Use of waxing screws for accurate primary placement of endosteal implants in the vascularized fibular bone-reconstructed mandible.
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The use of an alloplastic implant to fill the defect after resection of the central part of the mandible is described. This procedure makes the post-operative course more acceptable for the patient, and facilitates later reconstruction by a free bone graft in the absence of recurrence.
BACKGROUND: The development of endosseous implants and free vascularized bone grafting has permitted increased possibilities of oromandibular reconstruction in patients with oral cancer. In this study, a concept combining surgical and prosthodontic treatments for mandibular fibula free flap reconstruction after tumor surgery was made based on a classification of bone defects. A follow-up study was performed to evaluate the treatment concept for oral rehabilitation in order to identify possible factors which may influence the functional result. MATERIAL AND METHODS: A follow-up examination included 28 patients who underwent the ablative tumor surgery and mandibular reconstruction during a 4-year period. The follow-up protocol included clinical examination, radiological evaluation, and an interview using a standardized questionnaire. The timing of the study was set to allow for a minimum 2-year follow-up (mean 45 months). RESULTS AND CONCLUSION: At the time of examination, prosthesis-based oral rehabilitation was completed in six patients (21%), and the prosthodontic work was still unfinished in four other patients. The other 18 had no dental prosthetic rehabilitation. Thirteen patients received a total of 37 oral implants, and 23 implants were functionally loaded. No implant loss was recorded. Oral functions such as speech, diet tolerance and oral competence were not directly affected by the presence of dentures. A decisive factor affecting the oral function was the extent of soft-tissue loss. According to the classification described here, the extent of the mandibular defect did not correlate with oral functions. The application of oral implants seemed to be advantageous for the oral rehabilitation of patients who had undergone intraoral resections.
OBJECTIVE: Malignant epithelial tumours arising in the jaws are very rare. Adenoid cystic carcinoma (ACC) represents approximately 7.5% of all carcinomas and only a few cases of intraosseous (central) ACC have been reported in the literature. MATERIALS: The salient clinico-pathological features of a case of ACC, bilaterally occurring in the mandible of a young caucasian woman who also had lung metastases are reported to appropriately characterize such unusual lesions and discriminate them from other tumours that more commonly affect the mandible. RESULTS: The patient presented with a painful swelling of the right retro-molar area and paraesthesia of the ipsilateral lower lip and radiological investigations disclosed bilateral radiolucent lesions of the mandible with unequivocal signs of malignancy but without intra-lesional calcifications or association with teeth roots or cystic component. Conventional histological examination disclosed typical ACC with solid and cribriform growth patterns and extensive infiltration of the adjacent tissues. CONCLUSIONS: The diagnosis of intraosseous malignant salivary gland type neoplasms is very difficult in view of their rarity and lack of specific signs and mainly achieved after histological examination and complete clinico-radiological work up. As surgical treatment of the patient was not indicated, due to extensive neoplastic disease, the patient is being controlled with multimodal treatment, including chemo- and radiotherapy and is alive with persistent disease 3 years after the original diagnosis.
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Approximately 2% of chondromyxoid fibromas of bone present in the jaws, preponderantly in the mandible, where they must be distinguished from low-grade chondrosarcomas. A recurrence rate of 25% dictates careful complete removal of this histologically benign lesion.
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We present a patient in whom unexpectedly late sensory recovery occurred over 5 years after removal of a 3-cm piece of the right inferior alveolar nerve (IAN) in tumor surgery of the mandible. For a year after surgery, the distribution of the mental nerve, the terminal branch of the IAN, was totally anesthetic. Thereafter, a gradual subjective sensory recovery occurred centripetally from the surrounding skin distributions. Five years after surgery, findings in electrophysiologic tests were consistent with a total lesion of the right IAN. Two years later, electrophysiologic tests gave, for the first time in humans, objective evidence for sensory collateral sprouting in trigeminal distribution.
A study was performed to determine if patients who underwent mandibular reconstruction were functionally rehabilitated. Five parameters were evaluated: deglutition, mastication, cosmesis, diet, and the use of dentures. Deglutition was not improved in patients who had mandibular continuity restored. Problems with deglutition were related to soft tissue resection. Mastication was poorer in the reconstructed group due to scarring, loss of the muscles of mastication, and inhibition of compensatory mandibular motion. Cosmesis was improved in patients who had immediate restoration of mandibular continuity. Cosmesis was not improved in patients with delayed mandibular reconstruction due to previous scarring. Prosthetic rehabilitation was poor in both groups of patients. Reconstructed patients had a greater number of hospitalizations due to management of, or complications from reconstructive surgical procedures. The results of this study suggests that restoration of mandibular continuity does not enhance the functional rehabilitation of the majority of patients with oral-pharyngeal malignancy.
The combination of a myocutaneous flap or free cutaneous tissue transfer with a three-dimensional bendable reconstruction plate either of stainless steel or titanium has provided very satisfactory results in primary restoration of mandibular defects following surgical resections in irradiated patients or in those who require postoperative radiotherapy. Sixty-four cases have been treated and evaluated prospectively using this technique. Fifty-three of the patients had the soft-tissue defect restored with a myocutaneous flap, 8 had a free cutaneous tissue flap, 2 were reconstructed with tongue flaps, and 1 closed primarily. The stainless steel plate of the A.O. type was used in 53 cases and the titanium plate system and hollow screws in the other 11 cases. A success rate of 78.9% was found with a median follow-up of 384 days. Thirty of the 64 cases had preoperative irradiation and 15 were treated postoperatively. A plate failure rate of 23% was encountered in those treated with preoperative irradiation and in 20% with those having postoperative irradiation. Forty-nine of the 64 patients or 76.5% experienced no perioperative complications. Five or 7.8% of the complications were minor. Ten patients or 15.6% experienced a major complication with one death due to a myocardial infarct. A radiation dosimetric model was employed using both stainless steel and titanium. The results from this study showed that, when using a parallel pair of beams, an excess dose of irradiation for the lowest energy cobalt-60 is 13%, for 6 mV it is 15%, and for 18 mV it is 20%. The excess tissue dose, both for stainless steel and titanium plates, extends for about 0.2 mm for cobalt-60, 1.1 mm at 6 mV, and for 25 mm at 18 mV. Patients with plates, therefore, can be treated safely with postoperative irradiation using either cobalt-60 or 6-mV energy.
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A case of undifferentiated carcinoma arising in the minor salivary gland is reported. Preoperative chemotherapy, surgery and postoperative immunotherapy were performed and good results were obtained for 15 months after surgery. However, metastasis to the lung occurred 18 months after surgery. The histologic diagnosis, clinical findings and origin of this tumor are discussed.
An attempt was made to quantify the location of various oral lesions using panoramic radiographs of benign tumors (20 ameloblastomas, 5 myxomas, 26 odontomas, 10 cementomas and 4 osteomas). The metrical data (integers) were obtained from a conversion table and the abscissa values (to the first decimal place) were obtained from the centroid of each of the tumors. Differential diagnosis among these lesions revealed that in the mandible, it is possible to differentiate between ameloblastomas and odontomas or osteomas. Thus, the present findings demonstrate that data on lesion location can be changed into metrical data for differential diagnosis of benign tumors.
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