Mandibular reconstruction using AO/ASIF stainless steel reconstruction plate: a retrospective study of 36 cases

Quantification of the Bimodal Plate-Specific Complication Profile Associated With Reconstruction of Segmental Mandibular Defects With Reconstruction Plate and Soft Tissue Flap: Evidence From Systematic Review

ABSTRACT

Reconstruction of segmental mandibular defects with a mandibular reconstruction plate and separate soft tissue flap can be indicated in certain patients. Whilst this technique can provide acceptable results, its exact longevity and timing of associated complications is poorly understood. This study was designed to quantify and plot in time the complication profile associated with this technique of mandibular reconstruction.A search of the Medline and PubMed Central databases was conducted using the terms "Mandibulectomy" and "Reconstruction Plate." Articles reporting total number of plate extrusions and fractures and their postoperative timing were included.Nine articles were included, representing 265 patients with mandibulectomy defects reconstructed using mandibular reconstruction plates. Of these, 135 were male (62%) and 82 were female (38%). The mean age was 59 years. The predominant pathology was oral cavity Squamous Cell Carcinoma (SCC) (80%). Seventy-three patients (28%) experienced complications (mean follow-up: 24 months), with median time to complication of 3 months. Forty-three plate extrusions (16%), 20 plate fractures (8%) and 10 cases of loosened screws (4%) were reported. A bimodal temporal distribution of complications was found.Overall, a plate-specific complication rate of 28% was found, confirming a higher incidence of complications in comparison to osseous free flap reconstruction. These occur over a bimodal time distribution, with extrusion occurring earlier than fracture. Interference with speech, swallow and dental rehabilitation, and delay of adjuvant therapy are potential consequences. These findings indicate that patients may be better served by more complex reconstructive procedures, to minimize exposure to a frequent and prolonged complication profile.

Complications After Soft Tissue With Plate vs Bony Mandibular Reconstruction: A Systematic Review and Meta-analysis

OBJECTIVE

Mandibular reconstruction for segmental defects is a well-studied topic. However, there are conflicting data on the risks of delayed plate-related complications. The objective of this systematic review and meta-analysis was to assess long-term plate-related complications following reconstruction of the mandible with soft tissue and a plate as compared with immediate vascularized bony reconstruction.

DATA SOURCES

A medical librarian created search strategies with a combination of keywords and controlled vocabulary in Ovid Medline (1946-), Embase (1947-), Scopus (1960-), Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Clinicaltrials.gov.

REVIEW METHODS

Candidate articles were independently reviewed by 2 authors. Inclusion/exclusion criteria were uniformly applied. Articles were considered eligible if they included adequate reporting of plate extrusion and/or fracture and had follow-up ≥12 months.

RESULTS

A total of 2379 patients were included. The risk of plate fracture was low in cases of soft tissue with a plate (5%; 95% CI, 0.03-0.08) and osseous reconstruction (1%). The risk of extrusion following soft tissue and plate reconstruction was 20% (95% CI, 0.15-0.27). In the osseous reconstruction group, the risk of extrusion was 10% (95% CI, 0.06-0.18). Revision surgery was performed twice as often following soft tissue with a plate as compared with vascularized bony reconstruction (32% [95% CI, 0.25-0.40] vs 14% [95% CI, 0.09-0.21], respectively).

CONCLUSION

Delayed plate-related complications remain a significant problem following segmental defect reconstruction. Soft tissue and plate reconstruction techniques may increase the risk of plate removal and revision surgery.

Evaluation of complications and flap losses in mandibular reconstruction with microvascularized fibula flap

The mandibular defects caused by mandibulectomies can involve esthetic and functional sequelae in patients. The fibula presents positive aspects and can be used as an option for mandibular reconstruction after tumor resections or extensive traumas. Furthermore, this retrospective study of the patients who have passed through a mandibular reconstruction with a microvascular fibular flap over the last 17 years describes the experience of the Oral and Maxillofacial SurgeryService at the ErastoGaertner Hospital, Curitiba/PR. The use of this flap type has a complication rate of 32.3%, which includes the fixation material exposure, flap resorptions, fistulas, pathological fractures, tumor recurrence, infections, seromas, and thrombocytopenia. Most of them are associated with patients who have received radiotherapy and/or chemotherapy. These data suggest a high frequency of complications when a reconstruction plate fixation is used. Minor complications are usual and they should not be overlooked because they can lead to devastating consequences.

