Objective To investigate the clinical value of occlusal guide plate combined with intermaxillary fixation screw in mandibular defect repair with free fibular flap. Methods Between August and December 2011, 7 patients with mandibular tumor were treated, including 5 cases of ameloblastoma and 2 cases of gingival cancer. Of 7 patients, 4 were males and 3 were females, aged 32-65 years (median, 50 years). Occlusal guide plate was prepared and the implanted position of intermaxillary fixation screws was determined preoperatively. Hemimandibulectomy was performed in 5 cases, half mandibular segmental resection with condyle reservation in the other 2 cases. The free fibular flaps of 11-13 cm in length were harvested for repairing mandibular defects. When the free fibular flaps were fixed, the occlusal guide plate and intermaxillary fixation screws were utilized to restorate the occlusal relation. The donor site was sutured directly. Results The average operation time was 9.5 hours (range, 7-12 hours). All free fibular flaps survived completely. All incisions at the donor site and recipient site healed by first intention. All patients were followed up 10-14 months with an average of 12.3 months. All patients had symmetrical face, good occlusal relation, normal mouth opening, and normal mandibular lateral movement, and no pain of bilateral temporomandibular joints occurred. Panoramic tomography showed good mandibular contour and the suitable emplacement of fibular flaps postoperatively. No tumor recurrence occurred during follow-up period. Conclusion When repairing the mandibular defect with free fibular flap, occlusal guide plate with intermaxillary fixation screw contributes to simplifying operation, accurate recovery of the appearance and occlusal relation, and improving the oral comfort level postoperatively.
Objective To evaluate the directional significance of SurgiCase software in free fibula mandibular reconstruction. Methods Between September 2010 and March 2012, 10 patients with mandibular defect underwent free fibula mandibular reconstruction. There were 7 males and 3 females, with an age range of 19-43 years (mean, 27 years). The extent of lesions was 7 cm × 5 cm to 16 cm × 8 cm. In each case, three-dimensional spiral CT scan of the maxilla, mandible, and fibula was obtained before surgery. The CT data were imported into the SurgiCase software and the virtual surgery planning was performed. After that, the mandibular rapid prototyping was made according to customized design. The reconstruction surgery was then carried out using these preoperative data. During actual surgery, the extent of mandibular defect was from 6 cm × 3 cm to 16 cm × 5 cm; the length of fibula which was used to reconstruct mandible was 6-17 cm; and the area of flap was from 6 cm × 5 cm to 16 cm × 6 cm. Results Preoperative data could not be applied because the intraoperative size of tumor was larger than preoperative design in 1 case of mandibular ameloblastoma, and the fibula was shaped according to the actual osteotomy location; operations were performed successfully according to preoperative design in the other 9 patients. The operation time was 5-7 hours (mean, 6 hours). Primary healing of incision was obtained, without early complications. Ten patients were followed up 1 year. At last follow-up, 8 patients were satisfactory with the appearance and 2 patients complained with unsatisfied wide facial pattern. The panoramic radiograghs showed good bone healing. The range of mouth opening was 2.5-3.5 cm. Conclusion SurgiCase software can provide precise data for free fibula mandibular reconstruction during surgery. It can be applied widely in clinic.
Objective To build up a new contour and functional reconstruction technique of mandibular defects with rapid prototyping and reverse engineering technique. Methods From April 2002 to August 2004, 4 cases of mandibular defects due to resection of large mandible lesion were treated. Of 4 patients, there were 3 females and 1 male, with an age range of 21-42 years, which underwent secondary operation and presented a deviation as mandibular movement. The openingmouth extent was 1.8-2.5 cm(2.2 cm on average). The data of defects area were renewed withMimics and Geomagic Studio software; and the titanium reconstructive frame was designed and manufactured with rapid prototyping technigue. Defect were reconstructed by using CT digital data of patients. Results The CT data could be used by image software directly. The implant design could be completed by computer-aimed design(CAD)/computer-aided manufacture(CAM). The resin model and titanium frame were manufactured accurately by RP technique. Four patients achieved one stage healing. After a follow-up of 3 months to 2 years, largemandibular defect was reconstructed satisfactorily and the opening-mouth extent was 3.03.4 cm(3.2 cm on average). The occluding relation was normal. The implant denture was put on and the mastication function was good in 1 case. Conclusion Individual design and repair of large mandibular defect with CAD/CAM techniques is worth extending application clinically. It is a simple and accurate method.
