MANDIBULAR RECONSTRUCTIONMANDIBULAR RECONSTRUCTION

Literature ReadingLiterature ReadingFriday, March, 19th, 2004

Fari Ananda

Dept of Otorhinolaryngology – Head & Neck Dept of Otorhinolaryngology – Head & Neck SurgerySurgery

Padjadjaran UniversityPadjadjaran UniversityHasan Sadikin General HospitalHasan Sadikin General Hospital

BandungBandung, 2004, 2004

19/03/200419/03/2004 LR / FALR / FA 22

Mandibular reconstruction of segmental defects Mandibular reconstruction of segmental defects is important procedure after is important procedure after trauma or trauma or following ablative procedures for oral following ablative procedures for oral malignancies malignancies

Function of the Mandible :Function of the Mandible : Protection of the airwayProtection of the airway Support of the tongue & musculatureSupport of the tongue & musculature Anchorage of the lower dentitionAnchorage of the lower dentition Appearance of the lower third of the faceAppearance of the lower third of the face Facial cosmeticFacial cosmetic

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Interrupting the continuity of the mandible Interrupting the continuity of the mandible invariably produces a cosmetic and functional invariably produces a cosmetic and functional deformity.deformity.

The dysfunction may vary from minimal, as in The dysfunction may vary from minimal, as in thethe case of lateral defects with negligible loss case of lateral defects with negligible loss ofof tongue function, to major when more tongue function, to major when more extensive, combined soft- and hard-tissue extensive, combined soft- and hard-tissue losses are losses are incurred. incurred.

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The major causes of mandibular discontinuity :The major causes of mandibular discontinuity :

Tumor resectionTumor resection Loss from traumaLoss from trauma Unsuccessful healing of mandibular fractureUnsuccessful healing of mandibular fracture Osteonecrosis following radiation therapyOsteonecrosis following radiation therapy Atrophy due aging and dimeneralizationAtrophy due aging and dimeneralization

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The ultimate goal The ultimate goal reconstruction reconstruction is to restore is to restore the patient to the pre-disease statethe patient to the pre-disease state

Goals of primary oromandibular Goals of primary oromandibular reconstructionreconstruction Restore mandibular continuityRestore mandibular continuity Restore lower facial contourRestore lower facial contour Maintain mobility of residual tongueMaintain mobility of residual tongue Rehabilitate with a functional lower dentureRehabilitate with a functional lower denture Improve mastication, deglutition and speechImprove mastication, deglutition and speech Restore sensation to denervated lower lipRestore sensation to denervated lower lip Restore sensation to resurfaced portions of Restore sensation to resurfaced portions of

oraloral cavitycavity

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19/03/200419/03/2004 LR / FALR / FA 88

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Inferior Alveolar nerve Inferior Alveolar nerve teethteeth

Lingual nerve Lingual nerve lingual lingual gingivagingiva

Mylohyoid nerve Mylohyoid nerve mylohyoid musclemylohyoid muscle

Buccal branch Buccal branch buccal buccal gingivagingiva

One branch exits for One branch exits for mental mental sensory for sensory for lower lip and labial lower lip and labial gingivagingiva

Auriculotemporal and Auriculotemporal and messeter nerve messeter nerve TMJ TMJ

Main blood suply Main blood suply Inferior Inferior alveolar branch of the alveolar branch of the internal maxillary arteryinternal maxillary artery

Blood suply for TMJ Blood suply for TMJ Several branches of the Several branches of the

external carotid artery :external carotid artery :

Ascending pharyngeal Ascending pharyngeal arteryartery

Superficial temporal arterySuperficial temporal artery

Middle meningeal arteryMiddle meningeal artery

Anterior tympanic branches Anterior tympanic branches of the internal maxillary of the internal maxillary arteryartery

Classification of Dental Occlusion

Normal OcclusionNeurtocclusion

RetrocclusionRetrusive bite

MesioocclusionProtrusive bite

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Planning for reconstructive procedurePlanning for reconstructive procedure

Often the defect is composed of both softOften the defect is composed of both soft - - and hard-tissue componentsand hard-tissue components

