137

Click here to load reader

Mandible Reconstruction

Embed Size (px)

Citation preview

Page 1: Mandible Reconstruction

Mandible Mandible ReconstructionReconstruction

Dr. SHOUVIK CHOWDHURY

RAJA RAJESWARI DENTAL COLLEGE, BANGALORE

Page 2: Mandible Reconstruction

CONTENTSCONTENTS

►HistoryHistory►Causes of mandibular defectsCauses of mandibular defects►ClassificationClassification►Goals/ principles and criteriaGoals/ principles and criteria►TimingTiming►TMJ reconstructionTMJ reconstruction►ComplicationsComplications►Recent advancesRecent advances

Page 3: Mandible Reconstruction

HistoryHistory

► 1821- Vongraffe & Deadrick( partial 1821- Vongraffe & Deadrick( partial mandibulectomy)mandibulectomy)

► 1881-Free bone grafting was the first 1881-Free bone grafting was the first method of reconstructing mandibular method of reconstructing mandibular defects and was initially reported by defects and was initially reported by Bardenheuer Bardenheuer

► 1889- Martin described immediate 1889- Martin described immediate reconstruction with prosthetic appliance reconstruction with prosthetic appliance

► 1897- Partsh use metal band to restore 1897- Partsh use metal band to restore mandibular continuitymandibular continuity

► 1898- Berndt recommended use of celluloid 1898- Berndt recommended use of celluloid materialmaterial

Page 4: Mandible Reconstruction

► 1909- White favoured silver wire1909- White favoured silver wire► 1912- Schudder, Ollier, Martin use hard 1912- Schudder, Ollier, Martin use hard

rubberrubber► 1941- Vitallium, 1953-SS, 1954- Titanium1941- Vitallium, 1953-SS, 1954- Titanium► 1945- use of matal trays with cancellous bone 1945- use of matal trays with cancellous bone

chipschips► 1971- Conley and Snyder introduced the 1971- Conley and Snyder introduced the

osteomyocutaneous flaposteomyocutaneous flap► 1978- McKee and Daniel were the first to 1978- McKee and Daniel were the first to

report out comes of free vascularized report out comes of free vascularized composite rib flapscomposite rib flaps

► In 1989, Urken introduced the sensate free In 1989, Urken introduced the sensate free flap flap

Page 5: Mandible Reconstruction

Causes of mandibular Causes of mandibular defectdefect

►Ablative surgery of oral cancer Ablative surgery of oral cancer ►Removal of odontogenic tumors like Removal of odontogenic tumors like

ameloblastomaameloblastoma►Surgical treatment of cystsSurgical treatment of cysts►Trauma- RTA, assault Trauma- RTA, assault ►Resection following chronic osteomyelitisResection following chronic osteomyelitis►Resection of osteoradionecrosis of Resection of osteoradionecrosis of

mandiblemandible►Gun shot woundsGun shot wounds

Page 6: Mandible Reconstruction

Classification of Classification of mandibular defectsmandibular defects

Page 7: Mandible Reconstruction

Classification of mandibular Classification of mandibular defect according to BOYD et aldefect according to BOYD et al

Page 8: Mandible Reconstruction

Classification by Cantor and Classification by Cantor and CurtisCurtis

Page 9: Mandible Reconstruction

GOALS OF GOALS OF RECONSTRUCTIONRECONSTRUCTION

► Restoration of bone continuityRestoration of bone continuity:: restores much of the mechanical restores much of the mechanical

stability to thestability to the functions of functions of mastication, speech, and deglutitionmastication, speech, and deglutition

► Restoration of osseous bulkRestoration of osseous bulk::► a sufficient quantity of cellular a sufficient quantity of cellular

cancellous graft materials should be cancellous graft materials should be placed and firmly fixed into a vascular placed and firmly fixed into a vascular and cellular tissue bed that is free of and cellular tissue bed that is free of contaminationcontamination..

► Restoration of bone heightRestoration of bone height

Page 10: Mandible Reconstruction

► Bone maintenanceBone maintenance:: maintenance of the bone ossicle throughout maintenance of the bone ossicle throughout

the life of the patient. the life of the patient. . . Grafts that show initial bone formation Grafts that show initial bone formation

but later go on to resorb between 6 and but later go on to resorb between 6 and 12 months.12 months. Grafts that maintain or increase Grafts that maintain or increase their radiographic mineral density for 18 their radiographic mineral density for 18 months almost always maintain their ossicle months almost always maintain their ossicle throughout the patient’s lifetime.throughout the patient’s lifetime.

► Elimination of soft tissue defect:Elimination of soft tissue defect: unseating forces that prevent the seal of a unseating forces that prevent the seal of a prosthesis. prosthesis.

► Restoration of facial contour:Restoration of facial contour:► Vascularity of recipient bed: Vascularity of recipient bed: osteogenesis osteogenesis

of transplanted tissue depends on of transplanted tissue depends on revascularizationrevascularization

Page 11: Mandible Reconstruction

Timing of reconstructionTiming of reconstruction

► Primary Vs Delayed ReconstructionPrimary Vs Delayed Reconstruction::

Lawson et al in 1982, reported a success Lawson et al in 1982, reported a success rate of 90% for delayed reconstruction rate of 90% for delayed reconstruction versus 46% for primary reconstruction. In versus 46% for primary reconstruction. In addition, oral contamination of primary addition, oral contamination of primary reconstruction resulted in unacceptably high reconstruction resulted in unacceptably high complication rates from infection. complication rates from infection.

no functional benefit obtained with no functional benefit obtained with immediate restoration of mandibular immediate restoration of mandibular continuity. continuity.

Page 12: Mandible Reconstruction

► In 1991, Shockley, Weissler, and Pillsbury In 1991, Shockley, Weissler, and Pillsbury published a retrospective review of 19 published a retrospective review of 19 patients who underwent primary mandibular patients who underwent primary mandibular reconstruction using reconstruction plates reconstruction using reconstruction plates and noted a 79% success rate.and noted a 79% success rate.

► He concluded that immediate reconstruction He concluded that immediate reconstruction of mandibular defects using reconstruction of mandibular defects using reconstruction plates does not replace the use of free flaps plates does not replace the use of free flaps but should be remembered as an alternative but should be remembered as an alternative that offers fast and reliable reconstruction that offers fast and reliable reconstruction with no donor site morbidity and excellent with no donor site morbidity and excellent facial contour. facial contour.

Page 13: Mandible Reconstruction

Methods of mandibular Methods of mandibular reconstructionreconstruction

► 1. Prosthetic implants:1. Prosthetic implants:► A. Spacing devices:A. Spacing devices:► Kirschner wireKirschner wire► Bone plateBone plate► B. Formed appliances:B. Formed appliances:► Stainless steelStainless steel► Cr-coCr-co► TantalumTantalum► TitaniumTitanium► Dimethyl siloxane(Silastic)Dimethyl siloxane(Silastic)► Fluoroethylene(Teflon)Fluoroethylene(Teflon)

Page 14: Mandible Reconstruction

►PMMA(acrylic)PMMA(acrylic)►Polyurethane & Dacron meshPolyurethane & Dacron mesh►2. Bone grafts:2. Bone grafts:► A. fresh autografts- rib, iliac crest, A. fresh autografts- rib, iliac crest,

tibia, tibia, mandiblemandible B. treated autografts- Freeze dried, B. treated autografts- Freeze dried, irradiated, autoclaved.irradiated, autoclaved.►3. Combined Alloplast-autograft3. Combined Alloplast-autograft► tray with cancellous bonetray with cancellous bone► plate with cortical boneplate with cortical bone

Page 15: Mandible Reconstruction

►4. free & compound flaps:4. free & compound flaps:►A. free flaps: rib. Iliac crest, scaplar A. free flaps: rib. Iliac crest, scaplar

spine, metatarsalspine, metatarsal► pedicled osteomyocutaneous flap with pedicled osteomyocutaneous flap with

rib, clavicle, scapularib, clavicle, scapula►5. homograft-autograft combination5. homograft-autograft combination

Page 16: Mandible Reconstruction

Prosthetic implantProsthetic implant

►Used mainly as a spacing device in Used mainly as a spacing device in immediate reconstruction to span the immediate reconstruction to span the defect & maintain the position of defect & maintain the position of mandibular segment for future mandibular segment for future definitive repair.definitive repair.

