Early bone resorption of free microvascular reanastomized bone grafts for mandibular reconstruction – A comparison of iliac crest and fibula grafts

ObjectivesPatients with continuous bone defects of the mandible after ablative tumor surgery need bony reconstruction for proper function and aesthetics. Free microvascular reanastomized bone grafts provide a clinically proven option for such patients, yet the optimal source of donor tissue has not yet been established. The aim of this study was to evaluate and compare the bone volume stability of vascularized bone grafts, particularly in the early highly resorptive phase, from the iliac crest (DCIA) and the fibula and to assess the implantologic rehabilitations.Materials and methodsThirty-six patients with mandibular continuity defects due to tumor resection were reconstructed by the use of vascularized bone grafts; 21 patients received DCIA flaps and 15 patients received a composite free fibular flap, depending on the size and location of the defect. Bone resorption was assessed using digital panographs. Radiographs were taken immediately after bone reconstruction, 6 months postoperatively, prior to implant surgery, and at prosthetic loading.ResultsAfter a mean observation period of 6 months, vertical bone resorption was 6.79% for the patients of the iliac crest group (DCIA), 10.20% after 11 months, and 12.58% after 17 months. Fibular grafts showed a bone resorption of 5.30% after a mean observation time of 6 months, 8.26% after 11 months, and 16.95% after 17 months. Eighteen patients received 71 implants for implant-retained dental reconstructions.ConclusionsMicrovascular reanastomized bone grafts represent a reliable treatment option for reconstruction in cases of large defects of the mandible, with low graft resorption in the early healing phase. Additionally, the compared grafts provide sufficient bone volume to permit implant rehabilitation.     

A combined superficial inferior epigastric artery flap and vascularized iliac crest flap in the reconstruction of extended composite defects of the posterior mandible and adjacent soft tissue: first clinical results

The technique of posterior facial reconstruction using a combination of a superficial inferior epigastric artery (SIEA) flap and a microvascular iliac crest flap (deep circumflex iliac artery (DCIA) flap) is described. 12 cases are reported. The patients had unilateral squamous cell carcinoma of the posterior mandible affecting parts of the soft palate and tonsil region or the posterior cheek. In all patients unilateral neck dissection, resection of the posterior and lateral mandible, was performed. Reconstruction was carried out during primary surgical therapy, followed by postoperative radiotherapy. A flap combination of a SIEA and a DCIA flap was used. There were no problems with pedicle length or anastomoses. There was no flap loss or severe postoperative complications. All patients had good aesthetic and functional results. One patient had distant metastases 2 years postoperatively. All other patients were free of tumour relapse or metastases within 12-58 months of follow up. The SIEA flap and vascularized iliac bone flap combination is useful in reconstructing the posterior face. The iliac bone flap is well suited for posterior mandible reconstruction and the SIEA flap for reconstruction of the soft palate, lateral pharyngeal wall and cheek. Both flaps are harvested from the same donor site.     

Microvascular free flaps for mandibular reconstruction in Goldenhar syndrome

Although Goldenhar syndrome is a relatively common craniofacial malformation, there is some debate regarding the ideal treatment of severe mandibular hypoplasia. Traditionally, patients with severe mandibular deficits have been treated with iliac or costochondral bone grafts followed by distraction osteogenesis, with mixed results. The authors present their experience with the use of the osteocutaneous fibula and scapula free flap for mandibular reconstruction in patients with severe mandibular hypoplasia. The cases of 4 patients who underwent free-flap reconstruction of a severely hypoplastic mandible due to Goldenhar syndrome are presented. Microvascular reconstruction of the severely hypoplastic mandible is possible with the osteocutaneous scapula and the fibula flap. Minimal donor-site morbidity is elicited. Furthermore, the vertical relationship can be restored adequately, and breathing is facilitated. The microvascular fibula and scapula flap are a viable option for reconstruction of the severely hypoplastic mandible in patients with Goldenhar syndrome.     

