下颌骨节段性缺损541例临床回顾性研究

目的对下颌骨节段性缺损患者临床特点和治疗方法进行回顾和分析，为下颌骨个复重建提供理论依据和指导。方法 分析541例下颌骨节段性缺损患者的一般情况、下颌骨缺损原因、缺损部位、修复重建方法及并发症。结果541例下颌骨缺损中，肿瘤是导致缺损的主要原因；缺损中以不超过中线的一侧缺损为主要类型（426例，占下颌骨体部缺损的82.4%）。修复方法包括直接关闭创口、单纯软组织瓣修复、单纯钛板修复、钛板＋软组织瓣修复和骨瓣修复，其中骨瓣修复（234例）、钛板＋软组织瓣修复（103例）及单纯软组织瓣修复（142例）是最常的修复方法。最常见的局部并发症是感染或瘘道（55例），感染率10.2%。结论本组下颌骨缺损患者的年龄颁布与以往的有关报道相似，肿瘤是缺损主要原因，下颌骨体部是最容易累及的缺损部位，大部分缺损中包含软组织缺损下颌骨复合缺损，在诸多修复方法中，血管化的自体骨组织瓣移植已经成为下颌骨重建的主要方法。口腔颌面肿瘤患者在骨组织重建的同时，相邻软组织的重建应引起足够重视。     

Long-term results after mandibular continuity resection in infancy: the role of autogenous rib grafts for mandibular restoration

Reconstruction of mandibular defects after tumor resection in infants is a particular challenge. Although autogenous rib grafts have no relevance nowadays for restoration of mandibular bone defects after ablative tumor surgery because of limited bone stock and the availability of other donor areas, they are a useful surgical alternative after tumor surgery in infants.We here report on a 6-month, 5-year, and 10-year follow-up of three children who were diagnosed with benign tumors of the mandible with osseous destruction at the ages of 4 months, 6 months, and 2 years, respectively. Histologic diagnoses were melanotic neuroectodermal tumor, hemangioendothelioma of the mandible, and ameloblastoma. After continuity resection of the mandible, latero-mandibular bone defects were restored using autogenous rib grafts. Both clinical and radiologic follow-up visits in all children were performed to assess growth of the facial skeleton as well as the mandibular growth.Cephalometric measurements on Panorex films and three-dimensional computed tomographic scans revealed slight vertical growth excess and transversal growth inhibition of the reconstructed mandible in comparison with the nonoperated side.Although further growth of rib grafts is difficult to predict and occlusal disharmony may occur because of physiologic maxillary growth and growth of the unaffected mandible, we think that autogenous rib grafts can be ideally used for restoration of mandibular continuity defects in newborns and young children. Clinical follow-up visits on a yearly basis and orthodontic controls are useful for early orthodontic treatment of growth deficits. Further corrective surgery with bone augmentation or osseous distraction is required after completion of growth of the facial skeleton.     

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.     

Das autologe Rippentransplantat zur Überbrückung von Kontinuitätsdefekten des Unterkiefers

Background

Reconstruction of mandibular defects following tumor resection in infants is a particular challenge. Although autologous rib grafts have no relevance nowadays for restoration of mandibular bone defects following ablative tumor surgery due to limited bone stock and the availability of other donor areas, they are a useful surgical alternative following tumor surgery in infants.

Patients and method

We here report on the 5- and 10-year follow-up of two children who were diagnosed with benign tumors of the mandible with osseous destruction at the age of 4 and 6 months, respectively. Histological diagnoses were melanotic neuroectodermal tumor and hemangioendothelioma of the mandible. Following continuity resection of the mandible lateral mandibular bone defects were restored using autologous rib grafts. Yearly clinical and radiological follow-up visits in both children were performed to assess growth of the facial skeleton as well as mandibular growth.

Result

Cephalometric measurements on panorex films as well as 3D CT scans revealed slight vertical growth excess and transversal growth inhibition of the reconstructed mandible in comparison with the non-operated side.

