Category Archives: Surgical Reconstruction of Defects of the Jaws

Restoration of Continuity

Resotration of Continuity

Control of residual mandibular segments. When a continuity defect is present, the muscles of mastication attached to the residual mandibular fragments will distract them in different directions unless efforts were
made to stabilize the remaining mandible in its normal position at the time of partial resection. Mamtaining relationships of the remaining mandible fragments after resection of portions of the mandible is a key principle
of mandibular reconstruction. This is important for both occlusal and temporomandibular joint (TM]) positioning. When the residual fragments are left to drift, Significant facial distortions can occur from deviation
of the residual mandibular fragments (Fig. 28-3). Metal bone plates inserted at the time of resection are useful for controlling the position of the mandibular fragments (see Fig. 28-2. fl. They are of sufficient “strength to obviate the need for maxillomandibular fixation, permitting active use of the mandible in the immediate postoperative period. In older individuals or
those with significant medical compromise, this may be the final form of reconstruction. It provides soft tissue support to maintain facial symmetry. When the mandibular symphysis has been removed, the tongue
can be sutured to the plate, maintaining its forward position to prevent airway obstruction (see Fig. 28-2, E). The bone plate can be left in place when .the mandible is secondarily reconstructed with bone grafts,
permitting mobility of the mandible during the bone graft’s healing phase (see Fig. 28-2, /)

FIC..2ts-3 Patient whose left mandibular ramus and posterior body was removed 10 years previously to! malignant disease (A'). The deviation of the chin to the left side is ~sualiled. Postsurgical radiotherapy was also usee! during therapy. The patient underwent hyperbaric oxygen treatments before bone graft reconstruction. B, Panoramic radiograph showing residual mandible.

FIC..2ts-3 Patient whose left mandibular ramus and posterior body was removed 10 years previously
to! malignant disease (A’). The deviation of the chin to the left side is ~sualiled. Postsurgical radiotherapy
was also usee! during therapy. The patient underwent hyperbaric oxygen treatments before
bone graft reconstruction. B, Panoramic radiograph showing residual mandible.

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FIC..2ts-3 Patient whose left mandibular ramus and posterior body was removed 10 years previously to! malignant disease (A'). The deviation of the chin to the left side is ~sualiled. Postsurgical radiotherapy was also usee! during therapy. The patient underwent hyperbaric oxygen treatments before bone graft reconstruction. B, Panoramic radiograph showing residual mandible.

FIG..2ts-3 Patient whose left mandibular ramus and posterior body was removed 10 years previously
to! malignant disease (A’). The deviation of the chin to the left side is ~sualiled. Postsurgical radiotherapy
was also usee! during therapy. The patient underwent hyperbaric oxygen treatments before
bone graft reconstruction. B, Panoramic radio graph showing residual mandible.

 

FIG. 28-3-cont'd C, Maximum opening of mouth shows gross deviation to resected side. D, Intraoral photograph showing' the crossbite relationship from the deviation of the mandible to the left side.

FIG. 28-3-cont’d C, Maximum opening of mouth shows gross
deviation to resected side. D, Intraoral photograph showing’ the crossbite
relationship from the deviation of the mandible to the left side.

When the position of the residual mandibular fragments have not been maintained during the resection, realignment is more difficult during the reconstructive surgery. Over time the muscles of mastication become
atrophic. fibrotic, and nonpliable. which makes realignment of the fragments extremely difficult, During the reconstructive surgery, it may be necessary to strip several muscles off the mandibular fragments to
release the bone from their adverse pull. ,\ coronoidectorny is usually performed to remove he Srior pull of the ternporaljs muscle. Before

 

 

 

 

 

 

 

 

 

SURGICAL PRINCIPLES OF MAXILLOFACIAL BONE-GRAFTING PROCEDURES

SURGICAL PRINCIPLES OF MAXILLOFACIAL BONE GRAFTING PROCEDURES . 

any grafting procedure, They must be strictly adhered to if a successful outcoe is desired. The following are a few that pertain to reconstructing mandibular defect

Restoration of Osseous Bulk

Restoration of Osseous Bulk

Any bone-grafting procedure must provide enough osseous tissue to withstand normal function. If too thin an osseous strut is provided, fracture of the grafted area may occur

