Part II. Mandibular reconstruction using cancellous cellular bone grafts

Towards Optimum Mandibular Reconstruction for Dental Occlusal Rehabilitation: From Preoperative Virtual Surgery to Autogenous Particulate Cancellous Bone and Marrow Graft with Custom-Made Titanium Mesh-A Retrospective Study

The purpose of this retrospective study was to evaluate computer-assisted virtual surgery and the outcomes of mandibular reconstruction using an autogenous particulate cancellous bone and marrow (PCBM) graft combined with a custom-made titanium mesh (TiMesh) using a three-dimensional (3D) printing model. Eighteen consecutive patients were included, and preoperative virtual simulation surgery was performed using digital data. Segmental bone defects showed deviation of the mandible due to displacement of the condyle and segments, unnatural length of the mandibular body, or poorer intermaxillary relationship compared to the marginal bone defect caused by previous operations. These mandibular disharmonies could be simulated, and virtual surgery was performed on a computer with adjustment of displaced mandibular segments, length of the mandibular body, and dental arch with digital bone augmentation. TiMesh was manually pre-bent using a 3D printing model, and PCBM from the iliac crest was grafted with TiMesh. The short-term clinical results were good; reconstruction of the alveolar crest was prosthetically desirable; and minor complications were observed. In conclusion, virtual reconstruction is crucial for treating complex deviated mandibles. Accurate condylar and dental arch positions with an optimum mandibular length are important for prosthetically satisfactory mandibular reconstruction.

A case of effective oral rehabilitation after mandibular resection

Radical mandible resection causes significant functional and cosmetic impairment. Nonvascularized bone reconstruction and oral rehabilitation using fixed prosthesis with dental implants enabled recovery of appearance and mastication function.

Mandibular rescue: Application of the ALT fascia free flap to arrest osteoradionecrosis of the mandible

OBJECTIVES

To evaluate the use of the anterolateral thigh fascia free flap for use in neovascularization of mandibular bone in moderate osteoradionecrosis (ORN). All patients had ORN secondary to prior radiation therapy that was not severe enough to warrant segmental resection and reconstruction.

STUDY DESIGN

Case series.

SETTING

Tertiary medical center.

METHODS

IRB approval was obtained, and a retrospective chart review performed of all mandibular rescue procedures performed from 2011 to 2014. Patients with a minimum of two years of follow-up were included in the study.

RESULTS

All surgeries were performed by the senior surgeon (MF). Eight patients underwent the mandibular rescue procedure with resolution of pain and return to oral feeding in all patients, and no evidence of ORN progression on follow-up imaging. A total of 9 ALT free flaps were performed (one patient had 2 surgeries). Gender was distributed evenly (4 female/4 male). The average age was 66 (58-78), average length of hospitalization was 2.8 days (1-7), and average follow-up was 46.5 months (25-63).

CONCLUSIONS

The mandibular rescue procedure is a novel technique using the ALT fascia lata free flap to provide coverage and nutrient blood flow to mandible devascularized secondary to radiation therapy. The flap provides the advantages of low morbidity, ease of harvest, two-team approach to ablation and reconstruction, and quick recovery resulting in 'short-stay' free flap surgery. Although conclusions must be tempered in this small case series, our early clinical experience shows the ALT fascia lata flap holds promise in halting the destructive progression of ORN that is not yet advanced enough to require a segmental resection and reconstruction.

Reconstruction and Mandibular Rehabilitation After Resection of Juvenile Aggressive Ossifying Fibroma Using Undifferentiated Mesenchymal Cells and Osseointegrated Implants: A Case Report

PURPOSE

The aggressive juvenile ossifying fibroma is a benign fibro-osseous neoplasm that affects the jaws of young patients. The treatment can range from careful curettage to complete bone resection. Early dental rehabilitation through osseointegrated implants is indicated for functional recovery and esthetics.

MATERIALS AND METHODS

This article reports the case of a 20-year-old man submitted to osseous resection, installation of a titanium plate associated with bone graft and osteogenic substances with subsequent installation of osseointegrated dental implants.