Discussion

Although further growth of rib grafts is difficult to predict and occlusal disharmony may occur due to physiologic maxillary growth and growth of the unaffected mandible, we believe that autologous rib grafts can be ideally used for restoration of mandibular continuity defects in newborns. Clinical follow-up visits on a yearly basis and orthodontic controls are useful for early orthodontic treatment of growth deficits. Further corrective surgery with bone augmentation or osseous distraction is required following completion of growth of the facial skeleton.     

Results of mandibular bone plastic repair with vascularized autotransplants

A total of 96 vascularized flaps used in the reconstruction of the mandible in 91 patients are analyzed. In 82 cases the defects appeared after treatment of malignant and benign lesions of the mandible. In 18 patients the mandible was reconstructed using rib grafts. The lateral border of the scapula was used in 30 patients and fibular grafts in 12 patients. In 36 cases mandibular and soft tissue defects were corrected using vascularized latissmus dorsi flaps combined with the tenth or eleventh rib. The results were positive in 86-92% of the cases. The postoperative analysis shows excellent esthetic and functional results in all the patients who had primary plastic reconstruction of the mandible and the results were good in 36% of cases of secondary plastic reconstruction of the mandible. The donor sites in all cases showed no functional disturbances.     

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.     

35例自体髂骨同期修复重建下颌骨缺损回顾性分析

目的:对同期行自体游离髂骨修复重建下颌骨缺损患者的临床资料进行回顾性分析,比较非血管化/血管化两种髂骨移植形式修复下颌骨部分或节段性缺损术后的成活率。方法:选择2008年1月～2010年12月,在武汉大学口腔医院口腔颌面外科行同期自体游离髂骨移植修复重建下颌骨缺损的患者35例。回顾临床资料,对血管化或非血管化髂骨移植的病变类型、下颌骨缺损的部位和大小、修复重建方法以及髂骨的成活率进行比较。结果:纳入研究对象35例,男19例,女16例。年龄16～65岁,平龄39岁。非肿瘤性疾病4例,占11.6%;良性肿瘤22例,占62.7%;恶性肿瘤9例,占25.7%。血管化和非血管化髂骨的平均长度分别为(5.9±1.2)cm和(5.5±1.4)cm,(P=0.407);平均高度分别为(2.7±0.4)cm和(2.3±0.6)cm,(P<0.05)。血管化髂骨和非血管化髂骨的总成活率分别为100%和76.2%,(P<0.05)。非血管化髂骨修复重建下颌骨部分缺损和节段性缺损的成活率分为别91.7%和55.6%,(P=0.055)。非血管化髂骨长度>5.5 cm和≤5.5 cm的下颌骨缺损的成活率分别为63.6%和91.7%,(P=0.311)。结论:血管化髂骨移植适用于长度在8cm以内的下颌骨体部分或节段性缺损的修复重建;非血管化髂骨适用于修复重建长度<5.5 cm的下颌骨部分缺损。     

Restoration of oral functions following a (partial) mandibulectomy due to an oral carcinoma

For patients diagnosed with malignant oral lesions invading the mandible, a partial or complete mandibulectomy is unavoidable. In predicting the invasion of the lesion, preoperative imaging techniques are used, such as an orthopantomogram, computed tomography, and magnetic resonance imaging. A mandibular discontinuity can be restored using a stainless steel or titanium reconstruction plate, or using autogenous non-vascularized or vascularized bone grafts. In achieving the goal of complete rehabilitation endosseous permucosal implants can be inserted in order to support a prosthesis. There is a tendency of a higher implant loss frequency among bone-grafted patients who have had implants after irradiation when compared with non-irradiated patients. After a (partial) mandibulectomy, oromandibular reconstruction by non-vascularized or vascularized bone grafts and endosseous implants provides a unique opportunity to restore some oral functions.     

Immediate permanent reconstruction of a mandibular continuity defect with use of a prosthesis of chromium-cobalt alloy.