History of rHistory of radiation therapy and surgical adiation therapy and surgical scarringscarring

EEvaluation of the patient to define the full valuation of the patient to define the full extent of extent of the bony and soft-tissue componentsthe bony and soft-tissue components

Clinical examination Clinical examination

Radiographic evaluationRadiographic evaluation

Hyperbaric oxygen therapyHyperbaric oxygen therapy

Timing ReconstructionTiming Reconstruction

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The topography of mandibular discontinuity defects

A lateral defect limited to the body very often causes minimal cosmetic/functional deformities

Acquired laterognathia Some patients can compensate quite well

Bony defects that extend to the ramus presence of a proximal segment and a functional TMJ and condylar neck

Extirpative oncologic procedures of tumors Andy Gump deformities

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41 %

23 %

5 %

18%0,4%

3%

9%

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Complete Disarticulation Oblique

Subcondylar Osteotomy

Horizontal Osteotomy Above Lingula

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Andy Gump DeformityAndy Gump Deformity

19/03/200419/03/2004 LR / FALR / FA 1919

The quality and quantity of the soft-tissue bedThe quality and quantity of the soft-tissue bed

The ideal soft-tissue bed The ideal soft-tissue bed E Enough bulk, nough bulk, vascularity, fibroblasts, and pluripotential cellsvascularity, fibroblasts, and pluripotential cells

Some of the reasons for graft failure Some of the reasons for graft failure mucosal mucosal dehiscence, graft infection leading to complete dehiscence, graft infection leading to complete loss of the transplanted bone, and late graft loss of the transplanted bone, and late graft resorptionresorption

Graft resorption Graft resorption hypocellularity of the recipient hypocellularity of the recipient bedbed

TThe use of hyperbaric oxygen tends to reverse the he use of hyperbaric oxygen tends to reverse the hypocellularity, hypovascularity, and hypoxia hypocellularity, hypovascularity, and hypoxia

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Marx and AmesMarx and Ames

AA greater cellular matrix of viable fibroblasts and greater cellular matrix of viable fibroblasts and neo-angiogenesis is achievedneo-angiogenesis is achieved e enhances the nhances the level of perfusion level of perfusion heal and support the heal and support the transplantation of the nonvascularized bone grafttransplantation of the nonvascularized bone graft

Phase I Phase I Lag phaseLag phase

Phase II Phase II Rapid Rapid ResponseResponse

Phase III Phase III Plateu phasePlateu phase

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There are no absolutly rulesThere are no absolutly rulesBased on the location of the mandibular Based on the location of the mandibular defectdefect

ImmediateImmediate Resection secondary to Resection secondary to

benign tumorbenign tumor

Reconstruction of a Reconstruction of a failed mandibular failed mandibular repairrepair

Gun shot wounGun shot woun

DelayedDelayed

Malignant tumor Malignant tumor excisionexcision

Possible local tumor Possible local tumor reccurancereccurance

Post radiotherapyPost radiotherapy

Options in Options in MMandibular andibular RReconstructioneconstruction

AlloplastsAlloplasts Kirschner wire Kirschner wire Steinmann pin Steinmann pin Preformed appliances Preformed appliances

Silastic Silastic Acrylic Acrylic Fluoroethylene (Teflon) Fluoroethylene (Teflon) Titanium tray Titanium tray Vitallium (chromium-Vitallium (chromium-cobalt) tray cobalt) tray Polyurethane and Polyurethane and Dacron mesh Dacron mesh

Free bone graftsFree bone grafts Autogenous Autogenous

Cortical Cortical Cancellous Cancellous Corticocancellous chips Corticocancellous chips

Allogeneic Allogeneic Cancellous Cancellous Corticocancellous Corticocancellous Biodegradable cribs Biodegradable cribs (rib, ilium, mandible) (rib, ilium, mandible)

Combination graftsCombination grafts (allogeneic cribs filled (allogeneic cribs filled with with particulate autogenous particulate autogenous bone) bone) PBCM PBCM