Objective To investigate the clinical effect ofthe pectoralis major myocutaneous flap and Ti-plate system in repairing mandibular defects caused by resection of oral carcinoma.Methods From November 2001 to February 2003, 32patients with mandibular defect caused by resection of oral carcinoma were treated. Combined radical neck dissection with resection of gingival and mandible was performed on 11 patients with carcinoma of the lower gingival, combined radical neck dissection with glossectomy and mandibulectory on 13 patients with carcinoma of tongue, combined radical neck dissection with resection of floor of mouthand mandible on 4 patients with carcinoma of floor of mouth, and combined radical neck dissection with resection of cheek and mandible on 4 patients with carcinoma of buccal mucosa, respectively. The defects of mandible were associated with soft-tissue component, the sizes of defect ranged from 5.5 cm×7.6 cm to 8.2 cm×10.5 cm. The defects were reconstructed with 6 cm×7 cm to 9 cm×10 cm pectoralis major myocutaneous flaps and Tiplate system. The effect was studied retrospectively. Results Thirty-two cases were followed for 219 months; 29 cases offlaps survived and 3 cases of flaps partly necrosed (10% or less of the skin paddle). The appearance of face was satisfactory in 27 patients, and slight deformity of face was observed in 5 patients. The occluding relation and masticatory function were recovered well. Opening mouth extents ranged from 2.7 cm to 3.4 cm. No temporomandibular arthrosis relating to operation was found in all cases. Conclusion A combination of thhe pectoralis major myocut aneous flap and Ti-plate system is an ideal method for reconstruction of mandible defects associated with soft-tissue component after radical operation of oral carcinoma.
Objective To summary the clinical application of free fibular composite flaps in repair of mandibular defect. Methods Fiftyeight cases of mandibular reconstruction using free fibular flaps, from June 1999 to November 2000, were reviewed, among which there were 37 cases of male and 21 cases of female, aged from 12 to 65 years old. All of the relevant data of the operation, such as the cause of the defect, design of the flaps, the blood vessels of the recipientand the complications, were included and analyzed. Results The fibular flap was 10.9 cm (4-21 cm) averagely in length and was harvested for 2.1 times (1-4 times); the average size of the skin paddle was 5.88 cm×3.13 cm. Of 58 flaps, therewere 56 survived; the overall complication rate was 24.1%.Conclusion It’s safe and reliable to use free fibular flap to reconstruct the mandibular defect.
OBJECTIVE: To study the effect of collagen/hydroxyapatite(CHA) instead of autogenous bone transplantation on repairing the mandibular defects. METHODS: Ten Chinese experimental minipigs were made 2 cm bone defects in diameter in the mandible. The experimental group was implanted CHA, while the control group was implanted autogenous bone. The basic parameters of bone dynamics were determined by bone metrology. RESULTS: There was remarkable difference between the two groups in the mean distance and mineralization apposition rate of double label bands marked by tetracycline(P lt; 0.05), while the mean osteoid seam width and mineralization lag time had no remarkable difference(P gt; 0.05). It suggested that CHA had good osteogenesis. The collagen in CHA offered the condition of bone mineralization, and the mineralization peak of experimental group was present at 4 weeks earlier than that of control group (8 weeks). CONCLUSION: CHA may be a substitute of autogenous bone transplantation in repairing the mandibular defects, and the second operation for offering the implanting bone is avoidable, therefore, CHA may be an ideal material to repair bone defects.