RESULTS

After 28 months of clinical and radiographic follow-up, there were no signs of tumor recurrence. As the patient showed good graft integration, 3 dental implants could be installed and are now waiting to receive a prosthetic work.

CONCLUSIONS

The use of a graft with morphogenetic proteins proved to be stable and efficient as it allowed the rehabilitation with dental implants.

Nonvascularized Bone Grafts for Reconstruction of Segmental Mandibular Defects: Is Length of Graft a Factor of Success?

PURPOSE

The purpose of this study was to evaluate a long-debated question in the field of whether the success of reconstructing mandibular defects with nonvascularized bone grafts (NVBGs) is dependent on the length of the graft.

MATERIALS AND METHODS

The inclusion criteria were patients who had received NVBGs, such as anterior or posterior iliac crest and costochondral grafts, to reconstruct segmental defects of the mandible between 2008 and 2017 at the Department of Oral and Maxillofacial Surgery at Case Western Reserve University. Patients with a history of irradiation of the head and neck and patients with inadequate follow-up were excluded from this study. Data such as defect length, patient age, comorbidities, length of follow-up, location of defect, etiology of defect, and postoperative course were collected. Success was judged by radiographic and clinical evidence of bone continuity and stability at a minimum of 4 months postoperatively. Failures were considered loss of all or part of the graft, resulting in a residual continuity defect requiring further bone grafting.

RESULTS

We identified 61 potential cases, of which 29 met the inclusion and exclusion criteria. The mean age of the patients at the time of grafting was 55 years (range, 17 to 81 years), with a mean follow-up length of 18 months. The length of defects ranged from 2 to 22 cm. The grafts were 6 cm or less in length in 7 defects and greater than 6 cm in length in 22 defects. All cases were grafted at a minimum of 6 months after resection, and bone morphogenetic protein was used in 25 cases (86%). Failure occurred in 1 patient in the group with grafts of 6 cm or less and 2 patients in the group with grafts greater than 6 cm, corresponding to success rates of 86% and 91%, respectively. Eight patients experienced minor complications such as wound dehiscence or infection, which resolved with local measures and antibiotics.

CONCLUSIONS

The results of our study show that NVBGs are a viable, safe, and effective treatment option for segmental mandibular defects over 6 cm in length in non-irradiated patients.

Long-term structural changes and outcomes of implants in particulate cellular bone and marrow reconstructed jawbone

BACKGROUND

Association between long-term structural changes of grafted bone and outcomes of the implants is not clear.

PURPOSE

Morphometrical measurements and implant success were analyzed in subjects of particulate cellular bone and marrow (PCBM) reconstruction of the jawbone.

MATERIALS AND METHODS

Subjects were 30 implants in 13 patients from a series of 24 PCBM reconstruction cases. The cortical bone thickness and cancellous computed tomography (CT) radiodensity values were retrospectively analyzed from the CT data of 27 subjects. The cumulative success rate of the implants in the PCBM reconstructed cases (pure graft) was compared with that of 127 implants of 56 native bone cases and 42 implants of 28 bone augmentation (partial graft) cases.

RESULTS

In areas of PCBM reconstruction, cancellous CT radiodensity values were significantly high immediately after the surgery, and subsequently the values became stable. Cortical thickness was significantly increased, but did not reach that of native bone. Implant success rates were statistically not different (P = 0.783) between the native bone (91.3%), the partially grafted bone (95.2%), and the PCBM reconstructed bone (93.3%).

CONCLUSION

Implants in pure grafted bone are mainly supported by cancellous bone, because cortical thickness remained thin for a long period of time.

Mandibular reconstruction with a ready-made type and a custom-made type titanium mesh after mandibular resection in patients with oral cancer

Background

After the resection at the mandibular site involving oral cancer, free vascularized fibular graft, a type of vascularized autograft, is often used for the mandibular reconstruction. Titanium mesh (T-mesh) and particulate cancellous bone and marrow (PCBM), however, a type of non-vascularized autograft, can also be used for the reconstruction. With the T-mesh applied even in the chin and angle areas, an aesthetic contour with adequate strength and stable fixation can be achieved, and the pores of the mesh will allow the rapid revascularization of the bone graft site. Especially, this technique does not require microvascular training; as such, the surgery time can be shortened. This advantage allows older patients to undergo the reconstructive surgery.

