin
dual cure acrylic. Place predictive screw holes on the lower (Stellar DC; Taub Products, New Jersey City, NJ). This trans-
member for reproducibility of the reconstruction plate. With fers error from the occlusal relationship of the prosthesis
this design, the immediate prosthesis “snaps in” to the upper to the neomandible where errors are more readily accom-
member of the articulator. modated and helps prevent an unwanted “roll” of the fibula
The extraoral dental prosthesis position and indexing artic- segment.
ulator are additively manufactured by the craniofacial plating Seat the immediate prosthesis into the positioning attach-
company and the dental prosthesis is additively manufactured ment of the upper member with a “snap in” effect to ensure
 1532849x, 2025, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jopr.13800 by Director, INFLIBNET Centre, Wiley Online Library on [14/05/2025]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
104 BETZ ET AL.

FIGURE 7 Reverse scan bodies at time of surgery.

correct positioning of the dental prosthesis (Figure 6). Com-

F I G U R E 4 Fibula with custom guide for planned osteotomies and plete seating of the prosthesis can be visualized through the
implants prior to pedicle division. viewing windows of the upper member.
Place metal temporary cylinders on the intermediate abut-
ments through access windows of the indexing guide of the
upper member and through the widened access channels of
the prosthesis. Ensure the temporary cylinders do not contact
the prosthesis to minimize errors in passivity of the conver-
sion prosthesis to the intermediate abutments after pick up.
Lute the prosthesis to the temporary cylinders with a dual
cure acrylic (Stellar DC; Taub Products, New Jersey City,
NJ). Fully tighten the reconstruction plate screws and remove
the prosthesis for finishing and polishing (Figure 7).
If immediate load is deemed acceptable by the surgi-
cal team, parachute sutures are placed to improve access
of the intermediate abutments to the conversion prosthesis
(Figure 8).
Verify the occlusion with articulation paper and adjust
as necessary intraoperatively. Tighten prosthetic screws in
F I G U R E 5 Fibula and implant construct placed into the defect a counter-positioning fashion and seal access channels
model, the lower member of the articulator prior to pedicle division. temporarily with polyvinyl siloxane (GI Mask; Coltene
Fixation screws are placed in the predictive screw holes but not completely
Whaledent, Cuyahoga Falls, OH).
tightened at this stage. In this case, the left anterior implant was aborted due
to the planned position being clinically too close to the osteotomy site.

4. Post-operative course

Take post-operative imaging at the first clinic follow-up to

verify positioning and bone height of the neomandible, sur-
gical hardware, and implant placement (Figure 9). Occlusal
adjustments are performed as necessary.
Obtain final records at >6 weeks post-operatively. Remove
the immediate prosthesis for impressions and begin planning
for the final prosthesis.
Deliver the definitive prosthesis >3 months from the
surgical date (Figure 10).

F I G U R E 6 (a) Articulator with the prosthesis “snapped in” to

positioning index of the upper member. (b) Access channels of the DISCUSSION
positioning attachment enable access to the screw channels of the temporary
cylinders. Jaw in a day surgeries are increasing in popularity as
the psychosocial and quality of life benefits of immediate
 1532849x, 2025, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jopr.13800 by Director, INFLIBNET Centre, Wiley Online Library on [14/05/2025]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
EXTRAORAL PICK-UP FOR MANDIBULAR RECONSTRUCTION 105

F I G U R E 8 (a) Parachute sutures are placed

underneath the prosthesis for closure. The skin paddle
of the fibula free flap is present anteriorly. (b)
Immediate prosthesis in occlusion. No occlusal
adjustments were necessary intraoperatively or
subsequently.