 

Restoratiqn of Alveolar Bone Height

Restoratiqn of Alveolar Bone Height

The functional rehabilitation of the natient rests on the ability to masticate efficiently and comfortably. Prosthetic dental appliances are frequently necessary in patients who have lost a portion of their mandible. To facilitate
prosthetic appliance usage, an adequate alveolar process must be provided during the reconstructive surgery. The ideal ridge form outlined in Chapter 13 for the edentulous patient applies equally to patients undergoing mandibular
reconstructive surgery

Restrgoration of Continuity

Restrgoration of Continuity

Because the mandible is a bone with two articulating ends acted on by muscles with opposing forces, restoration of continuity is the highest priority when reconstructing mandibular defects. Achieving this goal will provide the   tient with better functional movemcnt and improved facial esthetics by realigning any deviated mandibular segments.

 

Associated Problems

Associated Problems

The clinician must always remember that the cure should be less offensive to the patient than the disease process, In other words, if a reconstructive procedure will significantly risk the individual’s life or is associated with a very
high incidence of complications that may make life worse for the patient, it would probably be in the patient’s best interest to forego the procedure. As with any type of therapy, significant factors must be assessed, such as the ‘patient’s age, health, psychologic state, and, most important perhaps, the patient’s desires, Thorough understanding by the patient of the risks and benefits of any treatment recommendation is imperative so that an informed decision can be made.

Restoration of Osseous Bulk

Restoration of Osseous Bulk

Any bone-grafting procedure must provide enough osseous tissue to withstand normal function. If too thin an osseous strut is provided, fracture of the grafted area may occur.

Restoratiqn of Alveolar Bone Height

Restoratiqn of Alveolar Bone Height

The functional rehabilitation of the natient rests on the ability to masticate efficiently and comfortably. Prosthetic dental appliances are frequently necessary in patients who have lost a portion of their mandible. To facilitate
prosthetic appliance usage, an adequate alveolar process must be provided during the reconstructive surgery. The ideal ridge form outlined in Chapter 13 for the edentulous patient applies equally to patients undergoing mandibular
reconstructive surgery .

 

Restoratiqn of Alveolar Bone Height

Restoratiqn of Alveolar Bone Height

The functional rehabilitation of the natient rests on the ability to masticate efficiently and comfortably. Prosthetic dental appliances are frequently necessary in patients who have lost a portion of their mandible. To facilitate
prosthetic appliance usage, an adequate alveolar process must be provided during the reconstructive surgery. The ideal ridge form outlined in Chapter 13 for the edentulous patient applies equally to patients undergoing mandibular
reconstructive surgery .

Soft Tissue Defect

Soft Tissue Defect

Proper preparation of the soft tissue bed that is to receive the bone. graft is just as important to the success of bone grafting as the bone graft mntcrihl itself. The transplanted bone cells must survive initially by diffusion of nutrients from the surrounding soft tissues, Revascularization of the
bone ‘graft through the development of new blood vessels from the soft tissue bed must then occur. Thus an essential factor for the success of any bone-grafting procedure is the availability of an adequately vascularized soft tissue bed. Fortunately this essential factor is usually obtainable in the lush vascular tissue of the head and neck region. However, occasionally the soft tissue’ bed is not as desirable as it could be, such as ‘after. radiotherapy or excessive scarring from trauma or infection. Therefore a thorough assessment of the quantity and quality of the surrounding soft tissues is necessary before undertaking bone graft procedures. The reason forthe osseous void often provides important  information on the amount and quality of soft tissuesremaining. For example, if the patient lost a large portion of the mandible from a composite resection for a malignancy,
the chances are that the patient will haw deficiencies both in quantity and quality of soft tissues. During the initial surgery, mahy. vital structures were probably removed, and denervation of the platysma muscle will
result in atrophy of the muscular fibers .. An intraoral examination helps the clinician determine how much oral mucosa was removed with the mandibular fragment. Frequently the tongue or floor of the mouth appears to be sutured to the buccal mucosa, with no intervening alveolar ridge or buccal sulcus, because the gingiva is sacrificed with the osseous specimen. If the patient received cancericidal doses of radiation  10 till’ area of the osseous defect, the clinician can assume