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Reconstruction of mandibular defects - clinical retrospective research over a 10-year period -

Reconstruction of mandibular defects - clinical retrospective research over a 10-year period - Backround: Functional and cosmetic defects in the maxillofacial region are caused by various ailments and these defects are addressed according to their need. Simplicity of procedure, intact facial function and esthetic outcome with the least possible donor site morbidity are the minimum requirements of a good reconstruction. Oro- mandibular reconstruction, although a challenge for the head and neck reconstructive surgeon, is now reliable and highly successful with excellent long-term functional and aesthetic outcomes with the use of autogenous bone grafts. Reconstruction of trauma- or mandibular oncologic defects with bony free flaps is considered the gold standard. However the the optimal reconstruction of mandibular defects is still controversial in regards to reconstructive options which include the donor site selection and the timing of surgery. The purpose of this study was to determine the outcome of different osseous reconstruction options using autogenous bone grafts for mandibular reconstructions. Methods: This study was carried out on 178 patients with mandibular bone defects. They were reconstructed with autogenous bone grafts from different donor sites. At post operative visits they were evaluated for functional and cosmetic results. Results: The success rate found in this study was around 90%. Only 7.6% of the cases showed poor results regarding facial contours and mouth opening. All other patients were satisfied with their cosmesis and mouth opening at the recipient sites was in the normal range during last follow-up visits. Donor sites were primarily closed in all cases and there was no hypertrophic scar. Conclusion: Based on this study, autogenous bone grafts are a reliable treatment modality for the reconstruction of mandibular bone defects with predictable aesthetic and functional outcomes. As the free vascularized fibular flap has the least resorption and failure rate, it should be the first choice for most cases of mandiblular reconstruction. Backround Reconstruction of mandibular defects represents a Functional and cosmetic defects in the maxillofacial challenge to the head and neck reconstructive surgeon. region are caused by various ailments that may be con- Interruption of the mandibular continuity produces both genital, pathologic or iatrogenic such as orofacial clefts, a cosmetic and functional deformity. There is limited tumor excision and post radiation necrosis [1,2]. Diverse range of motion when attempting lateral and protrusive injuries such as motor vehicle accidents, firearms, inter- movements of the jaw with a return to midline on open- personal assaults, burns, scalds, electrical flashes and ing or closing secondary to the remaining contralateral splashes are also playing their part to damage the soft muscles of mastication. In addition, malocclusion and and hard tissue of the whole body in general and the problems with proprioception occur [4,5]. maxillofacial region in particular [3]. When undertaking mandibular reconstruction, the restoration of bony continuity alone should not be con- * Correspondence: [email protected] sidered the measure of success. The functions of chew- Department of Oral and Maxillofacial Surgery, Hannover Medical School, ing, swallowing, speech articulation and oral competence Hannover, Germany must also be addressed. The ultimate goal of mandibular Full list of author information is available at the end of the article © 2011 Rana et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Rana et al. Head & Neck Oncology 2011, 3:23 Page 2 of 7 http://www.headandneckoncology.org/content/3/1/23 reconstruction is to return the patient to their previous a) Facial contur and mouth opening state of function. In order to achieve this goal, the b) Radiodensity of the bone and bone resorption rate reconstructive surgeon must attempt to restore bony c) Satisfaction and tolerance for the patients continuity and facial contour, maintain tongue mobility d) Failure of bone grafts and attempt to restore sensation to the denervated areas. Subjects The most common indication for mandibular recon- Approval for the study was obtained from the relevant struction remains ablative surgery for neoplastic pro- ethics committee. In addition, positive written consent cesses of the oral cavity and oropharynx. Other causes was obtained from each person who participated in the of mandibular defects include trauma, infection/inflam- study. mation, osteoradionecrosis, and congenital deformities. After mandibular resection, particularly following com- Patients plex radical resection for advanced oropharyngeal carci- The sample consisted of 178 patients. The patients with nomas invading the mandible, the restoration of form syndrome like cleft and craniofacial deformities were and function is paramount for the rehabilitation of these excluded in the study. Patients with systemic problems, patients [4,6]. pregnancy, coagulative disorders and drugs were also Autogenous bone grafting is the mainstay of mandibu- excluded in the study. lar reconstruction [7]. Sources of non-vascularized auto- genous bone for grafting can be broadly divided into Results local and distant sites and their successful application to The results were collated from 178 patients who reported maxillofacial reconstructive surgery is well documented. with mandibular defects and underwent reconstructions If the defect requiring a graft is small, often local or with various autogenous bone grafts, in the Department intra-oral donor sites are sufficient. When a moderate of Oral and Maxillofacial Surgery, from October 1998 to to substantial amount of bone is required, the distant or September 2008. All the cases that underwent recon- extra-oral sites are usually employed [8,9] structive surgery had some defects in the mandible, either Historically,freebonegraftswerefrequentlyusedfor primarily or after oncological resection/surgery. There mandibular reconstruction. Autogenous bone grafts were a total 178 patients, among those 131 (73.6%) from the calvarium, rib, ilium, tibia, fibula, scapula, and patients were males and 47 (26.4%) were females, radius have been used [10]. Over the past twenty years, age ranged from 13-85 years with an average of 55 years however, the use of vascularized bone grafts has become at the time of presentation. Among 178 patients, 42.1% state-of the-art for mandibular reconstruction. The most (n = 75) patients had oncological resections, 19.6% (n = common donor sites for osseous free-tissue transfer 35) patients were having post temporomanibular joint include the fibula, scapula, iliac crest, and radius [7,11]. ankylosis defects; 24.7% (n = 44) patients had post-trau- With the advent of vascularized osseous free flaps over matic defects and 13.5% (n = 24) patients presented with the past thirty years, reliable mandibular reconstruction the ostoeomyelitis of the mandible. Among 75 patients with success rates of over 90% is possible [11-14]. who had defects due to oncological resection, 50 were The field of mandibular reconstruction has seen monu- those presented with squamous cell carcinoma invading mental advances leading to the current state-of-the-art the mandible, 05 