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Mandibular replacements: a review of the literature
The use of various types of biologic and alloplastic implants for mandibular reconstruction is reviewed. Although repair with alloplastics has greatly increased since the 1930s, no one alloplastic material has been shown to be superior.
Mandibular replacements: a review of the literature Stephen M. Parel, DDS, S an A n to n io , Tex Joe B. Drane, DDS, H o u s to n Earl O. W illiam s, DD S, S an A n to n io , T e x
Although early literature is sparse regarding mandibular removal, it appears that the first dis articulations took place around 18001 or 1810,2,3 some 40 years before the discovery of general anesthesia.4,5 A fascinating collection of parts and materials has been subsequently used to re place part or all of removed sections of the man dible, with various degrees of success. This paper traces the evolution of mandibular replacements through a review of historical and contemporary literature. To facilitate this analy sis, the replacements are divided into two groups: biologic and alloplastic implants.
B io lo g ic im p la n ts
The implantation of viable or treated tissue has been the most widely used method for bridging defects in the mandible. Although soft tissue flaps have been used for this purpose, they are not generally intended to stabilize or replace mandibular bone; therefore, they are not in cluded here. ■ A u to g e n o u s solid bone grafts: In the earliest attempts reported, the investigators generally used osteoperiosteal bone grafts (bone trans ferred with a viable periosteum). Such attempts were described by Ivy,6 among others,7'9 to in 120 ■ JADA, Vol. 94, January 1977
clude clavicular and various cranial bones trans ferred in a variety of skin or muscle flaps. Skyloff (1900), using a rib section, reported what may have been the first free bone graft to the mandi b le.10 His efforts were followed in the early 1900s by repairs of defects with successful tibial and iliac crest free bone grafts to this area.6 The period before and during World War II established the crest of the ilium as the preferred donor site for mandibular bone grafts.11'13 Block er and Stout,14 in an extensive review of 1,010 cases of mandibular bone grafts done during World War II, concluded that nearly any type of bone graft can be used for small defects, but that the pure cancellous iliac crest graft was superior for defects o f any appreciable size. The literature abounds with additional re ports o f solid iliac crest grafts,15'21 including a report by Ivy22 of a successful mandibular graft 49 years postoperatively. As early as 1919, at tempts to replace the mandibular angle and sym physis curvatures with scored and bent15,23,24 or very large one-piece iliac crest grafts were re ported10 (Fig 1). Lexler was apparently unique in using a curved portion of the scapula to re place the mandibular angle and ramus.10 Recent publications by Manchester25,26 have shown that excellent contour and function can be obtained from one-piece curved iliac hemimandibular grafts used in conjunction with pre-
Fig 1 ■ Shaping iliac crest graft for anterior replacement. (Re printed from Millard, D.R., and others. Plast Reconstr Surg 48:600,
Fig 3 ■ First use of bone chip graft with extraoral splint. (Re
1971.)
printed from Mowlem, R. Lancet 2:746, 1944.)
a growth center was described by Klapp6 in 1915; he replaced the ascending ramus using the fourth metatarsal bone. Bromberg, Walden, and Ru bin15 also used the metatarsal head and bone from a costochondral junction to replace the ramus and condyle. They noted that jaw growth continued in both the ramus and condyle, but was slower than that in the contralateral growth center.
Fig 2 ■ Vitallium plate used to stabilize iliac crest graft. (Re printed from Conley, J.J. Cancer 6:568, 1953.)
cision cast splints and placement devices. His results also challenge many of the currently ac cepted theories of bone regeneration and recal cification. Variants in the one-piece graft technique were reported by C onley,27 who secured grafts with chrome-cobalt plates (Fig 2); and by Obwegeser,28 who used an intraoral approach quite suc cessfully, even in the presence of frank infection or radiation damage. An attempt to provide an articular surface and
■ Autogenous particulate bone grafts: Numer ous studies around the turn of the century re vealed that the endosteal surface cells of cancel lous bone had greater osteogenic potential than cortical bone.6,14,15,29-34 A trend toward bone grafts with predominantly cancellous surfaces was begun in the 1940s, largely because of the landmark work of Mowlem35 (Fig 3). Others dur ing this era reported successful bone chip grafts with and without stabilizing splints16,34,36,37 us ing fresh freeze-dried38 and gelantinized bone.39 The primary disadvantage of pocket-filled grafts is the tendency of the soft tissues to dis place the particles before or during consolida tion.23 For this reason, some surgeons have at tempted to stabilize the grafts by various means. Clarke40 and Soderberg and M ulvey,41 for examParel— Drane— W illiams: MANDIBULAR REPLACEMENTS * 121
Fig 4 ■ Left, scored and skewered rib graft bent to contour. Right, rib graft in place. (Reprinted from Millard, J.R. Am J Surg 114:605, 1967.)
