Non-vascularized auto bone grafting in segmental defect of mandible in treatment of benign tumor

Abstract: Introduction: Segmental resection of mandible followed by immediate reconstruction of the defect is a frequent procedure in treatment of benign tumors. There are various methods of reconstruction targeted to returning of mandible towards the previous status anatomically and functionally. Reconstruction of mandibular defect by auto nonvascular bone grafting is common approach among the all methods in case of subperiosteal resection due to some pathological lesions. Purpose: The aim of this observational study is to make sure the efficacy of non-vascularized auto bone grafting after resection of mandible in treatment some of the benign pathological conditions of mandible. Materials and Methods: In this observational study was done in the department of oral and maxillofacial of BSMMU and Health and Hope Hospital of Dhaka city during the period of December 2003 to December 2011, ( 84) seventy four consecutive patients under went to subperiosteal resection of mandible and reconstruction of various defect with auto nonvascularised bongrfting. All reconstructions of various length were done with iliac bone except in 3 cases. Bone fixation was done by miniplates, reconstruction plate, continuous miniplates in most of the cases including wiring in 2 cases. Results: Among the all excellent results were in 77 cases anatomically and funcationally. Complications were developed in 7 cases including infection in 3 cases. Conclusion: The reconstruction of mandible with auto nonvascularised bone grafting iliac bone is an excellent method in treatment of benign tumor of mandible after subperiosteal excision followed by rigid fixation.

Introduction:
Reconstruction of mandible is often cited as a major challenge to the modern Maxillofacial surgeons. Because of its complexity and unique characteristics in structure and contour, it is a unique bone of importance. It bears half of the dentition, facilitates mastication, contributes to speech & swallowing and also supports the tongue base to maintain a patent airway. Considering these attributes, it is obvious that reconstructive techniques for mandible are both technically demanding to perform and a challenge for

the surgeon. At the same time the resection of mandible is an obvious procedure in treatment of some benign pathologies like ameloblastoma, central gient cell tumor, ossifying fibroma, keratocyst etc. Segmental resection always creates a defect or a boney gape in the continue of total mandible. . The goals of mandibular reconstruction are restoration of both form and function. That involves duplication of bone form and volume, achievement of optimum primary fixation & stability to facilitate rapid bone union, reproduction of pre-existing jaw relationship, mandibular movement & soft tissue support and the provision of dental implants for dental rehabilitation. Different techniques of mandibular reconstruction have been demonstrated for over hundred years. A long standing controversy existed between immediate or primary reconstruction and delayed or secondary reconstruction. Patients undergoing reconstruction after mandibular resection usually have a benign odontogenic or nonodontogenic lesion or a malignant squamous cell carcinoma that has invaded the mandible. A malignant lesion has a high probability of requiring postoperative radiation. Effective radiotherapy requires that the dosing schedules are completed and not interrupted, so the surgical wounds needed to be healed within 4 to 6 weeks. Recent advent of local pedicled flaps and distant microvascular composite grafts meet this requirement. But the proponents of delayed reconstruction postulated that immediate reconstruction with microvascular composite flaps covers the primary site, decreasing he ability to detect recurrence and the post operative anastomosis sites. Composite flaps also may provide an insufficient height of bone disfavoring oral rehabilitation with dental implants. Moreover, the bone margin should be ensured clear because frozen section although are fairly reliable for soft tissue but are less suitable for mandibular margin. Again, argument follows in favour of immediate reconstruction that the fibrosis following surgery in many cases compounded by radiotherapy, fixes malpositioned mandibular segments and the associated soft tissues in an abnormal position and the spatial relationship is lost. The reconstruction plate used to maintain the spatial relationship often gets exposed by wound breakdown. And precise relocation of the mandibular segments is seldom achievable. Benign pathology of mandible can exhibit both aggressive and non-aggressive behaviour. The decision to resect a portion of mandible depends on the size & location of the lesion and the chances of recurrence. While en bloc principle of tumour excision with a healthy margin is respected in surgical management, appropriate immediate reconstruction can produce excellent early aesthetic and functional rehabilitation. Only a single, combined ablative and reconstructive surgery allows both simple and optimal reconstruction without distortion, deviation or any other complication. This study presents the quality of non-vascular bone graft for immediate reconstruction of mandibular defects after resection of bone in benign cases. Patients and Mathods:

Sl Type of bone defect 1 2 3 4 Segmental defect

Grafting material

No. of patient Result

Iliac crest as a block 51 (auto genous) Marginal defect with preservation of 2-3 mlIliac crest as a block 16 lower border of mandible (auto genous) Marginal defect inferior 1mm above inferiorRib(auto genous) alveolar nerve 1

Excellent (One poo

Excellent (one poo Excellent Poor

Segmental defect with disarticulation TMJ inIliac crest as a block1 same side with costochondral (auto genous)

Segmental defect

Non vascular graft

fibular1

Excellent

Segmental defect

Auto frozen mandible

4 84

Excellent(except 1)

Total

Distribuation of the patient according to pathology N0 1 2 3 4 5 Diagnosig Number Patient Ameloblastoma 37 Central gient 12 cell tumor Ossyfing 11 fibroma Keratocyst 23 Dentigerous 13 Cyst of

84

Distribution of Segmental Defects According to HCL classification No 1 2 3 4 5 6 7 Type of Defect H C L HL CL HCL LCL Number Patient 0 15 32 11 20 2 4 of

84

Lenhtg of Defect No Length of Number defect in cm Patient 1 2-3cm 5 2 4-5 cm 21 3 6-7 cm 25 4 8-9 cm 23 5 9-10 cm 10

of

84

Fixation methods N0 Fixation device 1 2 3 4

Number patient Trasossous Wiring with 12 additional IMF Miniplates in both 10 edns(stainless steel) Miniplates in both edns 24 titanium(coted) Contionuous miniplates 13 titanium (coted)

of

5 6 7

Contionuous 5 miniplates(stainless steel) Reconstruction plate 11 titanium (coted) Reconstruction plate 9 (stainless steel) 84

Results: N0 1 2 3 4 5

Excellent(anatomically & Functionally) TMJ pain Deformity & Occlusion Disharmony Rejection Infection

72 1 3 2 2

Dissussion: