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Mandibular reconstruction

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Mandibular reconstruction

  1. 1.  INTRODUCTION  ANATOMICAL FACTS  CAUSES OF DEFECTS  CLASSIFICATIONS  HISTORICAL FACTS  DIFFERENT OPTIONS  POST OPERATIVE CARE  COMPLICATIONS
  2. 2.  airway stability,  speech,  deglutition, and mastication,  Smiling  Determines shape of the lower face.
  3. 3.  Preservation of temporomandibular joint function with maximal opening ability and maintenance of occlusion  Dental Rehabilitation
  4. 4.  Symmetry,  preservation of lower facial height  anterior chin projection, and  correction of submandibular soft- tissue neck defects.
  5. 5.  Head n neck cancers ( SCC)  Osteogenic carcinoma  Mucoepidermopid carcinoma  Sdenoid cystic carcinoma  Leiomyosarcoma  Fibrous histiocystoma  Trauma : GUNSHOT WOUNDS
  6. 6.  Isolated › any single bone tissue resection  Compound › two tissue layers, such as bone and oral lining or bone and external skin  Compoiste › three-layer-defect involving the mucosal lining,bone, and external skin  En BLOC /extended composite › Defect that also include loss of soft tissue
  7. 7.  H (hemimandible)— › condyle and lateral segment that does not cross the symphysis (midline).  L (lateral)— › lateral segment without a condylar component; not crossing the symphysis.  C (central)— › bony region between the mental foramina.
  8. 8.  Smoking,  diabetes,  malnutrition,  cardiovascular disease,  liver cirrhosis,  Renal failure,  old age,  local advanced disease,  distal metastasis,  recurrent or second primary cancer,  postoperative radiation
  9. 9.  size,  volume,  and components of the involved soft tissue,  the length and location of the mandibular defect,  the available recipient vessels, and  the quality of the external skin.
  10. 10.  CT scan of mandible  Lateral cephalogram › For febrication of template
  11. 11.  An ideal reconstruction should mimic the missing tissue with regard to structure, geometry, and tissue character. 1. restoration of the bony scaffold, 2. adequate oral continence and 3. deglutition, 4. obliteration of dead space, and 5. re-establishment of optimal cosmesis.  there is not a single free flap that meets all reconstructive demands with regard to flap size, thickness, pliability, tissue bulk, and skin turgor.  Choosing an optimal flap for reconstruction should be based on the clinical situation and the patient’s own preference.
  12. 12.  Prosthesis  Nonvascularized bone graft,  Pedicled osteomusculocutaneous flap,  microsurgical osteocutaneous flap.
  13. 13.  Hausamen : 1886: plates & screw for reconstruction  Locking screws/plates with vascularized bone grafts  Mesh trays made of dacron : 1970s  Titanium plates: biocompatibility
  14. 14.  Decrease operating time  Avoidance of bone graft donar site  Extensive oncological resections  absence of suitable bone flaps,  presence of significant medical comorbidities
  15. 15.  risk of exposure  infection  risk of plate fracture  preclusion of dental reconstruction;  and a thin shape that does not provide adequate bulk for reconstruction.  Problematic in radiation therapy  Functional limitations
  16. 16.  Skkoff : end of 19th century  Anterior or posterior iliac crest.  Revascularization : recipient site  For mandibular defect of < 5cm in size  Complications › Bone resorption › Partial bone loss › Pseudoarthrosis
  17. 17.  Hueston and McConchie :1968: pectoralis major myocutaneous flap  first pedicled rib graft with the PM myocutaneous flap.  PM myocutaneous flap with the sternum as a bone graft.  Composite pedicled myocutaneous flaps transferred with clavicle bone graft
  18. 18.  Pectoralis major osteomusculocutaneous flap  Trapezius osteomusculocutaneous flap  Temporalis osteomuscular flap
  19. 19.  Traditional PM flap + the fifth rib as a bony scaffold  Blood supply : periosteal-muscular plexus  Disadvantages: › Blood supply not always reliable › The strength of the fifth rib is not as good for hardware fixation or osseous integration › Risks of pneumothorax and hemothorax
  20. 20.  Scapula spine + pedicled trapezius muscle  Upto 10cm of bone  Limitations › Restricted quality of bone › Shoulder mobility
  21. 21.  The vascularized cranial bone with the temporalis muscle.  based on :the superficial temporal Artery  as the outer cortex › inadequate bone stock for hardware fixation and can easily fracture during shaping  as a full-thickness bone graft. › more durable › donor site cosmesis is a major concern.
