Mandibular Reconstruction Plate Research Articles

Microvascular flap reconstruction of the mandible: a comparison of bone grafts and bridging plates for restoration of mandibular continuity

To compare the efficacy of vascularized bone grafts and bridging mandibular reconstruction plates for restoration of mandibular continuity in patients who undergo free flap reconstruction after segmental mandibulectomy. Study design and setting A total of 210 patients underwent microvascular flap reconstruction after segmental mandibulectomy. The rate of successful restoration of mandibular continuity in 151 patients with vascularized bone grafts was compared to 59 patients with soft tissue free flaps combined with bridging plates. Mandibular continuity was restored successfully for the duration of the follow-up period in 94% of patients who received bone grafts compared with 92% of patients with bridging mandibular reconstruction plates. This difference was not statistically significant. In patients who received bone grafts, most cases of reconstructive failure occurred during the perioperative period and were due to patient death or free flap thrombosis. In patients who received bridging plates, all instances of reconstructive failure were delayed for several months and were due to hardware extrusion or plate fracture. Vascularized bone-containing free flaps are preferred for reconstruction of most segmental mandibulectomy defects in patients undergoing microvascular flap reconstruction. However, use of a soft tissue flap with a bridging mandibular reconstruction plate is a reasonable alternative in patients with lateral oromandibular defects when the nature of the defect favors use of a soft tissue free flap. Both bone grafts and bridging plates represent effective methods of restoring mandibular continuity following segmental mandibulectomy, with the former being the preferred technique for patients undergoing microvascular reconstruction.

Microvascular flap reconstruction of the mandible: a comparison of bone grafts and bridging plates for restoration of mandibular continuity.

To compare the efficacy of vascularized bone grafts and bridging mandibular reconstruction plates for restoration of mandibular continuity in patients who undergo free flap reconstruction after segmental mandibulectomy. Study design and setting A total of 210 patients underwent microvascular flap reconstruction after segmental mandibulectomy. The rate of successful restoration of mandibular continuity in 151 patients with vascularized bone grafts was compared to 59 patients with soft tissue free flaps combined with bridging plates. Mandibular continuity was restored successfully for the duration of the follow-up period in 94% of patients who received bone grafts compared with 92% of patients with bridging mandibular reconstruction plates. This difference was not statistically significant. In patients who received bone grafts, most cases of reconstructive failure occurred during the perioperative period and were due to patient death or free flap thrombosis. In patients who received bridging plates, all instances of reconstructive failure were delayed for several months and were due to hardware extrusion or plate fracture. Vascularized bone-containing free flaps are preferred for reconstruction of most segmental mandibulectomy defects in patients undergoing microvascular flap reconstruction. However, use of a soft tissue flap with a bridging mandibular reconstruction plate is a reasonable alternative in patients with lateral oromandibular defects when the nature of the defect favors use of a soft tissue free flap. Both bone grafts and bridging plates represent effective methods of restoring mandibular continuity following segmental mandibulectomy, with the former being the preferred technique for patients undergoing microvascular reconstruction.

Fracture of mandibular reconstruction plates used after tumor resection

Purpose: We assessed the incidence of fractured plates after primary temporary AO plate reconstruction of the mandible following tumor resection. Patients and Methods: One hundred ten patients were retrospectively evaluated according to the extent of the tumor, anatomic location of the reconstruction, type of plate, additional use of radiotherapy or flap surgery (or both), and the incidence of fractured plates. Results: Fractured plates occurred in 8 of 110 patients. Most occurred less than 6 months after surgery. All of the 8 patients had a malignant tumor; 2 had received radiation therapy and 4 had skin flaps placed. The fractured plate was the straight type in 1 patient and the angular type in 7 patients. Among patients who had fractured plates, the average number of remaining teeth was 12.8 in the maxilla and 9.5 in the mandible. Conclusions: Fractured plates were more common among patients with oral cancer with a segmental defect that did not cross the midline in whom an angular-type plate was used and no bone grafting was performed. © 2002 American Association or Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 60:182-185, 2002

Reconstruction of soft tissue defects in the oral cavity and oropharynx.