Case presentation

Reported in this article are two cases of mandibular reconstruction using the ready-made type and custom-made type T-mesh, respectively, after mandibular resection. We had operated double blind peer-review process. A 79-year-old female patient visited the authors’ clinic with gingival swelling and pain on the left mandibular region. After wide excision and segmental mandibulectomy, a pectoralis major myocutaneous flap was used to cover the intraoral defect. Fourteen months postoperatively, reconstruction using a ready-made type T-mesh (Striker-Leibinger, Freibrug, Germany) and iliac PCBM was done to repair the mandible left body defect.

Another 62-year-old female patient visited the authors’ clinic with pain on the right mandibular region. After wide excision and segmental mandibulectomy on the mandibular squamous cell carcinoma (SCC), reconstruction was done with a reconstruction plate and a right fibula free flap. Sixteen months postoperatively, reconstruction using a custom-made type T-mesh and iliac PCBM was done to repair the mandibular defect after the failure of the fibula free flap. The CAD-CAM T-mesh was made prior to the operation.

Conclusions

In both cases, sufficient new-bone formation was observed in terms of volume and strength. In the CAD-CAM custom-made type T-mesh case, especially, it was much easier to fix screws onto the adjacent mandible, and after the removal of the mesh, the appearance of both patients improved, and the neo-mandibular body showed adequate bony volume for implant or prosthetic restoration.

Immediate mandibular reconstruction via patient-specific titanium mesh tray using electron beam melting/CAD/rapid prototyping techniques: One-year follow-up

BACKGROUND

Immediate mandibular reconstruction was performed using a patient-specific titanium mesh tray fabricated by electron beam melting (EBM) /rapid prototyping techniques.

METHODS

Patient-specific titanium trays were virtually designed and fabricated using EBM technology/rapid prototyping for patients requiring mandibular resection and immediate reconstruction using an iliac crest bone graft. Dental implants were placed in the grafted sites and the patients received prosthetic rehabilitation with a follow-up of one year. Clinical data, postoperative bone formation and complications were evaluated.

RESULTS

A symmetric appearance of facial contours was achieved. The titanium tray incorporated the particulate iliac crest bone graft that provided significant bone formation (mean 18.97 ± 1.45 mm) and predictable results. Stability of the dental implants was achieved.

CONCLUSION

The patient-specific titanium meshes and immediate particulate autogenous bone graft showed satisfactory clinical and surgical results in improving patients' quality of life and decreasing the overall treatment time with adequate functional rehabilitation.

Orthognathic Surgery and Implant-Supported Bridge in a Class III Patient Injured in a Motor Vehicle Accident

Occlusal and esthetic rehabilitation of jaw deformities in patients with partially edentulous maxilla are challenging procedures. This article describes a patient involving a skeletal Class III, 36-year-old male patient with a single bilateral anterior partially edentulous maxilla resulting from injuries sustained in a motor vehicle accident; his anterior teeth had been lost for more than 10 years. His lip protruded from the lateral view due to the proclined upper incisors and mandibular protrusion.Because of the facial deformity and inadequate prosthesis of the maxilla, the prosthesis had dropped out repeatedly. Bone deficiency was prominent in the area of the anterior maxillary region and required augmentation for implant restoration.Consultation among the prosthodontist, orthodontist, and patient led to a decision to perform an orthognathic surgery and bone graft before implant treatment. After orthodontic treatment combined with orthognathic surgery, 3 dental implants were placed with simultaneous iliac bone graft for prosthetic rehabilitation. The treatment restored the maxillary dental arch, which supported the upper lip with appropriate occlusion, both esthetically and functionally. After a 2-year clinical follow-up, the orthoprosthesis of the maxilla remained stable, and the patient was satisfied with the outcome of treatment. The combination of orthodontic, surgical, and dental implant treatment could be an option for skeletal Class III patients with bone-deficient, edentulous jaws.

Iliac crest bone grafting for mandibular reconstruction: 10-year experience outcomes

Purpose

To evaluate 10-year patient data related to mandibular reconstruction with NVBG at a tertiary academic center.