  22. 22.  McKee : 1978: microvascular free rib graft for mandibular defects.  Taylor et al. :1975: free fibula flap use  Hidalgo:free fibula flap for mandibular reconstruction.
  23. 23.  Circumflex iliac osteocutaneous flap  Scapular osteomusculocutaneous flap  Radius with radial forearm flap  Fibula osteoseptocutaneous flap
  24. 24.  Introduced by : Taylor : 1979  Advantages: › Reliable blood supply › Good contour of neomandible : natural curve  split lateral iliac crest chimeric flap based on the lateral femoral circumflex vessels to provide vascularized bone and soft tissue for complex mandibular reconstruction.
  25. 25.  Small or moderate-sized mandibular defects of type I-a to II-a.
  26. 26.  bulky skin paddle  abdominal wall weakness,  hernia,  contour deformity,  Limits early mobilization › harvest the inner cortex of the iliac as part of this flap
  27. 27.  Lateral border of the scapula, scapular and/or parascapular skin, and the latissimus dorsi muscle  based on the subscapular artery  The lateral border of the scapula : circumflex scapular artery  can be harvested up to a length of 14 cm  Skin pedicle : as long as 30cm
  28. 28. subscapular artery scapular artery parascapular artery
  29. 29.  valuable options for coverage of large complex oromandibular reconstruction
  30. 30.  bone quality of the scapula is not as good  intraoperative change in position,  Weakness & decreased range of shoulder motion
  31. 31.  inner volar cortex of the distal radius  Length of segment : 10-12 cm  Skin & pedicle are of best quality  Bone : the worst
  32. 32.  bone defect that is limited to the ramus and the proximal body with a large associated intraoral soft-tissue defect.
  33. 33.  Post operative radius fractures › Postoperative full-length plaster cast for 3–4 weeks › the use of a dynamic compression plate for rigid
  34. 34.  reconstructive standard for successful mandibular reconstruction  Wei et al. demonstrated the reliability of harvesting the fibula bone flap along with a skin paddle based on identifiable septocutaneous perforators
  35. 35.  The bone is available with enough length  The straight quality of the bone with adequate height thickness.  Flap contouring process  vascular pedicle has sufficient length  for filling adjacent soft-tissue defects in the submandibular portion.
  36. 36.  signs and symptoms of peripheral vascular disease or  an abnormal pedal pulse examination. › overt peroneal artery atherosclerotic disease
  37. 37.  Simple intermaxillary fixation is performed to obtain good dental occlusion  reconstruction plate  with at least two or three screws on each end.  Template
  38. 38.  four possible arteries 1. the facial artery, 2. superior thyroid artery, 3. Superficial temporal artery, and 4. the transverse cervical artery.  May be demaged by operative scars, radiations fibrosis, neck dissection.  Veins: › External juglar vein › Internal juglar vein: less kinking
  39. 39.  unique triangular bone,  peroneal vessels, usually › one artery › two concomitant veins,  located on the posteromedial aspect of the fibula, posterior to the fascia of the posterior tibialis, inside the flexor hallucis longus (FHL), and anterior to the posterior crucial septum.
  40. 40.  The skin paddle : › based on osteocutaneous perforators, which run inside the posterior crucial septum  The lateral surface is the safest and preferred site for reconstruction plate fixation  Soleus along with the flap: better soft tissue coverage & contour.
  41. 41.  The left fibula osteocutaneous flap is transferred to left mandibular defect type II-a  The pedicle of peroneal vessels is placed toward the right side to reach the recipient vessels of the ipsilateral side.