A report of ten-year follow-up examinations of a patient who had a hemimandibulectomy with disarticulation because of fibrous dysplasia and immediate permanent reconstruction of the mandible with a Vitallium custom-cast prosthesis is presented. Careful preoperative planning, operative technique, and postoperative follow-up examinations are essential for successful maintenance of the prosthesis. Autogenic bone grafts are, in general, superior to alloplasts in permanent reconstruction of defects in mandibular continuity after resection. However, there are indications for alloplastic reconstruction when the condyle is disarticulated with the resection.     

Vertical distraction osteogenesis of fibula transplants for mandibular reconstruction--a preliminary study.

INTRODUCTION: When reconstructing the mandible after tumour resection with a fibular graft, the mandible is often vertically deficient, making placement of dental implants impossible. PATIENTS: Segmental vertical distraction of the reconstructed mandible was performed in nine patients following tumour surgery between February 1998 and 2001. Their age was 14-65 years (average 46.3); all underwent radiotherapy with a dose of up to 55.6 Gy prior to tumour resection. Mandibular discontinuity was repaired with a microvascular fibular bone graft. All grafts had a vertical bone deficit ranging from 9 to 12 mm when compared with the non-resected part of the mandibles. METHODS: All patients underwent segmental vertical distraction of the transplants. The distraction devices were applied intraorally. Distraction of 1.0 mm/day was performed using a Martin distractor (TRACK 1.5) followed by 12 weeks retention time. RESULTS: The increase of vertical bone height was stable and enabled placement of dental implants without any complications. CONCLUSION: Vertical distraction osteogenesis may become a common procedure in the treatment of alveolar ridge deficiency resulting from transplanting fibulae for mandibular reconstruction following tumour surgery.     

Efficacy of PRP in the Reconstruction of Mandibular Segmental Defects Using Iliac Bone Grafts

This retrospective study was conducted to evaluate the role of platelet-rich plasma (PRP) in the reconstruction of segmental mandibular defects using iliac bone grafts. Thirteen patients underwent reconstruction of post-resection segmental defects of the mandible using titanium reconstruction plates, cortico cancellous iliac bone graft. The patients were randomly separated into two groups. One group of the patients received a PRP graft in addition to the iliac bone graft. Post-operative dimensions of the graft were measured and compared to assess the efficacy of PRP in reconstruction of segmental defects. The post-operative follow-up radiographs confirmed consolidation of the graft in all cases and the segmental defect was obliterated. Thereby mandibular continuity was successfully achieved in all cases. Two patients in the non-PRP group developed an infection and were administered additional antibiotics. The infection was contained and the grafts survived. The use of PRP along with autogenous bone graft may be advantageous since it appeared to enhance the quantity of bone formed. Further long-term follow-up and studies are required to effectively establish the efficacy of PRP and autogenous free bone grafts in the reconstruction of bony defects.     

Surgical treatment and reconstruction for central giant cell granuloma of the jaws: A review of 18 cases

Central giant cell granuloma (CGCG) is an uncommon benign bony lesion that occurs in the mandible and maxilla. The clinical behaviour of CGCG ranges from a slow-growing asymptomatic swelling to an aggressive lesion that presents pain, local bone destruction, root resorption and tooth displacement.Therapeutic options have varied greatly over the years. Non-surgical treatments with alpha interferon (α-IFN), calcitonin and corticosteroids have been described and their benefits may be worthy of consideration. Surgery is considered the traditional treatment and it is still the most accepted one, however in the literature not all authors agree on the type of surgery which should be performed.Although en bloc resection provides the lowest recurrence rate, only a few single case reports describe the use of this technique followed by reconstruction with autogenous bone grafts.The authors report their experience with en bloc resection of 18 wide CGCGs which had not been previously treated medically. Immediate reconstruction was carried out for all cases and in one, a fibula free flap was used to reconstruct the mandible. No recurrence was observed. After complete healing of the graft, prosthetic rehabilitation via implants was performed. This allowed the best functional and aesthetic results.     