►1992- Goode reported the use of 1992- Goode reported the use of tobramycin impregnated methacrylatetobramycin impregnated methacrylate

Page 17: Mandible Reconstruction

THORPTHORP

► (THORP) was an attempt to address the (THORP) was an attempt to address the failures of the older plating systems. This failures of the older plating systems. This plate has a hollow screw made of titanium plate has a hollow screw made of titanium with perforations along the screw body with perforations along the screw body which allow bone ingrowth and result in which allow bone ingrowth and result in increased plate stability at the bone-screw increased plate stability at the bone-screw interface. An expansion bolt within the interface. An expansion bolt within the screw head allows the plate to be anchored screw head allows the plate to be anchored to the interosseous screw instead of being to the interosseous screw instead of being compressed to the underlying mandible. compressed to the underlying mandible. This prevents pressure necrosis of the This prevents pressure necrosis of the underlying bone decreasing the potential for underlying bone decreasing the potential for plate failure at the screw-bone interface. plate failure at the screw-bone interface.

Page 18: Mandible Reconstruction

►Pedicled and free flaps may be Pedicled and free flaps may be combined with plate reconstruction for combined with plate reconstruction for soft tissue supplementation and to soft tissue supplementation and to minimize the possibility of minimize the possibility of postoperative complications. The postoperative complications. The pectoralis myocutaneous flap is the pectoralis myocutaneous flap is the most commonly used pedicled flap for most commonly used pedicled flap for this purpose. The plate is usually this purpose. The plate is usually placed first, and the muscular pedicle placed first, and the muscular pedicle is then suspended from the plate. is then suspended from the plate.

Page 19: Mandible Reconstruction

► Important considerations for using Important considerations for using reconstruction plates include reconstruction plates include

►(1) Preventing exposure of the plate and (1) Preventing exposure of the plate and the posterior need for removal using a the posterior need for removal using a full thickness pectoralis major full thickness pectoralis major myocutaneous flap, covering the full myocutaneous flap, covering the full extent of the plate to prevent dehiscence extent of the plate to prevent dehiscence during radiotherapy;during radiotherapy;

►(2) To allow the healing process of the (2) To allow the healing process of the soft-tissue cover to be completed for soft-tissue cover to be completed for adequate flap integration, radiotherapy adequate flap integration, radiotherapy should be postponed for as long as should be postponed for as long as possible without compromising the possible without compromising the cancer treatment;cancer treatment;

Page 20: Mandible Reconstruction

► (3) Whenever available, titanium 2.7-mm plates or (3) Whenever available, titanium 2.7-mm plates or THORP plates should be used instead of stainless THORP plates should be used instead of stainless steel 2.7-mm reconstruction plates; steel 2.7-mm reconstruction plates;

► (4) Stabilization of the reconstruction plate in the (4) Stabilization of the reconstruction plate in the mandible must be carried out with at least 3 screws mandible must be carried out with at least 3 screws in each reminiscent side as far as a correct plate in each reminiscent side as far as a correct plate banding to provide a good aesthetic result and not banding to provide a good aesthetic result and not compress the myocutaneous flap, causing ischemia compress the myocutaneous flap, causing ischemia and wound dehiscence.and wound dehiscence.

► Early plate failure in the first six weeks after Early plate failure in the first six weeks after surgery is most often due to technical variations in surgery is most often due to technical variations in plate application such as over projection or plate application such as over projection or unstable application of the plate which can lead to unstable application of the plate which can lead to soft tissue breakdown and infection. soft tissue breakdown and infection.

► Exposure after 12 - 18 months can occur from Exposure after 12 - 18 months can occur from resorption of bone around the hardware with resorption of bone around the hardware with resultant plate instability. resultant plate instability.

Page 21: Mandible Reconstruction

►Methylmethacrylate as a space Methylmethacrylate as a space maintainer in mandibular maintainer in mandibular reconstructionreconstruction::

•Methylmethacrylate is reported to be well toleratedby bone and soft tissues

•The stabilized methylmethacrylateblocks allow the overlying oral mucosa and skinto heal without delay or wound breakdown.•Heat-cured methylmethacrylate was originally usedin the early 1940s for facial prosthetics and coldcuredmethylmethacrylate was reported to be initiallyused in cranial reconstruction in 1941.

Page 22: Mandible Reconstruction

Free Bone GraftingFree Bone Grafting

► calvarium, rib, ilium, tibia, fibula, scapula, calvarium, rib, ilium, tibia, fibula, scapula, humerus, radius, and metatarsus humerus, radius, and metatarsus

► Cancellous bone grafts, consisting of Cancellous bone grafts, consisting of medullary bone and bone marrow, contain medullary bone and bone marrow, contain the highest percentage of viable the highest percentage of viable osteoblasts. These grafts become osteoblasts. These grafts become revascularized rapidly due to their revascularized rapidly due to their particulate structure and large surface area. particulate structure and large surface area. This results in a higher percentage of This results in a higher percentage of surviving cells after transplantation. surviving cells after transplantation.

Page 23: Mandible Reconstruction

► Corticocancellous grafts contain both cortical bone Corticocancellous grafts contain both cortical bone and underlying cancellous bone providing and underlying cancellous bone providing osteoblastic cells as well as strength necessary for osteoblastic cells as well as strength necessary for bridging discontinuous defects. bridging discontinuous defects.

► Allogenic bone graft:Allogenic bone graft:► Allogenic mandible, rib, or iliac crest has been used Allogenic mandible, rib, or iliac crest has been used

occasionally for mandibular reconstructionoccasionally for mandibular reconstruction► The allograft is usually hollowed and functions as a The allograft is usually hollowed and functions as a

biodegradable tray for particulate corticocancellous biodegradable tray for particulate corticocancellous bone grafts or as supplementation for autogenous bone grafts or as supplementation for autogenous bone grafting when insufficient bone is available. bone grafting when insufficient bone is available.

► The benefits of this method included low The benefits of this method included low immunogenicity of the graft, high immunogenicity of the graft, high concentration of transplanted osteocytes, and concentration of transplanted osteocytes, and complete bioresorbability of the tray with complete bioresorbability of the tray with transmission of increasing stress to the transmission of increasing stress to the autogenous graft which can facilitate autogenous graft which can facilitate osteogenesisosteogenesis

Page 24: Mandible Reconstruction

Advantages of Free Tissue Transfer

►Wide variety of available tissue types

►Large amount of composite tissue►Tailored to match defect►Wide range of skin characteristics►More efficient use of harvested

tissue►Immediate reconstruction

Page 25: Mandible Reconstruction

►Two team approach►Improved vascularity and wound

healing►Low rate of resorption►Defect size little consequence►Potential for sensory and motor

innervation►Permits use of osseointegrated

implants

Page 26: Mandible Reconstruction

Disadvantages of Free Tissue Transfer

►Technically demanding►Increased operating room time►Increased flap failure rate►Functional disability at donor site

Page 27: Mandible Reconstruction

Vascularized Pedicled Bone Vascularized Pedicled Bone TransfersTransfers

► Non vascular bone grafting is a less reliable Non vascular bone grafting is a less reliable technique, because high rates of infection technique, because high rates of infection secondary to salivary contamination, vascularity to secondary to salivary contamination, vascularity to the graft was limitedthe graft was limited

► Vascularized bone maintains an intact blood supply Vascularized bone maintains an intact blood supply ► Helps the graft to retain its original volume Helps the graft to retain its original volume ► Bone remains viable no need of replacement.Bone remains viable no need of replacement.

► Healing time is shortenedHealing time is shortened..

Page 28: Mandible Reconstruction

Method of fixationMethod of fixation► Free Bone Grafting:Free Bone Grafting:► Rib, ilium, tibia, fibula, scapula, radius, calvarium, metatarsusRib, ilium, tibia, fibula, scapula, radius, calvarium, metatarsus► Myocutaneous flapMyocutaneous flap: pectoralis major, sternocleidomastoid, : pectoralis major, sternocleidomastoid,

radial forearm flap, scapular, latissimus dorsi radial forearm flap, scapular, latissimus dorsi ► Free flapFree flap:, Illium based on deep circumflex iliac artery, :, Illium based on deep circumflex iliac artery,

Scapula based on superficial circumflex artery, Rib based on Scapula based on superficial circumflex artery, Rib based on internal mammary artery Radius based on radial artery & internal mammary artery Radius based on radial artery & cephalic veins, Fibula based on peroneal artery, ulna based on cephalic veins, Fibula based on peroneal artery, ulna based on ulnar artery ulnar artery

► Pedicle bone flaps:Pedicle bone flaps:► Clavicle/sternum based on sternocleidomastoid, Rib graft with Clavicle/sternum based on sternocleidomastoid, Rib graft with

Pectoralis major, Rib via serratus branch of thoracodorsal Pectoralis major, Rib via serratus branch of thoracodorsal artery, Calvarial graft with temporalis muscle, Trapezius flapartery, Calvarial graft with temporalis muscle, Trapezius flap