Deep circumflex iliac artery perforator flap with iliac crest for oromandibular reconstruction

When combined with iliac bone, perforator flaps are more chimeric, and there is increased mobile skin island to reconstruct soft tissue defects in the oral and maxillofacial region. This study examined oromandibular defects reconstructed using deep circumflex iliac artery perforator flap with iliac crest (DCIAPF). We retrospectively reviewed records of 23 patients with mandibular defects received DCIAPFs after oncological resection for oromandibular reconstruction from November 2015 to August 2016. All perforators, identified before surgery by Doppler examination, were terminal perforators of DCIA. DCIAPFs were successfully harvested in all patients. The flap survival rate was 95.6% (22/23); one flap failed due to artery spasm. Three patients developed slight skinedge necrosis in the skin island. Anatomical reconstruction contour of the mandible and sufficient bone length and height were achieved, with no serious donor-site complications during the follow-up period. The results demonstrated that DCIAPF is a favorable single-flap option for oromandibular reconstruction after oncological resection with fewer donor-site complications because of its adequate bone tissue and satisfactory soft tissue, with a constant location of the perforator.     

One-stage microvascular mandible reconstruction and alloplastic TMJ prosthesis

Severely deformed or absent temporomandibular joints (TMJ) benefit from total alloplastic joint replacement and large mandibular defects from revascularized free tissue transfer for reconstruction. However no cases of their combined one-stage placement with outcomes can be found in the literature. We present two cases with different indications and reconstruction.The first patient required mandibular body and ascending ramus reconstruction after previous sarcoma resection. This was with a condyle-bearing reconstruction plate which resulted in significant dysfunction, leaving the patient unable to open her mouth. A one-stage vascularized iliac crest free flap and alloplastic TMJ prosthesis was used to reconstruct the mandible. Subsequently, metal removal, soft tissue augmentation by lipotransfer and dental implant placement were performed. At 63 months follow-up patient was pain-free, with mouth opening, protrusion and lateral excursion back to normal.The second patient required mandibular body, ascending ramus and joint reconstruction, performed by transoral vascularized fibula free flap with temporal vessel anastomosis. The traumatic deep bite and posterior facial height were corrected, additional submandibular scars avoided by transoral placement of the fibula transplant and a miniaturized TMJ prosthesis along with the vascularised free flap with 28 months follow-up.A miniaturized TMJ prosthesis may become placed transorally for reconstruction of the TMJ, together with a vascularized free flap for mandibular reconstruction and promises good long-term stability with normal function above all for protrusion and lateral excursion.     

Three different techniques for mandibular reconstruction after hemimandibulectomy.

Mandibular reconstruction is a condition in which both bone defect and function must be restored. A wide range of approaches--from grafts to distant bone flaps--have been used for correcting bony defects. However, adequate mastication has been restored in only a few cases. In this article the results of three different techniques for mandibular reconstruction after hemimandibulectomy were studied. Sixteen patients underwent a second mandibular reconstruction after hemimandibulectomy and were monitored at least 1 year. Three different techniques were used: (1) full-thickness galeoparietal bone flap (eight patients), (2) free iliac crest graft (three patients), and (3) free fibular grafts (five patients). Occlusion on the nonoperated side and the possibility and function of osseointegrated denture in the vascularized bone transfer were evaluated. The full-thickness galeoparietal flap and free iliac crest bone flap appeared to be good options. However, only acceptable or poor occlusion could be achieved on the normal side. The fibular free flap demonstrated good results and good occlusion. Nonetheless, dental implantation was difficult because a prosthesis for reaching the normal height of the mandible was necessary.     

自体髁突再植于血管化髂骨瓣修复下颌骨缺损

目的:评价自体髁突再植于血管化髂骨瓣修复下颌骨缺损的临床应用价值.方法:对17例累及单侧下颌角和下颌升支上部的颌骨良性病变患者行下颌骨部分切除.采用自体髁突再植于血管化髂骨瓣修复下颌骨缺损.结果:自体再植髁突及血管化髂骨瓣移植全部成活,外形满意,咬合关系良好.结论:自体髁突再植于血管化髂骨瓣修复下颌骨缺损效果肯定.     

即刻植骨同期种植体植入修复下颌骨缺损

目的 :探讨下颌骨缺损即刻植骨同期种植的可行性。方法 :对 6例下颌骨部分切除的患者 ,行下颌骨缺损即刻植骨同期种植术。其中 2例行血管化腓骨双层折叠移植 ,另 4例为非血管化髂骨移植。同期植入种植体共 19颗。结果 :6例术后均一期愈合 ,X线显示种植体周围骨结合正常。结论 :下颌骨缺损血管化和非血管化骨移植同期种植术是可行的 ,但由于同期种植的复杂性 ,要求在适应症的选择及手术操作上应更加严格     