OBJECTIVE To study the anatomical basis of vascularized spina scapular bone flap, which was used in mandibular reconstruction. METHODS Fifteen adult cadavers were adopted in this study. The two common carotid arteries of each cadaver were intubed and perfused with red emulsion respectively. Then the course and distribution of the transverse cervical artery(TCA) and its spina scapular branches were observed on 30 sides. RESULTS The TCA was divided into two segments: the cervical segment originated from the origin of the artery to the superior margin of the trapezius muscle, and the dorsal segment originated from the superior margin of the trapezius muscle to the site where the TCA bifurcated into the superficial and deep branches. The average length and original caliber of the cervical segment were(4.7 +/- 0.1) cm and (4.0 +/- 0.1) mm. The average length and original caliber of the dorsal segment were (5.88 +/- 0.63) cm and (3.30 +/- 0.35) mm. 86.7% spina scapular branches originated from the superficial branch of TCA and 13.3% from TCA. The length of the spina scapular branch was (4.97 +/- 1.68) cm and its external diameter was (2.08 +/- 0.27) mm. It constantly sent 4-8 periosteal branches to spina with 0.20-1.25 mm in caliber. CONCLUSION The spina scapular branch of TCA is one of the main blood supplier to the spina scapular area. The spina scapular flap pedicled with spina scapular branch of TCA may provide a new operation for mandibular reconstruction, whose circumpoint locates at the origin of the dorsal segment and the average length of the pedicle is 10.85 cm which enough to transposite to mandibular area.
ObjectiveTo investigate the clinical outcomes of resection of mandibular benign tumors and primary reconstruction with autogenous bone graft via an intraoral approach. MethodsFifteen patients with mandibular benign tumors were treated between January 2009 and September 2012. There were 7 males and 8 females, aged from 18 to 45 years (mean, 30 years). The pathological diagnosis identified 11 cases of ameloblastoma, 3 cases of odontogenic keratocyst, and 1 case of odontogenic myxoma. According to the Urken's CRBS (Condyle, Ramus, Body, Symphysis) classification criteria based on the location of the mandibular defect, there were 3 cases of body type (B type), 3 cases of ramus type (R type), and 9 cases of body and ramus type (BR type). The surgeries were performed via an intraoral approach, except 1 patient with the lesion at the level of sigmoid notch via an auxiliary preauricular incision. To fix the bone grafts to the dissected mandibular defects, reconstructive titanium plates were used, either indirectly according to the computer aided design/computer aided manufacturing mandibular models before surgery (9 patients) or directly according to the exposed mandibles during surgery (6 patients). The patients received benign mandibular tumor resection and primary autogenous bone graft reconstruction with free iliac bones (11 cases) or vascularized fibular flaps (4 cases). The mandibular inferior alveolar nerves were preserved in 6 cases. ResultsPrimary healing of incision was obtained in 14 patients, while secondary healing in 1 patient suffering from bone graft infection. All the patients were followed up 1-4 years (mean, 2.5 years). At last follow-up, no patients showed facial nerve damage; occlusion of remaining teeth was similar to preoperative conditions; the chewing function was satisfactory; mouth opening was 30-35 mm (mean, 33 mm); and swallowing and speaking functions were normal. Only slight extraoral scars caused by the auxiliary incision and the transbuccal appliances were observed, and all the patients were satisfied with the facial appearance. Lower lip numbness was relived in patients with preserved inferior alveolar nerves. There was no tumor recurrence during follow-up period. ConclusionThe intraoral approach is a feasible and proper approach for resection of benign mandibular tumors and primary reconstruction with autogenous bone grafts, with the advantages of inconspicuous facial scars, minimum damage to the facial nerve, and expectable aesthetic appearance.