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Pedicle flaps Pedicle flaps Rib/pectoralis major Rib/pectoralis major Rib/latissimus major Rib/latissimus major Scapula/trapezius Scapula/trapezius Clavicle/Clavicle/sternocleidomastoid sternocleidomastoid Calvarum/Calvarum/temporalis temporalis

Free flapsFree flaps Rib Rib Scapula Scapula Fibula Fibula Ilium Ilium Radius Radius Ulna Ulna Humerus Humerus Metatarsus Metatarsus

Options in Options in MMandibular andibular RReconstructioneconstruction

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Bone formationBone formation Endochondral and Endochondral and membranousmembranous

Factors that influence of healing Factors that influence of healing Age, Age, Vascularized soft tissue, avoidance of Vascularized soft tissue, avoidance of contamination, degree of injury, bone contamination, degree of injury, bone fragments, complete immobilizationfragments, complete immobilization

Bone healing cellsBone healing cells osteoblast, osteoclast and osteoblast, osteoclast and osteocyteosteocyte

3 phases of bone healing3 phases of bone healing Immediate reactionImmediate reaction ReparationReparation RemodelingRemodeling

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Immediate PhaseImmediate Phase

Hematoma formationHematoma formation

InflammationInflammation

Cells inductionCells induction

ReparationReparation

Primary bone healing Primary bone healing Close defect, normal Close defect, normal bone remodelling with rigid fixation, no bone remodelling with rigid fixation, no external callus, type I collagenexternal callus, type I collagen

Secondary bone healing Secondary bone healing Gap exists in Gap exists in fracture fragment, no rigid fixation, callus fracture fragment, no rigid fixation, callus formationformation

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Early stage similar with healing but later stage differEarly stage similar with healing but later stage differAxhausen`s Axhausen`s two phase theory of osteogenesis two phase theory of osteogenesis

Phase IPhase I Start early after grafting , continues for the first 4 Start early after grafting , continues for the first 4 weeksweeksUltimate size of the bone graftUltimate size of the bone graft

Phase IIPhase IIBegins at 2 weeks, peaks 4 weeks, slowly 6 weeksBegins at 2 weeks, peaks 4 weeks, slowly 6 weeksTransformation of pluripotential host cells onto Transformation of pluripotential host cells onto osteoblastic cellsosteoblastic cellsRemodeling of phase IRemodeling of phase IHost fibroblast growth into graft mediated by BMPHost fibroblast growth into graft mediated by BMP

Total lossTotal loss host tissue cannot support the graft host tissue cannot support the graft

19/03/200419/03/2004 LR / FALR / FA 2727

Particulate Bone/Cancellous MarrowParticulate Bone/Cancellous Marrow The best osteogenic potential free bone graftsThe best osteogenic potential free bone graftsProvide sufficient amount osteoblast to support Provide sufficient amount osteoblast to support both phases both phases Lacks structural integrity and requires a carrier Lacks structural integrity and requires a carrier such as alloplastic or allogenic cribssuch as alloplastic or allogenic cribs

3 tipe allogeneic cribs3 tipe allogeneic cribs Allogenic mandiblesAllogenic mandiblesAllogenic ribsAllogenic ribsAllogenic iliac boneAllogenic iliac bone

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IdeallyIdeally similar similar morphologymorphology

Reconstructing ramus or Reconstructing ramus or TMJTMJ

Hollowed out to form crib, Hollowed out to form crib, adapted to remaining adapted to remaining fenestrated to facilitate fenestrated to facilitate host tissue ingrowth host tissue ingrowth fixed with screw fixed with screw packed with PBCMpacked with PBCM

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Rib is split longitudinally and the 2 cortical Rib is split longitudinally and the 2 cortical strips are then contoured to the surgical strips are then contoured to the surgical defectdefect

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For large defectFor large defect

19/03/200419/03/2004 LR / FALR / FA 3131

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Several cutaneous and myocutaneous flaps are Several cutaneous and myocutaneous flaps are available for use in the closure of soft-tissue available for use in the closure of soft-tissue defects of the oral cavity defects of the oral cavity

Cutaneous flapsCutaneous flaps Forehead Forehead Deltopectoral Deltopectoral Nape of neck Nape of neck

Muscle/musculocutaneous Muscle/musculocutaneous flapsflaps Pectoralis major Pectoralis major Trapezius Trapezius Latissimus dorsi Latissimus dorsi Sternocleidomastoid Sternocleidomastoid TemporalisTemporalis

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Vascularized bone, transferred as either a Vascularized bone, transferred as either a regional flap or a microvascular free flap, regional flap or a microvascular free flap, resists infection and extrusion.resists infection and extrusion.

Its independent blood supply allows it to heal Its independent blood supply allows it to heal rapidly and to become incorporated to the rapidly and to become incorporated to the remaining mandible, regardless of the quality remaining mandible, regardless of the quality of the vascularity in the surrounding recipient of the vascularity in the surrounding recipient bed.bed.

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Donor sites for vascularized bone-containing free flaps

Limitations in the use of regional flapsLimitations in the use of regional flaps The stock of The stock of bone is inadequatebone is inadequate

TThe introduction of free flap transfers he introduction of free flap transfers t the he vascularity to the bonevascularity to the bone was usually greater than the was usually greater than the regional flapsregional flaps

Bone Vascular pedicle

Ilium Deep circumflex iliac arteryScapula Subscapular arteryFibula Peroneal arteryRadius Radial arteryUlna Ulnar arteryHumerus Profunda brachii arteryMetatarsus Dorsalis pedis arteryRib Intercostal artery

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Ideal qualities for the Ideal qualities for the osseous component osseous component of a composite free of a composite free flapflap

Well vascularized Well vascularized Sufficient length, Sufficient length,

width, height width, height Natural contour Natural contour

simulates shape of simulates shape of mandible mandible

Minimal morbidity Minimal morbidity Accessible for two-Accessible for two-

team approach team approach

Ideal qualities for Ideal qualities for the soft-tissue the soft-tissue component of a component of a composite free flap composite free flap

Well vascularized Well vascularized Thin and pliable Thin and pliable Mobile relative to Mobile relative to

bone bone Sensate Sensate Lubricated Lubricated Minimal morbidity Minimal morbidity Accessible for two-Accessible for two-

team approach team approach

19/03/200419/03/2004 LR / FALR / FA 3636

Implants have been used as Implants have been used as spacersspacers and/or for the internal and/or for the internal fixationfixation and stabilization and stabilization of of bone graftsbone grafts and mandible and mandible

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Soft monofilament steel wire 0.35, 0.4, 0,5 mmSoft monofilament steel wire 0.35, 0.4, 0,5 mmStabilization wiring :Stabilization wiring :

Horizontal wiring Horizontal wiring Simple ligation, Essig & Simple ligation, Essig & Risdon wiringRisdon wiring Intermaxillary fixation Intermaxillary fixation Direct dental wiring, Direct dental wiring,

Noncontinuous, Continuous wiring, Noncontinuous, Continuous wiring, Circummandibular wiringCircummandibular wiring

Fixation Wiring :Fixation Wiring : Direct osseous Direct osseous 2 hole, 4 hole figure of 8, 2 2 hole, 4 hole figure of 8, 2 hole hole figure of 8figure of 8 Transosseous wiringTransosseous wiring

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Risdon Horizontal WiringRisdon Horizontal Wiring

CircummandibuCircummandibular Wiringlar Wiring

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Non Continuous WiringNon Continuous Wiring

Continuous WiringContinuous Wiring

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TransosseousTransosseous

Direct Osesseous

LR / FALR / FA 4141

Splints offer a number of approach to IMFSplints offer a number of approach to IMF

May be made of wire, arch bars or plasticsMay be made of wire, arch bars or plastics

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Metal Metal SplintsSplints

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Screw is used to Screw is used to stabilize lamellar stabilize lamellar fracturefracture

