MANDIBULAR RECONSTRUCTION

Literature Reading
Friday, March, 19th, 2004

Fari Ananda

Dept of Otorhinolaryngology Head & Neck

Surgery
Padjadjaran University
Hasan Sadikin General Hospital

Mandibular reconstruction of segmental defects

is important procedure after trauma or
following ablative procedures for oral
malignancies
Function of the Mandible :
Protection of the airway
Support of the tongue & musculature
Anchorage of the lower dentition
Appearance of the lower third of the face
Facial cosmetic
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Interrupting the continuity of the mandible

invariably produces a cosmetic and functional
deformity.
The dysfunction may vary from minimal, as in
the case of lateral defects with negligible loss
of tongue function, to major when more
extensive, combined soft- and hard-tissue
losses are
incurred.
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The major causes of mandibular discontinuity :

Tumor resection
Loss from trauma
Unsuccessful healing of mandibular fracture
Osteonecrosis following radiation therapy
Atrophy due aging and dimeneralization

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The ultimate goal reconstruction is to restore the

patient to the pre-disease state
Goals of primary oromandibular
reconstruction
Restore mandibular continuity
Restore lower facial contour
Maintain mobility of residual tongue
Rehabilitate with a functional lower denture
Improve mastication, deglutition and speech
Restore sensation to denervated lower lip
Restore sensation to resurfaced portions of
oral cavity
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Inferior Alveolar nerve

teeth
Lingual nerve lingual
gingiva
Mylohyoid nerve
mylohyoid muscle
Buccal branch buccal
gingiva
One branch exits for
mental sensory for
lower lip and labial
gingiva
Auriculotemporal and
messeter nerve TMJ

Main blood suply Inferior

alveolar branch of the
internal maxillary artery
Blood suply for TMJ
Several branches of the
external carotid artery :
Ascending pharyngeal
artery
Superficial temporal artery
Middle meningeal artery
Anterior tympanic branches
of the internal maxillary
artery

Classification of Dental Occlusion

Normal Occlusion
Neurtocclusion

Retrocclusion
Retrusive bite

Mesioocclusion
Protrusive bite

Planning for reconstructive procedure

Often the defect is composed of both soft and hard-tissue components
History of radiation therapy and surgical scarring
Evaluation of the patient to define the full extent
of the bony and soft-tissue components
Clinical examination
Radiographic evaluation
Hyperbaric oxygen therapy
Timing 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
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0,4%

18%

5%

3%
9%

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23 %

41 %

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Complete
Disarticulation

Oblique
Subcondylar
Osteotomy
Horizontal
Osteotomy
Above Lingula

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Andy Gump Deformity

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The quality and quantity of the soft-tissue bed

The ideal soft-tissue bed Enough bulk,
vascularity, fibroblasts, and pluripotential cells
Some of the reasons for graft failure mucosal
dehiscence, graft infection leading to complete
loss of the transplanted bone, and late graft
resorption
Graft resorption hypocellularity of the recipient
bed
The use of hyperbaric oxygen tends to reverse the
hypocellularity, hypovascularity, and hypoxia
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Marx and Ames

A greater cellular matrix of viable fibroblasts and
neo-angiogenesis is achieved enhances the
level of perfusion heal and support the
transplantation of the nonvascularized bone graft

Phase I Lag phase

Phase II Rapid
Response
Phase III Plateu phase
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There are no absolutly rules

Based on the location of the mandibular
defect
Immediate
Delayed
Resection secondary to
Malignant tumor
benign tumor
excision
Reconstruction of a
Possible local tumor
failed mandibular
reccurance
repair
Gun shot woun
Post radiotherapy
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Options in Mandibular
Reconstruction
Alloplasts
Kirschner wire
Steinmann pin
Preformed appliances
Silastic
Acrylic
Fluoroethylene (Teflon)
Titanium tray
Vitallium (chromiumcobalt) tray
Polyurethane and Dacron
mesh

Free bone grafts

Autogenous
Cortical
Cancellous
Corticocancellous chips
Allogeneic
Cancellous
Corticocancellous
Biodegradable cribs
(rib, ilium, mandible)
Combination grafts
(allogeneic cribs filled
with
particulate autogenous
bone) PBCM

Options in Mandibular
Reconstruction
Pedicle flaps
Rib/pectoralis
major
Rib/latissimus
major
Scapula/trapezius
Clavicle/sternocleid
omastoid
Calvarum/temporal
is
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Free flaps
Rib
Scapula
Fibula
Ilium
Radius
Ulna
Humerus
Metatarsus
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Bone formation Endochondral and membranous

