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Results for “Mandibular Reconstruction”

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PubMed1989

Rigid internal fixation and vascularized bone grafting in mandibular reconstruction.

The technique of mandibular reconstruction utilizing rigid internal fixation and vascularized bone grafts has been described. This type of repair should be considered in all patients undergoing mandibular resection for head and neck malignancies. Although no ideal method of reconstruction has yet been described, it appears that rigid internal fixation combined with vascularized bone grafts most satisfactorily fulfills the requirements associated with reconstruction of jaw defects.

Aged↗

PubMed1990

Major mandibular reconstruction with vascularized bone graft.

Mandibular reconstruction is one of the most challenging fields in plastic and reconstructive surgery. Deficiencies of the mandible occur in congenital anomalies, trauma, oral and mandibular neoplasms and osteoradionecrosis. Conventional reconstructive aids like bone grafting or insertion of a metallic implant often fail in such situations due to poor local blood supply, deficient oral lining, inadequate skin coverage, large mandibular defects, irradiated fields or infected wounds. A free vascularized bone graft of a osteocutaneous flap overcomes the incompetence of conventional mandible reconstruction. It offers not only a desirable length of vascularized bone, but also has an adequate skin lining for oral mucosa and external tissue deficiencies, as well as a "sandwich reconstruction" for the mandible. The results are usually satisfactory in terms of function and aesthetics. Experience in 8 cases with iliac and scapular osteocutaneous free flaps are presented and discussed in this report. We conclude that a vascularized bone graft, especially the iliac crest, provides reliable and contented results for major mandibular reconstruction.

Adult↗

PubMed2001

Aesthetically successful mandibular reconstruction with a single reconstruction plate.

Aesthetically successful mandibular reconstruction can be performed with free fibular flaps and with a single low-profile reconstruction plate. The keys to aesthetic success are accurate bending of the reconstruction plate, accurate alignment of the bone, and maintenance of the lower border of the mandible. If only the mandible and overlying oral lining are missing, the results can be indistinguishable from normal. In massive defects that include other structures besides the mandible, however, excellent aesthetic results can be difficult or impossible. Massive soft tissue deficits and heavy doses of postoperative radiation therapy can impact severely the aesthetic quality of the result. Patients should be aware of these limitations and have appropriately realistic expectations.

Bone Plates↗

PubMed2006

Adaquate fixation of plates for stability during mandibular reconstruction.

PURPOSE: To determine the most appropriate plate fixation for dispersing the stress around screws in mandibular reconstruction. MATERIAL AND METHODS: Forty-eight three-dimensional reconstructed mandibular models with Central (C) or right Lateral (L) defects were created and divided into three groups, fixed with: (1) two screws on each side, (2) three screws on the left side with the third (middle one) located distally, or (3) three screws on the left side with the third (middle one) located proximally. A 300N vertical load was applied to the left molar region. The maximum stress was calculated using a finite element method and statistically evaluated. RESULTS: Stress was concentrated around the screw at the distal end of the mandibular halves on the loaded side ('crucial screw'). For the C defect, stress concentrated around the 'crucial screw' was greater when there were only two screws for fixation (20.55MPa) than when there were three screws (16.17MPa; p=0.022). No significant difference was found between the two groups with three screws for fixation. For the L defect on the other hand, stress on the 'crucial screw' was relatively greater when there were three screws for fixation (18.9MPa) than when there were only two screws for (12.83MPa; p=0.051). No significant difference was found between the two groups with three screws for fixation. As for the reconstruction plate, the stresses on the plates were not different among the various screw groups for fixation nor among the C and L defects. CONCLUSION: This paradoxical result is explained by plate bowing. Thus in large defects screw positions should take into consideration the potential for plate bowing.

Bite Force↗

PubMed2005

[Evaluation of rigid internal fixation in mandibular reconstruction with autogenous bone].