pie, used wires to stabilize the bone fragments or skewer the larger particles and hold them in place. Others reported excellent results using a solid cancellous bridge along with the bone chips to stabilize the graft site.42 The most recent advances in the use of partic ulate grafts involve the use of an alloplastic tray to carry, protect, and shape the graft. Boyne34, 43,44 and others45'47 have popularized the use of a chrome-cobalt tray and a cellulose acetate fil ter (pore size of 0.45 nm) with autogenous mar row and bone. Similar operations with the use o f Dacron-urethane composite trays for osseous reconstruction, with good results, have been re ported up to one year.48'50 ■ A uto geno us rib grafts: Block or cortical grafts are not taken without some risk.23,31,51,52 Aside from the discomfort of a second operative site, there is a possibility of pathologic fracture in the tibia, loose pelvic tendon or muscular at tachments, or herniation of the cecum at the iliac crest. These possible complications, along with the fact that resected ribs usually reform within six months,52 have led some contemporary sur geons to make more extensive use of rib grafts.3, 2 7 ,5 3
A s the rib graft must usually be bent to con tour, some surgeons first notch the bone to pre vent fracture54'57 (Fig 4, left). A Kirschner wire or similar wire also has been used to skewer the graft and render it more stable.51,56'58 Longacre59 advises splitting the rib before grafting to expose a greater cancellous bone surface. Mil lard and co-workers55 suggest this procedure be delayed to allow flap healing, noting a 30% failure rate when rib grafts were used immediately (Fig 4, right). Autogenous rib grafts are easily molded, but 122 ■ JADA, Vol. 94, January 1977
are generally only suited to body or anterior re placement.22,27,51,57 They also are quite useful in children under 8 years of age who require a bone graft. Before this age, the iliac crestal bone is too cartilaginous to be an acceptable donor site.37, 5 2 ,5 8 ,6 0
Strauch and co-workers,61 using dogs, have described a method of transferring a rib and its pedicle and noted excellent results. Others,8, 27,57 using both ribs and the clavicle, have repor ted such grafts and noted that the best results occurred when the graft was not delayed. ■ H om og rafts: Apparently the first successful transplant of bone from one person to another was reported by MacEwen in 1878.62 Peer’s63 review of the subject notes that early homografts were used after chilling, boiling, refrigerating (not freezing) in petrolatum and saline solution (sterilization in ether or alcohol), or simply used fresh. These early reports indicated a success rate that is surprising, but few homografts were used as mandibular replacements. Although the use of homologous bone is not a universally acceptable procedure for mandib ular repair,6,15,33,57 Burwell,64'66 Converse and Campbell,67 and others68'72 have shown homo grafts to function well, at least over a short per iod. Homologous bone also may be hydrolized,28 frozen, radiated, or freeze dried72'74 for future use in mandibular repair. This type of graft may be particularly useful if the need for a bone graft becomes evident during surgery or if age or de bilitation contraindicate a second procedure to obtain donor bone.75 More recent applications of homografts are promising in terms of replacing large defects of the mandible. To replace large defects, Fries,
Marble, and Snell73 used a hollowed freeze-dried cadaver mandible filled with autogenous chips, and Mainous and co-workers74 used a freshfrozen, surface-decalcified cadaver mandible; both groups reported good initial results. ■ Replantation: Boiling or autoclaving of dis eased bone can sterilize and perhaps make the segment suitable for replantation into the orig inal defect. A review of this subject by Harding76 reveals that after several early successful at tempts,77,78 mention of heated bone grafts in the literature diminished primarily as a result of the development of new antibiotics and freezing pro cesses. There seems to have been no revival of interest in this type of bone graft in recent years but, as Harding points out, there may be a place for replantation in avulsive mandibular sur gery. Although not a true implant procedure, a tech nique of cauterizing bone in situ, used by Blair, Brown, and Byars,79 did stabilize the fragments during healing. The procedure was accompanied by continuous draining sequestration and a re sidual fistula. ■ H eterografts: Probably the first reported graft of animal bone to a human was recorded in 1668; a skull graft from a dog was used to replace a similar defect in a Russian soldier.80 In 1913, Konig81 replaced hemimandibles in two patients with ivory; one of these heterografts was suc cessful after two years. Krause used ivory as a temporary mandibular splint; it was later re placed with a bone graft.63 Other early accounts o f animal grafts used in humans involved cow and deer horns, rabbit, sheep, ox, or horse bone, walrus tusk and, most commonly, bovine bone.10,63 Opinions about the use of heterografts, the most common of which is particulate-treated or frozen despeciated bovine bone,82 cover a wide range; some consider a heterograft equal to an autogenous graft,63,77 whereas others believe a heterograft is not currently appropriate for use. 57,58 perhaps the most extensive series on man dibular heterografts is a collection of 20 such cases by Bell,52 who used despeciated bone (calf bone stored in bovine plasma) and anorganic bone (calf bone treated with ethyl diamine),82 with generally poor results. ■ Cartilage grafts: Cartilage implants, either viable or preserved, can be used to repair cos metic defects in the face and jaws, but they lack
s
Fig 5 ■ Hard rubber hemimandible with irrigating channels. (Reprinted from Martin, O. In Scudder, C.L. Philadelphia, W. B. Saunders Co., 1912, p 356.)
the strength necessary to support mandibular fragments.57 Although Byars83,84 mentions the use of cartilage grafts in conjunction with auto genous bone as a cosmetic supplement or alone in augmenting a severe micrognathic situation, generally this material has seldom been used in supportive mandibular reconstruction.
Alloplastic implants Alloplastic materials are found outside the hu man body, either in nature or as synthetics. Those that have been used as mandibular replacements can be divided into three groups: medical pol ymers, ceramics, and metals.85 The ready avail ability o f many allop lasts, along with modern research and technology related to their use, have made them the most promising materials for mandibular replacements. ■ M edical polym ers: Polymers as mandibular implants are infrequently mentioned in the early literature. Celluloid86 and gutta-percha4 were used around the turn of the century to stabilize hemimandibles and segmentally removed man dibles. Hard or vulcanized rubber was used as a permanent or temporary mandibular replace ment as early as 1890.87 Some of these prostheses could be removed for cleaning; others were made with irrigating channels and an intra oral communication for the passage of fluid (Fig 5). Polyethylenes, polyurethanes, and polyethylParel— Drane— W illiam s: MANDIBULAR REPLACEMENTS ■ 123
Fig 6 ■ Contoured and wire-stabilized silicone prosthesis. (Re
ments4,115 and was once used to replace an en tire mandible.114 The ability to vary pore size and allow for tis sue ingrowth116 makes Teflon a desirable im plant coating. Homsy, Kent, and H inds117,118 have reported on the use of Teflon in combina tion with pyrolytic graphite to produce a coat ing known as Proplast.§ This has been used for ridge augmentation, temporomandibular joint repair, and once as a segmental prosthesis.118
printed from McQuarrie, D.G. Arch Surg 102:447, 1971.)