patients had a keratocystic odontogenic reconstructive techniques. Vascularized osseous free tis- tumor, 09 with Ameloblastoma, 02 patients with Denti- sue transfer is the preferred reconstructive modality gerous cyst, 03 patients with Central Giant Cell Granu- today and has shown excellent long-term aesthetic and loma, 02 with Odontogenic Myxoma, 01 patient with functional outcomes. At the present time, autogenous Adenomatoid Odontogenic Tumor, 01 patient with Pind- bone grafting is the gold standard by which all techniques borg tumour and 02 patient had osteosarcoma of the of osseous reconstruction of the mandible must be mandible [Table 2], [Figure 1]. judged and amongst the other available options, is the Among the 44 patients who had post-traumatic most reliable and predictable modality to restore the defects were 22 patients with infected malunion of frac- form and function of the lost mandibular segments [5]. ture sites; 19 patients had the firearm injuries and three patients had the comminuted fracture of the mandible Methods due to road traffic accidents. None of the patients had The aim of this study was to was to determine the out- undergone any previous reconstructive surgical proce- come of different osseous reconstruction options using dure for the mandibular defects [Figure 2]. autogenous bone grafts for mandibular reconstruction in All patients who underwent reconstructive surgery, comparison with the had defects, which affected the patients’ normal lives, Rana et al. Head & Neck Oncology 2011, 3:23 Page 3 of 7 http://www.headandneckoncology.org/content/3/1/23 Table 1 Distribution of Cases by Age and Sex (N = 178) Table 2 Distribution of Cases by Etiology of Defects (N = 178) SEX NO. OF PATIENTS PERCENTAGE MEAN AGE ETIOLOGY NO. OF PATIENTS PERCENTAGE MALE 131 73.6% 55.1 yrs FEMALE 47 26.4% 55.4 yrs ONCOLOGICAL RES. 75 42.1% TOTAL 178 100 % TMJ ANKYLOSIS 35 19.6% POST-TRAUMATIC 44 24.7% OSTEOMYELITIS OF MANDIBLE 24 13.5% therefore, they willingly opted for reconstruction with TOTAL 178 100 % bone grafts [Figure 3]. Among the 178 total patients, 80 (44.9%) had iliac bone grafts, 12 (6.7%) ilium with DCIA, 39 (22.1%) one patient, pleural tear occurred which was successfully patients with rib grafts were harvested for reconstruc- repaired with uneventful recovery. Bone harvesting from tion, while 31 (17.4%) patients were reconstructed with ribprovedtobeareliablesourcewithavery fewcom- the free fibular flap and in 16 (9.1%) patients recon- plications. But the resorption rate was much higher than struction was accomplished with bone graft from the others. Of 31 (17.4%) patients who were reconstructed sternum. Of 92 patients of ilium, 80 (44.9%) patients with the free fibular flap, no major complication was were reconstructed with the iliac bone graft and 12 noted, in two cases there were mild wound infection, (6.7%) patients of ilium with DCIA. All these patients limited to superficial skin slough, which was managed successfully with the local measures and with antibiotic experienced mild to moderate pain at donor site which was well managed with analgesics [Table 3]. cover [Table 4]. Five (5.4%) patients had a postoperative limp, which Another patient presented with mild ankle stiffness resolved after a median of 07 days (range 01-25). There but that resolved well over the two weeks time period. were two (2.2%) superficial donor site infections, which Overall, reconstruction with the free fibula grafts proved resolved well with antibiotic cover. The median length to be very predictable with excellent results. 16 (9.1%) of scar was 60 mm (range 40-90). Only three (3.3%) patients received sternum bone graft for reconstruction patients experienced mild paresthesia of the skin sup- with pectoralis major muscle as a soft tissue cover. plied by the lateral cutaneous nerve of the thigh, which These patients experienced decreased weight lifting improved over the time period of six months. No cases capacity after the surgery. One patient presented with of incisional hernia or with permanent gait changes was suture dehiscence and mild wound infection at the noted. Overall, harvesting bone from iliac crest was well donor site which resolved with the antibiotics and local tolerated by patients with excellent aesthetic and func- wound care. No long term donor site morbidity was tional results. In 39 (22.1%) patients, rib grafts were har- noted in these patients. Infection was checked post- vested for reconstruction and apart from mild to operatively and was assessed whether present or not. On th moderate pain, no serious complication was noticed. In 7 day postoperatively, 18 (10%) patients developed mild infection and in the rest of 160 (90%) patient’s st bone grafts, no sign of infection was noted. On 1 month follow up visit, 08 (4.5%) patients developed infection with pus discharge but 170 (95.5%) patients th had no sign of infection. On 6 months follow up visits, there was improvement in the infection rate and 03 (1.7%) patients presented with the infection while in the rest of 175 (98.3%) patients, no infection was noted. While on their one year follow up visits, there was further improvement and only 02 (1.1%) patients were noted with infection but in the remaining 176 (99.9%) patients, no signs of infection were noted. Facial contour Facial contour was first recorded preoperatively. Only 10 (5.6%) patients had adequate facial contouring on initial Figure 1 Left mandibular defect in a 14 year-old boy following presentation while 168 (94.4%) patients presented with a removal of a keratocystic odontogenic tumor. The inferior poor facial profile. After reconstruction with the bone alveolar nerve was presented as well as mandibular continuity. grafts there were marked improvements postoperatively. Primary bone grafting is planned. On one year follow up visits, 140 (79.5%) patients had Rana et al. Head & Neck Oncology 2011, 3:23 Page 4 of 7 http://www.headandneckoncology.org/content/3/1/23 Table 3 Demonstrating the Donor Graft Sites of Patients Receiving Mandibular Reconstruction (N = 178) DONOR GRAFT SITES NO OF PATIENTS PERCENTAGE/% ILIAC GRAFT 80 44.9% ILIUM WITH DCIA 12 6.7% RIB 39 22.1% FREE FIBULA 31 17.4% STERNUM 16 9.1% TOTAL 178 100.0% while the least resorption after one year was found in free fibula grafts i.e 9.1% [Table 6]. Figure 2 Contomed monocortical bone graft from the iliac Failure of bone grafts crest for reconstruction of lateral mandibular cortex. Failure of bone grafts was assessed postoperatively only and it was based on the infection, radiodensity and good facial profiles, 26 (15.1%) patients had adequate resorption of the harvested bone grafts. Failure was noted results and only 12 (7.6%) patients remained with the whether it occurred or not. No failure of any bone graft th poor facial contour [Table 5]. reconstruction was noted on the 7 day postoperatively. st On the 1 month follow up visit, failure of 07 bone grafts Radiodensity of the bone and bone resorption rate were noted, 16 at the 6 month follow-up while failure of Radiodensity of the bone grafts was checked on radio- 31 patient’s bone grafts were noticed 1 year post opera- graphs postoperatively and was rated as GOOD, tively. Among 178 patients, failure of bone grafts were th PARTIAL or LUCENT. On 7 post operative day bone noted in 31 (17.4%) patients and the remaining 147 grafts of all 178 patients showed GOOD radiodensity, as (82.6%) patients, bone