OBJECTIVE: To investigate the application of rigid internal fixation in mandibular reconstruction with autogenous bone and to evaluate its efficacy. METHODS: From January 1994 to May 2004, 98 patients with mandibular defect received mandibular reconstruction with autogenous bone by using rigid internal fixation. Seventy-two cases of benign tumor and 26 cases of malignant tumor were included. Four hundred and ono rigid fixation plates were inserted. The clinical results and X-ray films were analyzed and the healing processes were evaluated. The functional and aesthetic results of the mandibular reconstruction were also evaluated according to Lopez assessment system. RESULTS: After a follow-up of 1 to 3 years, 95 patients (96.9%)achieved successful effect. The forms and function of the mandibles were resumed. Eighty-one (82.7%) patients were satisfied with the results of operations. Thirteen patients (13.3%) achieved acceptable results. Four patients (4.1%) were dissatisfied with the results of operations. CONCLUSION: The rigid internal fixation is conductive to healing and remodeling of the transplant bone in mandibular reconstruction.

Adolescent↗

PubMed2001

[Postoperative monitoring of free fibular grafts by dynamic magnetic resonance imaging. Preliminary results in three cases of mandibular reconstruction].

The vascularized free fibular graft has been used in mandibular reconstructive surgery since 1975. This technique has been progressively developed, and it is now the procedure of choice for mandibular reconstruction although in certain postoperative circumstances it can be difficult if not impossible to monitor bone vitality. However, bone vascularization can be detected by dynamic magnetic resonance imaging (MRI), as this technique has been experimentally and clinically validated in the early diagnosis of osteonecrosis. The aim of this study was to evaluate the efficacy of MRI for the postoperative monitoring of vascularized free fibular grafts in human mandibular reconstruction. Dynamic contrast-enhanced MRI was used to study the variation in contrast over time following injection of gadolinium contrast medium, and to evaluate the degree of bone marrow perfusion of the fibular graft. This variation in signal intensity was visualized in the form of a curve, i.e., a perfusion curve for the bone marrow region. An examination was performed in three patients at different postoperative times and under different conditions. In one case, MRI confirmed the presence of fibula blood supply in spite of the necrosis of the adjacent fascio-adipose layer. In this article, the methodological difficulties have been discussed, particularly as regards data processing, and the present results have been compared with the findings in the literature. Dynamic MRI is a simple, reliable, non-invasive technique and its use in the postoperative monitoring of bone marrow perfusion and vascularized free fibular grafts permits a determination of the status of the latter following surgery, i.e., whether there is an adequate blood supply or not.

Aged↗

PubMed1995

Mandibular reconstruction using the double barrel fibular graft.

Five patients underwent mandibular reconstruction using the double barrel fibular graft from 1989 to 1994. Bony defects ranged from 7 to 14 cm. In three patients, two skin flaps were taken with the fibular graft for composite reconstruction. In order to overcome the main disadvantage of the fibular graft, i.e., small circumference of the bone, a harvested fibula was osteotomized into several portions, folded into two parallel lengths, and fixed along the inferior border of the mandible and the alveolar ridge. The double barrel fibular graft provided more than 4-cm alveolar height without damaging bone viability. In Orientals, a fibula is approximately 1.5 cm thick, and using a single fibular strut for mandibular reconstruction may result in subsequent difficulty in wearing conventional dentures or osseointegrated implants. All patients acquired good mandibular contour and enough thickness of the alveolar ridge, and could wear a conventional denture and eat a solid diet. This procedure seems to be superior to the iliac bone graft for major mandibular reconstruction because of its length, the possibility of three-dimensional composite reconstruction, increased bone thickness, and minimal donor-site morbidity.

Adolescent↗

PubMed2001

Vascularized free fibular flap for mandibular reconstruction: a report of 26 cases.

PURPOSE: Mandibular reconstruction represents a challenge to the oral and maxillofacial surgeon and has been revolutionized by the modern microvascular techniques. Rehabilitation using techniques such as reconstruction plates frequently produce a functional and cosmetic defect. The primary objective of the current study was to evaluate the usefulness of the osteomuscular free fibular flap for this purpose. PATIENTS AND METHODS: The results of 26 vascularized free fibula flaps with or without a skin paddle that were used for mandibular reconstruction is presented. The "double barrel" technique was used in 6 cases. The donor site was closed directly in 2 cases and with an abdominal full-thickness skin graft in 24 cases. RESULTS: All flaps except 1 were viable. There was partial necrosis of the skin island in 1 patient. The average length of the fibula graft was 10.96 cm, and the number of osteotomies ranged from 0 to 3. In the donor site, the most significant problem was unsatisfactory scarring related to the use of a skin graft. There were no long-term functional complications in the lower leg. Two patients have been secondarily rehabilitated with osseointegrated implants. CONCLUSION: The fibula flap provides a successful bone graft for mandibular restoration with an acceptably low complication rate. This method meets most of the requirements for oral and mandibular replacement.