During the decade following its description by Ariyan and Baek et al in 1979, the pectoralis major myocutaneous flap was widely considered to be the “workhorse” flap for reconstruction of major soft tissue defects of the oral cavity and oropharynx. This flap’s reliability and the good to excellent outcome with its use inhibited exploration of other more versatile techniques of reconstruction. Although the first microscope-assisted transfer of a free flap was reported in 1973, and microvascular head and neck reconstruction was described in 1976, initially there was limited enthusiasm in the United States to apply free flaps for head and neck reconstruction. This reluctance arose from several perceived potential shortcomings of microvascular tissue transfer. Such concerns included questions regarding the reliability of a technique that was dependent on smallvessel vascular anastomoses for a successful outcome and the potential for an adverse impact on the costs and complications of therapy. The pectoralis major myocutaneous flap was the preferred method for reconstruction of significant soft tissue defects at our institution until the late 1980s, when initial efforts were undertaken to investigate the potential utility of free flaps for head and neck reconstruction. Initially, free flaps were only chosen for reconstruction of selected patients for whom our previous reconstructive efforts using regional flaps had been disappointing (eg, patients with segmental defects of the anterior mandibular arch). During the past decade, our favorable experience with microvascular free tissue transfer has resulted in an evolution of our reconstructive philosophy, so that free flaps are now the preferred method of soft tissue reconstruction when primary mucosal repair or skin grafting would be insufficient in patients who undergo surgical therapy for cancers of the oral cavity and oropharynx. This includes patients with soft tissue resection of many T2 and most T3/T4 tumors, as well as some patients who undergo lateral composite mandibulectomy, in whom a soft tissue free flap is used in conjunction with a bridging mandibular reconstruction plate. We will review our experience with soft tissue free-flap reconstruction of the oral cavity and oropharynx and compare it with the results of regionalflap and free-flap reconstruction reported in the literature to determine whether our current reliance on free flaps is justified. PRO

The bridging lateral mandibular reconstruction plate revisited.

Lateral oromandibular reconstruction using a soft tissue free flap with a first-generation locking mandibular reconstruction plate (MRP) was rejected in a previous series by the senior author (K.E.B.) owing to a high incidence of delayed plate extrusion through the cheek skin. To reexamine this method of reconstruction using a second-generation, low-profile MRP. A prospective case series of 27 patients with segmental defects of the lateral mandible after treatment of head and neck cancer. An academic tertiary care referral center. All patients had mandibular continuity restored using the Leibinger Locking System (Stryker Leibinger Inc, Kalamazoo, Mich) MRP. Associated soft tissue defects were repaired using radial forearm (n = 22) or rectus abdominis (n= 5) free flaps. Incidence of hardware-related complications. All microvascular flap transfers were successful. One patient experienced a plate fracture 9 months after reconstruction. Only 1 patient experienced external plate exposure, 6 months after undergoing reconstruction of a through-and-through defect. Reconstruction was successful in 25 (93%) of the cases after a median follow-up period of 19.5 months. The high incidence of external plate exposure in patients undergoing lateral oromandibular reconstruction using soft tissue free flaps and first-generation locking MRPs may have resulted from a plate geometry that was prone to result in extrusion. After a similar length of follow-up, the incidence of reconstructive failure was reduced by using a low-profile, rounded-contour MRP. Final assessment of the durability of this technique will require long-term follow-up.

The use of titanium mandibular reconstruction plates in patients with oral cancer

A series of 21 patients, who were selected for primary mandibular stabilisation with titanium plates following excision of advanced malignant tumours, is reported. Success was defined as a plate that did not have to be removed due to fracture, exposure or infection. The overall success rate was 71%, with follow-up ranging from 7–53 months. The majority of plate losses were experienced when either anterior or large lateral defects which included the condyle were bridged and when patients were subjected to either pre- or postoperative radiotherapy.