ene derivatives (Dacron*) have been used wide ly as surgical implants,3,88,89 but these usually lack sufficient inherent strength to serve alone as segmental mandibular replacements. Poly vinyl alcohol sponge and gelatinous sponge (G elfoam t) have been used primarily for bone augmentation,90,91 as defect fillers,92,93 for oblit eration o f undercuts,94,95 or as vehicles for med ication.96 Pennisi, Shadish, and C ox97 and Struthers98 found polyvinyl sponge to be inadequate by it self to prevent fragment collapse and to provide function; Hefner and others99 reported better results with an acrylate amide sponge. Acrylics have been used since the early 1940s for bone replacements in many parts o f the body. Various techniques and designs have been pro posed, involving one-stage100,101 and two-stage 1 0 2 . 1 0 3 techniques, a variety of shapes,104 and acrylic-metal combinations.100,101 Studies using acrylics with both humans and animals have produced conflicting success rates according to early and recent investigators.104'106 Silicone rubber (Silastict) is probably the most widely used medical implant. A great deal of clinical and histologic evidence shows that sili cones (medical grade) can be tolerated safely in nearly every region of the body. Generally speaking, silicone by itself does not provide the stability required o f a mandibular implant.107 For silicone used in combination with a second more stable material such as D acron,107,108 steel wires109 (Fig 6) or metal plates and screw s,110 good results have been reported. Small silicone blocks have been used to correct bilateral ankyl o s is ,111 and (for many years) to correct cosmetic deformities of the chin. Liquid silicone, although restricted as an injectable by the U S Food and Drug Administration, has been used to augment ridges and to correct contour.112,113 Teflon* is one o f the most inert polymers avail able for implantation,114 and one of the most ver satile. It has been used in segmental replace 124 ■ JADA, Vol. 94, January 1977
■ C eram ics: As early as 1892, plaster of Paris was used to fill cystic defects in the mandible,119 and subsequent investigators reported good re sults using plaster as an included defect filler.120' 122 Reviews o f the subject by Bahn96 and by others70,123'125 point out that although autogen ous bone is still the preferred material, plaster of Paris may be more rapidly absorbed and replaced by bone than most other implant materials. Variations in pore size of certain ceramic ma terials, such as aluminum oxide and calcium aluminate, can control hard (100 nm) or soft tissue (20 to 100 nm) ingrowth.119,126,127 The addition of bone chips to the matrix also may enhance hard tissue proliferation.128 These ma terials are highly insoluble (as opposed to plas ter) and are promising as ridge augmentations and as segmental replacements in animals85 and in humans.129"131 An epoxy-impregnated porous aluminal silica and calcium carbonate known as CerosiumH has been described recently as having the same strength and modulus of elasticity as bone.129'130 Although there is some debate regarding the toxicity and pore size of Cerosium,113 good clin ical results have been reported for a small num ber of patients. ■ M etals: Metals for use as mandibular replace ments came into prominence around the turn of the century, with several interesting applica tions. Anterior replacements were attempted during that time with best results in gold, alum inum, silver, and bronze.127,131,132 Carruthers127 noted that implants o f iron, steel, copper, zinc, and nickel steel wire were less successful. Per haps the longest surviving metal implant was a silver, anatomically shaped hemimandible placed in 1903,133 and reported by Robinson134 to be broken but in place and functioning 51 years after implantation. Undoubtedly the earliest and most consistent ly used application o f metals in the mandible was in the form o f wires.87,135 There have been re-
Fig 7 ■ Intraoral-extraoral wire stabilization by Hahl, 1900. (Re printed from Scudder, C.L. Philadelphia, W. B. Saunders Co., 1912, p 325.)
Washer
Fig 8 ■ Modified wire reconstruction to prevent erosion. (Re printed from Mladick, R.A., and others. Plast Recontr Surg 49: 228, 1973.)
ports o f wires twisted to form an angle or articu lar surface,136,137 embedded in the resected stump, and brought through the oral mucosa to attach to the teeth for added support87 (Fig 7). The literature tends to support the use of a wire or a pin splint as a temporary prosthesis to prevent initial fragment collapse and fibrosis83, 84,138-140. retention figures for pin splints range from 66% used permanently to 85% that required removal141'143 at a later date. Interestingly, one study reported a 62% long-range success rate using pin splints on irradiated patients.137 Recent modifications of techniques with wire seem to have lessened the initial failure rate of these prostheses. By using threaded wires and
bolt-sleeve assembly144,145 (Fig 8), precast thim ble seat,146 or a tubular threaded sleeve coup ling,139 several investigators have reported up to a 100% rate of retention over a five-year per io d .146 Cast metal implants became more widely used after 1936, largely because of the work o f Ven able and Stuck.147 Their investigations led to widespread use o f cobalt-chromium and related alloys for skeletal reconstruction; many of the alloys used for implantation have been histori cally reviewed by W eisman.148 The increasing success and apparent biocom patibility of these metals led to a wide variety of applications for mandibular replacements. Vital lium** and 18-8 stainless steel plates were used for fixation in conjunction with or instead o f bone grafts.148'152 The first hemimandibular replace ment was done in 1948153 and was reportedly successful after five years154; the first report of such an operation involving the use of Vitallium appeared in the literature in 1951.155 In 1956, the first total replacement of a mandible with a Vital lium appliance was reported.156 Others have had success in spanning large defects157,158 or by welding like metal pieces to form articular pro c e sse s.159 Space-age research has resulted in an in creased use o f titanium as an implant material. It is as biocompatible as Vitallium and can be used as a fixating plate,160 or in kits as a malle able (titanium 130) or a rigid (titanium 160) repro duction of the segments to be replaced161 (Fig 9). Collapsible, tubular, Vitallium mesh pros theses have been used widely, mostly as a result of the near 90% success rate reported by Hahn and Corgill162,163 in mandibular reconstruction. Stainless steel mesh is more easily formed and can provide a convenient method of holding a bone graft or supporting residual bone en d s.164' 166
Tantalum, another basic element, is used in sheet or mesh form as an aid in mandibular re construction. Although this material is difficult to fabricate in a form strong enough to be perm anently self-supporting, it can be valuable in sup porting a bone graft or as a temporary splint.41,167 Holland168 and Thoma169 described the use of a tantalum mesh for ridge augmentation, but their results were not totally satisfactory. The problem of fixation is considered by many to be the key to the long-range success o f metallic implants. Classically, bone screws have been Parel— Drane—W illiams: MANDIBULAR REPLACEMENTS ■ 125
Fig 9 ■ Titanium kit combinations. (Reprinted from Bowerman, J.E., and Controy, B. Br J Oral Surg 6:223, 1969.)