V 4 AS steels screws V 4 AS steels screws 2.0 – 2.7 mm 2.0 – 2.7 mm

Interfragmental Interfragmental compressionscompressions

Drilling process is a Drilling process is a critical partcritical part

Complication Complication Loosening of bone Loosening of bone screwscrew

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For all types of fractureFor all types of fracture

Rigid internal fixationRigid internal fixation

Four types of appliances of internal fixationFour types of appliances of internal fixation

Dynamic compression plateDynamic compression plate

Eccentric dynamic plateEccentric dynamic plate

Reconstruction plate/Mandibular bridging Reconstruction plate/Mandibular bridging plateplate

Lag ScrewsLag Screws

High stability defectHigh stability defect compression plate, compression plate, splinting or combinationsplinting or combination

Anatomic reconstructionAnatomic reconstruction small/large small/large compression plate, stabilization platecompression plate, stabilization plate

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Indication for RIFIndication for RIF Contraindicated for IMFContraindicated for IMF Special need for mandibular rigiditySpecial need for mandibular rigidity Special need for access to oral cavitySpecial need for access to oral cavity Prolonged fixationProlonged fixation

Contrandication for RIFContrandication for RIF Simple fracturesSimple fractures Insufficient bone tu support hardwareInsufficient bone tu support hardware Extensively comminuted fractureExtensively comminuted fracture Major loss of boneMajor loss of bone

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Advantages for RIFAdvantages for RIF More comfortable during healing processMore comfortable during healing process Good nutritionGood nutrition Oral hygiene easily maintainedOral hygiene easily maintained No compromise in oral airwayNo compromise in oral airway Lower rates of infectionLower rates of infection

DisadvantagesDisadvantages Need for wide exposure Need for wide exposure Longer incision Longer incision Large amount of implanted foreign materialLarge amount of implanted foreign material Longer operating and timesLonger operating and times Expensive and higher complicationExpensive and higher complication

4747

Pressing the bone Pressing the bone fragments tightly fragments tightly together and creating together and creating high degree of high degree of stabilitystability

Spherical gliding Spherical gliding principleprinciple

Classic design for 4 hole Classic design for 4 hole compression platecompression plate

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Overcountoring a compression plate by 3 to 5 degrees

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For segmental, For segmental, comminuted comminuted fractures and fractures and fractures of the fractures of the atrophic senile atrophic senile mandiblemandible

Usually function as a Usually function as a monocortical monocortical retention plate retention plate

Satisfied for Satisfied for treatment of treatment of pediatric fracturespediatric fractures

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IndicationIndication Long term stabilizationLong term stabilization Maintenance space and spatial relationshipsMaintenance space and spatial relationships Contraindicated for IMFContraindicated for IMF

AdvantagesAdvantages Relatively rigid immobilizationRelatively rigid immobilization Exact spatial relationships may be maintainedExact spatial relationships may be maintained Lack of instruments ang foreign body implantation Lack of instruments ang foreign body implantation

on fracture siteon fracture site

DisadvantagesDisadvantages Not cosmeticallyNot cosmetically Scars are produced at pin punctureScars are produced at pin puncture Bone infection and requires special equipmentBone infection and requires special equipment

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Refers to surgical procedure that cut into or Refers to surgical procedure that cut into or through the mandiblethrough the mandible

Gaining access to deeper structures, removing Gaining access to deeper structures, removing diseased tissue adjacent to mandible, diseased tissue adjacent to mandible, preserving maximum mandibular function preserving maximum mandibular function and facial appearanceand facial appearance

Is also a valuable technique for mandibular Is also a valuable technique for mandibular mobilization and repositioning to correct mobilization and repositioning to correct traumatic and congenital deformitiestraumatic and congenital deformities

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Approach for anterior Approach for anterior and posterior oral cavityand posterior oral cavity

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Approach to posterior, near the junction Approach to posterior, near the junction of the posterior body and the angle of the posterior body and the angle mandiblemandible

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Adequate acess to mid Adequate acess to mid and posterior oral and posterior oral cavity, tonsil, cavity, tonsil, oropharynxoropharynx

Avoiding injury and Avoiding injury and transection of the transection of the genioglossus, genioglossus, genihyoid and genihyoid and digastric muscledigastric muscle