The use of titanium mandibular reconstruction plates in patients with oral cancer

The use of titanium mandibular reconstruction plates in patients with oral cancer

Internal Fixation of the Sternum in Median Sternotomy Dehiscence

Sternal dehiscence may be defined as separation of the bony sternum and manubrium following median sternotomy. It may occur at any time postoperatively and has various etiologies. Restoration of sternal integrity in sternal dehiscence is a challenging problem, particularly when associated with deep-seated infection. This report reviews a single-stage technique that virtually eliminates the infected sternotomy wound and provides anatomic reduction and stabilization of the sternum. Complete debridement of infected and/or nonviable soft tissue, bone, and cartilage is followed by pulse irrigation. Parallel stainless steel mandibular reconstruction plates are then placed on each side of the remaining sternum and wired together. One or more transmanubrial compression plates may be added. Bilateral pectoralis major musculocutaneous flap advancement and primary skin closure is performed over two to three closed suction drains. From January of 1994 to July of 1996, this technique was used by the same surgeon in 26 male and 4 female patients aged 43 to 78 years (x = 61). Indications for the operation were sternal dehiscence with infection (osteomyelitis and/or mediastinitis) in 14 patients and sternal dehiscence without infection in 16 patients. All patients survived to discharge with mean time on the ventilator, intensive care unit length of stay, and postoperative length of stay of 0.7, 2, and 8 days, respectively. Choice and duration of antibiotics were based on culture results and operative findings. Subsequent hardware removal was necessary in one patient for hardware loosening and three patients for late periplate infection. A closed wound was eventually achieved in all 30 patients, and sternal stability was restored in 29 patients. In the management of sternal dehiscence, the described technique of internal fixation can provide anatomic sternal reduction and stabilization, elimination of infection, and wound closure in a single-stage operation. Successful outcomes were achieved despite the presence of severe infection.

The vascularized pig fibula bone flap model: effects of multiple segmental osteotomies on growth and viability.

Previous work by this laboratory introduced the pig fibula bone flap as a model for the study of the pathophysiology of vascularized bone flaps. Anatomic and hemodynamic studies demonstrated a significant (p < 0.05) decrease in vascular perfusion after a series of segmental osteotomies and rigid fixation (lag screws and miniplates) in the distal end of the flap, suggesting that blood flow to the distal osteotomized segment of the flap may be impaired. Killing the animals after blood flow studies precluded assessment of the effect of these hemodynamic changes on bone healing. Therefore, the aim of this study was to assess the pig fibula bone flap model with respect to viability, healing, and subsequent growth after multiple segmental osteotomies and rigid fixation to contribute to the understanding of vascularized bone flap pathophysiology. Yorkshire pigs (20 to 25 kg) were used for all experiments. Eight pigs underwent unilateral elevation of a vascularized fibula bone flap, which was osteotomized into three segments and orthotopically rigidly fixed using a 2.4-mm mandibular reconstruction plate. The left fibula remained as the control. Fluorochrome labels were injected to assess bone viability and turnover, and both fibulae were assessed for growth radiologically. The fibulae were harvested 21 days postoperatively (when the animals were killed), and bone healing was assessed histologically and clinically. There were no significant differences in preoperative and postoperative lengths of the osteotomized fibulae compared with the controls, suggesting that there was no impairment of growth potential after multiple segmental osteotomies and rigid fixation. Significant (p < 0.05) bony hypertrophy of the osteotomized fibulae was noted when compared with controls. Mobility was observed in 3 of the 32 osteotomies (9 percent), occurring across one proximal and two distal osteotomies in association with failure of fixation. However, histologic and fluorochrome assessment confirmed the viability of all bone segments, as supported by the presence of tetracycline given 2 days postoperatively. The pig fibula bone flap model is well tolerated by the pig. Multiple segmental osteotomies and rigid fixation, previously associated with a significant decrease in blood flow in the distal segment, did not impair either growth potential, viability, or healing ability. It is suggested that the pig fibula is a suitable model for the study of bone flap pathophysiology.

Primary leiomyosarcoma of the mandible in a 7-year-old girlReport of a case and review of the literature

Leiomyosarcoma is a malignant neoplasm of smooth muscle origin that manifests itself uncommonly in the oral cavity because of the paucity of smooth muscle in that location. To the best of our knowledge, only 10 cases of leiomyosarcoma primary to the jawbones have been reported in the English language literature. We report the first pediatric case of leiomyosarcoma arising from the mandible. Facial asymmetry and swelling were accompanied by a rapidly growing exophytic soft tissue mass that caused buccal displacement of the mandibular left permanent first molar. The lesion, observed radiographically as an extensive ill-defined area of osteolytic alveolar destruction, perforated the lingual cortex, displaced the inferior alveolar nerve canal inferiorly, and produced a “floating-in-air” appearance of the first molar. Diagnosis of leiomyosarcoma was made after initial incisional biopsy of the lesion. A 5-cm segmental mandibulectomy and supraomohyoid neck dissection were followed by reconstruction with a dynamic mandibular reconstruction plate and placement of a multidimensional mandibular distraction device in a transport rectangle of bone to promote bifocal distraction osteogenesis. Forty millimeters of distraction (the technical limit of the device) were performed; this was followed by terminal iliac crest bone grafting. Seventeen months after the definitive surgical procedure, the patient remains free of disease. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;87:477-84)