used to secure skeletal prostheses, but some recent alternatives have been offered. A pre milled bolt sleeve assembly that reduces surface bulk has been described by Guerra.170 Others have suggested cementing the metal end with acrylic,171 or making custom bone-end Vitallium castings during the operation.172
Discussion It is difficult to draw conclusions on the basis of a literature review, particularly of a field in which the diversity of method and opinion is so great. Around the mid-1930s, however, there seems to have been a shift in emphasis from re pair with autogenous bone to experimentation and widespread use of alloplastic materials. Several factors may have been responsible for this subtle change of thought. First, a number of new approaches to mandibular reconstruction were made possible when certain metallic alloys were shown to be biocompatible. Surgeons also were searching for a way to avoid the functional deficit left by trauma to the donor site, particu larly if large bone grafts were used. The intro duction of rigid implants with less bulk may have increased the use of alloplastic materials for re construction in patients with cancer, especially if removal of the tissue affected by the malignant disease compromised the amount of soft tissue available for closure. Although there appear to be some recent exceptions, the general failure of 126 ■ JADA, Vol. 94, January 1977
homografts and heterografts to repair mandibular defects may have contributed to the increased use of alloplastic materials. There seems to be universal agreement that autogenous bone is by far the best substitute for missing mandibular bone when an implant is be ing considered. The limited availability of prop erly shaped bone, particularly for defects involv ing curved surfaces, may compromise the use of many autogenous grafts. Theoretically, allo plastic materials seem to be ideal for many re constructive problems but the diversity of ma terials in use and the variety of success rates re ported have not established any particular allo plastic substance as the preferred material.
Dr. Parel is associate professor, department of prosthodontics, and head, division of maxillofacial prosthetics, University of Texas Dental School, 7703 Floyd Curl Dr, San Antonio, 78229. Dr. Drane is director, Regional Maxillofacial Restorative Center at the M. D. Anderson Hospital and Tumor Institute and the Uni versity of Texas Dental Branch, Houston. Dr. Williams is a pros thodontist, Air Force Base Hospital, Okinawa. Address requests for reprints to Dr. Parel. ‘ DuPont, Los Angeles, 90022. tUpjohn Co., Kalamazoo, Mich 49001. tDow Corning, Midland, Mich 48640. §Smith-Kllne Surgical Specialties, Philadelphia, 19101. HBaxter Laboratories, Morton Grove, III 60053. **Howmedica, Inc., Chicago, 60632. 1. Sims, J.M. Osteosarcoma of the lower jaw. Am J Med Sei 1847. 2. Bergenfeldt, E. Prosthetic treatment of defects of the man dible following unilateral exarticulation. Acta Chlr Scand 64:473, 1929.
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36. Marino, H.; Turco, N.B.; and Craviotte, M. Immediate re construction of lower jaw following surgical excision of large tumors. Plast Reconstr Surg 4:36, 1949. 37. Anlyn, A.J. Immediate reconstruction of mandibular de fects with autogenous bone chip grafts. Am J Surg 110:564, 1965. 38. Huebsch, R.F. The repair of defects of the jaws with can cellous bone chips: experience with forty cases. Br J Oral Surg 8:165, 1970. 39. Sheehan, J.E., and Swanker, W.A. Gelantinized bone for repair of skeletal losses. Br J Plast Surg 2:268, 1950. 40. Clarke, P.B. Internal fixation for bone grafts to the man dible. Br J Oral Surg 4:95, 1966. 41. Soderberg, B.N., and Mulvey, I.M. Mandibular reconstruc tion in jaw deformities. Plast Reconstr Surg 2:191, 1947. 42. Barclay, L.T.; Gordon, S.D.; and Campbell, H.H. Manage ment of jaw fractures. Surg Gynecol Obstet 84:973, 1947. 43. Boyne, P.T. Autogenous cancellous bone and marrow transplants. Clin Orthop 73:199, 1970. 44. Boyne, P.T. Regeneration of alveolar bone beneath cel lulose acetate filter Implants. J Dent Res 43:827, 1964. 45. Khosla, V.M. Immediate bone graft following resection of mandibular osteomyolytic lesion. Oral Surg 30:29, 1970. 46. Richter, H.E.; Surgg, W.E.; and Boyne, P.J. Stimulation of osteogenesis in the dog mandible by autogenous bone marrow transplants. Oral Surg 26:396, 1968. 47. Marble, H.B., and others. Grafts of cancellous marrow for restoration of avulsion defects of the mandible: report of two cases. J Oral Surg 28:138, 1970. 48. Leake, D.C., and Rappaport, M. Mandibular reconstruc tion: bone induction in an alloplastic tray. Surgery 72:332, 1972. 49. Rappaport, M., and Leake, D.C. Current experiments in polymeric mandibular implants for bone induction. Br J Oral Surg 10:326, 1973. 50. Leake, D.C. Dacron/urethane composite: a new biomaterIal for osseous contour reconstruction. J Prosthet Dent 32:182,
1974. 51. Skolnlk, M.S.; Tardy, E.M.; and Stagman, R.G. Rehabilita tion following anterior jaw resection. Laryngoscope 80:1580, 1970. 52. Bell, W.H. Current concepts of bone grafting. J Oral Surg 26:118, 1968. 53. Brown, J.B., and Cannon, B. Repair of major defects of the face. Ann Surg 126:624, 1947. 54. Millard, D.R., and others. Interim report on immediate man dibular repair. Am J Surg 118:726, 1969. 55. Millard, D.R., and others. Composite lower jaw reconstruc tion. Plast Reconstr Surg 46:22, 1970. 56. Millard, D.R., and others. Immediate reconstruction of the resected mandibular arch. Am J Surg 114:605, 1967. 57. Goode, R.L. Bone and cartilage grafts: current concepts. Otolaryngol Clin North Am 5:447, 1972. 58. Harding, R.L. Mandibular replacements. J Oral Surg 28:593, 1970. 59. Longacre, J.J. Transplantation of bone. In Converse, J.M. Reconstructive plastic surgery. Philadelphia, W. B. Saunders Co., 1964, p 140. 60. Hovell, J.H. Bone grafting in the mandible. Oral Surg 15:
