Management of the failed mandibular reconstruction plate

Abstract

The current options for primary reconstruction of a posttraumatic or postablative mandibular defect are es­ sentially alloplastic plates or trays and free vascularized osseous or osseocutaneous tissue transfers . The selec­ tion of either approach depends primarily on the type of patient, the disease, and the treatment philosophy used in a given center, as well as the availability and experience of the reconstructive team with free tissue transfer. The use of stainless steel and titanium reconstruction plates for postablative or traumatic defects of the mandi­ ble was initially described by Spiessl et al in 1976 1 and popularized in North America and Europe by Raveh et al and Gullane and Holmes.v The rationale for the use of reconstruction plates and other alloplasts is based on their ease of application and the na tural history of disease in patients undergoing mandibular resection for malignant disease. Most of the available plate systems are easily taught and the applica­ tion to a mandibular defect relatively simple, requiring limited special training. The major rationale for the use of these systems, however, relates to the long-term prog­ nosis for patients undergoing extensive mandibular re­ section for malignant disease. Approximately 30% to 40% of all patients with mandibular invasion will either have relapsed or succumbed to their disease within 2 years of primary treatment. Given this poor prognosis in spite of aggressive medical and surgical treatment, many groups have elected to use reconstruction plates instead of the more sophisticated and complex free ossecutaneous transfers in such patients. This approach has theoretical advantages as it eliminates potential do­ nor site complications, produces equivalent functional re­ sults to the autogenous reconstructions, and selects pa­ tients with the best long-term prognosis for free tissue transfer. Our approach has been to use reconstruction plates for defects that do not cross the midline and patients medi­ cally unfit for free tissue transfer. If the patient survives his or her disease and runs into a late, plate-related com­ plication, then the more complex free tissue transfers can be used at that point. It is clear from published reports and our own experience, however, that all of the cur­ rently available plating systems are associated with a rel­ atively high number of plate-related complications (20% to 40%) when evaluated over long follow-up intervals.i'