Page 29: Mandible Reconstruction

Free bone graftingFree bone grafting

Page 30: Mandible Reconstruction

iliumilium

► Anterior iliac crest- Anterior iliac crest- 6 cm. posterior to 6 cm. posterior to AIS & tubercle of AIS & tubercle of iliumilium

► 50 cc of cancellous 50 cc of cancellous bone can be bone can be harvestedharvested

► Posterior iliac crest- Posterior iliac crest- 100 cc of cancellous 100 cc of cancellous bonebone

Page 31: Mandible Reconstruction

incisionsincisions

► lateral approach lateral approach stripping tensor fascia stripping tensor fascia lata & gluteus mediuslata & gluteus medius

► Medial approach Medial approach stripping iliacusstripping iliacus

► Crestal approach- Crestal approach- spliting or removing a spliting or removing a portion of iliac crestportion of iliac crest

► AIC- 2-3 cm.(l) 1-2 cm. AIC- 2-3 cm.(l) 1-2 cm. posterior to tubercle 1 posterior to tubercle 1 cm. inf to AIScm. inf to AIS

Page 32: Mandible Reconstruction

► lateral scar lie parallel to crest, medial scar lateral scar lie parallel to crest, medial scar at 30-45 degree to crestat 30-45 degree to crest

► PIC- 6-8 cm curvillinear incision on pallable PIC- 6-8 cm curvillinear incision on pallable insertion of gluteusinsertion of gluteus

► Bone length available: 4-6 cmBone length available: 4-6 cm► disadvantage disadvantage ► Lateral approach: gait disturbanceLateral approach: gait disturbance► Crestal approach: irregularityCrestal approach: irregularity► Risk of damage to lateral cutaneous n.Risk of damage to lateral cutaneous n.

Page 33: Mandible Reconstruction

approachapproach

► Clamshell: expands Clamshell: expands medial & lateral cortices medial & lateral cortices to gain accessto gain access

► Trap door: pedicles Trap door: pedicles medial & lateral cortex medial & lateral cortex on muscleon muscle

► Tschopp: pedicles iliac Tschopp: pedicles iliac crest on external obliquecrest on external oblique

► Tessier: pedicles both Tessier: pedicles both medial & lateral portions medial & lateral portions by oblique osteotomyby oblique osteotomy

Page 34: Mandible Reconstruction

►Pros: ►-Good bone stock►Cons:Cons:

-shape of bone can make graft shaping -shape of bone can make graft shaping difficultdifficult

Page 35: Mandible Reconstruction

complicationscomplications

►Gait disturbance, infection, hematoma, Gait disturbance, infection, hematoma, sacroiliac instability, intra abdominal sacroiliac instability, intra abdominal perforation, abdominal herniaperforation, abdominal hernia

Page 36: Mandible Reconstruction

Costochondral Rib graftCostochondral Rib graft

Page 37: Mandible Reconstruction

incisionincision

► 5 cm.long. 5 cm.long. Inframammary Inframammary crease & carried crease & carried from mid axillary from mid axillary region to sternumregion to sternum

► Use-TMJ Use-TMJ reconstructionreconstruction

► 5-8 ribs are 5-8 ribs are harvestedharvested

► Subperiosteal Subperiosteal dissectiondissection

Page 38: Mandible Reconstruction
Page 39: Mandible Reconstruction
Page 40: Mandible Reconstruction

disadvantagedisadvantage

►Pleural tear, pneumothoraxPleural tear, pneumothorax

Page 41: Mandible Reconstruction

scapulascapula

► Lateral border- Lateral border- 1010×2 cm×2 cm

► Flat blade: 7×5 cmFlat blade: 7×5 cm► Transversely Transversely

located spine- 7cm.located spine- 7cm.► Pedicle:transverse Pedicle:transverse

cervical arterycervical artery

Page 42: Mandible Reconstruction

incisionsincisions

► Vertical incision from Vertical incision from standard radical standard radical neck incision or neck incision or serpiginous incision serpiginous incision from vertical back from vertical back incision-root of neck incision-root of neck & to lower border of & to lower border of mandiblemandible

► Scapular blade: Scapular blade: transverse incision transverse incision 2cm below & parallel 2cm below & parallel to spine of scapula to spine of scapula

Page 43: Mandible Reconstruction

► Trapezius m.-incised Trapezius m.-incised vertically from level vertically from level of mastoid processof mastoid process

► Incision carried Incision carried along infraspinatous along infraspinatous m. at the junction of m. at the junction of scapular spine & scapular spine & blade of scapulablade of scapula

Page 44: Mandible Reconstruction
Page 45: Mandible Reconstruction

Scapular bladeScapular blade

► Transverse incision Transverse incision 2cm. Below & 2cm. Below & parallel to spine of parallel to spine of scapulascapula

Page 46: Mandible Reconstruction

Fibular free flapFibular free flap

►19751975►Hidalgo – mandibular Hidalgo – mandibular

recon 1989recon 1989►Longest possible segment Longest possible segment

of revasularized bone (25-of revasularized bone (25-28 cm)28 cm)

► Ideal for osseointegrated Ideal for osseointegrated implant placementimplant placement

Page 47: Mandible Reconstruction

Neurovascular pedicleNeurovascular pedicle► Peroneal artery and veinPeroneal artery and vein► Sensate restoration with lateral Sensate restoration with lateral

sural cutaneous nervesural cutaneous nerve► Peroneal communicating branch Peroneal communicating branch

vascularized nerve graft for lower vascularized nerve graft for lower lip sensationlip sensation

► Skin perforatorsSkin perforators Posterior intermuscular septum Posterior intermuscular septum

(septocutaneous or (septocutaneous or musculocutaneous through flexor musculocutaneous through flexor hallucis longus and soleus)hallucis longus and soleus)

Should always include cuff of flexor Should always include cuff of flexor hallucis longus and soleus in flap hallucis longus and soleus in flap harvestharvest

5-10% of cases blood supply to skin 5-10% of cases blood supply to skin paddle is inadequatepaddle is inadequate

Pedicle length-3cmPedicle length-3cm

Page 48: Mandible Reconstruction

Technical considerationsTechnical considerations

► Choose leg based on ease of Choose leg based on ease of insettinginsetting Intraoral skin paddleIntraoral skin paddle

►Harvest flap from Harvest flap from contralateral side of contralateral side of recipient vesselsrecipient vessels

► 8 cm segment preserved 8 cm segment preserved proximally and distally to proximally and distally to protect common peroneal protect common peroneal nerve and ensure ankle nerve and ensure ankle stabilitystability

► Center flap over posterior Center flap over posterior intermuscular septumintermuscular septum Anterior to soleus and Anterior to soleus and

posterior to peroneusposterior to peroneus

Page 49: Mandible Reconstruction

Fibular free flapFibular free flap

►MorbidityMorbidity Donor site complicationsDonor site complications

►EdemaEdema►Weakness in dorsiflexion of great toeWeakness in dorsiflexion of great toe

Skin loss in 5 – 10% of flapsSkin loss in 5 – 10% of flaps

Page 50: Mandible Reconstruction
Page 51: Mandible Reconstruction

Myocutaneous flapsMyocutaneous flaps

Page 52: Mandible Reconstruction

STERNOCLEIDOMASTOID STERNOCLEIDOMASTOID FLAPFLAP

Introduced by Jinau in 1909.Introduced by Jinau in 1909. 1949-1955 – Owens.1949-1955 – Owens. Muscle, Myocutaneous or Myoosseous flapMuscle, Myocutaneous or Myoosseous flap ANATOMY :ANATOMY : Origin : Two heads – Manubrium sterniOrigin : Two heads – Manubrium sterni Medial third of clavicle.Medial third of clavicle. Insertion : Mastoid processInsertion : Mastoid process lateral third of superior Nuchal line.lateral third of superior Nuchal line.

Page 53: Mandible Reconstruction

Cutaneous innervations –SupraclavicularCutaneous innervations –Supraclavicular

Transverse colliTransverse colli

Greater auricular Greater auricular nervenerve

Motor – Spinal accessory nerveMotor – Spinal accessory nerve

Anterior rami of 2Anterior rami of 2ndnd and 3 and 3rdrd

Skin – Subcutaneous tissue- platysma-Skin – Subcutaneous tissue- platysma-

SternocleidomastoidSternocleidomastoid

Blood supply : Blood supply :

Superior- Occipatal artery (Dominant)Superior- Occipatal artery (Dominant)

Middle- Superior thyroid artery.Middle- Superior thyroid artery.