grafting was successful on the one no changes could occur in bone densities, while in the year follow up visit [Table 7], [Table 8]. one year follow up visits, out of 178 patients, radiodensity was GOOD for 147 (82.6%) patient’s bone grafts, it was Discussion PARTIAL for 17 (9.5%) patients and LUCENT for the Reconstruction in the oral and maxillofacial region is a bone grafts of 14 (7.9%) patients. Resorption of individual difficult task. Anatomical, functional and aesthetic bone grafts was checked only postoperatively on radio- aspects have to be taken into account while performing th st graphs on the 7 day, 1 month, 6 months and 1 year reconstructive surgery. Facial contours and animation follow-ups. Out of 178 patients, the highest bone resorp- have to be achieved; normal speech, deglutition and tion after 1 year was found in rib grafts i.e 64.1% followed movements of the jaw are to be considered; upper aero- by sternum 25%, iliac graft 23.7%, ilium with DCIA 16.7% digestive function has to be ensured. Aesthetic units need to be kept in mind and the donor site impairment has to be avoided. Though there are many reconstruc- tive options, from alloplastic bone substitutes to the autogenous bone grafts; the best suited reconstruction option for a particular patient is critical for the restora- tions of mandibular form and function. A total number of one hundred and seventy eight patients were included in our study. Among them 131 were males and 47 were females and people of various ages were included in this study sample. The same surgeon performed all the pro- cedures to reduce the bias. In oncological resection the tumours affecting the mandible, for example, a squa- mous cell carcinoma, ameloblastoma, Pindborg tumour, adenomatoid odontogenic tumour, central giant cell granuloma, odontogenic myxoma were included and the Figure 3 Bone graft fixation was achieved using 2.0 mm cystic lesions like dentigerous cyst, odontogenic kerato- titanium miniplates. Additional autogenous bone chips were cyst; while the post-traumatic defects and the cases of harvested to fill gaps. osteomyelitis of the mandible were also included in the Rana et al. Head & Neck Oncology 2011, 3:23 Page 5 of 7 http://www.headandneckoncology.org/content/3/1/23 Table 4 Distribution Ofinfections up to 1 Year after Mandible Reconstruction (N = 178) th INFECTION IN BONE GRAFTS At 7 day follow-up At 1st month follow-up At 6 months follow-up At 1 year follow-up No. of pts. % No. of pts. % No. of pts. % No. of pts. % PRESENT 18 10.0 8 4.5 03 1.7 02 1.1 ABSENT 160 90 170 95.5 175 98.3 176 99.9 TOTAL 178 100.0 178 100.0 178 100.0 178 100.0 study sample. The most commonindicationfor the of the patient; all these led to poor wound healing with reconstruction in our study was the oncological resec- final failure of the bone grafts. In another patient, the fail- tion (42.1%) secondary to the benign or malignant ure of the bone graft was noted, who was found to be dia- betic after surgery and developed infection with an diseases of the mandible, followed by post-traumatic defect (24.7%); post-operative defects after gap arthro- orocutaneous fistula. This patient also had a history of plasty in TMJ ankylosis (19.6%) and the osteomyelitis of firearm injury with a comminuted fracture of the mandib- the mandible (13.5%). In a similar study carried out by ular body area and reconstruction was undertaken with a Szpindor [15], the most common indication for the rib graft. Though vigorous debridement of the infected reconstruction of the mandibular defects was oncologi- fractured site was done prior to grafting, the underlying cal resection, followed by resections due to osteodystro- immunocompromised host defense with longstanding phy, osteoradionecrosis and trauma. infection, might have caused failure of the bone graft. In our study the success rate of reconstruction with Chiapasco et al [16], in their recently published study autogenous bone grafts was 82.6% (147 patients) while on similar lines, described that no total failure of the the rate of the graft failure was 17.4% (31 patients). graft was observed, while partial loss of the graft was Szpindor [15] demonstrated the positive results or suc- observed in one patient. Cumulative survival and success cess rate of bone grafts of 84%, though his study sample rates were 96.7% and 93.3%, respectively. The success (n = 64) was smaller than that of ours (n = 178), the suc- rate is higher to that of our study i.e. 82.6 % (n = 147) cess rate in our study, is compareable to Szpindor study. and 17.4% (n = 31) failure of the grafts. Underlying In our study the failure of bone grafts was noted in 17.4 comorbidities could be implicated in those patients. % (n = 31) of patients, while many other factors attribu- We also noted facial contour/profile restored by the ted to the failure of these bone grafts. In two patients the bone grafts in the reconstructed patients. In general, the failure of the bone graft was due the recurrence of the contour was restored well in all those patients in whom squamous cell carcinoma which also got secondarily we could maintain the continuity of the mandible com- infected and we had to remove the bone grafts and the pared to those patients with a continuity defect. It’s partly because of the fact that correct anatomical posi- mini plates along with the local excision of the recurrent tion (alignment) of the mandibular resected segments lesion. These patients were subsequently reconstructed withtheiliac crestbonegraft.While in threepatients, and their deviation after a continuity defect is known to there were intraoral extrusion of the bone grafts with be difficult to achieve. associated dehiscence of the sutures and pus discharge. Preoperatively only 10 patients presented with ADE- Curettage of the area was undertaken in these patients QUATE and 168 patients were with POOR facial profile along with removal of the dead bone to treat the osteo- while after reconstruction, on one year follow up visits myelitis of the mandible, which was not resolved in spite 140 (79.5%) patients were satisfied and had GOOD of giving the antibiotic cover and bone graft from the rib. facial contour. 26 (15.1%) patients had ADEQUATE and The contributing factors to the failure of bone grafts in 12 (7.6%) patients remained with the POOR facial con- these cases might be the longstanding chronic osteomyeli- tours. Among these two who were not satisfied with tis of the mandible, additional infection and advanced age their poor contour, one was the patient with the Table 5 Post Operative Facial Contour up to 1 Year after Mandible Reconstruction (N = 178) FACIAL CONTOUR PRE-TEST POST-TEST th No. of pts % At 7 day follow-up At 1st month follow-up At 6 months follow-up At 1 year follow-up No. of pts. % No. of pts. % No. of pts. % No. Of pts. % GOOD 00 00 142 80.7 140 79.5 143 80.3 140 79.5 ADEQUATE 10 5.6 26 15.1 25 14.0 24 13.5 26 15.1 POOR 168 94.4 10 6.2 13 7.3 11 6.2 12 7.6 TOTAL 178 100 178 100 178 100 178 100 178 100 Rana et al. Head & Neck Oncology 2011, 3:23 Page 6 of 7 http://www.headandneckoncology.org/content/3/1/23 Table 6 Distribution of Radiodensity after Mandible Reconstruction (Post-test) (N = 178) th RADIODENCITY OF BONE GRAFTS At 7 day follow-up At 1st month follow-up At 6 months follow-up At 1 year follow-up No. of pts. % No. of pts. % No. of pts. % No. of pts. % GOOD 178 100 171 96.1 162 91.0 147 82.6 PARTIAL 