1281, 1962. 61. Strauch, B., and others. An experimental approach to mandibular replacement: island vascular composite rib grafts. Br J Plast Surg 24:334, 1971. 62. Bush, L.P. The use of homogenous bone grafts: a prelim inary report on the bone bank. J Bone Joint Surg 29:620, 1949. 63. Peer, L.A. Transplantation of tissue. Baltimore, Williams & Wilkins Co., 1955, vol 1, p 203. 64. Burwell, R.G. Studies in transplantation of bone: V. The capacity of fresh and treated homografts of bone to evoke trans plantation immunity. J Bone Joint Surg 45:386, 1963. 65. Burwell, R.G. Studies in transplantation of bone: VIII. Treated composite homograft-autografts of cancellous bone. J Bone Joint Surg 48:532, 1966. 66. Burwell, R.G. Studies in the transplantation of bone: VII. The fresh composite homograft-autograft of cancellous bone. J Parel— Drane— W illiam s: MANDIBULAR REPLACEMENTS ■ 127
Bone Joint Surg 46B:110, 1964. 67. Converse, J.M., and Campbell, R.M. Experiences with a bone bank in plastic surgery. Plast Reconstr Surg 5:258, 1950. 68. Bell, W.H. Resorption characteristics of bone and bone sub stitutes. Oral Surg 17:650, 1964. 69. Markowitz, A. The use of homogenous bone in mandibu lar reconstruction. Am J Surg 96:755, 1958. 70. Marble, H.B. Homografts of freeze dried bone in cystic defects of the jaws. Oral Surg 26:118, 1968. 71. Holmstrand, K. Biophysical investigations of bone trans plants and bone implants: an experimental study. Acta Orthop Scand 26:(Supp 26) 1, 1957. 72. Kreuz, F.P., and others. Preservation and clinical use of freeze dried bone. J Bone Joint Surg 33:863, 1951. 73. Fries, H.O.; Marble, H.B.; and Snell, K.W. Reconstruction of the mandible. Arch Otolaryngol 93:426, 1971. 74. Mainous, E.G., and others. Restoration of resected man dible by grafting with combination of mandible homograft and autogenous iliac marrow, and postoperative treatment with hy perbaric oxygenation. Oral Surg 35:13, 1973. 75. Kolesov, A.A., and others. [Use of preserved homologous bone in plastic surgery of the mandible in children.] Stomatologica 5 1 :49, 1972. 76. Harding, R.C. Replantation of the mandible In cancer sur gery. Plast Reconstr Surg 19:373, 1957. 77. Gallie, W.E. The use of boiled bone in operative surgery. Am J Ortho Surg 16:373, 1918. 78. Orell, S. Surgical bone grafting with "Os Novum” and boiled bone. J Bone Joint Surg 19:873, 1937. 79. Blair, V.P.; Brown, J.B.; and Byars, L.T. Cancer of the cheek and neighboring bone. Am J Surg 30:250, 1935. 80. Georglade, N., and Dingwall, J. Use of heterogenous bone implants and osteogenic extract in maxillofacial surgery. Bull Soc In tC hir 24:21, 1965. 81. König, G. In Groves, E.W. Methods and results of trans plantation of bone in the repair of defects caused by injury or disease. Br J Surg 5:202, 1917. 82. Boyne, P.T., and Losee, F.L. Use of anorganic bone im plants in oral surgery. J Oral Surg 16:53, 1958. 83. Byars, L.T. Subperiosteal mandibular resection with internal bar fixation. Plast Reconstr Surg 1:236, 1946. 84. Byars, L.T. Surgical management of the mandible invaded by oral cancer. Surg Gynecol Obstet 98:564, 1954. 85. Topazian, R.G., and others. Use of alloplastics for ridge augmentation. J Oral Surg 29:792, 1971. 86. Erndt, J. Prosthesis after jaw resection. Arch Clin Chir 52:210, 1968. 87. Scudder, C.L. Tumors of the jaws. Philadelphia, W. B. Saunders Co., 1912, p 354. 88. Blocksma, R., and Braley, S. Implantation materials. In Grabb, W.C., and Smith J., eds. Plastic surgery. Boston, Little Brown & Co., 1968, p 111. 89. Bienstock, J.S. A review of research, as regards tissue reac tion to metal plastic and dental implants. Oral Surg 8:430, 1955. 90. Moss, M.L. Bone graft substitutes. NY State Dent J 24:353, 1958. 91. Cranin, A.N. Polyvinyl resin sponge Implants In rebuilding atrophic ridges: a new surgical approach. In Cranin, A.N., ed. Oral implantology. Springfield, III, Charles C Thomas, 1970, p314. 92. Thoma, K.H. A new method of space obliteration after odentectomy. Am J Orthod Oral Surg 31:198, 1945. 93. Thoma, K.H., and Sleeper, E.L. Gelatin sponge in obliter ation of cavities resulting from the excision of cysts from the jaws. Oral Surg 1:24, 1948. 94. Moore, R.H.; Smith, Q.M.; and Field, J.L. Stimulation of newtissue growth as an adjunct to alveoloplasty. Oral Surg 6:812, 1953. 95. Lewin-Epstein, J. Use of polyvinyl alcohol sponge in alveol oplasty, a preliminary report. J Oral Surg 18:453, 1960. 96. Bahn, S.L. Plaster: a bone substitute. Oral Surg 21:672, 1966. 97. Pensi, V.; Shadish, W.; and Cox, R. Plastic material as a bone substitute in the dog mandible. Plast Reconstr Surg 15:274, 1955. 128 ■ JADA, Vol. 94, January 1977
98. Struthers, A.M. An experimental study of polyvinyl sponge as a substitute for bone. Plast Reconstr Surg 15:274, 1955. 99. Heffner, E.P.; McFall, T.A.; and Hanschild, D.C. Acrylate amide sponge for repair of alveolar bone defects. J Oral Surg 26:577, 1968. 100. Healy, M.J., and others. The use of acrylic Implants in one stage reconstruction of the mandible. Surg Gynecol Obstet 98: 395, 1954. 101. Niebel, H.H., and others. Immediate prosthesis for the resected mandible. JADA 49:1, 1954. 102. Martin Lagos, F. Dos casos de aloplastia con Plexiglas. Rev Espan Cirug Valencia 4:213, 1946. 103. Arandes, A.R. In Niebel, H.H., and others. Immediate pros thesis for the resected mandible. JADA 49:1, 1954. 104. Van Reenen, P.F. The use of acrylic implants after exten sive mandibular resection. J Dent Assoc S Africa 19:367, 1964. 105. Caorsi, V.A. In Healy, M.T., and others. The use of acrylic implants in one stage reconstruction of the mandible. Surg Gyne col Obstet 98:395, 1954. 106. Hector, A. In Healy, M.T., and others. The use of acrylic implants in one stage reconstruction of the mandible. Surg Gyne col Obstet 98:395, 1954. 