Patients and Methods

Sixty patients with mandibular mandibular reconstruction were included. Patients were divided to continuity defect and non-continuity defect. Pathology lesion, immediate reconstruction, smoking habit, medical comorbidities, site and size of the defect, surgical approach, intraoperative perforation, cadaveric bone use, and maxilla-mandibular fixation use were analyzed as factors of influence on success. Success was defined as maintenance of more than 50% of graft for non-continuity defects (NCD) and bone continuity and stability for continuity defect (CD), and absence of infection on last follow up upon clinical and radiographic examination. Complications were classified as minor or major.

Results

The reconstruction was successful in 28 (87%) of CD patients and 23 (82.1%) of NCD patients. Analyses showed that the size of defect was significantly associated with failure. All 4 failed cases of CD had defects more than 9 cm. Four patients had major complications and 43 minor complication.

Conclusions

Nonvascularized iliac crest bone grafts are highly successful in mandibular continuity reconstruction for non-Cancer patients and should be considered as first choice for defects less than 9 cm. They are less predictable for defects larger than 9 cm but can be considered in these cases with osteoconductive cribs. Symphysis involvement may or may not be associated with lower success rate if our protocol is followed.

Mandibular reconstruction with different techniques

Traumas, malformative or dysplastic pathologies, atrophy, osteoradionecrosis, and benign or malignant neoplasm can cause bone deficits in the mandible. Consequent mandibular defects can determine aesthetic and functional problems; therefore, being able to perform a good reconstruction is of critical importance.Several techniques have been proposed for mandibular reconstruction over the years. In this article, we present and discuss the evolution during the time of the methods of mandible reconstruction as well as pros and cons of each procedure on the basis of experience of 10 years in the maxillofacial department of the Catholic University of Sacred Heart of Rome.Free flaps represent the gold standard method of reconstruction of large mandibular defects: the fibula bone flap represents the best choice for large defects involving the arch and the mandibular ramus, whereas the deep circumflex iliac artery represents a valid alternative for mandibular defects involving the posterior region.In cases where free flap reconstructions are contraindicated, the use of regional pedicle flap combined with autologous bone grafts still represents a valid choice. Patients who are not deemed suitable for long and demanding surgery can still be treated using alloplastic materials in association with regional pedicle flap or, when adjuvant radiation therapy is needed, by simple locoregional pedicle flap. Finally, in selected cases, the bone transporting technique should be considered as a valid alternative to the more "traditional" reconstructive methods because of the extraordinary potential and its favorable cost-benefit ratio.

Autogenous bone harvest for implant reconstruction

Autogenous bone harvest is the gold standard for restoring deficiencies of the recipient site. A deficient site requires adequate grafting before placement of implants; therefore, proper understanding of the wide variety of grafting options is the key to successfully planned implant dentistry. This provides general dentists with a better understanding of autogenous bone harvest and the variety of techniques available to provide the best outcomes for the patient.

Is immediate reconstruction of the mandible with nonvascularized bone graft following resection of benign pathology a viable treatment option?

PURPOSE

The purpose of this study was to address the following clinical question: Is immediate reconstruction of the mandible with a nonvascularized bone graft after resection of benign pathology a viable treatment option? Another purpose was to determine whether any variables affect the success of this treatment approach.

MATERIALS AND METHODS

The authors implemented a retrospective cohort study from a sample of patients diagnosed with a benign tumor of the mandible who were treated with segmental resection and primary reconstruction with an autogenous nonvascularized bone graft. The predictor variables were age, gender, lesion size, and diagnosis, and the outcome variable was graft success determined by re-establishment of mandibular continuity with sufficient bone for implant placement. The χ(2) test was used for statistical analysis of the categorical data and P values less than .05 were considered statistically significant.

RESULTS

Twenty patients with benign mandibular tumors were treated with transoral resection and immediate reconstruction with nonvascularized bone grafts. The mean age was 28.3 years (range, 9 to 63 yr) and 55% (11 of 20) were men. The most common lesion type was ameloblastoma (13 of 20) and all patients underwent reconstruction with autogenous anterior iliac crest bone grafting. Ninety percent of patients (18 of 20) had successful reconstruction. Ten patients underwent successful implant placement and restoration.