00 00 03 1.7 09 5.1 17 9.5 LUCENT 00 00 04 2.2 07 3.9 14 7.9 Total 178 100.0 178 100.0 178 100.0 178 100 Table 7 Results of Resorption of Bone Graft up to 1 Year after Mandible Reconstruction (N = 178) RESOPTION OF BONE GRAFTS th st DONOR SITE (total No. of 7 DAY FOLLOW 1 MONTH FOLLOW 6 MONTHS FOLLOW 1 YEAR FOLLOW TOTAL (%) cases) UP UP UP UP Ilium (n = 80) 00 02 07 10 19 (23.7%) Ilium with DCIA (n = 12) 00 00 01 01 02 (16.7%) Rib (n = 39) 00 03 06 16 25 (64.1%) Free Fibula (n = 31) 00 01 01 02 04 (12%) Sternum (n = 16) 00 01 01 02 04 (25%) osteomyelitis, who also presented with the orocutaneous months postoperatively, and we adopted a one year fistula after reconstruction with rib graft but the infec- follow up period for our study. Our study shows slightly tion did not resolve with the local measures and antibio- superior aesthetic results than those but the difference tics. The second patient had a firearm injury of the is not significant, as their study sample was smaller (n = mandible and rib graft failed to be taken up with forma- 150) than that of ours (n = 178). tion of a discharge sinus and the facial contour was not Radiodensity of the bone grafts was checked on up to the mark. radiographs postoperatively and was rated as GOOD, st Hidalgo and Pusic [17] reported on the aesthetic out- PARTIAL or LUCENT. On 1 month follow up visit come in their study and it was excellent to good in 75% only 03 bone grafts showed PARTIAL and 04 LUCENT of patients, fair in 15% and poor in 10% cases. This dif- while the remaining 171 patient’s bone grafts were rated ference is not that much higher than that of our study. as GOOD. On the 6 month visit bone grafts of 162 One reason for achieving more excellent aesthetic out- patients showed GOOD, 09 PARTIAL and only 07 bone come is that in Hidalgo DA, Pusic AL’s study, most of grafts were rated as LUCENT. In the final one year fol- the reconstructions were accomplished with free micro- low up visit, out of 178 patients, radiodensity was vascular flaps which resulted in more pleasing and pre- GOOD for 147 (82.6%) patient’sbonegrafts, it was dictable outcomes. PARTIAL for 17 (9.5%) patients and LUCENT for the Cordeiro PG et al [18], evaluated aesthetic and func- bone grafts of 14 (7.9%) patients only. tional results in their study; they judged the aesthetic Myoung [19] also described almost the same radio- outcome as excellent (32%), good (27%), fair (27%) and density rating of the bone grafts in their study. They poor (14%) This study demonstrates a very high success showed rib as more radiodense than the fibula but the rate, with good to excellent functional and aesthetic finding was reversed in our study. results using osseous free flaps for primary mandible We also assessed the resorption of the bone grafts reconstruction. They evaluated the patients after six radiograghically on post operative follow up visits om Table 8 Results of Bone Graft Failure after Mandibular Reconstruction (N = 178) th FAILURE OF BONE GRAFTS At 7 day follow-up At 1st month follow-up At 6 months follow-up At 1 year follow-up No. of pts. % No. of pts. % No. of pts. % No. of pts. % YES 00 00 07 3.9 16 9.0 31 17.4% NO 178 100 171 96.1 162 91 147 82.6% Total 178 100.0 178 100.0 178 100.0 178 100 Rana et al. Head & Neck Oncology 2011, 3:23 Page 7 of 7 http://www.headandneckoncology.org/content/3/1/23 th th Conflict of interest statement the 7 day, one month, 6 month and 1 year follow-up The authors declare that they have no competing interests. visits. Out of 178 patients the highest bone resorption after 1 year was found in rib grafts i.e 64.1%, followed Received: 25 March 2011 Accepted: 28 April 2011 Published: 28 April 2011 by sternum 25%, iliac graft 23.7%, ilium with DCIA 16.7%. The least resorption after one year was found in References free fibula i.e 9.1%. 1. Rashid M, Zia-Ul-Islam M, Sarwar SU, Bhatti AM: The expansile Szpindor [15] demonstrated that in patients with Supraclavicular artery flap for release of post-burn contractures. Plast Reconstr Aesthet Surg 2006, 59:1094-101. immediate reconstruction, more than 50% of the bone 2. Kalanter-Hormozi A, Khorvash B: Repair of skin covering grafts resorbed. Out of 55 bone grafts which showed Osteoradionecrosis of the mandible with the fasciocutaneous severe resorption after one year, 16 were rib grafts, 10 Supraclavicular artery island flap: Case report. J Craniomaxillofac Surg 2006, 34:440-2. iliac crest bone graft, 01 was an iliac crest bone graft 3. Laredo COA, Valverde CA, Novo TL, Navarro S, Marquez M: Supraclavicular with DCIA and 2 were of the sternum. The 02 fibular bilobed fasciocutaneous flap for post burn cervical contractures. Burns bone flaps showed moderate resorption but these were 2007, 33:770-75. 4. Foster RD, Anthony JP, Sharma A, Pogrel MA: Vascularized bone flaps taken up successfully. 16 ribs and 11 iliac crest grafts versus nonvascularized bone grafts for mandibular reconstruction: an showing severe resorption and the bone grafts were not outcome analysis of primary bony union and endosseous implant taken up and ended up in failure. The grafts with mod- success. Head Neck 1999, 21:66-71. 5. Mehta RP, Deschler DG: Mandibular reconstruction in 2004:an analysis of erate and severe resorption also showed partial and different techniques. Curr Opin Otolaryngol Head NeSurg 2004, 12:288-93. lucent radiodensity on radiographs. Lenzen C, Meiss A, 6. Cordeiro PG, Disa JJ, Hidalgo DA, Hu QY: Reconstruction of the mandible Bull HG [20] in their study reported lower resorption with osseous free flaps: a 10-year experience with 10 consecutive patients. Plast Reconstr Surg 1999, 104:1314-1320. with the calvarial bone grafts than when using iliac bone 7. Genden E, Haughey BH: Mandibular reconstruction by vascularized free grafting. But we never used calvarial bone graft for man- tissue transfer. Am J Otolaryngol 1996, 17:219-27. diblular reconstruction. 8. Marx RE: Philosophy and particulars of autogenous bone grafting. Oral Maxillofac Surg Clin North Am 1993, 5:599-612. 9. Kainulainen VT, Sàndor GKB, Clokie CML, Oikarinen KS: (a) Intraoral bone Conclusions harvesting in oral and maxillofacial surgery. Suomen Hammaslääkärilehti Reconstruction of mandibular defects represents a chal- 2002, 5:216-222. 10. Urken ML, Buchbinder D: Chapter 86. Oromandibular Reconstruction. In lenge to the head and neck reconstructive surgeon. Otolaryngology-Head and Neck Surgery.. 3 edition. Edited by: Cummings CC. Autogenous bone grafting produce the most successful St Louis: Mosby Year Book, Inc; 1998:1654-1668. and predictable results when selected from the available 11. Urken ML, Weinberg H, Vickery C, et al: Oromandibular reconstruction using microvascular composite free flaps. Arch Otolaryngol Head Neck reconstruction options for mandibular bone defects. At Surg 1991, 117:733-44. the present time, autogenous bone grafting is the gold 12. Burkey BB, Coleman JR: Current concepts in oromandibular standard by which all techniques of osseous reconstruc- reconstruction. Otolaryngol Clin N Am 1997, 30:607-630. 13. Hidalgo DA, Pusic AL: Free-flap mandibular reconstruction: a 10-year tion of the mandible must be judged, and amongst the followup study. Plast Reconstr Surg 2002, 110:438-449. other available options, is the most reliable and predict- 14. Robb G: Abstract commentary on “Free-flap mandibular reconstruction: able modality to restore form and function of the miss- a 10-year follow-up study”. Arch Facial Plast Surg 2004, 6:65-6. 