Inferior- Thyrocervical trunkInferior- Thyrocervical trunk

Page 54: Mandible Reconstruction

Skin – Superior-Skin – Superior-Occipital/ Posterior Occipital/ Posterior auricular arteryauricular artery

Inferior- Transverse Inferior- Transverse cervical/ cervical/ ThyrocervicalThyrocervical

Page 55: Mandible Reconstruction

For only muscle flap – For only muscle flap – Vertical incision on Vertical incision on musclemuscle

Alternate two horizontal Alternate two horizontal incisionincision

Myocutaneous – Superior Myocutaneous – Superior / Inferior based/ Inferior based

Mc fee incision.Mc fee incision.

Page 56: Mandible Reconstruction

Superiorly basedSuperiorly based : Oral reconstruction / : Oral reconstruction / Soft tissue coverageSoft tissue coverage

►Muscle flap is developed by elevating Muscle flap is developed by elevating skin, platysma.skin, platysma.

►Once the muscle is exposed sternal and Once the muscle is exposed sternal and clavicular head is transacted.clavicular head is transacted.

►Dissected between superficial fascia and Dissected between superficial fascia and deep surface of the muscle.deep surface of the muscle.

►Fascia is left in place over carotid sheath Fascia is left in place over carotid sheath –for protection.–for protection.

►The vascular supply thyrocervical trunk is The vascular supply thyrocervical trunk is ligated.ligated.

Page 57: Mandible Reconstruction

► proceeded to superior thyroid artery is proceeded to superior thyroid artery is ligated.ligated.

► Preserve the spinal accessory nerve.Preserve the spinal accessory nerve.► Then muscle is transposed.Then muscle is transposed.

MYOCUTANEOUS MYOCUTANEOUS : Superiorly based: Superiorly based

Skin outline is doneSkin outline is done

Inferiorly based flapInferiorly based flap

Pedicled flapPedicled flap

Page 58: Mandible Reconstruction
Page 59: Mandible Reconstruction

Advantage : Proximity of recipient site.Advantage : Proximity of recipient site.

One stage procedureOne stage procedure

Total flap loss is rare.Total flap loss is rare.

Good colour match.Good colour match.

Bulk.Bulk. Disadvantage : Disadvantage :

Deformity at donor siteDeformity at donor site

Muscle atrophyMuscle atrophy

Page 60: Mandible Reconstruction

Pectoralis major Pectoralis major myocutaneous flapmyocutaneous flap

►Workhorse for head and neck Workhorse for head and neck reconstructionreconstruction

►First described by Ariyan 1977First described by Ariyan 1977

Page 61: Mandible Reconstruction

PECTORALIS MAJOR PECTORALIS MAJOR MYOCUTANEOUS FLAPMYOCUTANEOUS FLAP

The Pectoralis major muscle is a broad, The Pectoralis major muscle is a broad, flat, fan shaped muscle covers pec flat, fan shaped muscle covers pec minor, subclavius, serratus anterior minor, subclavius, serratus anterior and intercostal musclesand intercostal muscles

Page 62: Mandible Reconstruction

Origin : Origin : Medial- sternumMedial- sternum S- medial clavicleS- medial clavicle Lateral- intertubercular Lateral- intertubercular

groove of humerusgroove of humerus Adjacent cartilage of 1Adjacent cartilage of 1stst

six ribssix ribs Bony portion of 4Bony portion of 4th th 5 5thth

66thth ribs ribs

THREE MAJOR SEGMENTSTHREE MAJOR SEGMENTS1.1. Clavicular segments Clavicular segments 2.2. Sternocostal segmentSternocostal segment3.3. Laterally placed external Laterally placed external

segment segment

Page 63: Mandible Reconstruction

Clavicular segment :Clavicular segment :

Blood supply : Deltoid branch of thoraco Blood supply : Deltoid branch of thoraco acromial arteryacromial artery

Nerve : Lateral pectoral nerveNerve : Lateral pectoral nerve

Sternocostal segment :Sternocostal segment :

Blood supply : Pectoral branch of Blood supply : Pectoral branch of thoracoacromial arterythoracoacromial artery

Nerve : Lateral/Medial pectoral nerveNerve : Lateral/Medial pectoral nerve

Page 64: Mandible Reconstruction

External segment :External segment :

Blood supply :Lateral thoracic arteryBlood supply :Lateral thoracic artery

Pectoral branch Pectoral branch thoracoacromialthoracoacromial

artery.artery.

Nerve : Medial pectoral nerveNerve : Medial pectoral nerve

Other branch which supplies Other branch which supplies pectoralis ispectoralis is

Internal mammary artery.Internal mammary artery.

Page 65: Mandible Reconstruction

TECHNIQUE :TECHNIQUE :

2 types of flaps 2 types of flaps

1. PMMC Island flap1. PMMC Island flap

2. PMMC Paddle flap2. PMMC Paddle flap

ISLAND FLAP:ISLAND FLAP:► Measurement is from the clavicle to the Measurement is from the clavicle to the

inferior margin of the skin island. The inferior margin of the skin island. The measuring tape is rotated to the defect to measuring tape is rotated to the defect to arrive at the appropriate length of the flap.arrive at the appropriate length of the flap.

► Skin paddle should be medial and inferior to Skin paddle should be medial and inferior to nipple.nipple.

Page 66: Mandible Reconstruction

► In women the In women the inframammary crease inframammary crease corresponds to the inferior corresponds to the inferior edge of the skin paddle.edge of the skin paddle.

1.1. Midpectoral or Midpectoral or inframammary incisioninframammary incision

► Incision is made through Incision is made through

skin/subcutaneous tissue.skin/subcutaneous tissue.► Dissected upto fascia of Dissected upto fascia of

thethe muscle.muscle.

Page 67: Mandible Reconstruction

► Dissection proceeds laterally towards the free Dissection proceeds laterally towards the free margin of pectoralis major muscle and insertion margin of pectoralis major muscle and insertion of the muscle superiorly, medially toward the of the muscle superiorly, medially toward the sternal origination. Superiorly towards sternal origination. Superiorly towards clavicular origination.clavicular origination.

► Skin paddle margin is incised carefully.Skin paddle margin is incised carefully.► Elevation of flap is done.Elevation of flap is done.► Entire muscle is elevated leaving 1cm thickness Entire muscle is elevated leaving 1cm thickness

attached to lateral sternum/ humerus. attached to lateral sternum/ humerus. Superficial to ribs/ intercoastal musculature, Superficial to ribs/ intercoastal musculature, pectoralis minorpectoralis minor

► Avoid trauma to pectoralis major pedicle.Avoid trauma to pectoralis major pedicle.

Page 68: Mandible Reconstruction

► Complete elevation of the flap with skin island.Complete elevation of the flap with skin island.► Dissecttion of supraclavicular tissue to Dissecttion of supraclavicular tissue to

communicate the neck and chest wall.communicate the neck and chest wall.► Flap is taken through the tunnel.Flap is taken through the tunnel.

PEDICLE FLAP:PEDICLE FLAP:

Here skin for the paddle flap is not attached Here skin for the paddle flap is not attached directly to the muscle itself but rather get its directly to the muscle itself but rather get its blood supply from an extension of the muscle blood supply from an extension of the muscle fascia.fascia.

Page 69: Mandible Reconstruction

► Two separate island flap outlined.Two separate island flap outlined.► After flap is elevated and transposed. The muscle is After flap is elevated and transposed. The muscle is

folded so that one island may be sutured into the oral folded so that one island may be sutured into the oral defects and other into skin.defects and other into skin.

Page 70: Mandible Reconstruction

ADVANTAGE : ADVANTAGE : ► Arch of rotation is more than 20cmArch of rotation is more than 20cm► Bulk Bulk ► Functional/Cosmetic resultsFunctional/Cosmetic results► Donor site is early closeDonor site is early close► Hairless area.Hairless area.

DISADVANTAGE :DISADVANTAGE :► Loss of muscle noticeable is male.Loss of muscle noticeable is male.► Difficulty to identify vascular pedicle.Difficulty to identify vascular pedicle.

Page 71: Mandible Reconstruction

TRAPEZIUS MYOCUTANEOUS TRAPEZIUS MYOCUTANEOUS FLAPFLAP

Mutter described the flap in 1842.Mutter described the flap in 1842.

Zovickian popularized in 1957.Zovickian popularized in 1957.

ANATOMY: Flat, triangular muscle covers the ANATOMY: Flat, triangular muscle covers the superior posterior part of the neck and superior posterior part of the neck and shoulder.shoulder.

Origin : Nuchal line of occipital boneOrigin : Nuchal line of occipital bone

Spine process of C7 through T12.Spine process of C7 through T12.

Page 72: Mandible Reconstruction

InsertionInsertion : Lateral 1/3 : Lateral 1/3rdrd of of clavicle.clavicle.