Evaluation and complications of the use of long span plates in mandibular reconstruction

Evaluation and complications of the use of long span plates in mandibular reconstruction

下顎骨再建インプラントの作製に３次元実体模型を用いた下顎再建の１例

We performed secondary mandibular reconstruction with a mandibular reconstruction implant in a 58-year-old man after hemimandibulectomy for gingival carcinoma. The mandibular reconstruction implant was made by combining mandibular reconstruction plates with a cast chromium-cobalt alloy plate.The cast plate had to be accurately placed between the reconstruction plate and the mandibular condyle. We thesefored used a solid model based on three-dimensional computed tomography image data to manufacture the cast plate. The good fit of the cast plate demonstrated the high usefulness of the threedimensional solid model.

Clinical study of immediate reconstruction using a mandibular reconstruction plate (LEIBINGER®)

Clinical study of immediate reconstruction using a mandibular reconstruction plate (LEIBINGER®)

Lateral Mandibular Reconstruction Using Soft-Tissue Free Flaps and Plates

To assess the outcome of patients who are undergoing reconstruction of segmental lateral mandibular defects by using soft-tissue free flaps combined with mandibular reconstruction plates. Retrospective case series of 15 patients who were undergoing primary reconstruction of mandibular segments posterior to the mental foramen, resulting from treatment of head and neck cancer. All patients received either preoperative or postoperative radiation therapy. Academic tertiary care referral center. Fourteen patients had mandibular continuity restored by using the titanium hollow screw reconstruction plate system, and 1 patient received a stainless steel mandibular reconstruction plate. Associated soft-tissue defects were repaired by using radial forearm (n = 11), rectus abdominis (n = 2), scapular and parascapular (n = 1), or lateral arm (n = 1) free flaps. Early and delayed complications. All 15 microvascular free tissue transfers were successful. Early complications were minor and occurred in 5 (33%) of 15 patients. One patient in whom the titanium hollow screw reconstruction plate system had been used experienced a fracture at 15 months after reconstruction. Three patients experienced delayed external plate exposure between 7 and 15 months after primary oromandibular reconstruction. Patients who experienced delayed external plate exposure required secondary reconstruction with a vascularized bone-containing free flap. The overall rate of delayed reconstructive failure was 40% in patients who were followed up for a minimum of 1 year. For patients who are undergoing free flap reconstruction of lateral mandibulectomy defects, the technique that used soft-tissue free flaps combined with mandibular reconstruction plates has been abandoned in favor of using vascularized bone-containing free flaps or a combination of free flaps to achieve optimal long-term results.

Mandibular reconstruction using a titanium plate: The impact of radiation therapy on plate preservation