15. Szpindor E: Evaluation of the usefulness of autogenic bone grafts in ing mandibular segments. The free vascularized fibular reconstruction of the mandible. Ann Acad Med Stetin 1995, 41:155-69. flap has the least resorption and failure rate as proven 16. Chiapasco M, Colletti G, Romeo E, Zaniboni M, Brusati R: Long-term results in our study hence it should be the first choice for most of mandibular reconstruction with autogenous bone grafts and oral implants after tumor resection. Clin Oral Implants Res 2008, 10:1074-80. cases, particularly those with anterior or large bony 17. Hidalgo DA: Pusic ALFree-flap mandibular reconstruction: a 10-year defects requiring multiple osteotomies. follow-up study. Plast Reconstr Surg 2002, 110(2):438-49, discussion 450-1. 18. Cordeiro PG, Disa JJ, Hidalgo DA, Hu QY: Reconstruction of the mandible with osseous free flaps: a 10-year experience with 150 consecutive Funding patients. Plast Reconstr Surg 1999, 104(5):1314-20. The article processing charges are funded by the 19. Myoung H, Kim YY, Heo MS, Lee SS, Choi SC, Kim MJ: Comparative Deutsche Forschungsgemeinschaft (DFG), “Open Acess radiologic study of bone density and cortical thickness of donor bone used in mandibular reconstruction. Oral Surg Oral Med Oral Pathol Oral Publizieren”. Radiol Endod 2001, 92(1):23-9. 20. Lenzen C, Meiss A, Bull HG: Augmentation of the extremely atrophied maxilla and mandible by autologous calvarial bone transplantation. Author details Mund Kiefer Gesichtschir 1999, 3(Suppl 1):S 40-2. Department of Oral and Maxillofacial Surgery, Hannover Medical School, Hannover, Germany. Department of Oral and Maxillofacial Surgery, King doi:10.1186/1758-3284-3-23 Edward Medical University, Lahore, Pakistan. Cite this article as: Rana et al.: Reconstruction of mandibular defects - clinical retrospective research over a 10-year period -. Head & Neck Authors’ contributions Oncology 2011 3:23. MR, RW, JL, HE, HK, FT, AE and NCG conceived of the study and participated in its design and coordination. MR drafted the manuscript. All authors read and approved the final manuscript. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Head & Neck Oncology Springer Journals

Reconstruction of mandibular defects - clinical retrospective research over a 10-year period -

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Copyright © 2011 by Rana et al; licensee BioMed Central Ltd.
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Medicine & Public Health; Oncology; Otorhinolaryngology; Head and Neck Surgery
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Abstract

Backround: Functional and cosmetic defects in the maxillofacial region are caused by various ailments and these defects are addressed according to their need. Simplicity of procedure, intact facial function and esthetic outcome with the least possible donor site morbidity are the minimum requirements of a good reconstruction. Oro- mandibular reconstruction, although a challenge for the head and neck reconstructive surgeon, is now reliable and highly successful with excellent long-term functional and aesthetic outcomes with the use of autogenous bone grafts. Reconstruction of trauma- or mandibular oncologic defects with bony free flaps is considered the gold standard. However the the optimal reconstruction of mandibular defects is still controversial in regards to reconstructive options which include the donor site selection and the timing of surgery. The purpose of this study was to determine the outcome of different osseous reconstruction options using autogenous bone grafts for mandibular reconstructions. Methods: This study was carried out on 178 patients with mandibular bone defects. They were reconstructed with autogenous bone grafts from different donor sites. At post operative visits they were evaluated for functional and cosmetic results. Results: The success rate found in this study was around 90%. Only 7.6% of the cases showed poor results regarding facial contours and mouth opening. All other patients were satisfied with their cosmesis and mouth opening at the recipient sites was in the normal range during last follow-up visits. Donor sites were primarily closed in all cases and there was no hypertrophic scar. Conclusion: Based on this study, autogenous bone grafts are a reliable treatment modality for the reconstruction of mandibular bone defects with predictable aesthetic and functional outcomes. As the free vascularized fibular flap has the least resorption and failure rate, it should be the first choice for most cases of mandiblular reconstruction. Backround Reconstruction of mandibular defects represents a Functional and cosmetic defects in the maxillofacial challenge to the head and neck reconstructive surgeon. region are caused by various ailments that may be con- Interruption of the mandibular continuity produces both genital, pathologic or iatrogenic such as orofacial clefts, a cosmetic and functional deformity. There is limited tumor excision and post radiation necrosis [1,2]. Diverse range of motion when attempting lateral and protrusive injuries such as motor vehicle accidents, firearms, inter- movements of the jaw with a return to midline on open- personal assaults, burns, scalds, electrical flashes and ing or closing secondary to the remaining contralateral splashes are also playing their part to damage the soft muscles of mastication. In addition, malocclusion and and hard tissue of the whole body in general and the problems with proprioception occur [4,5]. maxillofacial region in particular [3]. When undertaking mandibular reconstruction, the restoration of bony continuity alone should not be con- * Correspondence: [email protected] sidered the measure of success. The functions of chew- Department of Oral and Maxillofacial Surgery, Hannover Medical School, ing, swallowing, speech articulation and oral competence Hannover, Germany must also be addressed. The ultimate goal of mandibular Full list of author information is available at the end of the article © 2011 Rana et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Rana et al. Head & Neck Oncology 2011, 3:23 Page 2 of 7 http://www.headandneckoncology.org/content/3/1/23 reconstruction is to return the patient to their previous a) Facial contur and mouth opening state of function. In order to achieve this goal, the b) Radiodensity of the bone and bone resorption rate reconstructive surgeon must attempt to restore bony c) Satisfaction and tolerance for the patients continuity and facial contour, maintain tongue mobility d) Failure of bone grafts and attempt to restore sensation to the denervated areas. Subjects The most common indication for mandibular recon- Approval for the study was obtained from the relevant struction remains ablative surgery for neoplastic pro- ethics committee. In addition, positive written consent cesses of the oral cavity and oropharynx. Other causes was obtained from each person who participated in the of mandibular defects include trauma, infection/inflam- study. mation, osteoradionecrosis, and congenital deformities. After mandibular resection, particularly following com- Patients plex radical resection for advanced oropharyngeal carci- The sample consisted of 178 patients. The patients with nomas invading the mandible, the restoration of form syndrome like cleft and craniofacial deformities were