Acromion.Acromion. Spine of scapula.Spine of scapula. ActionAction : Rotation of scapula : Rotation of scapula Elevation, flexion, Elevation, flexion,

abduction of the upperabduction of the upper arm.arm.Blood supplyBlood supply : : ► Branch of thyrocervical Branch of thyrocervical

trunk- transverse cervical trunk- transverse cervical arteryartery

► Occipital arteryOccipital artery► Paraspinal perforators Paraspinal perforators

Page 73: Mandible Reconstruction

Venous drainageVenous drainage : :► Sub dermal plexus.Sub dermal plexus.► Deeper venae commitants.Deeper venae commitants.► Transverse cervical vein. Transverse cervical vein. ► Suprascapular vein.Suprascapular vein.

Nerve :Nerve :► Motor – Spinal accessory nerveMotor – Spinal accessory nerve► Sensory – Cervical/Intercoastal nerve.Sensory – Cervical/Intercoastal nerve.

Page 74: Mandible Reconstruction

TECHNIQUE:TECHNIQUE: Transverse cervical Transverse cervical

trapezius myocutaneous trapezius myocutaneous flap.flap.

► The vessel must be identified in The vessel must be identified in the neck and traced to the the neck and traced to the anterior border of the muscle.anterior border of the muscle.

► Anterior incision for the skin Anterior incision for the skin island extend along the island extend along the anterior border of trapezius.anterior border of trapezius.

► Muscle and its blood supply is Muscle and its blood supply is elevated.elevated.

► Appropriate skin island is cut Appropriate skin island is cut and underlying muscle is and underlying muscle is incised.incised.

Page 75: Mandible Reconstruction

Transverse cervical Transverse cervical trapezius myocutaneous trapezius myocutaneous

flapflap

Page 76: Mandible Reconstruction

► It is rotated into defect and sutured.It is rotated into defect and sutured.

Lower trapezius myocutaneous flap Lower trapezius myocutaneous flap 1.1. Island flapIsland flap2.2. Solid flapSolid flap► Vessels are identified and trace the Vessels are identified and trace the

muscle.muscle.► Muscle is divided lateral to vessel artery.Muscle is divided lateral to vessel artery.► Appropriate skin island is cut.Appropriate skin island is cut.► Muscle is completely divided along lateral Muscle is completely divided along lateral

line.line.► Muscle is elevated below upwards.Muscle is elevated below upwards.► Then it is rotated/ and sutured.Then it is rotated/ and sutured.

Page 77: Mandible Reconstruction

► Cephalic end flap – 7-8cm proximal to Cephalic end flap – 7-8cm proximal to tip of scapulatip of scapula

► McCraw –Anterior margin follows the McCraw –Anterior margin follows the border of trapezius. Posterior margin border of trapezius. Posterior margin runs parallel and extends upto midline runs parallel and extends upto midline of the posterior neck.of the posterior neck.

Width – 10cmWidth – 10cm

Length – 30cmLength – 30cm

Advantage :Advantage :

1.1. HairlessHairless

2.2. Scar is not obviousScar is not obvious

3.3. Skin of uniform thickness available.Skin of uniform thickness available.

Page 78: Mandible Reconstruction

Disadvantage :Disadvantage :

1.1. Short pedicleShort pedicle

2.2. Limited arch of rotationLimited arch of rotation

3.3. Vessels may be injuredVessels may be injured

4.4. Painful shoulderPainful shoulder

Page 79: Mandible Reconstruction

Lower trapezius Lower trapezius myocutaneous flapmyocutaneous flap

Page 80: Mandible Reconstruction

Radial Forearm FlapRadial Forearm Flap► 1978 (China) by Yang etal, 1985 1978 (China) by Yang etal, 1985

(pharyngeal recon)(pharyngeal recon)► Thin, pliable skinThin, pliable skin

Reconstitution of contours, sulci, Reconstitution of contours, sulci, vestibulesvestibules

► Fasciocutaneous flaps are highly tolerant of Fasciocutaneous flaps are highly tolerant of radiation therapy radiation therapy

► Composite flap with bone, tendon, Composite flap with bone, tendon, brachioradialis muscle and vascularized brachioradialis muscle and vascularized nerve.nerve.

Page 81: Mandible Reconstruction

Neurovascular pedicleNeurovascular pedicle

► Up to 20 cm longUp to 20 cm long► Vessel caliber 2 – 2.5 Vessel caliber 2 – 2.5

mmmm► Radial arteryRadial artery► cephalic veincephalic vein► Lateral antebrachial Lateral antebrachial

cutaneous nerve cutaneous nerve (sensory)(sensory)

Page 82: Mandible Reconstruction

Technical considerationsTechnical considerations

► TourniquetTourniquet

► Flap designed with skin Flap designed with skin paddle centered over the paddle centered over the radial arteryradial artery

► Dissection in subfascial level Dissection in subfascial level as the pedicle is as the pedicle is approached.approached.

► Pedicle identified b/w medial Pedicle identified b/w medial head of the brachioradialis, head of the brachioradialis, and the flexor carpi radialisand the flexor carpi radialis

► Radial artery is dissected to Radial artery is dissected to its originits origin

Page 83: Mandible Reconstruction

Radial Forearm FlapRadial Forearm Flap

► MorbidityMorbidity Hand ischemiaHand ischemia Fistula rates - 42% to 67% in early seriesFistula rates - 42% to 67% in early series Radial nerve injuryRadial nerve injury Variable anesthesia over dorsum of hand.Variable anesthesia over dorsum of hand.

Advantage:Advantage:

Thin pliable skin, often hairless,long pedicle(12-Thin pliable skin, often hairless,long pedicle(12-15cm),15cm),

Disadvantage:Disadvantage:

Donor site defect visibleDonor site defect visible

Page 84: Mandible Reconstruction

Pedicle bone flapsPedicle bone flaps

Page 85: Mandible Reconstruction

Rib graft with Pectoralis Rib graft with Pectoralis majormajor

► In 1980, In 1980, Ariyan and Ariyan and CuonoCuono reported the use reported the use of a pectoralis major of a pectoralis major pedicled myocutaneous pedicled myocutaneous flap transferred with a flap transferred with a segment of the underlying segment of the underlying fifth rib.fifth rib.

► Latissimus dorsi Latissimus dorsi with attached rib has also with attached rib has also been used. been used. Richards Richards et.alet.al reported use of reported use of Serratus anterior/rib Serratus anterior/rib composite flap in composite flap in mandibular reconstructionmandibular reconstruction

Page 86: Mandible Reconstruction

Rib flapRib flap► First vascularized bone to be First vascularized bone to be

used in mandibular used in mandibular reconstruction. reconstruction. (osteocutaneous)(osteocutaneous)

► Blood supply to the rib Blood supply to the rib Internal mammary arteryInternal mammary artery Posteriorly or Posteriorly or

posterolaterally on the posterolaterally on the posterior intercostal posterior intercostal vesselsvessels

Transferred with the Transferred with the pectoralis major, serratus pectoralis major, serratus anterior, or latissimus dorsi anterior, or latissimus dorsi muscle muscle

► Poor bone stock except for Poor bone stock except for condylar reconstructioncondylar reconstruction

► Not commonly usedNot commonly used

Page 87: Mandible Reconstruction

Combined lattissimus dorsi serratus

anterior/rib composite free flap ► First described by First described by

Tansini in 1895Tansini in 1895► Not as versatile as Not as versatile as

pmmc but certain pmmc but certain qualities such as the qualities such as the hair free skin and donor hair free skin and donor site scar make it an site scar make it an invaluable alternativeinvaluable alternative

► Indicated when large Indicated when large amount of tissue is amount of tissue is required required

Page 88: Mandible Reconstruction

Neurovascular pedicleNeurovascular pedicle

► Thoracodorsal arteryThoracodorsal artery► Arise from subscapular vessels Arise from subscapular vessels

off of third portion of axillary off of third portion of axillary artery and veinartery and vein

► Pedicle length 9.3 cm (6 to Pedicle length 9.3 cm (6 to 16.5)16.5) Can be lengthened by sacrificing Can be lengthened by sacrificing

branch to serratus anteriorbranch to serratus anterior► Numerous variationsNumerous variations

Most common: independent Most common: independent origin of thoracodorsal origin of thoracodorsal vein/arteryvein/artery

Page 89: Mandible Reconstruction

Technical considerationsTechnical considerations► Lateral decubitis positionLateral decubitis position

If at 15 degrees, flap may If at 15 degrees, flap may be harvested be harvested simultaneously with primary simultaneously with primary lesion resectionlesion resection

Anterior muscle border Anterior muscle border along line b/w midpoint of along line b/w midpoint of axilla and point midway b/w axilla and point midway b/w ASIS and PSISASIS and PSIS

► Vessels enter undersurface of Vessels enter undersurface of muscle 8 to 10 cm below muscle 8 to 10 cm below midpoint of axillamidpoint of axilla

► Serratus vessels ligated during Serratus vessels ligated during harvestharvest

► Can design two paddle flap Can design two paddle flap based on medial and lateral based on medial and lateral branches of thoracodorsal branches of thoracodorsal vesselsvessels

Page 90: Mandible Reconstruction

Latissimus dorsiLatissimus dorsi

►MorbidityMorbidity Marginal flap necrosisMarginal flap necrosis Pedicled flaps pass b/w pec major and Pedicled flaps pass b/w pec major and

minorminor►Changes in arm position may occlude pedicleChanges in arm position may occlude pedicle►Should immobilize arm in flexed positionShould immobilize arm in flexed position

Page 91: Mandible Reconstruction

Serratus anteriorSerratus anterior

►based upon a pedicle derived from a branch of the thoracodorsal artery which supplies the lower third of the muscle

►The latissimus dorsi muscle may be transferred with serratus anterior on a common pedicle of thoracodorsal vessels

Page 92: Mandible Reconstruction

Deep  circumflex iliac artery Deep  circumflex iliac artery bone flap bone flap

► Blood supply: Deep Blood supply: Deep circumflex iliac artery circumflex iliac artery from the external iliac from the external iliac artery. artery.