Adult↗

PubMed2005

Virtual planning of composite mandibular reconstruction with free fibula bone graft.

Functional mandibular reconstruction after tumor resection is challenging. Currently, voxel-based craniofacial surgery and virtual planning of craniofacial surgical procedures are becoming increasingly popular. We report on a 56-year-old patient with an infiltrating recurrent squamous cell carcinoma of the mandible and buccal mucosa. Virtual resection of the mandible was accomplished using virtual reality techniques. Based on virtual geometric data, a metal template was configured for optimal contouration of a fibular bone graft while it was still pedicled in the donor field. Our operative procedure demonstrates the usefulness of voxel-based three-dimensional cephalometry in virtual planning of microsurgical bone transfer for mandibular reconstruction.

Bone Transplantation↗

PubMed1996

[Surgical strategy of osteocutaneous free transfer of the fibula in complex mandibular reconstructions: technical notes].

The fibula osteocutaneous free flap now has a recognized place in the therapeutic arsenal of microsurgical mandibular reconstructions. Based on a review of the literature and their own experience, the authors propose a preoperative and intraoperative strategy adapted to reconstructions of mandibular defects. The place of complementary investigations, the site of the skin flap, the choice of osteotomy, the type of fixation, and spatialisation of the skin flap are presented. They conclude on the excellent plastic and vascular qualities of the fibula flap in complex mandibular reconstructions.

Adult↗

PubMed1988

Osteocutaneous free scapular flap for one-stage mandibular reconstruction.

Developments in microvascular surgery have overcome much of the problem of inadequate vascularity encountered by more conventional methods of mandibular reconstruction. The advantage of the osteocutaneous scapular flap compared with earlier described revascularized bone grafts or composite flaps is its greater versatility in reconstruction of soft-tissue defects of the oral cavity concomitant with mandibular reconstruction. This is primarily related to the independent vascular pedicles of the cutaneous and osseous portions of the flap. This flap is our preferred method of reconstructing mandibular defects.

Adult↗

PubMed1994

[Mandibular reconstruction using a vascularized osteocutaneous scapular flap].

Composite tissue defect of the mandible following the surgical resection of head and neck neoplasma or osteoradionecrosis causes functional and cosmetic disorders. Mandibular reconstruction is, therefore, necessary to obtain satisfactory results. The introduction of microvascular surgery has made it possible to transfer various types of vascularized bone grafts and this technique is considered one of the most reliable procedures for mandibular reconstruction. Recently it has been reported that an osteocutaneous scapular flap is useful for mandibular reconstruction. We have performed, over the last 2.5 years, 13 mandibular reconstructions using a vascularized osteocutaneous scapular free flap, and successful results have been achieved. The features of this flap are as follows: 1) it provides a consistent blood supply to the bone and the skin and has a constant vascular pedicle; 2) since the skin island and bone flap have separate pedicles, three-dimensional reconstructions are facilitated; 3) if needed, two skin flaps can be elevated; 4) the skin island is not so bulky; 5) the lateral border of the scapula provides highly vascularized bone of thick cortical density and osteotomies are safely performed; 6) using an angular branch based on thracodorsal artery, a bi-pedicled scapula bone can be raised and two completely vascularized bone segments can be transferred with a single pedicle. Thus, a vascularized osteocutaneous scapular flap has proven very useful for complex mandibular reconstructions.

Adult↗

PubMed1988

Mandibular reconstruction in an irradiated field using median sternotomy and anterior rib axial graft.