Factors that influence of healing Age,
Vascularized soft tissue, avoidance of
contamination, degree of injury, bone
fragments, complete immobilization
Bone healing cells osteoblast, osteoclast and
osteocyte
3 phases of bone healing
Immediate reaction
Reparation
Remodeling
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Immediate Phase
Hematoma formation
Inflammation
Cells induction
Reparation
Primary bone healing Close defect, normal
bone remodelling with rigid fixation, no
external callus, type I collagen
Secondary bone healing Gap exists in fracture
fragment, no rigid fixation, callus formation
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Early stage similar with healing but later stage differ

Axhausen`s two phase theory of osteogenesis
Phase I
Start early after grafting , continues for the first 4
weeks
Ultimate size of the bone graft
Phase II
Begins at 2 weeks, peaks 4 weeks, slowly 6 weeks
Transformation of pluripotential host cells onto
osteoblastic cells
Remodeling of phase I
Host fibroblast growth into graft mediated by BMP
Total loss host tissue cannot support the graft
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Particulate Bone/Cancellous Marrow

The best osteogenic potential free bone grafts
Provide sufficient amount osteoblast to support
both phases
Lacks structural integrity and requires a carrier
such as alloplastic or allogenic cribs
3 tipe allogeneic cribs
Allogenic mandibles
Allogenic ribs
Allogenic iliac bone
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Ideally similar
morphology
Reconstructing ramus or
TMJ
Hollowed out to form crib,
adapted to remaining
fenestrated to facilitate
host tissue ingrowth
fixed with screw
packed with PBCM

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Rib is split longitudinally and the 2 cortical

strips are then contoured to the surgical
defect
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For large defect

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Several cutaneous and myocutaneous flaps are

available for use in the closure of soft-tissue
defects of the oral cavity
Cutaneous flaps
Forehead
Deltopectoral
Nape of neck

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Muscle/musculocutaneous
flaps
Pectoralis major
Trapezius
Latissimus dorsi
Sternocleidomastoid
Temporalis

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Vascularized bone, transferred as either a

regional flap or a microvascular free flap,
resists infection and extrusion.
Its independent blood supply allows it to heal
rapidly and to become incorporated to the
remaining mandible, regardless of the quality
of the vascularity in the surrounding recipient
bed.

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Limitations in the use of regional flaps The stock of

bone is inadequate
The introduction of free flap transfers the vascularity
to the bone was usually greater than the regional flaps

Donor sites for vascularized bone-containing free flaps

Bone

Vascular pedicle

Ilium
Scapula
Fibula
Radius
Ulna
Humerus
Metatarsus
Rib

Deep circumflex iliac artery

Subscapular artery
Peroneal artery
Radial artery
Ulnar artery
Profunda brachii artery
Dorsalis pedis artery
Intercostal artery

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Ideal qualities for the

osseous component
of a composite free
flap

Well vascularized
Sufficient length,
width, height
Natural contour
simulates shape of
mandible
Minimal morbidity
Accessible for twoteam approach

Ideal qualities for

the soft-tissue
component of a
composite free flap
Well vascularized
Thin and pliable
Mobile relative to
bone
Sensate
Lubricated
Minimal morbidity
Accessible for twoteam approach
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Implants have been used as

spacers and/or for the internal
fixation and stabilization of
bone grafts and mandible

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Soft monofilament steel wire 0.35, 0.4, 0,5 mm

Stabilization wiring :
Horizontal wiring Simple ligation, Essig &
Risdon wiring
Intermaxillary fixation Direct dental wiring,
Noncontinuous, Continuous wiring,
Circummandibular wiring
Fixation Wiring :
Direct osseous 2 hole, 4 hole figure of 8, 2
hole
figure of 8
Transosseous wiring
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Risdon Horizontal Wiring

Circummandibu
lar Wiring
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Non Continuous Wiring

Continuous Wiring
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Direct
Osesseous

Transosseous
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Splints offer a number of approach to IMF

May be made of wire, arch bars or plastics

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Metal
Splints

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Screw is used to
stabilize lamellar
fracture
V 4 AS steels screws
2.0 2.7 mm
Interfragmental
compressions
Drilling process is a
critical part
Complication
Loosening of bone
screw
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For all types of fracture