► Artery: Large caliber of Artery: Large caliber of 1.5 to 4 mm.1.5 to 4 mm.

► Pedicle length: From 4 Pedicle length: From 4 to 7 centimeters. to 7 centimeters. Length depends on size Length depends on size and position of the and position of the bone flap and skin bone flap and skin paddle.paddle.

Page 93: Mandible Reconstruction

► The incision is marked a The incision is marked a finger breadth above finger breadth above and parallel to the and parallel to the inguinal ligament. inguinal ligament.

► SCIA and DCIA vessels SCIA and DCIA vessels are identified at or near are identified at or near their origin.  Once their origin.  Once identified, the DCIA identified, the DCIA vessels are traced vessels are traced distally toward the distally toward the anterior superior iliac anterior superior iliac spine, in the substance spine, in the substance of the transversalis of the transversalis fascia.  fascia.  

► The external and The external and internal oblique internal oblique muscular fascia is muscular fascia is divided superficial to divided superficial to and along the course of and along the course of the artery and vein the artery and vein

Page 94: Mandible Reconstruction

► As the dissection proceeds As the dissection proceeds lateraly and the iliac crest is lateraly and the iliac crest is encountered,encountered,

► the muscles superficial to the the muscles superficial to the pedicle are divided from the pedicle are divided from the iliac crest insertion, exposing iliac crest insertion, exposing the iliacus muscle and iliac the iliacus muscle and iliac crest.  crest. 

► The vessels lie on the surface The vessels lie on the surface of the iliacus muscle, guiding of the iliacus muscle, guiding the dissection as it proceeds the dissection as it proceeds posteriorly. The vessels posteriorly. The vessels diverge later into branches diverge later into branches that penetrate the iliacus and that penetrate the iliacus and the overlying transversalis the overlying transversalis fascia. fascia.

► On the anterior surface of the On the anterior surface of the iliac crest, the cautery is used iliac crest, the cautery is used to score the iliacus muscle to score the iliacus muscle and “square off” the area and “square off” the area need for osteotomy need for osteotomy

Page 95: Mandible Reconstruction

Trapezius osteomyocutaneous flapTrapezius osteomyocutaneous flap

► Demergasso Demergasso and and Piazza Piazza (1977) (1977) ► provide 12 x 2.5 cm of provide 12 x 2.5 cm of

scapular bone scapular bone ► The medial scapular The medial scapular

spine is used in spine is used in combination with either a combination with either a superiorly based superiorly based trapezius flap, based on trapezius flap, based on the paraspinous the paraspinous perforators and the perforators and the occipital artery, or an occipital artery, or an island trapezius flap island trapezius flap based on the transverse based on the transverse cervical vessels. cervical vessels.

Page 96: Mandible Reconstruction

► Cephalic end flap – 7-8cm proximal to Cephalic end flap – 7-8cm proximal to tip of scapulatip of scapula

► McCraw –Anterior margin follows the McCraw –Anterior margin follows the border of trapezius. Posterior margin border of trapezius. Posterior margin runs parallel and extends upto midline runs parallel and extends upto midline of the posterior neck.of the posterior neck.

Width – 10cmWidth – 10cm

Length – 30cmLength – 30cm

Advantage :Advantage :

1.1. HairlessHairless

2.2. Scar is not obviousScar is not obvious

3.3. Skin of uniform thickness available.Skin of uniform thickness available.

Page 97: Mandible Reconstruction

Disadvantage :Disadvantage :

1.1. Short pedicleShort pedicle

2.2. Limited arch of rotationLimited arch of rotation

3.3. Vessels may be injuredVessels may be injured

4.4. Painful shoulderPainful shoulder

Page 98: Mandible Reconstruction

Lower trapezius Lower trapezius myocutaneous flapmyocutaneous flap

Page 99: Mandible Reconstruction

Calvarial graft with Calvarial graft with temporalis muscletemporalis muscle

► Gratz et alGratz et al ► Advantages:Advantages:► thick enough to take an thick enough to take an

endosseous implant, endosseous implant, ► early revascularization early revascularization

which is related to which is related to numerous vascular systemsnumerous vascular systems

► morbidity is low, morbidity is low, ► there is virtually no there is virtually no

postoperative pain, postoperative pain, ► the scar is invisible, the scar is invisible, ► and there is only one donor and there is only one donor

area for both hard and soft area for both hard and soft tissue.tissue.

Page 100: Mandible Reconstruction

Scapular osseocutaneous Scapular osseocutaneous free flapsfree flaps

► In 1993, In 1993, Sevin etSevin et alal described a described a hemimandibular reconstruction with hemimandibular reconstruction with scapular crest vascularized by two scapular crest vascularized by two pedicles (circumflex scapular artery pedicles (circumflex scapular artery and angular branch) associated with a and angular branch) associated with a parascapular skin flap parascapular skin flap

Page 101: Mandible Reconstruction
Page 102: Mandible Reconstruction

Sternocleidomastoid Sternocleidomastoid Osteomyocutaneous FlapOsteomyocutaneous Flap

► Conley and GullaneConley and Gullane ► After tumor resection, the After tumor resection, the

clavicle is measured to clavicle is measured to obtain the desired segment obtain the desired segment to fill the mandibular defect. to fill the mandibular defect. The clavicle that is The clavicle that is harvested must include its harvested must include its medial portion and at least medial portion and at least two thirds of the lateral two thirds of the lateral clavicular body. Clavicle is clavicular body. Clavicle is released from all its released from all its attachments except for the attachments except for the SCM; it is rotated on the SCM; it is rotated on the muscular pedicle across the muscular pedicle across the midline into the defect and midline into the defect and fixated with conventional fixated with conventional bone fixation systems. bone fixation systems.

Page 103: Mandible Reconstruction

Scapular flapsScapular flaps► Fasciocutaneous, Fasciocutaneous,

osteofasciocutaneous, cutaneous flap, osteofasciocutaneous, cutaneous flap, parascapular cutaneous flap, parascapular cutaneous flap, latissimus dorsi myocutaneous flap, latissimus dorsi myocutaneous flap, and serratus anterior flapand serratus anterior flap

► Thin, hairless skinThin, hairless skin► Two cutaneous flaps may be harvestedTwo cutaneous flaps may be harvested

Horizontally oriented flap – transverse Horizontally oriented flap – transverse cutaneous branchcutaneous branch

Vertically oriented flap parascapular Vertically oriented flap parascapular flap – descending cutaneous branchflap – descending cutaneous branch

► Long pedicle lengthLong pedicle length► Large surface areaLarge surface area► Complex composite midfacial or Complex composite midfacial or

oromandibular defects oromandibular defects ► Up to 10 cm boneUp to 10 cm bone► Osseointegrated implants possibleOsseointegrated implants possible► Single team approachSingle team approach

Page 104: Mandible Reconstruction

Neurovascular pedicleNeurovascular pedicle► Subscapular artery and veinSubscapular artery and vein

Circumflex scapular artery and vein emerge Circumflex scapular artery and vein emerge from triangular space (teres major, teres from triangular space (teres major, teres minor and long head of triceps)minor and long head of triceps)

Paired venae comitantesPaired venae comitantes Artery caliber – 4 mm at takeoff from Artery caliber – 4 mm at takeoff from

subscapularsubscapular► Subscapular caliber – 6 mm at takeoff from Subscapular caliber – 6 mm at takeoff from

axillary arteryaxillary artery Pedicle length – 7 to 10 cm, 11 to 14 cm (from Pedicle length – 7 to 10 cm, 11 to 14 cm (from

axillary artery)axillary artery)► Largest amount of tissue available for transferLargest amount of tissue available for transfer

Page 105: Mandible Reconstruction

Technical considerationsTechnical considerations

► Decubitis positioningDecubitis positioning 15 degree angle15 degree angle Separate axillary incision Separate axillary incision

helpful in dissecting pedicle helpful in dissecting pedicle to axillary artery and veinto axillary artery and vein

Bone harvestBone harvest► Teres major, Teres major,

subscapularis and subscapularis and latissimus dorsi need to latissimus dorsi need to be reattached to scapulabe reattached to scapula

► Flap harvest opposite side of Flap harvest opposite side of modified or radical neck modified or radical neck dissectiondissection

Page 106: Mandible Reconstruction

Scapular flapsScapular flaps

►MorbidityMorbidity Brachial plexus injury 2/2 lateral decubitis Brachial plexus injury 2/2 lateral decubitis

positioningpositioning►Use axillary rollUse axillary roll

Stay 1 cm inferior to glenoid fossa Stay 1 cm inferior to glenoid fossa Detach teres major and minor to harvest Detach teres major and minor to harvest

bonebone►Can cause shoulder weakness and limit range Can cause shoulder weakness and limit range

of motion.of motion.

