Most honorable presidents, Dr. Morgan, Prof. Mauro, worthy and most commendable colleagues, ladies and gentlemen, my name is Drago Jelovac. On behalf of our head and neck, surgery of the head and neck. I’m addressing here today with a topic, simultaneous implant placement with the free flaps as a surgical technique, drawings from innovation to clinical practice. So this is the Fortress of Belgrade known as Belgrade Fortress and it is essential to establish which side of the gate you are. It is one of the most significant cultural sites in the city offering insights into tumultuous history and strategic importance. So I would like to speak about free flaps and simultaneous implant placement and the importance of medical drawings, something maybe what is a little bit forgotten in the new era and to give some case presentation with surgical techniques and videos. So, free flap surgery is considered one of the most complex procedure in medicine. It is a technically very challenging procedure and each step of that long lasting procedure is time dependent and requires meticulous preparation, meticulous execution of each unique step. So, to provide the progress to the next level, in this surgical armamentarium, we have added one more level which makes the whole, if I may say, more tangled. That’s the Bicon implant insertion. So all of these semantically presented donor regions, fibula, iliac bone or scapula within well known free flap raising traditional techniques have been enriched with simultaneous implant placement either in the donor region or at the table. I got the questions yesterday where we put, what is the time. Usually we put at the donor region and the pedicle after the pedicle has been divided before the insert of the flap in the oral cavity. This very complex and precise procedure requires to be successful, very detailed, comprehensive preoperative planning supported with an in house three d printed lab. So some cases in our daily practice may require mandibular or you can see maxillary resection, a procedure that has many adverse effects such as facial disfigurement, aesthetic impairment, etc. Affect the patient quality of life and the rehabilitation of these patients presents a challenge for a whole team and I would like here to emphasize some of our virtual planning biomodels. And through the lecture, all of these gadgets are going to be presented. It is important to mention that all of these guides are made of biocompatible materials which could be autoclaved in order to prevent any chance of perioperative infection. So this is the first case I would like to present with you today. It is the post traumatic defect due to osteomyelitis and that was the case thirteen years after a car accident. And the lady got the defect at the right mandibular body as you can see here, the right mandibular body. And we planned the mandibular reduction, vessel harvesting secondary reconstruction with a free flap and immediate implant. This is the first place where we put implant immediately. So you’re going to see here the preoperative CT, preoperative panoramic, X-ray showing segmental defect. And then on the left, you’re going to see virtually preoperative planning with the reduction of mandibular ramus, condyle and synthesis. So now, the first guide here is presented. We called it three in one. So it is in the same time reconstruction guide, condyle position guide and guide for mandibular resection. And of course, in the same stage as it is same stage procedure, we got guides in the fibular bone like graft cutting guides presenting in the right in the orange color and implant templates. So here, can you play this video? The video presented would present, but should present the the technique of implant placement in the fibula with the graft. You can see the graft cutting guides and implant templates. And maybe the second one is going to work. Yes. You you you will see the positioning of the Bicon implants, opening of the perioste, and stitching of the perioste, neo perioste in order to provide a a good closure and a good neo gingiva, keratinized, the neo gingiva for this patient. This was very hard. This was very first patient of us before and after surgery with four Bicon implants placed and the work which was under final prosthetic work. And the second case, we planned together seventy years old ladies who has referred to us with cemento ossifying fibroma of the mandible with no comorbidities and she complained to the numbness in the region of the inferior alveolar nerve and the severe pain. So resection plan was one centimeter free tumor margins together with Professor. Planned virtually after our last meeting in Rome. We decided to go in more detail in order to provide and to predict the predictable placement of the implant at the proper position. And you will see this is the preoperative CBCT. And we did intraoral scanning with Medit and performed in order to have a occlusal relation digitally preoperatively. And here you can see our guide. It is guide we called five in one. So it is guide in the yellow color, you can see. Is guide enables tumor resection according to the preplan. Also, it keeps mandible in the stable position during positioning, flap inset and flap fixation. So also it is mandibular reduction guide and it enable plating of mini plates as we also left to place within this guide. And this is dually made because it is made by intraoral scanning and together with pre operative CBCT. So with this kind of guides, you can see the superimposition of the tumor at the left side, existing thick lower jaw and the DCIA graft. And our first idea was to put the implant in central fissure of the existing teeth, but it was not, you can see here, it is at the edge of the flap. We decided and here I would like to highlight that implant would be placed medially close to graft borders. In order to be more precise, we decided to move the initial point a few millimeters laterally in the projection of the buccal cuspid of the existing second molar and after virtual removal of the tumor and segmental mandiblectomy, we got a better alignment of the virtual implant within the middle of the DCIA flap. So here is highlighted the pre operative determination of the initial point of the second virtual Bicon implant. So you see here and now I would like to present the video here where we put everything together. I hope it works. So you can see all guides we used at the donor region. So usually we place the implants at donor region. And you can see the biomodel, resected biomodel. You see the resected tumor virtually. And you see the bar which connects to ramus opposite. It is important as it is resected mandible at the donor site. Also, have to respect the pedicle, the blood vessels, the deep circumflex iliac artery. And I would like to highlight and to stress the importance of protecting the pedicle from the stretching as the stretching of pedicle could cause microthrombosis which could lead to flap failure. So there are a lot of details we have to incorporate together in order to be successful at the end. And here is presented, this is our start of medical drawing. This is the combination of three d technology, the muscles. Also, we added the muscles and we drew this external iliac artery and deep circumflex artery and iliacus muscle. So we are of course going to precisely describe our technique in detail which we’re going to see later on with maxillary case. So this is in live model. This is how it looks after the resection of the tumor. This is the patient I show and this is the implant template. And you will see that as I saw from yesterday, Laura mentioned that we used just implant template. It is enough to use for initial drilling. Two T for initial drill. And that’s enough. After that, we could place Bicon. So the position according to our detailed preplan. So you can see that it is in the perfused flap. So the artery has not been clamped yet, and we we did everything to be on the safe side regarding the stretching of the pedicle with preserving a little bit of fascia of external external oblique muscle of the abdomen, one of the muscle, and a little bit of inguinal ligament. So we made a double check here with the you can see the resected tumor and the implant with the donor and always use the sinus lift abutments, particularly in fibula, as the fibula got a specific bone. So how to protect the implant go much more deep. So you can see also as we pre planned according to plan with Paolo and the rest of the team because we would like to have a TRINIA as definitive prosthodontic work. According to plan, we left ten millimeters plus three millimeters for neo gingiva. So we have to calculate everything in soft and hard tissue and the position and the proper position of the graft. And this is what we got. So you can see the position of the bony position of the implants and the graft. It was performed just seven days after the surgery. And it is our last case where we put immediate implants. This slide presents her OPG three months following the surgery. And you can see the perfect functional result and aesthetical as well. So, I would like to remind you that she got preoperatively very deep bite and this is her clinical appearance. And you remember the slide where we planned and we got there was slight eruption of the upper teeth in the meantime and prosthodontist would perform some endocrowns to make enough space. But it is our intraoral view six months after the surgery and intraoral view after the surgery. Just a few weeks ago, I put healing caps. So the medical drawings belongs from the history to Ernst Haeckel who tried to describe some microorganisms and ascidia and then John Hunter made several important contributions to surgical practice through close observation and experimentation to inform the surgical. The medical drawings have artistic and professional aspects and through artistic skills, we could follow medicine deeply. So I would like to also mention one picture of Théodore Géricault, Le Radeau de la Méduse, which is exhibited in the Louvre and contains the visages of people who actually were mental patients, alcoholics, pedophiles, women with obsessive mania, etc. And he caught the visual characteristics more precisely than any textual or verbal attempt to describe it would have achieved. So as I presented yesterday, and just to remind about the virtual resection we performed for the scapula and now to explain with medical drawings presented here to be clear what we have performed as we can understand each other if we are speaking with the drawings. And you can see here the scapula, the scapula tip. I got questions. What part of scapula we have been used? The scapula tip. It has been used before, but nobody did the implants in the scapula tip in the same stage procedure. And we did cadaveric study. We we ensured that it could be safe and we described, you can see the cutting of subscapularis muscle and then placing Bicon implants as the the quality of bone was enough to support Bicon implant stitching of subscapularis muscle and then transfer transfer into the oral cavity. You see the resection plan and the one teeth here. So also you can see the horizontal or sagittal view of the defect. And we also published this paper. This is here presented the stitching and enabling proper healing and oropharyngeal oropharyngeal edge. So you already see these slides. And today, I would like just to mention the drawings. You saw this patient yesterday. So we will recognize that through our through our 3D printing lab among others very recognize the center to the Europe and the world. And also, our protocols seems it seems that protocol is very safe, that simultaneous short implant placement within donor regions. And also it could be very feasible for the patients who are planned for post operative radiotherapy as we expect that implants will be also integrated before the onset of radiotherapy. So we also tend to decrease the number of surgical procedure. And I would like to end with some sentence that knowledge can be bought but skills cannot. Also, Asclepius wrote that every stick has two ends that only this one ends for the beginning. And we have almost enough elements that give us insight into the mechanism of this medical field. What is that ultimately makes the difference? That is what we could do and did. That is what we know so far and that is exactly the problem. There the doctor feels like Caesar in front of Rubicon. What is ahead can be salvation or disaster. So when we know we could prevent, when we don’t know what is the key fact, what makes the difference, then the biggest part of our works come to the alea iacta est. So we do something and wait to see the result. Thank you very much for your kind attention.
