[Large cementoma associated with cyst and its immediate reconstruction following resection of the lower jaw (author's transl)].
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A part of the people who need prosthetic treatment in the maxillofacial area are in the stage of after-surgical operation of tumors. One of the most commonly discovered defects in the mandible is the lateral resection with exarticulation. Our goal is to examine the possibilities of achieving optimal prosthetic restoration of the patients with lateral resection and exarticulation of the mandible through clinical application and combination of the modern technology and supportive-retentioned elements.
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A retrospective study of 68 patients was carried out to assess the complications arising from the use of reconstruction plates in the maintainance of space and contour following mandibular segmental resection. Skin or mucosal perforation, plate fracture and loss of screw retention were the main complications. The most susceptible sites to screw loosening in the plates were situated nearest to and farthest from the resection margin on the proximal residual segments. Some of the possible causative biomechanical mechanisms of plate failure were studied using photoelastic models simulating the types of mandibular defect and plate fixation. Isochromatic fringe analysis was used to analyse stress lines in the bone surrounding screws. It was found that, during functional loading, moment and shear forces produced high concentrations of squeeze and press stress in this bone, causing bone resorption with consequent loss of screw retention.
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A 3-year-old white girl was seen because of an enlarging mass in the left side of the mandible. The mass was 10 cm in diameter and the entire left hemimandible was involved. Examination of tissue after incisional biopsy showed desmoplastic fibroma. Surgical removal of the tumor required a hemimandibulectomy. The mandible was replaced immediately with a stainless steel mesh prosthesis with an acrylic condyle. A year later, there was no evidence of recurrence. Though the mesh became exposed in one area, we believe that esthetics and function were best served by its use.
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The mandibular reconstruction plate can be improved by constructing a shaped acrylic spacer secured with self-tapping screws. It is removed to leave space for bone grafting.
Prosthetic aids in resections of the middle piece of the mandible. The authors describe a prosthesis which is inserted during the resection of the middle piece of the mandible. Due to its construction it prevents the soft tissues of the floor of the mouth from sinking back. Such a prosthesis has been used in 18 cases. Respiratory complications did not occur; no tracheotomy was necessary. During the postoperative phase, the prosthesis came up to expectations, but it could not prevent cicatricial contraction in the operating area. Occlusion-conformable positioning of the fragments will be achieved only it the remaining teeth are suited for function-stable prosthetic care. Consequently, secondary osteoplasty should not be abandoned.
OBJECTIVE: The purpose of this study was to locate the mandibular canal in relation to the impacted mandibular third molar by conventional cross-sectional tomography. METHOD AND MATERIALS: Conventional axially corrected cross-sectional tomograms of 347 successive impacted mandibular third molars of 234 patients referred for removal of the impacted teeth were acquired with a Scanora x-ray unit. The images were assessed for location of the mandibular canal and the impacted mandibular third molar. Descriptive analysis was performed. RESULTS: Examination of the tomograms revealed the alveolar nerve to have, in relation to the mandibular third molar, a lateral (buccal) course in 53.6% (n = 186), a course between the roots in 26.8% (n = 93), a lingual course in 13.0% (n = 45), and an inferior course in 6.0% (n = 21). Supplementary canals were found in 6.3% (n = 22). Two of the tomograms (0.6%) could not be evaluated, in 1 case because of incorrect patient positioning, resulting in an incorrectly adjusted transverse cut, and in the other case because of a mandibular carcinoma. CONCLUSION: Conventional axially corrected cross-sectional tomograms offer additional information in cases where there is a close relationship between impacted third molars and the alveolar nerve (superimposition of the roots and the canal, grooving, or a varied direction of the canal on the panoramic radiograph) and may contribute to a higher level of intrasurgical safety.
Nerve repositioning is a viable alternative for patients with an atrophic edentulous posterior mandible. Patients, however, should be informed of the potential risks of neurosensory disturbance. Documentation of the patient's baseline neurosensory function should be performed with a two-point discrimination test or directional brush stroke test preoperatively and postoperatively. Recovery of nerve function should be expected in 3 to 6 months. The potential for mandibular fracture when combining nerve repositioning with implant placement also should be discussed with the patient. This can be avoided by minimizing the amount of buccal cortical plate removal during localization of the nerve and maintaining the integrity of the inferior cortex of the mandible. Additionally, avoid overseating the implant, thus avoiding stress along the inferior border of the mandible. The procedure does allow for the placement of longer implants, which should improve implant longevity. Patients undergoing this procedure have expressed overall satisfaction with the results. Nerve repositioning also can be used to preserve the inferior alveolar nerve during resection of benign tumors or cysts of the mandible. This procedure allows the surgeon to maintain nerve function in situations in which the nerve would otherwise have to be resected.
Reconstruction of a particular defect is an highly complex problem, that is reflected in the number and variety of techniques proposed. This is particularly true for reconstruction of mandibular segment defects usually together with the need to repair oro-pharnygeal soft tissues defects of various size. The high rate of successes that can be obtained today using microvascular reconstruction techniques explains the reason why bone free flaps have progressively become the "gold standard" used as benchmark for all other forms of primary mandibular reconstruction. However, for selected patients (elderly patients or individuals in poor general health; the presence of lateral oro-mandibular defects or soft tissue defects significantly exceeding the bone defect) the association of non-osseous microvascular free flaps (such as forearm skin flaps or miocutaneous free flaps of the abdominal rectus muscle) with a titanium mandibular reconstruction plate (THORP) can prove a valid alternative. Indeed, in these cases reconstruction of choice would be the association of two free flaps, one osseous and the other non osseous. The use of THORP-type mandibular reconstruction plates in repairing lateral defects increases the overall risk of complications related to the reconstruction technique which is already hindered by the risks associated with the use of microvascular free flaps. The present work starts with a retrospective evaluation of 5 years series of primary mandibular reconstruction for lateral oro-mandibular defects following oncological surgery. The role of THORP-type titanium mandibular plates, used in combination with non-osseous free flaps in the treatment of selected patients, is then described and discussed.