Page 107: Mandible Reconstruction

Scapular flapsScapular flaps

► Preoperative Preoperative ConsiderationsConsiderations Prior axillary node Prior axillary node

dissection – dissection – contraindicationcontraindication

► Postoperative Postoperative managementmanagement Immobilize for 3 to 4 Immobilize for 3 to 4

daysdays Early ambulationEarly ambulation 5 days for bone 5 days for bone

harvestharvest PTPT

Page 108: Mandible Reconstruction

► Pros:Pros:-more soft tissue than other flaps-more soft tissue than other flaps-can get skin island up to 30cm long-can get skin island up to 30cm long-can also include latissimus-can also include latissimus-bone and soft tissue independent-bone and soft tissue independent-14 cm of bone-14 cm of bone► ConsCons-bone does not have a segmental blood supply-bone does not have a segmental blood supply-skin is thick -skin is thick -can’t harvest flap during tumor resection-can’t harvest flap during tumor resection-can have compromised shoulder fxn-can have compromised shoulder fxn

Page 109: Mandible Reconstruction

TMJ RECONSTRUCTIONTMJ RECONSTRUCTION

► The first arthroplasty was made by The first arthroplasty was made by Percy and Barton in 1826.Percy and Barton in 1826.

►GOALSGOALS::►To reduce patient suffering and improve To reduce patient suffering and improve

TMJ function. TMJ function. ►To reduce disability.To reduce disability.►To contain excessive treatment and cost. To contain excessive treatment and cost. ►To prevent morbidity To prevent morbidity

Page 110: Mandible Reconstruction

Autogenous Temporomandibular Autogenous Temporomandibular Joint ReplacementJoint Replacement

►defined as construction or defined as construction or reconstruction of the mandibular reconstruction of the mandibular ramus condyle unit (RCU), glenoid ramus condyle unit (RCU), glenoid fossa, and TMJ meniscus with the fossa, and TMJ meniscus with the patient's tissue.patient's tissue.

Page 111: Mandible Reconstruction

Goals Goals

►Restoration of mandibular ramus Restoration of mandibular ramus length and morphology, length and morphology,

►Normal range of motion and jaw Normal range of motion and jaw relations relations

►occlusion. occlusion.

Page 112: Mandible Reconstruction

Costochondral GraftCostochondral Graft

►Goals:Goals:►To reestablish vertical height of lower To reestablish vertical height of lower

faceface►Reestablish premorbid occlusionReestablish premorbid occlusion►Dynamic grow of new condylar headDynamic grow of new condylar head

Page 113: Mandible Reconstruction

►Popularized by Poswillo, Mcintosh, Popularized by Poswillo, Mcintosh, HennyHenny

►Adv: biologically acceptable with Adv: biologically acceptable with possessing growth & remodelling possessing growth & remodelling potentialpotential

►Disadv: fracture, resorption, donor site Disadv: fracture, resorption, donor site morbidity, recurrence of ankylosis morbidity, recurrence of ankylosis

Page 114: Mandible Reconstruction

Metatarsal Head GraftMetatarsal Head Graft

► Harvested from 2Harvested from 2ndnd metatarsal phalangeal metatarsal phalangeal jointjoint

► Pedicle: Pedicle: dorsal metatarsal artery

► The MTPJ is capable of providing only rotational movement to the jaw without the ability to translate,

► interincisal opening- 25 mm to 30 mm.

Page 115: Mandible Reconstruction

DisadvantageDisadvantage

►Charcot joint is insensate and is Charcot joint is insensate and is unable to provide sensory feedback unable to provide sensory feedback regarding any potentially damaging regarding any potentially damaging functional overload. functional overload.

Page 116: Mandible Reconstruction

Other flaps usedOther flaps used

►Sternoclavicular Joint GraftSternoclavicular Joint Graft►Calvarial Bone GraftCalvarial Bone Graft►Fibular Free FlapFibular Free Flap►Iliac CrestIliac Crest ►Coronoid ProcessCoronoid Process

Page 117: Mandible Reconstruction

Alloplastic Alloplastic temporomandibular joint temporomandibular joint

reconstructionreconstruction► 1840- John Murray Camochan attempt to 1840- John Murray Camochan attempt to

mobilize a patient's ankylosed TMJ by placing mobilize a patient's ankylosed TMJ by placing a small block of wood between the raw bony a small block of wood between the raw bony surfaces of the residual mandible after surfaces of the residual mandible after creating a gap at the neck of the condyle. creating a gap at the neck of the condyle.

► 1890- a German surgeon named Gluck 1890- a German surgeon named Gluck reported total joint arthroplasties with ivory reported total joint arthroplasties with ivory prosthetic TMJs and hip joints that he prosthetic TMJs and hip joints that he stabilized with cement made of colophony, stabilized with cement made of colophony, pumice, and gypsum.pumice, and gypsum.

Page 118: Mandible Reconstruction

► Goodsell (1947)- use of Tantalum foil.Goodsell (1947)- use of Tantalum foil.► 1951, Castigliano and Kleitsch resurfaced the 1951, Castigliano and Kleitsch resurfaced the

bone in TMJ ankylosis cases with Vitallium.bone in TMJ ankylosis cases with Vitallium.► In 1952 Smith reported the use of stainless In 1952 Smith reported the use of stainless

steel in hemiarthroplasty for ankylosis. steel in hemiarthroplasty for ankylosis. ► Ueno et al reported experimental and clinical Ueno et al reported experimental and clinical

results with zirconium in TMJ ankylosis in 1955.results with zirconium in TMJ ankylosis in 1955.► In 1960 Henry described replacement of In 1960 Henry described replacement of

an ankylosed TMJ with prosthesis; that same an ankylosed TMJ with prosthesis; that same year Robinson reported correction of a TMJ year Robinson reported correction of a TMJ ankylosis by means of an artificial stainless-ankylosis by means of an artificial stainless-steel fossa.steel fossa.

Page 119: Mandible Reconstruction

Indications for alloplastic Indications for alloplastic joint reconstructionjoint reconstruction

► Ankylosis or re-ankylosis with severe anatomic Ankylosis or re-ankylosis with severe anatomic abnormalities.abnormalities.

► Failure of autogenous grafts in patients who have Failure of autogenous grafts in patients who have undergone multiple operations. undergone multiple operations.

► Destruction of autogenous graft tissue by Destruction of autogenous graft tissue by pathosis. pathosis.

► Failure of Proplast-Teflon resulting in severe Failure of Proplast-Teflon resulting in severe anatomic joint mutilation. anatomic joint mutilation.

► Severe inflammatory joint disease, such as Severe inflammatory joint disease, such as rheumatoid arthritis, that results in anatomic rheumatoid arthritis, that results in anatomic mutilation of the joint components and functional mutilation of the joint components and functional disabilitydisability..

Page 120: Mandible Reconstruction

contraindicationscontraindications

► Insufficient patient age. Insufficient patient age. ► Lack of understanding on the part of Lack of understanding on the part of

the patientthe patient► Uncontrolled systemic disease, such as Uncontrolled systemic disease, such as

diabetes mellitus.diabetes mellitus.► Allergy to the materials that are used in Allergy to the materials that are used in

the devices to be implanted.the devices to be implanted.► Active infection at the implantation Active infection at the implantation

site.site.

Page 121: Mandible Reconstruction

AdvantagesAdvantages

►Physical therapy can begin Physical therapy can begin immediately.immediately.

►no need for a secondary donor site, no need for a secondary donor site, and surgery time is decreasedand surgery time is decreased..