107. Leake, D., and others. Custom fabrication for mandibular reconstruction. Oral Surg 33:879, 1972. 108. Gatewood, T.B. Reconstruction of the alveolar ridge with silicone-Dacron implants: a pilot study. J Oral Surg 26:441, 1968. 109. McQuarrie, D.G. Immediate function of restoration of the mandible after surgical treatment of advanced oral cancer. Arch Surg 102:447, 1971. 110. Schecter, L.M., and Pories, W.J. Partial mandibular re placement with a silicone strute. Am J Surg 113:846, 1967. 111. Brown, J.B., and others. Silicone and Teflon prostheses: including full jaw substitution. Am Surg 157:932, 1963. 112. Boucher, L.T. Injected Silastic for tissue protection. J Prosthet Dent 15:73, 1965. 113. Boucher, L.T. Injected Silastic in ridge extension proce dures. J Prosthet Dent 14:460, 1964. 114. LaVeen, H.H., and Barberio, J.R. Tissue reaction to plastics used in surgery with special reference to Teflon. Ann Surg 127: 1079, 1948. 115. Small, I.; Brown, S.; and Kobernick, S. Teflon and Silastic for mandibular replacement: experimental studies and reports of cases. J Oral Surg 22:377, 1964. 116. Friedenberg, Z.B., and Simon, W.H. Bone growth in Teflon sponge. Surg Gynecol Obstet 116:588, 1963. 117. Homsy, C.A.; Kent, T.N.; and Hinds, E.D. Materials for oral implantation— biological and functional criteria. JADA 86:817, 1973. 118. Kent, T.N., and Homsy, C.A. Pilot studies of a porous im plant in dentistry and oral surgery. J Oral Surg 30:608, 1972. 119. Peltier, L.F. The use of Plaster of Paris to fill defects In bone. Clin Orthop 21:1, 1961. 120. Edberg, E. Some experiences filling osseous cavities with plaster. Acta Chir Scand 67:313, 1931. 121. Berner, A. In Bahn, S.L. Plaster: a bone substitute. Oral Surg 21:672, 1966. 122. LeBourg, L., and Biou, C. Imbedding of Plaster of Paris in surgical cavities of the jaws. Sem Hop Paris 37:1195, 1961. 123. Calhoun, N.R., and Blackledge, G.T. Plaster of Paris im plants in the mandible of dogs. Q Nat Dent Assoc 21:13, 1962. 124. Calhoun, N.R.; Greene, C.W.; and Blackledge, G.T. Effects of plaster of Paris implants on osteogenesis in the mandibles of dogs. J Dent Res 42:1244, 1963. 125. Hulbert, S.F., and others. Materials and design consider ations for dental implants. Presented at the International sym posium on biomaterials, prosthesis and tissue: the interface problem, Clemson, SC, 1973. 126. Topazian, R.G. Ridge augmentation, alloplastics. Read before Reconstructive Surgery for Oral Prosthesis Conference, Los Angeles, April 1971. 127. Carruthers, F.W. Historical review of metals used in orth opedic surgery. South Med J 34:1223, 1941. 128. Hulbert, S.F., and others. Materials of construction for
artificial bone segments, research in dental and medical mater ials. Clemson, SC, Plenum Press 1969, p 19. 129. Smith, L. Ceramic plastic material as a bone substitute.
151. Winter, L.; Litton, J.C.; and McQuillan, A.S. Embedment of a Vitallium mandibular prosthesis as. an integral part of the operation for removal of an adamatinoma. Am J Surg 69:318,
Arch Surg 87:653, 1963. 130. Cook, G.B.; Walker, A.W.; and Schewe, E.J. The cerosium mandibular prosthesis. Am J Surg 110:568, 1965. 131. Partsch. Prosthesis of lower jaw after resection. Arch Klin Chir 55:746, 1897. 132. White, S. The employment of silver wire to bridge the gap after resection of a portion of the lower jaw .Br Med J 2:1525,1909. 133. Murphy, J.B. Contribution to surgery of bones, joints and tendons. JAMA 58:1178, 1912. 134. Robinson, M. Silver Implant in situ fifty-one years after resection of the mandible. JAMA 171:890, 1959. 135. Blair, V.P. In Small, I.A., and others. The search for a man dibular substitute. J Mt Sinai.Hosp, Winter, 1961, p 243. 136. Phillips, C.M. Primary and secondary reconstruction of the mandible after ablative surgery,: report of 24 cases using stainless steel prostheses. Am J Surg 114:601, 1967. 137. Gaskins, J.A.; Ertugrul, E.; and Rush, B.F. Tolerance of stainless steel prostheses In patients after postradiation hemimandlbulectomy. Am J Surg 117:375, 1969. 138. Ivy, R.H., and Curtis, L. Operative treatment of losses of substance of mandible with special reference to fixation of eden tulous fragments. Surg Gynecol Obstet 52:849, 1931. 139. Byars, L.T. Preservation and restoration of mandibular function and contour. Ann Surg 127:863, 1948. 140. Walsh, T.S. Buried metallic prosthesis for mandibular defects. Cancer 7:1002, 1954. 141. Sako, K., and Marchette, F.C. The use of metal prostheses following anterior mandibulectomy and neck dissection for car cinoma of the oral cavity. Am J Surg 104:715, 1,962. 142. Masson, J.K. A variation of Kirschner wire prosthesis for reconstruction of mandible after partial mandibular resection for intraoral malignancy. Plast Reconstr Surg 35:457, 1965. 143. Gaisford, J.C.; Hanna, D.C.; and Gutman, D. Management of the mandibular fragments following resection. Plast Reconstr Surg 28:192, 1961. 144. Hamilton, J.M., and Hardy, S.B. The use of the Webb Bolt as a space maintaining appliance in defects of the mandible. Plast Reconstr Surg 22:296, 1958. 145. Mladick, R.A., and others. A simple technique for securing a K-wire to the mandible. Plast Reconstr Surg 49:228, 1972. 146. Lovett, D.W.; Brintnall, E.S.; and Grandon, E.L. Mandib ular reconstruction in cases of partial mandibulectomy with dis articulation. Plast Reconstr Surg 30:76, 1962. 147. Venable, C.S., and Stuck, W.G. The effects on bone of the presence of metals, based on electrolysis: an experimental study. Ann Surg 105:917, 1937. 148. Weisman, S. Metals for implantation in the human body. Oral Implant 2:5, 1971. 149. Freeman, B.S. The use of Vitallium plates to maintain function following resection of the mandible. Plast Reconstr Surg 3:73, 1948. 150. Conley, J.J. The use of Vitallium prostheses and implants In the reconstruction of the mandibular arch. Plast Reconstr Surg 8:150, 1951.