ObjectiveTo evaluate the value of computer assisted navigation system (CANS) in the reconstruction of mandibular defects. MethodsBetween April 2012 and September 2014, 8 patients with mandibular defects were included in this study. There were 5 males and 3 females with an age range of 22-50 years (mean, 34.5 years), including 4 cases of ameloblastoma, 3 cases of odontogenic keratocyst, and 1 case of condylar osteoma. According to the CRABS (condyle, ramus, angle, body, symphysis) classification criteria based on the location of mandibular defect, there were 1 case of right CRAB type, 1 case of left RABS type, 1 case of left CR type, 1 case of right RAB type, 1 case of left C type, 1 case of right RABS+left S type, and 2 cases of right AB type. With the biteplate fixing mandible, maxillofacial CT and the donor site CT scan were done. Computer assisted design was made by using Surgicase CMF5.0 software and BrainLab Iplan software, included delineating the osteotomy lines for resection, ascertaining the normal anatomic structures for defect reconstruction, and determining the reconstructive morphology. With guide plates and the guidance of BrainLab navigation system, an en bloc tumor resection and simultaneous defect reconstruction were performed under the precise localization of mandibular angle and condyle. Preoperative and postoperative CT images were superimposed in Geomagic studio12.0 software system, and both were compared by three-dimensional (3D) objects and 2D slices. The complications and signs of recurrence were observed. ResultsUnder the guidance of navigation, preoperative facial symmetry design, surgery simulation, and simultaneous navigation operation were performed successfully. The postoperative CT and postoperative 3D error analysis showed osteotomy lines and reconstruction contour had good matching with the preoperative planning. The error of important corresponding points (mandibular angle and external pole of condyle) in the reconstruction of mandibular defects were (1.83±0.19) mm and (1.61±0.24) mm. The patients were followed up 2-6 months (mean, 3.5 months). No complication was observed in the other patients except the patients undergoing rib transplantation who had mild limitation of mouth opening. Good facial symmetry was obtained, and no tumor recurrence was found. ConclusionCANS can effectively increase the surgical precision in the reconstruction of mandibular defects and reduce complications, and recover facial symmetry. It is regarded as a valuable technique in this potentially complicated procedure.
Objective To explore the application of personalized guide plate combined with intraoperative real-time navigation in repairing of mandibular defect using fibula muscle flap, providing the basis for the precise repair and reconstruction of mandible. Methods The clinical data of 12 patients (9 males and 3 females) aged from 23 to 71 years (mean, 55.5 years) between July 2019 and December 2021 were recorded. These patients were diagnosed as benign or malignant mandibular tumors, including 2 cases of ameloblastoma, 6 cases of squamous cell carcinoma, 2 cases of osteosarcoma, 1 case of adenoid cystic carcinoma, and 1 case of squamous carcinoma. All patients were treated with mandibular amputation, and then repaired by double-stacked three-segment fibula muscle flap. Preoperative virtual design scheme and guide plate were performed. During the operation, personalized guide plate combined with real-time navigation was used for fibular osteotomy and shaping. Thin-slice CT examination was performed at 2-3 weeks after operation, and was fitted with the preoperative virtual design scheme. The difference between the distance of bilateral mandibular angles relative to the reference plane in three-dimensional directions (left-right, vertical, and anterior-posterior) and the difference of the medial angle of the lower edge of the mandible reconstructed by fibula were measured, and the mean error of chromatographic fitting degree was calculated. Results The guide plate and navigation were applied well, and the fibula shaping and positioning were accurate. The fibula muscle flap survived, the incision healed well, and the occlusal relationship was good. All 12 patients were followed up 1-29 months, with an average of 17 months. There was no significant difference on the distance of bilateral mandibular angles relative to the reference plane in the left-right [(−0.24±1.35) mm; t=−0.618, P=0.549], vertical [−0.85 (−1.35, 1.40) mm; Z=−0.079, P=0.937], and anterior-posterior [(−0.46±0.78) mm; t=−2.036, P=0.067] directions. The difference of the medial angle of the lower edge of the mandible reconstructed by fibula was also not significant [(−1.35±4.34)°; t=−1.081, P=0.303)]. Postoperative CT and preoperative virtual design fitting verified that there was no significant difference in the change of the mandibular angle on both sides, and the average error was (0.47±1.39) mm. ConclusionThe personalized guide combined with intraoperative real-time navigation improves the accuracy of peroneal muscle flap reconstruction of the mandible, reduces the complications, and provides a preliminary basis for the application of visual intraoperative navigation in fibula muscle flap reconstruction of the mandible.