ITI种植体即刻植入血管化髂骨修复下颌骨缺损12例分析

目的:种植体植入血管化髂骨修复下颌骨缺损已成为一种常规治疗方法。本研究对一组ITI种植体即刻植入血管化髂骨后的效果进行评价。方法:对2000～2004年间12例患者共36枚ITI种植体植入血管化髂骨的情况进行研究。髂骨瓣移植完成即刻种植体植入,3～5个月愈合期后进行修复负载。结果:种植体植入髂骨后初期稳定性良好,经1年观察,垂直骨吸收<1m m,进入稳定状态。在观察期间无种植体失败。结论:血管化髂骨是下颌骨缺损修复安全的种植床。种植体支持的固定义齿和覆盖义齿修复,是下颌骨缺损可靠的修复方法。     

Costochondral Graft as Interpositional material for TMJ Ankylosis in Children: A Clinical Study

Abstract

TMJ ankylosis is one of the most disruptive anomaly that affects the masticatory system. The inability to move the mandible has significant functional ramification, such as the inability to eat a normal diet. Additionally, speech is affected, making it difficult for some individuals to communicate and express themselves to others. As there are several biologic and anatomic similarities to the mandibular condyles, autogenous costochondral grafts have been considered to be the most acceptable tissue for temporomandibular joint reconstruction. In addition donor site complications are infrequent and regeneration of the rib usually occurs within a year post operatively in children.

Aim

The aim of this study was to evaluate the function of costochondral grafts to replace the mandibular condyles and to assess the position, growth, overgrowth, function, success, failure and resorption of costochondral grafts.

Materials and Methods

Ten TMJ ankylosis patients were operated in the Department of Oral and Maxillofacial Surgery at Institute of Dental Sciences, Bareilly. Out of the 10 cases 6 were male patients and 4 female patients in age group of ≤14 years; of which 8 patients were of unilateral TMJ ankylosis and 2 were of bilateral TMJ ankylosis. All ten patients underwent interpositional gap arthroplasty with reconstruction of the condyle by costochondral graft.

Results

All patients with costochondral grafts had improved mandibular symmetry and growth with adequate mouth opening.

Conclusion

This study indicates that using costochondral grafts to reconstruct TMJ ankylosis in children provides a good result.     

The free fibula flap for treating benign mandibular lesions

A variety of benign lesions that are typically treated conservatively can affect the mandible. The treatment must be radical when these lesions are locally aggressive and involve the perimandibular soft tissues or involve most of the thickness of the mandible. The main treatment is mandibular resection and reconstruction with bone grafts, mainly iliac crest bone grafts for segmental mandibulectomy or a calvaria bone graft for resection without interruption of the mandible body. These grafts are limited due to the possibility of infection and the unpredictable long-term resorption. Free flap surgery, particularly with fibula free flaps, represents a new era in mandibular reconstruction. This technique has similar donor site morbidity, while the transferred bone resists infection and bone resorption. These advantages are achieved at the cost of a procedure that is about 1 h longer when performed by an experienced microsurgical team. We report our experience with mandibular reconstruction following the surgical resection of benign lesions in 7 patients. All the reconstructions had good RESULTS: After reconstruction, the facial morphology showed restored symmetry of the lower third profile in all patients. The functional results were satisfactory, with restored mandibular function in all cases. No signs of recurrence have appeared in any patient after a mean follow-up of 24 months.     

Mandibular Condyle Reconstruction With Inlay Application of Autogenous Costochondral Graft After Condylectomy: Cerrahpaşa’s Technique

PURPOSE: Mandibular condyle reconstruction with free costochondral grafting is the most common method because of some advantages, such as its biological and anatomic similarities to the condyle, and growth potential in juveniles. Application techniques of the costochondral graft were reported in numerous articles with several advantages and disadvantages up to now. The purpose of this article is to present a new modification in application of the costochondral graft to the ramus of the mandible. This technique is pretty simple, but very effective. MATERIALS AND METHODS: The new technique described here consisted of a costochondral graft application for temporomandibular joint reconstruction, which was inserted into the medullary cavity of the mandibular ramus in 4 patients. This modification provided the graft placement as anatomical as the original condyle and further stabilized the graft in its position and inhibited its displacement without any fixation. This technique is pretty simple because an additional incision to the preauricular, facial nerve dissection, wide exposition and stabilization efforts are not required. RESULTS: Clinical and radiological evaluations on 14-month mean follow-up of 4 cases showed very satisfactory functional results with normal anatomic adaptation and configuration. In all cases, function of mandible was considered to be good with at least maximal interincisal opening of 30 mm. Good anatomical position of the graft and good bony healing were seen on the radiographs. Additionally, there was no need for postoperative intermaxillary fixation. CONCLUSION: With this technique, temporomandibular joint reconstruction by the costochondral graft can be performed as far as possible to the original condyle position.     