To evaluate the soft tissue and bone tolerance of radiation therapy (RT) in patients undergoing radical composite resection and mandibular reconstruction using a bridging titanium plate with myocutaneous flap closure. From 1990 to 1994, 47 patients with primary or recurrent oral cavity or oropharyngeal carcinomas were treated with radical composite resection and mandibular reconstruction using a bridging titanium plate with myocutaneous flap closure. Eleven patients received no RT (no RT), 10 patients received RT greater than 10 months from the time of surgery (remote RT), and 26 patients received RT within 12 weeks of surgery (perioperative RT). The radiation dose to the reconstructed mandible ranged from 45 to 75 Gy (median 63 Gy). The effect of the titanium plate on the radiation dose was measured using film dosimetry and soft tissue and bone-equivalent materials. The median follow-up was 17 months (range: 3-50 months). Late complications included four patients with osteomyelitis or necrosis, two plate exposures requiring flap revision, one chronic infection, two cases of chronic pain, two fistulae, and one case of trismus and malocclusion. The crude incidence of late complications by treatment was: (a) no RT: 3 of 11 patients (27%); (b) remote RT: 2 of 10 patients (20%); and (c) perioperative RT: 9 of 26 patients (35%). One patient in the no-RT group lost the plate due to chronic pain. Five patients in the perioperative RT group also had plate loss, four due to osteomyelitis and/or necrosis, and one due to pain related to a recurrent tumor. No patients in the remote RT group had plate loss. The actuarial prosthesis preservation rate at 2 years was 88% for the no RT, 100% for the remote RT, and 57% for the perioperative RT groups (p = 0.05). Phantom dose measurements showed that for parallel opposed 6 MV photon beams, there was no significant increase in the dose proximal or distal to the plate in either a soft tissue- or bone-equivalent phantom. The impact of radiation therapy on plate preservation after mandibular reconstructive surgery using a titanium plate may be dependent on the timing of RT relative to surgery. Significantly more mandibular reconstruction plates were lost when the involved mandible received RT in the perioperative period than when RT was delivered beyond 10 months from surgery or when no RT was given. The use of alloplastic implants such as titanium plates in conjunction with myocutaneous flap coverage for mandibular reconstruction is attractive because it allows immediate reconstruction of the defect and promotes a good functional and cosmetic result; however, administration of perioperative RT may result in a higher plate failure rate.

Comparison of Artifact from Craniomaxillofacial Internal Fixation Devices

This study compares artifact from craniomaxillofacial internal fixation devices in magnetic resonance images and examines heating and magnetic deflection effects on these devices. Stainless steel wires, microfixation plates of vitallium and titanium, and minifixation and mandibular reconstruction plates of stainless steel, vitallium, and titanium were evaluated. The plates were mounted on a dry skull and submerged in dilute copper sulfate solution. All images were obtained in duplicate by two independent, nonblinded teams of observers with a 1.5-T Signa magnetic resonance system. Each team ranked artifact size for each material by computerized measurement. The rank order of artifact size for each material within each fixation system group and between fixation groups was identical between the two teams. Bath and plate temperatures were recorded before and after imaging. Artifact production was related to hardware size and composition. Titanium hardware caused the least amount of black-hole artifact. Vitallium and stainless steel fixation devices of similar size produced significantly more artifact. No significant heating or magnetic deflection effects were seen with any of the fixation devices.

Indications for the AO plate with a myocutaneous flap instead of revascularized tissue transfer for mandibular reconstruction.

Our preferred technique for mandibular reconstruction uses a revascularized osseomyocutaneous flap. However, to reconstruct small lateral defects in dentulous patients, the AO mandibular reconstruction plate (MRP) is used. Its advantages include quick, reliable placement without a donor site or the need for advanced technical training. This review examines 16 patients who underwent primary mandibular reconstruction after ablative oncologic surgery using an AO MRP without a bone graft. The average follow-up was 32 months. Twelve patients (75%) had successful reconstructions, while 4 (25%) developed serious complications resulting in failure of the MRP. The most significant factor limiting rehabilitation was disease progression, affecting 12 (75%) of the 16 patients. In this subgroup of selected patients with small (< 6 cm) lateral mandibular defects, useful dentition, and advanced disease, or whose general medical condition precludes prolonged general anesthesia, primary mandibular reconstruction using an AO MRP and a myocutaneous flap without a bone graft is a viable reconstructive alternative.

Management of the failed mandibular reconstruction plate

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'

Reconstruction of mandibular discontinuity defects using autogenous grafting and a mandibular reconstruction plate: A prospective evaluation of nine consecutive cases

Reconstruction of mandibular discontinuity defects using autogenous grafting and a mandibular reconstruction plate: A prospective evaluation of nine consecutive cases

Reconstruction of mandibular discontinuity defects using autogenous grafting and a mandibular reconstruction plate: A prospective evaluation of nine consecutive cases

This article presents the clinical results of a prospective evaluation of nine cases of mandibular discontinuity that were reconstructed using autogenous grafting and a reconstruction plate. All patients were allowed to function immediately postsurgery. Acceptable esthetic and functional results were obtained with minimal donor and recipient site complications. All cases showed complete graft incorporation and restoration of osseous continuity.