CONCLUSIONS

Using careful patient selection, treatment of benign pathology with transoral resection and immediate reconstruction with a nonvascularized bone graft from the anterior iliac crest can be successful. In addition, the total treatment time from implant restoration to return to preoperative function is minimized. Therefore, this method of treatment is a viable treatment option and an alternative to delayed reconstruction or reconstruction with vascularized bone flaps.

Evaluation of Non-vascular Fibula Graft for Mandibular Reconstruction

INTRODUCTION

Functional and cosmetic defects in maxillofacial region are caused by various ailments like trauma, neoplasm, developmental, infections and iatrogenic causes. Reconstruction of these defects with free flaps remains the gold standard but demerits like need for surgical expertise and equipment, prolonged duration of surgery, compliance of the patient and increased cost are associated with microvascular reconstruction. Hence reconstruction with nonvascular bone grafts can be considered when defect is nonirradiated and <9 cm and with sufficient soft tissue cover available.

PURPOSE

To retrospectively evaluate clinical, radiological outcome and complications encountered with mandibular reconstruction using non vascular fibula graft.

PATIENTS AND METHODS

This retrospective study included 7 patients who were treated in the Department of Oral and Maxillofacial Surgery, Narayana Dental College and Hospital, Nellore, AP between 2011 and 2013 with histologically proven benign osteolytic lesions of mandible that require a segmental mandibulectomy and primary reconstruction using autogenous non-vascularised fibular graft. The clinical case records of the patients and personal patient assessment forms (Quality of Life Assessment Forms) were analysed. They were recalled every 3rd, 6th and 9th month after surgery for evaluation of clinical, radiological outcome of the graft and complications occurring at recipient and donor sites.

RESULTS

In all the 7 patients, the lower border continuity was maintained except in one where the graft was dislodged. Tongue movements in all the patients were unrestricted. Jaw movements were affected in cases of ramus defects with slight deviation to operated side and reduced mouth opening. Radiological observations revealed no significant changes in 3 months except for slight reduction in graft height. The radioopaque bridging with continuity of lower border of mandible was noticed in 6th month indicating the take of the graft. This was achieved in every case except in one where the graft was lost due to dislodged reconstruction plate. In 9th month the edges of the graft i.e., graft to native mandible junction showed more resorption (3 mm) especially where there is >2 mm of gap. Whereas increase in height of graft in other areas especially in graft to graft junction was seen. Significant graft resorption was seen in two cases. There were no major complications associated with the donor site.

CONCLUSION

Avascular fibula graft although a second choice to vascularised fibula, is a favourable option for mandible defects of 6-10 cm under optimum conditions especially in developing countries where financial and/or surgical resources are limited. An attempt for primary reconstruction with this is never futile as it prevents aesthetic deformity even in the event of failure and thus makes secondary reconstruction easy. However in order to confirm the results a prospective study with large scale of patients is necessary.

Evaluation of mandibular reconstruction with particulate cancellous bone marrow and titanium mesh after mandibular resection due to tumor surgery

There are numerous treatment modalities for mandibular defects after tumor surgery. Autogenous particulate cancellous bone marrow graft combined with titanium mesh (PCBM-MESH) is an alternative procedure. The purpose of this study was to evaluate PCBM-MESH for mandibular reconstruction. There were a total of 10 cases from 2000 to 2011. Mandibles were successfully reconstructed in 9 cases; however, reconstruction failed in 1 case. Overall, the recovery of facial contours was excellent; conversely, the evaluation of prosthetic treatment varied widely. Thus, we suggest 3 steps for mandibular reconstruction: (1) recover the continuity of bone segments; (2) simulate optimum facial contours and dental occlusion; and (3) perform the occlusion with dental prostheses. PCBM-MESH is a valuable method for mandibular defects-particularly for restoring facial contours and a favorable alveolar ridge.