Staged protocol for resection, skeletal reconstruction, and oral rehabilitation of children with jaw tumors.

PURPOSE: The purpose of this study was to evaluate a staged protocol for resection of jaw tumors and reconstruction including implants in pediatric patients. PATIENTS AND METHODS: Nine children were evaluated retrospectively. Data included age at resection, tumor type, use of adjuvant therapy, type of bone graft, and number of implants. Occurrence of postoperative infection, tumor margins, recurrence, plate fractures, number of bone grafts, implants restored, and failures were recorded. RESULTS: Ages ranged from 3.5 to 16 years with 2 maxillary and 7 mandibular tumors. Diagnoses included giant cell lesion (n = 3), osteosarcoma (n = 2), myofibroma (n = 1), ossifying fibroma (n = 1), desmoplastic fibroma (n = 1), and ameloblastoma (n = 1). No patients experienced postoperative infection, wound dehiscence, or jaw instability after en bloc resection. One patient had recurrence of a giant cell lesion. To date (mean, 56 months; range, 24 to 93 months), there have been no additional recurrences. There was 1 plate fracture. Eight patients underwent iliac bone grafts (stage 2), and in 1 patient, the mandible regenerated. There were no graft infections or wound dehiscences. Three patients required additional bone grafting for implant placement. Twenty-three implants were placed in 7 patients without complications, and 21 implants have gone to second stage. One implant failed to osseointegrate. Six patients have had prostheses placed and loaded for a mean of 26 months (range, 5 to 64 months). One patient is scheduled for prosthetic restoration and 2 for implant placement. CONCLUSION: Pediatric maxillofacial tumors can be successfully treated by resection, rigid fixation, and delayed reconstruction with minimal morbidity and a high success rate.     

Early treatment of severe mandibular hypoplasia with distraction mesenchymogenesis and bilateral free fibula flaps

The technique of distraction has revolutionized the treatment of mandibular hypoplasia; however, presently large mandibular defects still require bone grafts. Microvascular grafting is commonly used in adults. Conversely, in pediatric reconstruction, nonvascularized rib grafts remain standard. Unfortunately, resorption of nonvascularized bone remains a major issue, particularly when soft tissue is hypoplastic. This case study represents a combination of techniques in the treatment of severe mandibular deficiency, and introduces the concept of distraction mesenchymogenesis. The patient was a 2 1/2-year-old boy with severe bilateral Pruzansky class III mandibular hypoplasia. He had a permanent open mouth posture, an overjet of 23 mm, and was unable to move the lower mandibular segment. His oropharyngeal airway diameter was 2.2 mm and he was tracheostomy dependent. The patient was treated with distraction of the lower jaw mesenchyme followed by bilateral functional free fibular microvascular flaps containing reinnervated muscle. This created a well-vascularized body, ramus, and condyle bilaterally within an adequate soft-tissue envelope. Postoperatively, the overjet was reduced to 5 mm. The patient can now actively move his mandible. Airway diameter increased to 10 mm, and the patient is able to tolerate intermittent tracheostomy plugging. This innovative combination of techniques allows early intervention, limits graft resorption, and improves airway control.     

Long-term evaluation after mandibular reconstruction with fibular grafts versus microsurgical fibular flaps.

PURPOSE: This retrospective study was performed to compare the bone resorption rates of revascularized free fibular flaps with those of avascular fibular bone grafts. Special attention was drawn to horizontal bone resorption. PATIENTS AND METHODS: One hundred twelve patients who had received fibular grafts for reconstruction of the mandible were included in this study. Surgery was performed between 1991 and 2004, leading to a follow-up of 12 to 140 months. In 7 cases, microvascular onlay grafts (group A), and in 61 cases, microvascular reconstruction of segmental defects (group B) were performed. Avascular onlay grafts were applied (group C) in 41 patients and avascular reconstruction of segmental defects (group D) was performed in 7 patients. Bone heights were measured on panoramic views at 1, 3, and 7 years postoperatively. RESULTS: Most of the resorption in group B occurred during the first postoperative year, at an average rate of 16% (range, 3% to 30%). After the first year, transplants became almost stable, and an average of 80% of bone height was maintained after 7 years. Conversely, bone resorption continued regularly in group C, and up to an average of 51% (range, 5% to 80%) of bone height was lost after 7 years postoperatively. CONCLUSION: After mandibular reconstruction with fibular transplants, resorption occurs among both microsurgical and free grafts; however, the bone resorption rate was higher among avascular grafts. In group A and B patients, fibular grafts became stable after 1 year, but bone resorption continued at a regular rate in groups C and D.     