1945. 152. Edgerton, M.T.; Ward, G.E.; and Sikes, T.E. Fixation and plastic repair after partial mandibular resection. Plast Reconstr Surg 5:231, 1950. 153. Castigliano, S.G., and Gross, P.P. Immediate prostheses following radical resection in advanced primary malignant neo plasm of mandible. J Oral Surg 9:31, 1951. 154. Castigliano, S.G. Massive metallic implant in site five years after resection of mandible. Am J Surg 88:490, 1954. 155. Kleltsch, W.P. Vitallium reconstruction of a hemi-mandible and temporomandibular joint. Plast Reconstr Surg 7:244,
1951. 156. Genest, A. Vitallium jaw replacement. Am J Surg 92:904, 1956. 157. Lane, S.L.; Hoffman, B.; and Lane, J.V. Vitallium implant for hemimandible. Am J Surg 96:768, 1958. 158. Flinchbaugh, R.W. Prosthodontlc aspects of an implant for hemimandible. J Prosthet Dent 8:1039, 1958. 159. Dewey, A.R., and Moore, J.W. Mandibular repair after radical resection. J Oral Surg Anesth Hosp Dent Serv 20:34, 1962. 160. Cook, H.P. Titanium in mandibular replacement. Br J Oral Surg 7:108, 1969. 161. Bowerman, J.E., and Controy, B. A universal kit of titanium for immediate replacement of the resected mandible. Br J Oral Surg 6:2,23, 1969. 162. Hahn, G.W., and Corglll, D.A. Chrome-cobalt mesh man dibular prosthesis. J Oral Surg 27:5, 1969, 163. Hahn, G.W. Vitallium mesh mandibular prosthesis. J Prosthet Dent 14:777, 1964. 164. Byrd, D.C., and Holton, J.B. Immediate mandibular re placement with stainless steel mesh prosthesis: case report. J Oral Surg 29:436, 1971. 165. Attie, J.N.; Catania, A.; and Ripstein, C.B. Stainless steel mesh prostheses for immediate replacement of the mandible. Surgery 5:712, 1953. 166. Bear, S.E.; Green, R.K.; and Wentz, W.W. Stainless steel wire mesh—an aid in difficult oral surgery problems. J Oral Surg
29:27, 1971. 167. Williams, E.O. A review of mandibular implants which have been placed at M. D. Anderson Hospital. Res rep. no. 115. M. D. Anderson Hospital and Tumor Institute, Houston, 1972. 168. Holland, J. Alveoloplasty with tantalum mesh. J Prosthet Dent 3:354, 1953. 169. Thoma, K.H. Oral surgery, ed 5. St. Louis, C. V. Mosby Co., 1969, p 434. 170. Guerra, O.N. A new method of implant fixation. Res rep no. 19. M. D. Anderson Hospital and Tumor Institute, Houston, 1971, p 17, 171. Lang, B.R., and Chiappa, A.A. Mandibular implants, a new method of attachment. J Prosthet Dent 22:261, 1969. 172. Lang, B.R.; Dootz, E.R., and Craig, R.G. Constructing mandibular implants during surgery. J Prosthet Dent 22:360,1969.
Parel—Drane— W illiam s: MANDIBULAR REPLACEMENTS ■ 129
Mandibular replacements: a review of the literature Stephen M. Parel, DDS, S an A n to n io , Tex Joe B. Drane, DDS, H o u s to n Earl O. W illiam s, DD S, S an A n to n io , T e x
Although early literature is sparse regarding mandibular removal, it appears that the first dis articulations took place around 18001 or 1810,2,3 some 40 years before the discovery of general anesthesia.4,5 A fascinating collection of parts and materials has been subsequently used to re place part or all of removed sections of the man dible, with various degrees of success. This paper traces the evolution of mandibular replacements through a review of historical and contemporary literature. To facilitate this analy sis, the replacements are divided into two groups: biologic and alloplastic implants.