Rigid internal fixation
Four types of appliances of internal fixation
Dynamic compression plate
Eccentric dynamic plate
Reconstruction plate/Mandibular bridging
plate
Lag Screws
High stability defect compression plate,
splinting or combination
Anatomic reconstruction small/large
compression plate, stabilization plate

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Indication for RIF

Contraindicated for IMF
Special need for mandibular rigidity
Special need for access to oral cavity
Prolonged fixation
Contrandication for RIF
Simple fractures
Insufficient bone tu support hardware
Extensively comminuted fracture
Major loss of bone
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Advantages for RIF

More comfortable during healing process
Good nutrition
Oral hygiene easily maintained
No compromise in oral airway
Lower rates of infection
Disadvantages
Need for wide exposure Longer incision
Large amount of implanted foreign material
Longer operating and times
Expensive and higher complication
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Pressing the bone

fragments tightly
together and creating
high degree of stability
Spherical gliding
principle
Classic design for 4 hole
compression plate

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Overcountoring a compression plate by 3 to 5 degrees

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For segmental,
comminuted
fractures and
fractures of the
atrophic senile
mandible
Usually function as a
monocortical
retention plate
Satisfied for treatment
of pediatric fractures

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Indication
Long term stabilization
Maintenance space and spatial relationships
Contraindicated for IMF
Advantages
Relatively rigid immobilization
Exact spatial relationships may be maintained
Lack of instruments ang foreign body implantation
on fracture site
Disadvantages
Not cosmetically
Scars are produced at pin puncture
Bone infection and requires special equipment
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Refers to surgical procedure that cut into or

through the mandible
Gaining access to deeper structures, removing
diseased tissue adjacent to mandible,
preserving maximum mandibular function
and facial appearance
Is also a valuable technique for mandibular
mobilization and repositioning to correct
traumatic and congenital deformities

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Approach for anterior

and posterior oral cavity

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Approach to posterior, near the junction

of the posterior body and the angle
mandible

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Adequate acess to mid

and posterior oral
cavity, tonsil,
oropharynx
Avoiding injury and
transection of the
genioglossus,
genihyoid and digastric
muscle
Preserves the sensory
innervation of the
lower lip and chin
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Problem after oromandibular reconstruction loss of

sensation in larger areas of oral and pharyngeal
mucosa
Oral cavity food trapping, disturbed oral hygiene ,
mastication problems, disturbed deglutition and lifethreatening aspiration
Solution Sensate soft tissue free flap + vascularized
bone
Donor sites radial forearm, ulnar forearm, lateral
arm, dorsalis pedis, and rib donor sites provide skin
with a sensory nerve
The use of a separate sensate cutaneous free flap in
combination with a vascularized bone free flap such
as the iliac crest or fibula
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The sensory innervation of the lower lip

restored via nerve grafting between the
proximal stump of the inferior alveolar nerve
and distally the mental nerve
The nerve can then be reconstructed using an
autogenous nerve graft :
Greater auricular
Sural nerve
Anterior bracheocutaneous nerve
Lateral femoral cutaneous nerves
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Three types of dental prostheses

1. Conventional tissue-borne dentures
Least stable prosthesis
Partial restoration if the residual teeth can be used

2. Implant-borne denture
Fixed, retrievable, most stable form
It is useful for one-quadrant restoration

3. Implant-assisted denture
Removable prosthesis supported by two or more
implants
in the symphyseal region
More stable and retentive than conventional
dentures
and less costly than the implant-borne
prosthesis.
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Oromandibular reconstruction is a problem of both

the bone and the soft tissue. The quality and
quantity of the soft-tissue bed are critical part
The ultimate goal mandibular reconstruction is to
restore the patient to the pre-disease state
good mandibular function and appearance
There are many option for mandibular
reconstruction Corticocancellous bone chips are
advantageous they provide the osteoblasts
necessary for bone formation promote rapid
revascularization.
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Bone vascularity may be maintained through

regional flaps or composite free flaps.
Vascularized bone-containing free flaps
broadening the surgeons ability to restore
oral cavity anatomy and function
Sensation oral cavity and lip can be restored
with sensate free flaps

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Brent.B. Brent.B.P The Artistry of Reconstructive Surgery.
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Butcbinder D.W. Urken M.L. Mandibular Reconstruction in Byron
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Cumming W C. Frederickson J M. Otolaryngology-Head and Neck
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