Hollings clinicians perform Jaw in a Day procedure on head and neck cancer survivor

Our teeth are working for us every second of the day. They chew food, of course, but they also give shape to our faces and help us to pronounce words correctly.

Losing a section of teeth is profoundly life-altering. For those who’ve survived cancer, it’s an additional blow while trying to regain a sense of normalcy.

But a multidisciplinary team at MUSC Hollings Cancer Center, the only National Cancer Institute-designated cancer center in the state, is now offering a Jaw in a Day procedure to people with a cancer history. This surgery, which builds upon an already highly complex surgery to remove the jawbone and then transplant a bone from the leg to create a new jawbone, now enables patients to wake up with a full set of teeth.

MUSC previously provided this procedure to people with benign tumors. However, for people affected by head and neck cancer, whose treatment can often involve removing the jawbone either as part of cancer treatment or due to side effects from radiation therapy, options were more limited until now. Recently, the multidisciplinary head and neck oncology team performed the first successful case at MUSC, and possibly the state, on someone with head and neck cancer.

“That someone's had a life-altering cancer treatment and we can fix a devastating side effect of treatment and give them back the shape of their face and their teeth – and do it in a way that’s timely so they leave the OR that day with a set of smiling teeth instead of waiting maybe nine months between surgeries, which is a long time to go with missing teeth – is important for cancer survivors,” said Evan Graboyes, M.D., a head and neck cancer surgeon who was part of the team performing the surgery.

 

As director of the Survivorship and Cancer Outcomes Research (SCOR) program at Hollings, Graboyes is also keenly aware of the long-term challenges that cancer survivors can face and the need to develop new treatments to address side effects that can linger or even appear years after cancer treatment.

That was the situation for Tammy Duncan, the recipient of the Jaw in a Day procedure, who was successfully treated for cancer more than a decade ago.

Osteoradionecrosis – an uncommon side effect

Duncan, who lives in Greenville, was diagnosed with adenoid cystic carcinoma, a rare cancer that develops in the salivary glands, in 2012 after she asked her doctor to look at something that felt odd.

Her doctor thought it was most likely an inflamed gland but suggested they remove her left submandibular gland, just below the jawbone, to be sure. Once removed, it became clear that it was cancerous.

The doctor hadn’t been able to get clear margins – meaning there were still some cancer cells on the edges when pathologists looked at the tumor under a microscope. Because of the location of the tumor, more surgery wasn’t an option, so Duncan was referred to radiation therapy for further treatment.

“And I remember the radiation oncologist told me when they were setting me up for radiation, ‘I've got one shot to cure this.’ And so I think I got a pretty heavy dose,” Duncan said.

It worked.

But more than a decade later, in 2023, Duncan began having awful pain in her jaw.

She visited the dentist and then a series of different specialists as clinicians tried to pinpoint and treat the source of the pain. An infectious disease doctor thought it might be osteomyelitis, a bone infection, but when antibiotics failed to work, the doctor raised the possibility of necrosis – dead bone tissue.

At the same time, though, Duncan was caring for her husband in his last months. With her focus on him, she set her own needs aside.

“I did put off a few things until it got to be that very sharp, stabbing pain,” she said. “Finally, I said, ‘There is something wrong still – it just feels like I get shot in the jaw occasionally with pain. It’s so sharp I scream out, almost.’”

 

Finally, a scan revealed a fracture in her jawbone.

Duncan was suffering from osteoradionecrosis, or dead bone caused by radiation therapy. It's a side effect of radiation therapy for head and neck cancer that affects about 5 to 10% of patients.

Osteoradionecrosis might take years to show symptoms. As the bone dies, it weakens, which led to the fracture in Duncan’s jaw. And because it is no longer living tissue, it can’t heal in the way that broken bones usually do.

Much like cancer, osteoradionecrosis can spread, so it’s important to remove the dead bone.

A local surgeon performed two procedures in hopes of clearing out the dead bone, promoting healing and helping Duncan to avoid major surgery. But the osteoradionecrosis was too far along. The surgeon referred her to MUSC.

Jaw in a Day

As it happened, the head and neck cancer team at Hollings had been waiting for a patient who could benefit from a Jaw in a Day.

Graboyes, head and neck cancer surgeon W. Greer Albergotti, M.D., and maxillofacial prosthodontist Byung Joo Lee, D.D.S., had traveled together to Dallas for specialized training in the procedure.

The team regularly performs surgeries that send people out of the operating room with a newly transplanted bone and implants – the screws inside the bone that will hold the teeth.

“That's standard of care and commonly performed at large academic head and neck practices and NCI-designated cancer centers,” Graboyes said.

Surgeons take a piece of the fibula, the smaller bone in the lower half of the leg, and create a jawbone to replace the dead bone.

“Jaw in a Day is really the last piece of the puzzle, which is being able to put teeth on the implant the same day,” Albergotti said.