Resection and immediate reconstruction of parts of the mandible via intra-oral route

Our experience in partial resection of parts of the mandible with immediate reconstruction using the iliac crest via the intraoral route is presented. 12 patients were treated in this way and the follow up varied between 1 to 3 years. The criteria assessed in the follow up included, behaviour of the bone graft, aesthetics functional behaviour of the bone transplant under the denture plates, and function of the mandibular branch of the facial nerve. Though infection with discharge of pus was noticed a few days post-operatively, with meticulous care with the use of systemic antibiotics and local irrigation of the wounds with antibiotics solution, the infection was usually overcome. Only in 2 cases were the bone grafts removed because the patients could not tolerate the nasogastric tube feeding for more than 2 or 3 days post-operatively and there was wound dehiscence with exposure of the graft. However the result achieved in this study made us conclude that the intra-oral approach for resection and immediate reconstruction of parts of the mandible will be our method of choice whenever possible.     

Mandibular reconstruction with bone grafts.

A total of 23 patients with partly resected mandible were repaired with autogenous bone grafts from the iliac crest and ribs. The reasons for reconstruction are presented in Table 1. The grafts healed without complications in 21 cases. With the exception of two of the cases with gunshot wounds, all patients recovered good mobility of the jaw and satisfactory mandibular contours. The patients had been folloed up for 6 months to 11 years. Radiographic examination at the last examination showed that resorption of the graft had been only slight or moderate. Through marrow-spongious bone grafts are regarded as best from an osteogenetic point of view, our cases showed that good results can be achieved also with solid block grafts. The authors discuss the use of plate osteosynthesis without IMF instead of other types of graft fixation and IMF. In six cases where the area of the graft was loaded with a prosthesis, resorption was not more extensive than in the other cases.     

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.     

自体颏外板在眶底骨折缺损重建中的应用

目的 探讨自体颏外板修复眶底骨折缺损的效果。方法 对11例眶底骨折缺损患者,采用自体下颌骨颏外板进行眶底重建修复,术后随访6~12月。结果 11例患者术后伤口均一期愈合,眶底结构恢复,无视力下降和眼球运动受限,移植物均无感染排出或吸收,供区无并发症发生。结论 自体颏外板是眶底骨缺损较为理想的一种修复材料。     

Immediate reconstruction of a large mandibular defect of locally invasive benign lesions (a new method)

Locally invasive benign tumor and large lesions such as ameloblastoma, giant cell granuloma, odontogenic keratocyst, and odontogenic myxoma are a benign, invasive, lesions of the jaws that predominantly affects the mandible. Despite the benign nature of these lesions, there is a high rate of local recurrence after curettage, which usually requires resection. The traditional surgical approach for resection of these lesions, via either mandibulotomy or mandibulectomy is extraoral approach which is associated with significant functional and esthetic sequelae. A case series is presented here in which less invasive and intraoral approach. An intraoral approach provides wide and fast access to the mandible. This approach represents a less invasive alternative that provides access to the mandible for curative resection of benign tumors with minimal postoperative sequelae. At 5 years follow-up, there were minimal functional and esthetic defects.We explored the use of the less invasive and more esthetic incision as an approach to resection and reconstruction of the mandible. It is our belief that these concerns have been best addressed by the minimally invasive procedure used in this report. This approach resulted in a minimal esthetic and functional defect even though a massive mandibular resection was performed.