Mandibular reconstruction in elderly patients

BACKGROUND AND OBJECTIVES

The choice of reconstructive technique for a segmental mandibular defect in elderly patients is controversial. The aim of this study was to establish an algorithm for selecting a method of mandibular reconstruction in elderly patients.

METHODS

We retrospectively evaluated 121 patients aged ≥65 years who underwent immediate microvascular mandibular reconstruction after oncologic resection. Patients were divided into three groups based on method of reconstruction: vascularized bone graft (n = 49), mandibular reconstruction plate and soft tissue flap (n = 22), and soft-tissue flap (n = 50). We compared perioperative outcomes among groups and investigated factors affecting the choice of reconstructive technique.

RESULTS

Rates of postoperative complications did not differ significantly among groups. Mandibular reconstruction plate was indicated only for anterior mandibular defects. Soft-tissue flap was indicated for posterior mandibular defects in patients aged ≥75 years or with a poor postoperative Eichner index.

CONCLUSIONS

Mandibular reconstruction plate and soft-tissue flap can be good alternatives to vascularized bone graft in the elderly. Our algorithm uses defect type, patient age, and postoperative Eichner index to determine reconstructive technique.

Preliminary clinic study on computer assisted mandibular reconstruction: the positive role of surgical navigation technique

Background

The objectives of the present study were to investigate the reliability and outcomes of computer-assisted techniques in mandibular reconstruction with a fibula flap and verify whether the surgical navigation system was feasible in mandible reconstructive surgery.

Methods

Eight cases were enrolled in the computer assisted surgery (CAS) group and 14 cases in the traditional group. The shaping and fixation of the fibula grafts were guided by computer assisted techniques, which could be monitored with the BrainLAB surgical navigation system. The variation of mandible configuration was evaluated by CT measurement in the Mimics software, including the variation of length, width, height and gonial angle of the mandible. The 3D facial soft tissue alteration was also analyzed in 3D chromatogram by Geomagic software.

Results

All 22 fibula flaps survived. The mandibular configurations and facial contours had a better clinic result in the CAS group. The length, width, height and gonial angle of the reconstructive mandible were more similar to the original one. The Wilcoxon rank sum test analysis suggested significant differences in the measurements. The chromatographic analysis also visually showed superiority over the traditional group.

Conclusions

The computer assisted surgical navigation method used in mandibular reconstruction is feasible and precise for clinical application. The contour of the reconstructed mandible and facial symmetry are improved with computer techniques.

Does Prolonged Reconstruction of Disarticulation Defect With Bone Plate Affect the Electromyography Records of Masticatory Muscles?

OBJECTIVES

For medical or socioeconomic reasons, the primary reconstruction of disarticulation defects with bone plates stays for many years. This study was performed to assess the effect of this delay on electromyography (EMG) records of masticatory muscles.

MATERIALS AND METHODS

Twenty-five patients treated by insertion of reconstruction plates in disarticulation defects were prospectively included in this study. Electromyography records for masticatory muscles were obtained before surgery and 3 months, 6 months, 1 year, 2 years, and 3 years afterward. Paired t-test was used to determine whether there was significant difference between the EMG values.

RESULTS

At 3 years after surgery, the amplitude values of the masseter and temporalis muscles, on the resected side, have decreased by 39% and 60%, respectively, whereas on the nonoperated side, they have increased by 35% and 29%. The peak decrease, on the resected sides, has occurred at 3 months for the temporalis and 2 years for the masseter. On the nonoperated side, the peak increase has occurred at 6 months for both the temporalis and the masseter.

CONCLUSIONS

A prolonged use of bone plates to reconstruct disarticulation defects leads to alterations in EMG values of masticatory muscles. These alterations present clinically as muscle atrophy on the operated side and hypertrophy on the nonoperated side.