 

“I think this will ultimately become a standard of care for these types of surgeries,” Albergotti continued. “When I was in residency 10 years ago, we didn’t put implants in any fibulas. Now, for the vast majority, we put implants in. I think in the future, the vast majority of people will have teeth coming out of surgery.”

Jaw in a Day has been performed before at MUSC, but for a younger patient with a benign tumor.

A patient with a history of cancer is an entirely different proposition. First, Albergotti said, there’s always the possibility that doctors will spot a cancer recurrence once they begin the surgery.

“For about 10% of patients, we will be surprised and find cancer at the time of surgery,” he said.

Second, the previous cancer and cancer treatment means that the anatomy has changed. Osteoradionecrosis can progress, or spread, and sometimes as doctors begin to cut into the bone they discover more dead or dying spots than were visible on scans.

“There’s risk for having to take more than what we were expecting. A benign tumor is very predictable. You can take a 5 millimeter margin and be very confident in your margins. That’s not necessarily the case for radionecrosis. There’s a level of unpredictability with it,” Albergotti said.

In Duncan’s case, the previous attempt at fixing the problem meant that she already had a titanium plate in her jaw. And because of the fracture, her teeth were out of alignment with each other.

The Hollings team needed to cut out the dead bone, cut out a piece of her fibula, shape it to perfectly recreate her facial structure, insert the implants into the fibula, connect the new teeth to the implants and then transplant the newly created jawbone into her mouth, fitting it exactly into the space and ensuring her teeth and jaw were in alignment.

“Every millimeter matters,” Lee said.

A team effort

“You have to work together as a team. One or two surgeons alone can’t pull this off. And everyone has to trust each other, too,” Lee said.

“I tell the patient, in the year 2024, this is what's possible. But it's only possible if every portion of the surgery and all these variables are perfect,” he added.

Virtual surgical planning is the most important part of this surgery. The team uses CT and intraoral scans of the patient’s mouth and 3-D modeling to plan exactly where they’ll make cuts and insert the implants.

 

“Even if it's a millimeter off, that's enough to derail the potential reconstruction,” Albergotti said.

Lee and senior maxillofacial lab technician Matthew Gilliland work together to craft custom teeth ahead of the surgery in-house using the latest technology.

During the surgery, the team uses cutting guides developed during the planning process to ensure they don’t deviate from the plan.

Once Graboyes cut the section of fibula, he shaped it to fit into the gap in Duncan’s jawbone. Because the fibula is more or less a straight line, whereas the jawbone is curved, surgeons cut it at angles to fit it in. They may have to use two or three sections, depending on how much jawbone needs to be replaced, much as one might use multiple Lego bricks, attached in an octagonal fashion, to replicate a circle.

While the fibula was still connected to a blood supply from the leg, Lee placed the implants into the fibula. Then, the shaping of the fibula was finished, and teeth were connected to the implants. The new structure was then connected to a blood supply in the jaw and a new titanium plate was added to hold it together until the old and new bones fuse together.

 

After 10 hours in the operating room, Duncan was wheeled out with a full set of teeth.

“It was amazing. They told me they might put the teeth in during surgery, on the bone, but they didn’t know. So the first thing when I opened my eyes – it was my brother and my friend who said, ‘They were able to get the teeth in.’ And so when they said they did it, I reached my hand in and I felt those little teeth. That’s so cool that he was able to do it,” she said.

Graboyes cautioned that Duncan’s teeth should be considered “smiling” teeth, not “chewing” teeth for now. The bone needs time to grow into place so that it can support the force of chewing. But it’s important to be able to offer patients the option to go home with teeth rather than having to return many months later for follow-up surgery, Albergotti said.

“Humans are very adaptable. Most people learn to accept the new normal and are OK with most things. I think part of our job as physicians is to see what could be and try to maximize what people can get out of their reconstruction even if they would potentially be happy with less.”

W. Greer Albergotti, M.D.

Obviously, being cancer-free is the most important thing. But “being as close to the best version of themselves as possible coming out of surgery,” Albergotti said, is also important.

“There's also the concept of treatment fatigue,” Albergotti said. “The more people have to do, the more steps to the process, the less likely they are to actually complete the process. So the more that we can do in a single day makes it more likely that, No. 1, the patient can have an immediate good cosmetic outcome and then, No. 2, better long-term functional outcome and actually follow through with the plan of treatment rather than stopping halfway and saying, ‘You know, I've been through a lot and I've run out of energy to go through this last step.’”

“Humans are very adaptable,” he added. “Most people learn to accept the new normal and are OK with most things. I think part of our job as physicians is to see what could be and try to maximize what people can get out of their reconstruction even if they would potentially be happy with less.”

For Duncan, after mourning her husband Danny’s death last fall and then dealing with the pain and uncertainty in her jaw, her new teeth mark the beginning a new chapter in her life. She’s come to realize, she said, that he would want her to enjoy life again.

“Danny would want me to live. He wouldn’t want me to sit at home and die of a broken heart.”

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