►can be constructed in such a way as to can be constructed in such a way as to mimic the normal anatomic contours mimic the normal anatomic contours of the structures they are to replaceof the structures they are to replace

Page 122: Mandible Reconstruction

DisadvantagesDisadvantages

►Cost of the prosthesesCost of the prostheses..►Material wear and failure.Material wear and failure.►Long-term stabilityLong-term stability. . Screws may Screws may

loosen with time and function and may loosen with time and function and may thus require replacement.thus require replacement.

► Inability to follow a patient's growth.Inability to follow a patient's growth.

Page 123: Mandible Reconstruction

The Christensen The Christensen Temporomandibular Joint Temporomandibular Joint

Prosthesis SystemProsthesis System►used as a partial joint for treatment of used as a partial joint for treatment of

severe internal derangement, severe internal derangement, adhesions, disc perforation, and adhesions, disc perforation, and ankylosis. ankylosis.

►The condylar prosthesis is always used The condylar prosthesis is always used in conjunction with a Fossa Eminence in conjunction with a Fossa Eminence Prosthesis and constitutes a total joint Prosthesis and constitutes a total joint replacement (TJR)..replacement (TJR)..

Page 124: Mandible Reconstruction

FabricationFabrication

► This device is This device is fabricated entirely fabricated entirely of Co-Cr alloy and is of Co-Cr alloy and is approximately 20 approximately 20 mm to 35 mm mm to 35 mm across and 0.5 mm across and 0.5 mm thickthick

Page 125: Mandible Reconstruction

Indications Indications

► Ankylosis or reankylosis with severe anatomic Ankylosis or reankylosis with severe anatomic abnormalities.abnormalities.

► Failed autogenous grafts in patients who have Failed autogenous grafts in patients who have undergone multiple operations.undergone multiple operations.

► Destruction of autogenous graft tissue by pathologyDestruction of autogenous graft tissue by pathology► Failed Proplast-Teflon that results in severe Failed Proplast-Teflon that results in severe

anatomic joint mutilation.anatomic joint mutilation.► Failed stock or custom total or partial joints.Failed stock or custom total or partial joints.► Severe inflammatory joint disease, such as Severe inflammatory joint disease, such as

rheumatoid arthritis, that results in anatomic rheumatoid arthritis, that results in anatomic mutilation of the joint components and functional mutilation of the joint components and functional disability.disability.

Page 126: Mandible Reconstruction

Contraindications Contraindications

► Age of the patientAge of the patient► Mental status of the patient Mental status of the patient ► Disease, such as diabetes mellitus Disease, such as diabetes mellitus ► Active infection at the implantation Active infection at the implantation

site.site.

Page 127: Mandible Reconstruction

Lorenz ProsthesisLorenz Prosthesis

► The basic goal for this The basic goal for this prosthesis was to prosthesis was to maximize the mating of maximize the mating of articular surfaces, which articular surfaces, which was accomplished with a was accomplished with a spherical condylar head. spherical condylar head. This design feature This design feature allows positional allows positional freedom of the freedom of the mandibular component, mandibular component, following fixation of the following fixation of the fossa component, in all fossa component, in all planes planes

Page 128: Mandible Reconstruction

COMPLICATIONSCOMPLICATIONS► Plate complicationsPlate complications► Consists of extraoral exposure , intraoral Consists of extraoral exposure , intraoral

exposure , screw loosening, plate fracture, exposure , screw loosening, plate fracture, and osteomyelitisand osteomyelitis

► musculoskeletal or soft tissue, with varying musculoskeletal or soft tissue, with varying degrees of defects in shape, position, stability, degrees of defects in shape, position, stability, and function. and function.

► Secondary deformities may arise from Secondary deformities may arise from structural instability that occurs from structural instability that occurs from infection, osteoradionecrosis, nonunion, or infection, osteoradionecrosis, nonunion, or fracture of the reconstruction plate for cases fracture of the reconstruction plate for cases in which hardware was used alone without in which hardware was used alone without bone replacement bone replacement

Page 129: Mandible Reconstruction

► Carlson and Monteleone Carlson and Monteleone have givenhave given Protocol for managing intraoperative Protocol for managing intraoperative perforations of mucosa and skin:perforations of mucosa and skin:

► 1. Irrigation of perforation1. Irrigation of perforation► 2. Two-layer closure2. Two-layer closure► 3. Consider the use of growth factors to 3. Consider the use of growth factors to

seal submucosal/dermal tissue closureseal submucosal/dermal tissue closure► 4. Eliminate dead space in neck closure4. Eliminate dead space in neck closure► 5. Passive drainage of neck closure5. Passive drainage of neck closure► 6. Consider maxillomandibular fixation6. Consider maxillomandibular fixation► 7. Administer intravenous antibiotics 7. Administer intravenous antibiotics

throughout hospital coursethroughout hospital course

Page 130: Mandible Reconstruction

►8. Provide enteral tube feeds for at 8. Provide enteral tube feeds for at least 3 days postoperativelyleast 3 days postoperatively

►9. Perform twice-daily mucosal/skin 9. Perform twice-daily mucosal/skin suture line caresuture line care

►10. Prescription for oral antibiotics for 10. Prescription for oral antibiotics for 1 week following discharge from 1 week following discharge from hospitalhospital

Page 131: Mandible Reconstruction

RECENT ADVANCESRECENT ADVANCES

► Tissue EngineeringTissue Engineering::► Tissue engineering is an interdisciplinary Tissue engineering is an interdisciplinary

field that combines and applies the principles field that combines and applies the principles of engineering and the life sciences for the of engineering and the life sciences for the development of biological substitutes to development of biological substitutes to restore, maintain, or improve tissue function. restore, maintain, or improve tissue function.

► Biodegradable polymers such as polyglycolic Biodegradable polymers such as polyglycolic acid (PGA) have been combined with bovine acid (PGA) have been combined with bovine periosteum to form new bone. Poly DL-lactic–periosteum to form new bone. Poly DL-lactic–co-glycolic acid (PLGA) has also been used to co-glycolic acid (PLGA) has also been used to tissue engineer bone. tissue engineer bone.

Page 132: Mandible Reconstruction

Transport disc distraction Transport disc distraction osteogenesisosteogenesis

►A segment of bone is cut adjacent to A segment of bone is cut adjacent to the defect and moved gradually across the defect and moved gradually across the defect by a mechanical device. the defect by a mechanical device. New bone fills in between the two New bone fills in between the two bone segments. The piece of bone bone segments. The piece of bone being moved or transported is referred being moved or transported is referred to as the transport disc. to as the transport disc.

Page 133: Mandible Reconstruction

Modular endoprosthesisModular endoprosthesis

► . An endoprosthesis is a metallic device that . An endoprosthesis is a metallic device that replaces diseased bone in long bones and is fixed replaces diseased bone in long bones and is fixed internally with bone cement within the medullary internally with bone cement within the medullary space of the remaining healthy bone. There is no space of the remaining healthy bone. There is no need for screw fixation. The variable length of the need for screw fixation. The variable length of the bone gap can be bridged by using modules that bone gap can be bridged by using modules that allow for accurate three-dimensional allow for accurate three-dimensional reconstructions. The modules are connected by a reconstructions. The modules are connected by a locking system. In principle, the mandible would locking system. In principle, the mandible would qualify for such an endoprosthesis because of the qualify for such an endoprosthesis because of the existing medullary space. Occlusal rehabilitation existing medullary space. Occlusal rehabilitation could be achieved on implants that are screwed could be achieved on implants that are screwed into existing holes of the endoprosthesis. into existing holes of the endoprosthesis.

Page 134: Mandible Reconstruction

Gunshot injuryGunshot injury

► Reconstruction with a Reconstruction with a free fibular free fibular osteocutaneous flap osteocutaneous flap

► 23 cm fibular 23 cm fibular osteocutaneous flap osteocutaneous flap was harvested was harvested

► Two osteotomies were Two osteotomies were performed at the performed at the proximal part of the proximal part of the flap for the symphyseal flap for the symphyseal and parasymphyseal and parasymphyseal defect reconstruction. defect reconstruction.

Page 135: Mandible Reconstruction

► Osteotomies were Osteotomies were stabilised with stabilised with miniplates miniplates

► osteomuscular osteomuscular dorsal scapular dorsal scapular (OMDS) flap is used (OMDS) flap is used as an alternative as an alternative technique technique

Page 136: Mandible Reconstruction

Other flaps Other flaps

►PMMCPMMC►Latissimus dorsiLatissimus dorsi►DP flapDP flap►Reconstruction platesReconstruction plates

Page 137: Mandible Reconstruction

Reconstruction in ORNReconstruction in ORN