Mandibular reconstruction in an irradiated field continues to be a challenge to the reconstructing surgeon. Several methods use rib grafts to bring vascularized tissue to the mandibular region. A median sternotomy provides excellent exposure to harvest the internal mammary artery and anterior axial rib graft for subsequent mandibular reconstruction. The modified technique described provides an alternative method of bringing a vascularized rib graft to an irradiated field for mandibular reconstruction avoiding multiple rib resections and microvascular anastomosis. This technique has been used in two patients who had anterior mandibular resection and irradiation therapy for advanced squamous cell carcinoma. The results from this technique were excellent and without major complications.

Graft Survival↗

PubMed1991

Use of the AO plate for immediate mandibular reconstruction in cancer patients.

Free vascularized bone grafts have revolutionized mandibular reconstruction, yet their use in all mandibulectomy patients is not always necessary. A recently developed alternative to bony reconstruction has been the use of the AO reconstruction plate. We compared the use of the AO reconstruction plate with immediate free bone graft mandibular reconstruction in 31 patients. Reconstruction plates were used in 20 and immediate free bone grafts were used in 11 patients. The overall success rate for use of the plate was 15 of 20 (75 percent). There were 6 anterior reconstructions, of which only 2 (33 percent) were successful. This is opposed to 13 of 14 (93 percent) lateral reconstructions that were successful in lateral plate placements. There were 11 immediate composite free flaps: 4 iliac crest, 4 scapula, 2 fibula, and 1 composite radial forearm flaps. Six repairs were for anterior defects, and there were 5 full-thickness defects, 3 of which were in the anterior position. All 11 flaps were successful. In conclusion, we believe the reconstruction plates are a useful adjunct for mandibular replacement in the head and neck cancer patient but should be reserved for lateral defects. For anterior reconstructions, even in patients with locally advanced disease, free-tissue transfer of composite osteocutaneous flaps is the reconstructive method of choice.

Bone Plates↗

PubMed1996

Reliability of the fibular osteocutaneous flap for mandibular reconstruction: anatomical and surgical confirmation.

There is ongoing controversy regarding the reliability of the skin island associated with the fibular osteocutaneous flap for mandibular reconstruction. Anatomical dissections and a clinical series of mandibular reconstructions using the fibular osteocutaneous flap have demonstrated unequivocally that a skin flap can be reliably harvested with the fibula based purely on the septal perforators, without needing to incorporate portions of the soleus or flexor hallucis longus muscles or to perform any intramuscular dissection or anastomosis of the muscle perforators. However, the skin island should be designed more distally over the distal third of the lower leg at the junction of the middle and distal thirds of the fibula. A fibular osteocutaneous flap was designed over the distal third of the fibula in 60 fresh cadavers, and each flap was completely isolated on the septum and all muscle perforators were ligated before dye injection. A major perforator through the soleus muscle or flexor hallucis muscle was identified in 41 of 60 dissections (67 percent) and discrete septal perforators were identified under loupe magnification in 45 dissections (75 percent). All 60 flaps demonstrated 100 percent reliable perfusion of the skin island after injection of the proximal peroneal artery with methylene blue or red latex. This anatomical study was corroborated with 100 percent survival of 34 fibular osteocutaneous flaps for mandibular reconstruction with the skin island designed over the distal third of the lower leg and based only on septal perforators without incorporating the soleus or flexor hallucis muscles. Reliability of this fibular osteocutaneous flap for mandibular reconstruction is attributed to (1) design of the skin island more distally over the distal third of the lower leg, (2) preoperative precision Doppler mapping of the perforators, and (3) design of the closing wedge osteotomies of the fibula to protect the septocutaneous perforators transversing through the posterior periosteum of the fibula.

Cadaver↗

PubMed1988

[The osteocutaneous outer arm flap. A new concept in microsurgical mandibular reconstructions].

The authors present five cases where the OCLAF technique was adapted to reconstruct large mandibular defects. Some significant advantages made us think about the possibility of the OCLAF as an acceptable alternative in that specific case. These are the ease and safety of the dissection, the respect of a bony vascularisation, a very valuable pedicle size, and a remarkable mobility of the skin paddle to the underlying bone. Of course we had to face some minor disadvantages: the microsurgical procedure, the donor site scar, the absence of cancellous bone in the transfer and the weakening of the bone shaft at the donor site. Nevertheless we think the OCLAF is to be considered whenever large mandibular defects have to be reconstructed with vascularized bone.