Reconstruction of irradiated mandible after segmental resection of osteoradionecrosis-a technique employing a microvascular latissimus dorsi flap and subsequent particulate iliac bone grafting

The fibula osteocutaneous flap has revolutionized the options of mandibular segmental defect bridging in osteoradionecrosis (ORN). In selected cases, however, the fibula flap is not an option because of atherosclerosis or other features that compromise the vascularity of the lower leg and foot. The aim of this study is to present an alternative method of mandibular segmental reconstruction employing a latissimus dorsi (LD) flap and subsequent particulate iliac free bone graft reconstruction. In 15 patients with ORN, a mandibular segmental defect was bridged with a reconstruction plate, and the defect site was primed with a LD musculocutaneous flap wrapped around the reconstruction plate to bring in vascularized tissue and optimize healing conditions for a subsequent particulate iliac free bone graft reconstruction. The management of defect closure was successful in all 15 patients. Twelve patients had a subsequent bone grafting from the posterior ileum for repair of defects up to 14 cm length. Three patients had no bone graft for various reasons. In three patients dental rehabilitation was achieved with implant supported prosthodontic appliances. Ten patients met the success criteria of uneventful graft healing with restitution of osseous continuity, mandibular height, symmetry and function, and avoidance of reconstruction plate fracture.

Five-year follow-up of modified implant-supported overdenture in an iliac crest autograft failure: clinical report

The treatment of extensive pathologic lesions in the jaw, most of the time, can generate rehabilitation problems to the patient. The solid ameloblastoma is a locally invasive odontogenic tumor with a high recurrence rate. Its treatment is aggressive and accomplished through resection with safety margin. The criterion standard for reconstruction is autogenous bone, but it can provide a high degree of resorption, causing inconvenience to the patient because of lack of rehabilitative option. This study aimed to describe a patient with ameloblastoma treated through resection and reconstruction with autogenous bone graft, in which, after an extensive resorption of the graft was made, a modified bar was applied to support a prosthetic implant overdenture.

Bilateral sagittal split osteotomy in a mandible previously reconstructed with a non-vascularized bone graft

We report a bilateral sagittal split osteotomy (BSSO) in a reconstructed mandible. A 28-year-old woman underwent a segmental mandibulectomy due to a multicystic ameloblastoma in the left jaw. After primary plate reconstruction, final reconstruction was performed with a left posterior iliac crest cortico-cancellous autograft. Due to a pre-existing Class II malocclusion, the patient was analyzed for combined orthodontic-surgical treatment. Subsequently, after 1 year of orthodontic treatment, the BSSO was planned. The sagittal split was performed in the remaining right mandible and on the left side in the iliac crest cortico-cancellous autograft. Ten months later, oral rehabilitation was completed with implant placement in the neomandible. Follow-up showed a Class I occlusion, with good function. The patient was very satisfied with the functional and aesthetic results. This case shows that a BSSO can be performed in a reconstructed mandible, without side effects and with good functional and aesthetic results.

Application of CAD/CAM-assisted technique with surgical treatment in reconstruction of the mandible

OBJECTIVE

The purpose of this clinical study was to explore the optimal method of reconstruct mandible defects individually and immediately.

STUDY DESIGN

Three-dimensional model simulation technique and vascularized fibular osteomyocutaneous flap were used to repair 15 cases of mandible defects, which were caused by ameloblastoma. A three-dimensional computed tomography (CT) images were converted to a virtual model using CAD software and the 3-dimensional (3D) simulated resin models of skeleton and fibula were used to design the osteotomies, bone segment replacement and titanium mesh shaping preoperatively.

RESULTS

Fibula flaps were alive and no complication occurred. The patients were satisfied with the results both esthetically and functionally.

CONCLUSIONS

This preliminarily clinical study and case demonstrated that CAD/CAM-assisted technique with surgical treatment offers an individual anatomical reconstruction of the mandible in ameloblastoma patients. The procedures guarantee intraoperatively an exact placement of the preformed mesh even for precise reconstruction of extensive mandible defects.

Effects of fibrin-binding oligopeptide on osteopromotion in rabbit calvarial defects

PURPOSE

Fibronectin (FN) has been shown to stimulate bone regeneration in animal models. The aim of this study was to evaluate the capacity of bovine bone mineral coated with synthetic oligopeptides to enhance bone regeneration in rabbit calvarial defects.