and function is paramount for the rehabilitation of these excluded in the study. Patients with systemic problems, patients [4,6]. pregnancy, coagulative disorders and drugs were also Autogenous bone grafting is the mainstay of mandibu- excluded in the study. lar reconstruction [7]. Sources of non-vascularized auto- genous bone for grafting can be broadly divided into Results local and distant sites and their successful application to The results were collated from 178 patients who reported maxillofacial reconstructive surgery is well documented. with mandibular defects and underwent reconstructions If the defect requiring a graft is small, often local or with various autogenous bone grafts, in the Department intra-oral donor sites are sufficient. When a moderate of Oral and Maxillofacial Surgery, from October 1998 to to substantial amount of bone is required, the distant or September 2008. All the cases that underwent recon- extra-oral sites are usually employed [8,9] structive surgery had some defects in the mandible, either Historically,freebonegraftswerefrequentlyusedfor primarily or after oncological resection/surgery. There mandibular reconstruction. Autogenous bone grafts were a total 178 patients, among those 131 (73.6%) from the calvarium, rib, ilium, tibia, fibula, scapula, and patients were males and 47 (26.4%) were females, radius have been used [10]. Over the past twenty years, age ranged from 13-85 years with an average of 55 years however, the use of vascularized bone grafts has become at the time of presentation. Among 178 patients, 42.1% state-of the-art for mandibular reconstruction. The most (n = 75) patients had oncological resections, 19.6% (n = common donor sites for osseous free-tissue transfer 35) patients were having post temporomanibular joint include the fibula, scapula, iliac crest, and radius [7,11]. ankylosis defects; 24.7% (n = 44) patients had post-trau- With the advent of vascularized osseous free flaps over matic defects and 13.5% (n = 24) patients presented with the past thirty years, reliable mandibular reconstruction the ostoeomyelitis of the mandible. Among 75 patients with success rates of over 90% is possible [11-14]. who had defects due to oncological resection, 50 were The field of mandibular reconstruction has seen monu- those presented with squamous cell carcinoma invading mental advances leading to the current state-of-the-art the mandible, 05 patients had a keratocystic odontogenic reconstructive techniques. Vascularized osseous free tis- tumor, 09 with Ameloblastoma, 02 patients with Denti- sue transfer is the preferred reconstructive modality gerous cyst, 03 patients with Central Giant Cell Granu- today and has shown excellent long-term aesthetic and loma, 02 with Odontogenic Myxoma, 01 patient with functional outcomes. At the present time, autogenous Adenomatoid Odontogenic Tumor, 01 patient with Pind- bone grafting is the gold standard by which all techniques borg tumour and 02 patient had osteosarcoma of the of osseous reconstruction of the mandible must be mandible [Table 2], [Figure 1]. judged and amongst the other available options, is the Among the 44 patients who had post-traumatic most reliable and predictable modality to restore the defects were 22 patients with infected malunion of frac- form and function of the lost mandibular segments [5]. ture sites; 19 patients had the firearm injuries and three patients had the comminuted fracture of the mandible Methods due to road traffic accidents. None of the patients had The aim of this study was to was to determine the out- undergone any previous reconstructive surgical proce- come of different osseous reconstruction options using dure for the mandibular defects [Figure 2]. autogenous bone grafts for mandibular reconstruction in All patients who underwent reconstructive surgery, comparison with the had defects, which affected the patients’ normal lives, Rana et al. Head & Neck Oncology 2011, 3:23 Page 3 of 7 http://www.headandneckoncology.org/content/3/1/23 Table 1 Distribution of Cases by Age and Sex (N = 178) Table 2 Distribution of Cases by Etiology of Defects (N = 178) SEX NO. OF PATIENTS PERCENTAGE MEAN AGE ETIOLOGY NO. OF PATIENTS PERCENTAGE MALE 131 73.6% 55.1 yrs FEMALE 47 26.4% 55.4 yrs ONCOLOGICAL RES. 75 42.1% TOTAL 178 100 % TMJ ANKYLOSIS 35 19.6% POST-TRAUMATIC 44 24.7% OSTEOMYELITIS OF MANDIBLE 24 13.5% therefore, they willingly opted for reconstruction with TOTAL 178 100 % bone grafts [Figure 3]. Among the 178 total patients, 80 (44.9%) had iliac bone grafts, 12 (6.7%) ilium with DCIA, 39 (22.1%) one patient, pleural tear occurred which was successfully patients with rib grafts were harvested for reconstruc- repaired with uneventful recovery. Bone harvesting from tion, while 31 (17.4%) patients were reconstructed with ribprovedtobeareliablesourcewithavery fewcom- the free fibular flap and in 16 (9.1%) patients recon- plications. But the resorption rate was much higher than struction was accomplished with bone graft from the others. Of 31 (17.4%) patients who were reconstructed sternum. Of 92 patients of ilium, 80 (44.9%) patients with the free fibular flap, no major complication was were reconstructed with the iliac bone graft and 12 noted, in two cases there were mild wound infection, (6.7%) patients of ilium with DCIA. All these patients limited to superficial skin slough, which was managed successfully with the local measures and with antibiotic experienced mild to moderate pain at donor site which was well managed with analgesics [Table 3]. cover [Table 4]. Five (5.4%) patients had a postoperative limp, which Another patient presented with mild ankle stiffness resolved after a median of 07 days (range 01-25). There but that resolved well over the two weeks time period. were two (2.2%) superficial donor site infections, which Overall, reconstruction with the free fibula grafts proved resolved well with antibiotic cover. The median length to be very predictable with excellent results. 16 (9.1%) of scar was 60 mm (range 40-90). Only three (3.3%) patients received sternum bone graft for reconstruction patients experienced mild paresthesia of the skin sup- with pectoralis major muscle as a soft tissue cover. plied by the lateral cutaneous nerve of the thigh, which These patients experienced decreased weight lifting improved over the time period of six months. No cases capacity after the surgery. One patient presented with of incisional hernia or with permanent gait changes was suture dehiscence and mild wound infection at the noted. Overall, harvesting bone from iliac crest was well donor site which resolved with the antibiotics and local tolerated by patients with excellent aesthetic and func- wound care. No long term donor site morbidity was tional results. In 39 (22.1%) patients, rib grafts were har- noted in these patients. Infection was checked post- vested for reconstruction and apart from mild to operatively and was assessed whether present or not. On th moderate pain, no serious complication was noticed. In 7 day postoperatively, 18 (10%) patients developed mild infection and in the rest of 160 (90%) patient’s st bone grafts, no sign of infection was noted. On 1 month follow up visit, 08 (4.5%) patients developed infection with pus discharge but 170 (95.5%) patients th had no sign of infection. On 6 months follow up visits, there was improvement in the infection rate and 03 (1.7%) patients presented