Preserves the sensory Preserves the sensory innervation of the innervation of the lower lip and chinlower lip and chin

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Problem Problem after oromandibular reconstructionafter oromandibular reconstruction loss of loss of sensation sensation in in larger areas of oral and pharyngeal larger areas of oral and pharyngeal mucosamucosa

OOral cavityral cavity food trapping, disturbed oral hygienefood trapping, disturbed oral hygiene, , mastication problemsmastication problems, , disturbed deglutition and disturbed deglutition and life-threatening aspirationlife-threatening aspiration

SolutionSolution Sensate soft tissue free flap + Sensate soft tissue free flap + vascularized bone vascularized bone

Donor sitesDonor sites radial forearm, ulnar forearm, lateral radial forearm, ulnar forearm, lateral arm, dorsalis pedis, and rib donor sites provide arm, dorsalis pedis, and rib donor sites provide skin with a sensory nerveskin with a sensory nerve

The use of a separate sensate cutaneous free flap in The use of a separate sensate cutaneous free flap in combination with a vascularized bone free flap combination with a vascularized bone free flap such as the iliac crest or fibulasuch as the iliac crest or fibula

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The sensory innervation of the lower lip The sensory innervation of the lower lip restored via nerve grafting between the restored via nerve grafting between the proximal stump of the inferior alveolar nerve proximal stump of the inferior alveolar nerve and distally the mental nerveand distally the mental nerve

The nThe nerve can then be reconstructed using an erve can then be reconstructed using an autogenous nerve graftautogenous nerve graft : : GGreater auricularreater auricular SSuralural nerve nerve AAnterior bracheocutaneousnterior bracheocutaneous nerve nerve LLateral femoral cutaneous nerves ateral femoral cutaneous nerves

19/03/200419/03/2004 LR / FALR / FA 5858

TThree types of dental prostheseshree types of dental prostheses

1. 1. Conventional tissue-borne denturesConventional tissue-borne dentures LLeast stable prosthesiseast stable prosthesis

PPartial restoration if the residual teeth can be usedartial restoration if the residual teeth can be used2. 2. Implant-borne dentureImplant-borne denture

FFixed, retrievableixed, retrievable, , most stable form most stable form

It is useful for one-quadrant restorationIt is useful for one-quadrant restoration

3. 3. Implant-assisted dentureImplant-assisted denture RRemovable prosthesis supported by two or more emovable prosthesis supported by two or more implants implants in the symphyseal regionin the symphyseal region

MMore stable and retentive than conventional ore stable and retentive than conventional dentures dentures and less costly than the implant-borne and less costly than the implant-borne prosthesis.prosthesis.

19/03/200419/03/2004 LR / FALR / FA 5959

Oromandibular reconstruction is a problem of both Oromandibular reconstruction is a problem of both the bone and the soft tissue. The quality and the bone and the soft tissue. The quality and quantity of the soft-tissue bed are criticalquantity of the soft-tissue bed are critical part part

The ultimate goalThe ultimate goal mandibular reconstruction mandibular reconstruction is to is to restore the patient to the pre-disease staterestore the patient to the pre-disease state good mandibular function and appearancegood mandibular function and appearance

There are many option for mandibular There are many option for mandibular reconstruction reconstruction Corticocancellous bone chips Corticocancellous bone chips are advantageous are advantageous they provide the they provide the osteoblasts necessary for bone formation osteoblasts necessary for bone formation promote rapid revascularization. promote rapid revascularization.

19/03/200419/03/2004 LR / FALR / FA 6060

Bone vascularity may be maintained through Bone vascularity may be maintained through regional flaps or composite free flaps.regional flaps or composite free flaps.

VVascularized bone-containing free flapsascularized bone-containing free flaps broadening the surgeon’s ability to restore broadening the surgeon’s ability to restore oral cavity anatomy and functionoral cavity anatomy and function

Sensation Sensation oral cavity and lip oral cavity and lip can be restored can be restored with sensate free flapswith sensate free flaps

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