METHODS

Oligopeptides including fibrin-binding sequences of FN repeats were synthesized on the basis of primary and tertiary human plasma FN structures. Peptide coated and uncoated bone minerals were implanted into 10 mm calvarial defects in New Zealand white rabbits, and the animals were sacrificed at 4 or 8 weeks after surgery. After specimens were prepared, histologic examination and histomorphometric analysis were performed.

RESULTS

At 4 weeks after surgery, the uncoated groups showed a limited amount of osteoid formation at the periphery of the defect and the oligopeptide coated groups showed more osteoid formation and new bone formation in the center of the defect as well as at the periphery. At 8 weeks, both sites showed increased new bone formation. However, the difference between the two sites had reduced.

CONCLUSIONS

Fibrin-binding synthetic oligopeptide derived from FN on deproteinized bovine bone enhanced new bone formation in rabbit calvarial defects at the early healing stage. This result suggests that these oligopeptides can be beneficial in reconstructing oral and maxillofacial deformities or in regenerating osseous bone defects.

Mandibular reconstruction with vascularized fibula flap and osseointegrated implants: a clinical report

Primary and secondary reconstruction of mandibular discontinuity defects with vascularized flap is currently the standard of care in many institutions. The most commonly used donor site for such flaps is fibula. Fibula provides enough bone length, allows 2-team approach, and has low donor site morbidity and abundant periosteal blood supply. The placement of endosseous implants in the vascularized fibula flap also facilitates functional dental rehabilitation. This clinical report describes the prosthetic rehabilitation and the complications of 2 mandibular discontinuity defects treated with vascularized fibula flap and implant-supported fixed prosthesis.

The tent pole splint: a bone-supported stereolithographic surgical splint for the soft tissue matrix expansion graft procedure

This report details the use of computer-aided planning and intraoperative stereolithographic direct-bone-contact surgical splints for the accurate extraoral placement of dental implants in the soft tissue matrix expansion (tent pole) graft of the severely resorbed mandible.

Scapula free flap for complex maxillofacial reconstruction

INTRODUCTION

Composite tissue defects of the mandible and maxilla, after resection of head and neck malignancies, osteoradionecrosis, malformations, or traumas, cause functional and aesthetic problems. Nowadays, microvascular free flaps represent the main choice for the reconstruction of these defects. Among the various flaps proposed, the scapula flap has favorable characteristics that make it suitable for bone, soft tissue, or combined defects.

MATERIALS

We report 7 cases of reconstruction of complex maxillofacial defects with subscapular system flaps. The patients treated had Romberg syndrome (1 case), malignant tumors (5 cases), and result of previous trauma (1 case).Location of deficit was the maxilla (3 cases), the mandible (2 case), the ethmoidal-maxillary region (1 case) and the upper and middle thirds of the face in the last case.

METHODS

In 2 cases, a parascapular system flap was used; in 5 cases, a composite flap with latissimus dorsi muscle and scapular bone.

RESULTS

Neither failure of the harvested flaps nor complications in the donor site were evidenced. A good aesthetic and functional outcome was obtained in all cases.

DISCUSSION

: Many free flaps have been proposed for the reconstruction of defects in the maxillofacial region such as fibula, deep circumflex iliac artery, scapula, among the bone flaps; and forearm, rectus abdominis, and anterolateral thigh, among the soft tissue flaps. The choice of the flap to use depends on the length of the bone defect and the amount of soft tissues required. The subscapular system has the advantage of providing different flaps based on the same pedicle. The osteofasciocutaneous scapular free flap, in particular, allows wide mobility of soft tissues (parascapular flap) with respect to its bone component (scapular bone), resulting suitable for defects of large size involving both the soft tissues and the bone.

CONCLUSIONS

Although the fibula flap and the deep circumflex iliac artery flap remain the first choice for bone reconstructions of the mandible and maxilla, the scapula flap has some features that make its use extremely advantageous in some circumstances. In particular, we advocate the use of the osteomuscular latissimus dorsi-scapula flap for reconstruction of large-volume defects involving the bone and soft tissues, whereas fasciocutaneous parascapular flaps represent a valid alternative to forearm flap and anterolateral thigh flap in the reconstruction of soft tissue defects.