  42. 42.  An osteomyocutaneous peroneal artery combined flap was harvested  with a skin paddle of 12 × 8 cm based on two septocutaneous perforators
  43. 43.  Mandibular defect type II-a included a bone defect of 9 cm in length;  a buccal mucosal and adjunct soft- tissue defect  tailored template for measurement of the length, angle, and number of osteotomies
  44. 44.  The osteotomy was performed to obtain three bone segments to simulate the tailored paper ruler templates on the back table.
  45. 45.  The three fibula segments were fixed to the reconstruction plate with one screw for each. The pedicle was placed forward to right-sided and curved to reach the ipsilateral superior thyroid artery and facial vein
  46. 46.  The soleus muscle could be flipped over on top of the fibula and the reconstruction plate to prevent  exposure of the reconstruction plate and  potential osteoradionecrosis  better cheek contouring.
  47. 47.  further osteotomies are performed with an electric saw according to the tailored paper ruler templates  Protect the vascular pedicle and septocutaneous perforators to the skin paddle during the osteotomies to prevent injury to these structures
  48. 48.  flap is inset from the osteotomized fibula segments that are contoured to fit the reconstruction plate.  single screw fixation for each bone segment: minimize vascular compromise  One skin paddle :for the intraoral lining, and  a second skin paddle :for the external cheek  soleus muscle : placed on top of the fibula and reconstruction plate to : › improve cosmesis › prevent possible osteoradionecrosis › plate exposure after postoperative radiation
  49. 49.  Intermaxillary fixation with screws or wires  titanium reconstruction plate : to bridge both residual mandibular ends, with at least two screws for each end  Errors: › prognathism, › retrognathia, › increased or decreased lower facial height,. › asymmetry caused by a twist in the flap, or › a shift in the midline to one side as a result of unequal lengths of the mandible body.
  50. 50.  Watertight closure of the intraoral wound  Contamination of the miniplates  Orocutaneous fistula  Suction drains  positioned away from the microvascular anastomoses.
  51. 51.  malocclusion  Trismus  Options : › avascular bone graft, › Rounding off the end of the fibula › costochondral graft attached to the fibula end › a titanium condyle prosthesis
  52. 52.  Dead space created by the extirpation of masticator muscles, the buccal fat pad, and the parotid gland  can lead to fluid accumulation and infection  sunken appearance from soft-tissue contracture, trismus, plate exposure, and impaired speech and swallowing function  exacerbated by postoperative radiotherapy.  Radial forearm flap,  anterolateral thigh, rectus abdominis,  pectoralis major flaps
  53. 53.  Transferred to ICU for 3-7 days  Tracheostomy /ETT  Restricted neck movements  Prophylactic antibiotics— 7 days  PPI--- 3 days  Hydration status/IOP monitering  Enteral feeding
  54. 54.  Every hour : for 24 hours  Every 2 hours : next 24 hours  Every 4 hours : 3rd post op till discharge  Physical examination  Hand held doppler  Irrigation of oral cavity for hygeine : 3rd day  Mobilization  Weight bearing : 3rd week  Follow up : periodic panorex radiographs
  55. 55.  appear within 1 week postoperatively,  re-exploration,  wound dehiscence,  partial skin paddle loss.
  56. 56.  occur between 1 week and 1 month postoperatively,  infection,  skin flap loss,  wound dehiscence,  donor site morbidity, and  fibula bone loss.
  57. 57.  beyond the 1-month period  infection,  malocclusion,  donor site morbidity,  skin flap loss,  radiotherapy-related orocutaneous fistula or osteoradionecrosis
  58. 58.  hypovascularity,  hypocellularity, and  local tissue hypoxia  Radiation-related osteoradionecrosis, neck contractures, and wound-healing problems with subsequent plate exposure are frequent in patients undergoing fibula osteocutaneous flap for mandibular reconstruction  preventing osteoradionecrosis : › Enough soft tissue and bone coverage in the irradiated field
  59. 59.  MAR28,2013PI  A 23 year old female underwent right hemi-mandibulectomy and a neck dissection for a primary sarcoma of the mandible 2 years ago. She had a post-operative radiation but no reconstruction was done. She now wants a correction of her deformity.  a) what problems do you anticipate in the procedure and how can you avoid them?
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