两种血管化游离骨肌瓣移植修复下颌骨缺损临床分析

目的:评价血管化游离髂骨肌瓣和腓骨肌瓣移植修复下颌骨缺损的临床效果,比较两种修复方法的优缺点。方法:对44例血管化髂骨肌瓣和腓骨肌瓣移植修复下颌骨缺损的病例进行回顾性研究,分析两种骨肌瓣修复后对患者面部外形与口腔功能的影响,对比供受区并发症的差异。结果:20例髂骨肌瓣,24例腓骨肌瓣均成活;二者在恢复面部外形与口腔功能上无明显差异,在移植骨长度上,两者有明显不同。结论:血管化游离髂骨肌瓣与腓骨肌瓣作为下颌骨缺损修复的常用方法,可以满足不同类型下颌骨缺损修复的需要,但根据两种骨肌瓣的特点,对于缺损长度低于8 cm,可优先考虑髂骨瓣,而缺损范围大于8 cm的可选腓骨瓣。     

Sagittal split osteotomy of a vascularised iliac crest free flap to correct residual asymmetry and malocclusion in the reconstructed mandible

Reconstruction of the mandible with a vascularised bone graft from the iliac crest based on the deep circumflex iliac artery is an established and reliable technique. We report two cases in which mandibular asymmetry followed reconstruction with such grafts and was corrected by sagittal split osteotomies.     

深冻辐射灭菌同种异体大块下颌骨移植的临床应用

目的　探讨深低温冷冻放射辐照同种异体大块下颌骨移植的临床方法和价值。方法　采用深冻同种异体下颌骨置换 10例大块病变下颌骨 ,术中尽可能保留植骨床骨膜 ,植骨块去除一侧部分皮质 ,并在保留皮质上打孔 ,浸泡抗生素液 ,骨松质区放置自体髂嵴松质骨和骨髓 ,严密缝合口腔粘膜 ,口外放置引流。结果　所有病例术后随访 12～ 3 0月 ,X线平片见宿主骨与移植骨生长愈合良好 ,未出现明显的高度降低 ,ECT显示植入骨有骨盐代谢。结论　深冻辐照同种异体大块下颌骨可用于下颌骨缺损的修复。     

Iliac flap versus fibula flap in mandibular reconstruction

The mandible is one of the important parts of the body in terms of facial appearance and function. Vascularized free bone grafts have become the criterion standard in mandible reconstruction. With flap survival rates not too much distant to 100%, the focus is now on function and aesthetics. With the various free-flap options now available, reconstruction of the mandibular defect has achieved significant improvement in both functional and aesthetic results. However, few studies have compared the results of these options. The fibula is defined as the most popular flap in mandibular reconstruction, and only in few papers iliac flaps are preferred. However, quality of life and effectiveness data are not available to support this choice. Not any previous study prospectively compared these 2 flaps. Short- and long-term results of an outcome-research study were prospectively compared in microvascular mandibular reconstruction with fibular flap and iliac crest flaps. Mean functional and quality-of-life scores were higher following iliac crest reconstructions. Fibular flap was the flap of choice in total/subtotal mandibulectomy, but it does not appear preferable in hemimandibulectomy and/or in cases of segmental mandibulectomy, if compared with the iliac crest.     

Sliding reconstruction of the condyle using posterior border of mandibular ramus in patients with temporomandibular joint ankylosis

The traditional approach for ankylosis is gap arthroplasty or interpositional arthroplasty followed by reconstruction of the condyle using, for example, costochondral grafts. As these are non-pedicled grafts, there is eventual resorption with subsequent decrease in height of the ramus, facial asymmetry and deviated mouth opening. The authors have applied the method of total and partial sliding vertical osteotomy on the posterior border of the mandibular ramus for reconstruction of the mandible condyle as a pedicled graft for the correction of temporomandibular joint (TMJ) ankylosis. From 2004 to 2008, 18 patients who were diagnosed with TMJ ankylosis underwent operations for resection of the ankylosed condyle. Two methods were performed depending on the level of osteotomy on the posterior part of the mandibular ramus. All patients were followed-up for an average of 36 months (range 24-48 months). All patients showed apparent improved joint function with no cases of re-ankylosis. The results showed that sliding vertical osteotomy on the posterior border of the mandibular ramus seems to be an alternative and promising method for condylar reconstruction in patients with TMJ bony ankylosis.     

