Practical guidelines for the reconstruction of the mandible and maxilla

Abstract

With the wide range of treatment options now available, surgeons are challenged to select the optimal method, material, and timing for a particular reconstruction. Four areas of the maxillofacial complex frequently require reconstruction: the mandible, maxilla, orbit, and zygoma. Part I of this clinic will cover reconstruction of the mandible and maxilla while Part II will cover the orbit and zygoma. Mandibular defects can be divided into marginal defects, continuity defects, and continuity defects that include the mandibular condyle. Treatment varies among these 3 types of defects and also depends a great deal on the quantity and quality of the surrounding soft tissue. Mandibular defects with well-vascularized surrounding soft tissue of good volume can be treated by a variety of techniques using free autogenous bone grafts. When the soft tissue is deficient in quantity and/or quality, it must be improved or replaced before free autogenous bone grafting or free vascularized flaps may be used. The choice of reconstructive system is based on the experience of the surgeon and on the specific characteristics of the defect and the overall health of the patient. Our preferred technique in the nonirradiated patient with healthy surrounding soft tissue is a combination of a reconstruction plate and block corticocancellous graft from the posterior ilium. These grafts have demonstrated excellent retention over time and are compatible with osseointegrated implants. Maxillary defects can be divided into those defects that have loss of hard and soft tissue and those with loss of hard tissue only. Defects with loss of hard tissue only are less difficult to treat and are frequently treated by placement of free autogenous bone grafts, in many cases with subsequent or simultaneous implant placement. For the hemimaxillectomy defect in which there is loss of both hard and soft tissue, 3 general approaches can be used. The first is use of the traditional prosthetic obturator. A second is use of a pedicled flap such as the temporalis muscle flap, which separates the oral cavity from the nasal cavity and maxillary sinus region. A third would be use of free vascularized tissue transfer of soft tissue or soft tissue and bone. Although the obturator approach may be difficult for younger patients to accept, it has the advantage of avoiding another donor site and may give the most stable and predictable results long term. References Macintosh RB: Current spectrum of costochondral and dermal grafting, in Bell WH (ed): Modern Practice of Orthognathic and Reconstructive Surgery. Philadelphia, PA, Saunders, 1992, p 873 Keller EE: Mandibular discontinuity reconstruction with composite grafts: Free autogenous iliac bone, titanium mesh trays and titanium endosseous implants. Oral Maxillofac Surg Clin North Am 3:877, 1991 Bach DE, Burgess LPA, Zislis T, et al: Cranial, iliac and demineralized freeze-dried bone grafts of the mandible in dogs. Arch Otolaryngol Head Neck Surg 117:390, 1991