with the infection while in the rest of 175 (98.3%) patients, no infection was noted. While on their one year follow up visits, there was further improvement and only 02 (1.1%) patients were noted with infection but in the remaining 176 (99.9%) patients, no signs of infection were noted. Facial contour Facial contour was first recorded preoperatively. Only 10 (5.6%) patients had adequate facial contouring on initial Figure 1 Left mandibular defect in a 14 year-old boy following presentation while 168 (94.4%) patients presented with a removal of a keratocystic odontogenic tumor. The inferior poor facial profile. After reconstruction with the bone alveolar nerve was presented as well as mandibular continuity. grafts there were marked improvements postoperatively. Primary bone grafting is planned. On one year follow up visits, 140 (79.5%) patients had Rana et al. Head & Neck Oncology 2011, 3:23 Page 4 of 7 http://www.headandneckoncology.org/content/3/1/23 Table 3 Demonstrating the Donor Graft Sites of Patients Receiving Mandibular Reconstruction (N = 178) DONOR GRAFT SITES NO OF PATIENTS PERCENTAGE/% ILIAC GRAFT 80 44.9% ILIUM WITH DCIA 12 6.7% RIB 39 22.1% FREE FIBULA 31 17.4% STERNUM 16 9.1% TOTAL 178 100.0% while the least resorption after one year was found in free fibula grafts i.e 9.1% [Table 6]. Figure 2 Contomed monocortical bone graft from the iliac Failure of bone grafts crest for reconstruction of lateral mandibular cortex. Failure of bone grafts was assessed postoperatively only and it was based on the infection, radiodensity and good facial profiles, 26 (15.1%) patients had adequate resorption of the harvested bone grafts. Failure was noted results and only 12 (7.6%) patients remained with the whether it occurred or not. No failure of any bone graft th poor facial contour [Table 5]. reconstruction was noted on the 7 day postoperatively. st On the 1 month follow up visit, failure of 07 bone grafts Radiodensity of the bone and bone resorption rate were noted, 16 at the 6 month follow-up while failure of Radiodensity of the bone grafts was checked on radio- 31 patient’s bone grafts were noticed 1 year post opera- graphs postoperatively and was rated as GOOD, tively. Among 178 patients, failure of bone grafts were th PARTIAL or LUCENT. On 7 post operative day bone noted in 31 (17.4%) patients and the remaining 147 grafts of all 178 patients showed GOOD radiodensity, as (82.6%) patients, bone grafting was successful on the one no changes could occur in bone densities, while in the year follow up visit [Table 7], [Table 8]. one year follow up visits, out of 178 patients, radiodensity was GOOD for 147 (82.6%) patient’s bone grafts, it was Discussion PARTIAL for 17 (9.5%) patients and LUCENT for the Reconstruction in the oral and maxillofacial region is a bone grafts of 14 (7.9%) patients. Resorption of individual difficult task. Anatomical, functional and aesthetic bone grafts was checked only postoperatively on radio- aspects have to be taken into account while performing th st graphs on the 7 day, 1 month, 6 months and 1 year reconstructive surgery. Facial contours and animation follow-ups. Out of 178 patients, the highest bone resorp- have to be achieved; normal speech, deglutition and tion after 1 year was found in rib grafts i.e 64.1% followed movements of the jaw are to be considered; upper aero- by sternum 25%, iliac graft 23.7%, ilium with DCIA 16.7% digestive function has to be ensured. Aesthetic units need to be kept in mind and the donor site impairment has to be avoided. Though there are many reconstruc- tive options, from alloplastic bone substitutes to the autogenous bone grafts; the best suited reconstruction option for a particular patient is critical for the restora- tions of mandibular form and function. A total number of one hundred and seventy eight patients were included in our study. Among them 131 were males and 47 were females and people of various ages were included in this study sample. The same surgeon performed all the pro- cedures to reduce the bias. In oncological resection the tumours affecting the mandible, for example, a squa- mous cell carcinoma, ameloblastoma, Pindborg tumour, adenomatoid odontogenic tumour, central giant cell granuloma, odontogenic myxoma were included and the Figure 3 Bone graft fixation was achieved using 2.0 mm cystic lesions like dentigerous cyst, odontogenic kerato- titanium miniplates. Additional autogenous bone chips were cyst; while the post-traumatic defects and the cases of harvested to fill gaps. osteomyelitis of the mandible were also included in the Rana et al. Head & Neck Oncology 2011, 3:23 Page 5 of 7 http://www.headandneckoncology.org/content/3/1/23 Table 4 Distribution Ofinfections up to 1 Year after Mandible Reconstruction (N = 178) th INFECTION IN BONE GRAFTS At 7 day follow-up At 1st month follow-up At 6 months follow-up At 1 year follow-up No. of pts. % No. of pts. % No. of pts. % No. of pts. % PRESENT 18 10.0 8 4.5 03 1.7 02 1.1 ABSENT 160 90 170 95.5 175 98.3 176 99.9 TOTAL 178 100.0 178 100.0 178 100.0 178 100.0 study sample. The most commonindicationfor the of the patient; all these led to poor wound healing with reconstruction in our study was the oncological resec- final failure of the bone grafts. In another patient, the fail- tion (42.1%) secondary to the benign or malignant ure of the bone graft was noted, who was found to be dia- betic after surgery and developed infection with an diseases of the mandible, followed by post-traumatic defect (24.7%); post-operative defects after gap arthro- orocutaneous fistula. This patient also had a history of plasty in TMJ ankylosis (19.6%) and the osteomyelitis of firearm injury with a comminuted fracture of the mandib- the mandible (13.5%). In a similar study carried out by ular body area and reconstruction was undertaken with a Szpindor [15], the most common indication for the rib graft. Though vigorous debridement of the infected reconstruction of the mandibular defects was oncologi- fractured site was done prior to grafting, the underlying cal resection, followed by resections due to osteodystro- immunocompromised host defense with longstanding phy, osteoradionecrosis and trauma. infection, might have caused failure of the bone graft. In our study the success rate of reconstruction with Chiapasco et al [16], in their recently published study autogenous bone grafts was 82.6% (147 patients) while on similar lines, described that no total failure of the the rate of the graft failure was 17.4% (31 patients). graft was observed, while partial loss of the graft was Szpindor [15] demonstrated the positive results or suc- observed in one patient. Cumulative survival and success cess rate of bone grafts of 84%, though his study sample rates were 96.7% and 93.3%, respectively. The success (n = 64) was smaller than that of ours (n = 178), the suc- rate is higher to that of our study i.e. 82.6 % (n = 147) cess rate in our study, is compareable to Szpindor study. and 17.4% (n = 31) failure of the grafts. Underlying In our study the failure of bone grafts was noted in 17.4 comorbidities could be implicated in those patients. % (n = 31) of patients, while many other factors attribu- We also noted facial contour/profile restored by the ted to the failure of these bone grafts. In two patients the bone grafts in the reconstructed patients. In general, the failure of the bone graft was due the recurrence of the contour