Treatment of temporomandibular joint ankylosis in children: is it necessary to perform mandibular distraction simultaneously?

Temporomandibular joint (TMJ) ankylosis in children disturbs not only mandibular growth, but also facial skeletal development. Costochondral graft was used to ensure growth, but it had proven to be unpredictable. The authors evaluate retrospectively 41 patients who underwent temporomandibular joint reconstruction during the last 10 years. Twenty were treated by costochondral graft, 15 by arthroplasty, and 6 by other surgical procedures, and they were excluded. The etiology was septic in 54% of the cases. Follow-up was at least 12 months in all cases. Arthroplasty was a quicker and easier procedure than the costochondral graft, reducing operating time, risk of blood transfusion, and hospital stays and costs. It also was associated with less risk of reankylosis, 13%vs 25%. Furthermore, it was associated with a minor morbidity and secondary complications. Seventy-five percent of the patients treated with bone graft required additional secondary surgery. Radiographically, the authors observed a remodeled neocondyle at the level of proximal mandibular end in cases treated by arthroplasty. On clinical examination, patients showed variable degrees of facial deformity and an unknown potential of mandibular growth after TMJ arthroplasty. The authors also observed improved clinical and radiologic appearance after ankylosis correction. Is it reasonable to perform ankylosis release and mandibular distraction simultaneously without knowing which patients will be able to experience growth with time? In that case it would be necessary a predict growth to apply the exact amount of mandibular distraction for obtaining stable results. Timing of mandibular distraction, after TMJ arthroplasty is performed and mandibular function restored, must be specific to each patient's needs, assuring the best distraction conditions and planning. The authors present their treatment protocol, including TMJ joint arthroplasty with temporal muscle interposition, and mandibular distraction osteogenesis, as a second procedure, to correct residual asymmetry or retrognathism if necessary.     

髂骨血管化移植与非血管化移植修复下颌骨缺损的比较

目的：对髂骨修复下颌骨缺损的血管化与非血管化骨移植两种形式进行比较。方法：对71例连续行下颌骨切除和髂移植的病例进行了回顾性研究,对血管化与非血管化移植病例在手术过程及术后效果方面作了比较和分析。结果：非血管化骨操作相对简单,用时较少,并发症发生率也低,但术后植入骨吸收明显,高度下降较大;血管化骨手术过程复杂,用时较长,并发症略高,但失败率低,植入骨吸收较少,高度下降不明显。结论：血管化骨较非血管化骨有着无可比拟的优越性,但非血管化骨操作简单,目前两种形式均有其存在价值,适用于不同情况的病例。     

Histologic analysis of costochondral and sternoclavicular grafts in the TMJ of the juvenile monkey

Variability in growth response of the mandible after replacement of the mandibular condyle with the costochondral junction of a rib (CCJ) is common. Other donor graft sites that are more similar to the mandibular condyle might be more suitable for mandibular condylar replacement. Previous studies have shown the histomorphologic and developmental similarities between the sternoclavicular joint (SCJ) and temporomandibular joint (TMJ). The purpose of this study was to evaluate histologically short-term adaptations within the TMJ after replacement of the mandibular condyle with the autogenous sternal head of the clavicle, and to compare these adaptations with autogenous CCJ and mandibular condyle (surgical control) transplants. Bilateral vertical ramus osteotomies were performed in 12 juvenile Macaca mulatta with the left condyle being immediately replaced and the right condyle removed and replaced with either the sternal head of the clavicle or costochondral junction of a rib. All grafts were stabilized with maxillomandibular fixation for five weeks. Two animals in each group were killed at five, 11, and 17 weeks postsurgery and prepared for histologic analysis. The results indicate that: 1) incorporation of all grafts into the recipient site occurred and all animals had good mandibular function and occlusion throughout the follow-up period; 2) the clavicular and mandibular condylar grafts were incorporated sooner than the CCJ grafts; 3) clavicular graft changes resembled those of the condylar grafts histologically while the costal grafts remained inert and unchanged; and 4) a new condylar process with cartilage similar to that of a normal mandibular condyle regenerated in the costal graft animals from cells presumably contributed by the periosteum of the mandibular ramus and TMJ capsule.(ABSTRACT TRUNCATED AT 250 WORDS)