Reconstruction of the mandible after ablative surgery for the treatment of aggressive, benign odontogenic tumours in Tanzania: a preliminary study

This study presents results on 11 patients suffering from ameloblastoma who had ablative surgery followed by reconstruction of the mandible in a single operative procedure in Tanzania. The procedure included the use of autogenous particulate bone from the anterior or posterior iliac crest. In 6 of the patients, the tumour was removed from the cortical scaffold, which was then irradiated with 50 Gy. Perforations were made on the scaffold and it was then placed back to fit the defect and was held in place by custom-made titanium plates, fixed on both ends with screws. The particulate bone chips were mixed with autogenous platelet rich plasma (PRP) and Tissue Col. In 5 of the patients, the cortical scaffold was not used but rather a mixture of bone and PRP was packed into the defect under the titanium plates. Four patients had some complications varying from fracture of the scaffolds to infection. None from the group reconstructed without scaffolds suffered any complications. A quality of life (QOL) assessment of the 7 successful cases showed that these patients were satisfied and had a good QOL. These results imply that this immediate means of reconstruction is feasible and thus, offers a big advantage to the patients.

Reconstruction of the mandible with an autogenous irradiated cortical scaffold, autogenous corticocancellous bone-graft and autogenous platelet-rich-plasma: an animal experiment

This paper reports on an experimental animal study evaluating a method of mandibular reconstruction using irradiated cortical scaffolds. Twelve goats underwent a continuity resection at the mandibular angle. Primary reconstruction was carried out using specially designed osteosynthesis plates and screws. The defect was bridged by the original, irradiated cortical scaffold, which was filled with an autogenous particulate bone graft from the anterior iliac crest. To accelerate bone healing, platelet rich plasma (PRP) was mixed with the particulate bone graft. The hypothesis of this study was that bone healing in segmental reconstruction of the goat mandible by means of an irradiated cortical scaffold, filled with a particulate cancellous bone graft mixed with PRP, would be as successful as when using a non-irradiated scaffold. All goats had an uneventful healing. The osteosynthesis plates and screws withstood immediate loading for periods varying from three to six weeks. The radiologic and histologic results were less favourable with regard to bone remodelling than the results obtained in similar experiments with non-irradiated cortical bone scaffolds.

An analysis of inadvertent perforations of mucosa and skin concurrent with mandibular reconstruction

PURPOSE

This article reports on the incidence and outcome of inadvertent perforations of mucosa and skin during the reconstruction of segmental defects of the mandible using cancellous cellular bone.

PATIENTS AND METHODS

This study reviews 11 patients experiencing an inadvertent perforation of skin and/or mucosa among 211 consecutive patients (5.2%) undergoing reconstruction of the mandible with this graft model.

RESULTS

Eleven patients experienced 16 perforations of either mucosa (n = 14) or skin (n = 2). Six diagnoses necessitated these 11 reconstructions where a perforation was encountered, including ameloblastoma (n = 3), chronic osteomyelitis (n = 2), stage III osteoradionecrosis (n = 2), fibrosarcoma (n = 1), synovial cell sarcoma (n = 1), stage IV squamous cell carcinoma (n = 1), and odontogenic myxoma (n = 1). Fourteen of the 16 perforations occurred intraoperatively, and 2 occurred postoperatively (dehiscence). Eleven of the 16 perforations occurred at either the distal or proximal segment, while 5 of the perforations occurred in the mid portion of the segmental defect tissues. Postreconstruction follow-up ranged from 11 to 70 months (mean, 28.5 months). Infection occurred in 1 of the 11 patients (9.1%) with resultant partial graft loss. Protocols are proposed that serve to preserve a contamination-free tissue bed and minimize or eliminate infection of the graft when a perforation is encountered.

CONCLUSION

An inadvertent perforation of mucosa or skin does not result in automatic graft infection and failure when proper intraoperative management is carried out. When the graft perforates through the mucosa postoperatively, proper wound management similarly can preserve the graft. This information reinforces the fact that it is not necessary to abort reconstructive surgery once a perforation is identified intraoperatively, nor to debride an entire graft that becomes exposed postoperatively.