F I G U R E 9 (a) Post-operative panoramic

imaging. The positioning and bone height of the
neomandible, surgical hardware, and implant
placement are verified to be consistent with the
pre-surgical plan. (b) A heat map of the occlusion of
the immediate prosthesis to the maxilla demonstrates a
balanced occlusion. No occlusal adjustments were
necessary.

ing and indexing articulator at our institution, the need for

intraoperative occlusal adjustments has reduced drastically.
The complexity of JIAD surgery requires a multidis-
ciplinary approach, often involving teams of surgeons,
prosthodontists, oncologists, speech and language pathol-
ogists, social workers, nurses, vendor teams, biomedical
engineers, and support staff.6 As subject matter experts
on maxillomandibular relationships, prosthetics, materials,
and techniques, prosthodontists are critical to the suc-
cess of same-day dental rehabilitation. With ever-advancing
technologies, prosthodontists are imperative for dental reha-
bilitation and uniquely poised to continuously innovate and
champion novel technologies and techniques in JIAD surgery.
F I G U R E 1 0 Delivery of the final prosthesis 3 months after the date
of surgery. The esthetics and occlusion of the final prosthesis are consistent
with the patient’s pre-surgical dentition. Soft tissue integration of the flap is SUMMARY
appreciated. Patients may be referred to Dermatology for hair removal at
this stage.
The design of the novel dental prosthesis positioning and
indexing articulator allows for translation of the patient’s
reconstruction are acknowledged.6 Advancing technologies planned maxillomandibular relationship to the immediate
allow for a completely digital workflow through high- prosthesis and neomandible with high fidelity. This full arch
quality 3D imaging, intraoral scanning, and virtual surgical extraoral pick up technique minimizes the need for intra-
planning.6 They also allow for the development of innovative operative adjustments, lowers the risk of acrylic debris in
devices and techniques to reduce intraoperative time, such as the surgical site, prevents an unwanted “roll” of the fibula
the extraoral prosthesis positioning and indexing articulator. segment, and reduces overall surgical time.
This articulator replicates the patient’s pre-surgical maxillo-
mandibular relationship and reliably transfers it to the new C O N F L I C T O F I N T E R E S T S TAT E M E N T
prosthesis and neomandible through the design of the hinges Drs. Andersen and Hammer are consultants for Stryker,
and struts of the upper member. Kalamazoo, Michigan. The views expressed in this article
The positioning attachment uses a physical index of the are those of the author(s) and do not necessarily reflect the
patient’s planned immediate prosthesis for a “snap in” effect official policy or position of the Department of the Navy,
at the time of pick-up. Indexing to this, rather than the Department of Defense, or the U.S. Government. I am a mil-
maxillary dentition through the use of a stereolithic model itary Service member or employee of the U.S. Government.
or occlusal splints, minimizes conjecture of the occlusal This work was prepared as part of my official duties. Title 17,
relationship, error, amount of acrylic debris due to intraop- U.S.C., §105 provides that copyright protection under this
erative prosthesis adjustments, and surgical time. Since the title is not available for any work of the U.S. Government.
implementation of this extraoral dental prosthesis position- Title 17, U.S.C., §101 defines a U.S. Government work as
 1532849x, 2025, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jopr.13800 by Director, INFLIBNET Centre, Wiley Online Library on [14/05/2025]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
106 BETZ ET AL.

a work prepared by a military Service member or employee 5. Williams FC, Hammer DA, Wentland TR, Kim RY. Immediate teeth in
of the U.S. Government as part of that person’s official fibulas: planning and digital workflow with point-of-care 3D printing. J
Oral Maxillofac Surg 2020;78(8):1320-27.
duties.
6. Qaisi M, Kolodney H, Swedenburg G, Chandran R, Caloss R. Fibula
jaw in a day: State of the art in maxillofacial reconstruction. J Oral
Maxillofac Surg 2016;74(6):1284.e1-1284.e15.
ORCID
7. Swennen GRJ, Barth E-L, Eulzer C, Schutyser F. The use of a new 3D
Sasha J. Betz DDS, MS https://orcid.org/0000-0001-6041- splint and double CT scan procedure to obtain an accurate anatomic
8474 virtual augmented model of the skull. Int J Oral Maxillofac Surg
2007;36(2):146-52. https://doi.org/10.1016/j.ijom.2006.09.019
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