Adult↗

PubMed1995

Mandibular reconstruction using a titanium plate: the impact of radiation therapy on plate preservation.

PURPOSE: To evaluate the soft tissue and bone tolerance of radiation therapy (RT) in patients undergoing radical composite resection and mandibular reconstruction using a bridging titanium plate with myocutaneous flap closure. METHODS AND MATERIALS: From 1990 to 1994, 47 patients with primary or recurrent oral cavity or oropharyngeal carcinomas were treated with radical composite resection and mandibular reconstruction using a bridging titanium plate with myocutaneous flap closure. Eleven patients received no RT (no RT), 10 patients received RT greater than 10 months from the time of surgery (remote RT), and 26 patients received RT within 12 weeks of surgery (perioperative RT). The radiation dose to the reconstructed mandible ranged from 45 to 75 Gy (median 63 Gy). The effect of the titanium plate on the radiation dose was measured using film dosimetry and soft tissue and bone-equivalent materials. The median follow-up was 17 months (range: 3-50 months). RESULTS: Late complications included four patients with osteomyelitis or necrosis, two plate exposures requiring flap revision, one chronic infection, two cases of chronic pain, two fistulae, and one case of trismus and malocclusion. The crude incidence of late complications by treatment was: (a) no RT: 3 of 11 patients (27%); (b) remote RT: 2 of 10 patients (20%); and (c) perioperative RT: 9 of 26 patients (35%). One patient in the no-RT group lost the plate due to chronic pain. Five patients in the perioperative RT group also had plate loss, four due to osteomyelitis and/or necrosis, and one due to pain related to a recurrent tumor. No patients in the remote RT group had plate loss. The actuarial prosthesis preservation rate at 2 years was 88% for the no RT, 100% for the remote RT, and 57% for the perioperative RT groups (p = 0.05). Phantom dose measurements showed that for parallel opposed 6 MV photon beams, there was no significant increase in the dose proximal or distal to the plate in either a soft tissue- or bone-equivalent phantom. CONCLUSIONS: The impact of radiation therapy on plate preservation after mandibular reconstructive surgery using a titanium plate may be dependent on the timing of RT relative to surgery. Significantly more mandibular reconstruction plates were lost when the involved mandible received RT in the perioperative period than when RT was delivered beyond 10 months from surgery or when no RT was given. The use of alloplastic implants such as titanium plates in conjunction with myocutaneous flap coverage for mandibular reconstruction is attractive because it allows immediate reconstruction of the defect and promotes a good functional and cosmetic result; however, administration of perioperative RT may result in a higher plate failure rate.

Adolescent↗

PubMed2007

Maxillary and mandibular reconstruction using bicortical calvarial bone grafts: a retrospective study of 122 reconstructions in 73 patients.

BACKGROUND: Using classic maxillary and mandibular reconstruction with mandibular bone grafts or unicortical calvarial bone grafts, the authors performed 122 reconstructions in 73 patients using bicortical calvarial bone grafts and report the results in this article. Such a technique has not been previously described in the world literature. METHODS: Seventy-three patients, 55 women and 18 men, with severely atrophied maxillas or mandibles were treated with bicortical calvarial bone grafts and placement of implants over a 5-year period. Patient selection was based on the important insufficient remaining height or width of bone placement of multiple 10-mm implants and the thinness of the calvaria (<5 mm). All patients had major bone atrophy. RESULTS: Twenty-nine patients had 121 implants placed in vertical bicortical bone grafts and 40 patients had 170 implants placed in horizontal bicortical bone grafts. All patients underwent a two-stage procedure, with the implants being placed 4 to 5 months after the grafting procedure. The majority of maxillary implants were placed between the canine eminence and zygomatic buttress. Of the 122 bicortical calvarial bone grafts that took, two cases presented an incised wound of the dura. A simple nonabsorbable suture was performed in these two cases without any postoperative problems. There were no cerebral injuries encountered with the donor sites. CONCLUSIONS: Bicortical bone grafting seems to be a solution for reconstruction of voluminous bone atrophy in cases of thin calvaria. Because of legal issues, such a technique must be performed by a trained craniofacial surgery team. The resorption rate seems to be lower in cases of bicortical bone graft.

Adolescent↗