was restored well in all those patients in whom squamous cell carcinoma which also got secondarily we could maintain the continuity of the mandible com- infected and we had to remove the bone grafts and the pared to those patients with a continuity defect. It’s partly because of the fact that correct anatomical posi- mini plates along with the local excision of the recurrent tion (alignment) of the mandibular resected segments lesion. These patients were subsequently reconstructed withtheiliac crestbonegraft.While in threepatients, and their deviation after a continuity defect is known to there were intraoral extrusion of the bone grafts with be difficult to achieve. associated dehiscence of the sutures and pus discharge. Preoperatively only 10 patients presented with ADE- Curettage of the area was undertaken in these patients QUATE and 168 patients were with POOR facial profile along with removal of the dead bone to treat the osteo- while after reconstruction, on one year follow up visits myelitis of the mandible, which was not resolved in spite 140 (79.5%) patients were satisfied and had GOOD of giving the antibiotic cover and bone graft from the rib. facial contour. 26 (15.1%) patients had ADEQUATE and The contributing factors to the failure of bone grafts in 12 (7.6%) patients remained with the POOR facial con- these cases might be the longstanding chronic osteomyeli- tours. Among these two who were not satisfied with tis of the mandible, additional infection and advanced age their poor contour, one was the patient with the Table 5 Post Operative Facial Contour up to 1 Year after Mandible Reconstruction (N = 178) FACIAL CONTOUR PRE-TEST POST-TEST th No. of pts % At 7 day follow-up At 1st month follow-up At 6 months follow-up At 1 year follow-up No. of pts. % No. of pts. % No. of pts. % No. Of pts. % GOOD 00 00 142 80.7 140 79.5 143 80.3 140 79.5 ADEQUATE 10 5.6 26 15.1 25 14.0 24 13.5 26 15.1 POOR 168 94.4 10 6.2 13 7.3 11 6.2 12 7.6 TOTAL 178 100 178 100 178 100 178 100 178 100 Rana et al. Head & Neck Oncology 2011, 3:23 Page 6 of 7 http://www.headandneckoncology.org/content/3/1/23 Table 6 Distribution of Radiodensity after Mandible Reconstruction (Post-test) (N = 178) th RADIODENCITY OF BONE GRAFTS At 7 day follow-up At 1st month follow-up At 6 months follow-up At 1 year follow-up No. of pts. % No. of pts. % No. of pts. % No. of pts. % GOOD 178 100 171 96.1 162 91.0 147 82.6 PARTIAL 00 00 03 1.7 09 5.1 17 9.5 LUCENT 00 00 04 2.2 07 3.9 14 7.9 Total 178 100.0 178 100.0 178 100.0 178 100 Table 7 Results of Resorption of Bone Graft up to 1 Year after Mandible Reconstruction (N = 178) RESOPTION OF BONE GRAFTS th st DONOR SITE (total No. of 7 DAY FOLLOW 1 MONTH FOLLOW 6 MONTHS FOLLOW 1 YEAR FOLLOW TOTAL (%) cases) UP UP UP UP Ilium (n = 80) 00 02 07 10 19 (23.7%) Ilium with DCIA (n = 12) 00 00 01 01 02 (16.7%) Rib (n = 39) 00 03 06 16 25 (64.1%) Free Fibula (n = 31) 00 01 01 02 04 (12%) Sternum (n = 16) 00 01 01 02 04 (25%) osteomyelitis, who also presented with the orocutaneous months postoperatively, and we adopted a one year fistula after reconstruction with rib graft but the infec- follow up period for our study. Our study shows slightly tion did not resolve with the local measures and antibio- superior aesthetic results than those but the difference tics. The second patient had a firearm injury of the is not significant, as their study sample was smaller (n = mandible and rib graft failed to be taken up with forma- 150) than that of ours (n = 178). tion of a discharge sinus and the facial contour was not Radiodensity of the bone grafts was checked on up to the mark. radiographs postoperatively and was rated as GOOD, st Hidalgo and Pusic [17] reported on the aesthetic out- PARTIAL or LUCENT. On 1 month follow up visit come in their study and it was excellent to good in 75% only 03 bone grafts showed PARTIAL and 04 LUCENT of patients, fair in 15% and poor in 10% cases. This dif- while the remaining 171 patient’s bone grafts were rated ference is not that much higher than that of our study. as GOOD. On the 6 month visit bone grafts of 162 One reason for achieving more excellent aesthetic out- patients showed GOOD, 09 PARTIAL and only 07 bone come is that in Hidalgo DA, Pusic AL’s study, most of grafts were rated as LUCENT. In the final one year fol- the reconstructions were accomplished with free micro- low up visit, out of 178 patients, radiodensity was vascular flaps which resulted in more pleasing and pre- GOOD for 147 (82.6%) patient’sbonegrafts, it was dictable outcomes. PARTIAL for 17 (9.5%) patients and LUCENT for the Cordeiro PG et al [18], evaluated aesthetic and func- bone grafts of 14 (7.9%) patients only. tional results in their study; they judged the aesthetic Myoung [19] also described almost the same radio- outcome as excellent (32%), good (27%), fair (27%) and density rating of the bone grafts in their study. They poor (14%) This study demonstrates a very high success showed rib as more radiodense than the fibula but the rate, with good to excellent functional and aesthetic finding was reversed in our study. results using osseous free flaps for primary mandible We also assessed the resorption of the bone grafts reconstruction. They evaluated the patients after six radiograghically on post operative follow up visits om Table 8 Results of Bone Graft Failure after Mandibular Reconstruction (N = 178) th FAILURE OF BONE GRAFTS At 7 day follow-up At 1st month follow-up At 6 months follow-up At 1 year follow-up No. of pts. % No. of pts. % No. of pts. % No. of pts. % YES 00 00 07 3.9 16 9.0 31 17.4% NO 178 100 171 96.1 162 91 147 82.6% Total 178 100.0 178 100.0 178 100.0 178 100 Rana et al. Head & Neck Oncology 2011, 3:23 Page 7 of 7 http://www.headandneckoncology.org/content/3/1/23 th th Conflict of interest statement the 7 day, one month, 6 month and 1 year follow-up The authors declare that they have no competing interests. visits. Out of 178 patients the highest bone resorption after 1 year was found in rib grafts i.e 64.1%, followed Received: 25 March 2011 Accepted: 28 April 2011 Published: 28 April 2011 by sternum 25%, iliac graft 23.7%, ilium with DCIA 16.7%. The least resorption after one year was found in References free fibula i.e 9.1%. 1. Rashid M, Zia-Ul-Islam M, Sarwar SU, Bhatti AM: The expansile Szpindor [15] demonstrated that in patients with Supraclavicular artery flap for release of post-burn contractures. Plast Reconstr Aesthet Surg 2006, 59:1094-101. immediate reconstruction, more than 50% of the bone 2. Kalanter-Hormozi A, Khorvash B: Repair of skin covering grafts resorbed. 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Author details Mund Kiefer Gesichtschir 1999, 3(Suppl 1):S 40-2. Department of Oral and Maxillofacial Surgery, Hannover Medical School, Hannover, Germany. Department of Oral and Maxillofacial Surgery, King doi:10.1186/1758-3284-3-23 Edward Medical University, Lahore, Pakistan. Cite this article as: Rana et al.: Reconstruction of mandibular defects - clinical retrospective research over a 10-year period -. Head & Neck Authors’ contributions Oncology 2011 3:23. MR, RW, JL, HE, HK, FT, AE and NCG conceived of the study and participated in its design and coordination. MR drafted the manuscript. All authors read and approved the final manuscript.

Journal

Head & Neck Oncology – Springer Journals

Published: Apr 28, 2011

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