B io lo g ic im p la n ts
The implantation of viable or treated tissue has been the most widely used method for bridging defects in the mandible. Although soft tissue flaps have been used for this purpose, they are not generally intended to stabilize or replace mandibular bone; therefore, they are not in cluded here. ■ A u to g e n o u s solid bone grafts: In the earliest attempts reported, the investigators generally used osteoperiosteal bone grafts (bone trans ferred with a viable periosteum). Such attempts were described by Ivy,6 among others,7'9 to in 120 ■ JADA, Vol. 94, January 1977
clude clavicular and various cranial bones trans ferred in a variety of skin or muscle flaps. Skyloff (1900), using a rib section, reported what may have been the first free bone graft to the mandi b le.10 His efforts were followed in the early 1900s by repairs of defects with successful tibial and iliac crest free bone grafts to this area.6 The period before and during World War II established the crest of the ilium as the preferred donor site for mandibular bone grafts.11'13 Block er and Stout,14 in an extensive review of 1,010 cases of mandibular bone grafts done during World War II, concluded that nearly any type of bone graft can be used for small defects, but that the pure cancellous iliac crest graft was superior for defects o f any appreciable size. The literature abounds with additional re ports o f solid iliac crest grafts,15'21 including a report by Ivy22 of a successful mandibular graft 49 years postoperatively. As early as 1919, at tempts to replace the mandibular angle and sym physis curvatures with scored and bent15,23,24 or very large one-piece iliac crest grafts were re ported10 (Fig 1). Lexler was apparently unique in using a curved portion of the scapula to re place the mandibular angle and ramus.10 Recent publications by Manchester25,26 have shown that excellent contour and function can be obtained from one-piece curved iliac hemimandibular grafts used in conjunction with pre-
Fig 1 ■ Shaping iliac crest graft for anterior replacement. (Re printed from Millard, D.R., and others. Plast Reconstr Surg 48:600,
Fig 3 ■ First use of bone chip graft with extraoral splint. (Re
1971.)
printed from Mowlem, R. Lancet 2:746, 1944.)
a growth center was described by Klapp6 in 1915; he replaced the ascending ramus using the fourth metatarsal bone. Bromberg, Walden, and Ru bin15 also used the metatarsal head and bone from a costochondral junction to replace the ramus and condyle. They noted that jaw growth continued in both the ramus and condyle, but was slower than that in the contralateral growth center.
Fig 2 ■ Vitallium plate used to stabilize iliac crest graft. (Re printed from Conley, J.J. Cancer 6:568, 1953.)
cision cast splints and placement devices. His results also challenge many of the currently ac cepted theories of bone regeneration and recal cification. Variants in the one-piece graft technique were reported by C onley,27 who secured grafts with chrome-cobalt plates (Fig 2); and by Obwegeser,28 who used an intraoral approach quite suc cessfully, even in the presence of frank infection or radiation damage. An attempt to provide an articular surface and
■ Autogenous particulate bone grafts: Numer ous studies around the turn of the century re vealed that the endosteal surface cells of cancel lous bone had greater osteogenic potential than cortical bone.6,14,15,29-34 A trend toward bone grafts with predominantly cancellous surfaces was begun in the 1940s, largely because of the landmark work of Mowlem35 (Fig 3). Others dur ing this era reported successful bone chip grafts with and without stabilizing splints16,34,36,37 us ing fresh freeze-dried38 and gelantinized bone.39 The primary disadvantage of pocket-filled grafts is the tendency of the soft tissues to dis place the particles before or during consolida tion.23 For this reason, some surgeons have at tempted to stabilize the grafts by various means. Clarke40 and Soderberg and M ulvey,41 for examParel— Drane— W illiams: MANDIBULAR REPLACEMENTS * 121
Fig 4 ■ Left, scored and skewered rib graft bent to contour. Right, rib graft in place. (Reprinted from Millard, J.R. Am J Surg 114:605, 1967.)
pie, used wires to stabilize the bone fragments or skewer the larger particles and hold them in place. Others reported excellent results using a solid cancellous bridge along with the bone chips to stabilize the graft site.42 The most recent advances in the use of partic ulate grafts involve the use of an alloplastic tray to carry, protect, and shape the graft. Boyne34, 43,44 and others45'47 have popularized the use of a chrome-cobalt tray and a cellulose acetate fil ter (pore size of 0.45 nm) with autogenous mar row and bone. Similar operations with the use o f Dacron-urethane composite trays for osseous reconstruction, with good results, have been re ported up to one year.48'50 ■ A uto geno us rib grafts: Block or cortical grafts are not taken without some risk.23,31,51,52 Aside from the discomfort of a second operative site, there is a possibility of pathologic fracture in the tibia, loose pelvic tendon or muscular at tachments, or herniation of the cecum at the iliac crest. These possible complications, along with the fact that resected ribs usually reform within six months,52 have led some contemporary sur geons to make more extensive use of rib grafts.3, 2 7 ,5 3
A s the rib graft must usually be bent to con tour, some surgeons first notch the bone to pre vent fracture54'57 (Fig 4, left). A Kirschner wire or similar wire also has been used to skewer the graft and render it more stable.51,56'58 Longacre59 advises splitting the rib before grafting to expose a greater cancellous bone surface. Mil lard and co-workers55 suggest this procedure be delayed to allow flap healing, noting a 30% failure rate when rib grafts were used immediately (Fig 4, right). Autogenous rib grafts are easily molded, but 122 ■ JADA, Vol. 94, January 1977
are generally only suited to body or anterior re placement.22,27,51,57 They also are quite useful in children under 8 years of age who require a bone graft. Before this age, the iliac crestal bone is too cartilaginous to be an acceptable donor site.37, 5 2 ,5 8 ,6 0
Strauch and co-workers,61 using dogs, have described a method of transferring a rib and its pedicle and noted excellent results. Others,8, 27,57 using both ribs and the clavicle, have repor ted such grafts and noted that the best results occurred when the graft was not delayed. ■ H om og rafts: Apparently the first successful transplant of bone from one person to another was reported by MacEwen in 1878.62 Peer’s63 review of the subject notes that early homografts were used after chilling, boiling, refrigerating (not freezing) in petrolatum and saline solution (sterilization in ether or alcohol), or simply used fresh. These early reports indicated a success rate that is surprising, but few homografts were used as mandibular replacements. Although the use of homologous bone is not a universally acceptable procedure for mandib ular repair,6,15,33,57 Burwell,64'66 Converse and Campbell,67 and others68'72 have shown homo grafts to function well, at least over a short per iod. Homologous bone also may be hydrolized,28 frozen, radiated, or freeze dried72'74 for future use in mandibular repair. This type of graft may be particularly useful if the need for a bone graft becomes evident during surgery or if age or de bilitation contraindicate a second procedure to obtain donor bone.75 More recent applications of homografts are promising in terms of replacing large defects of the mandible. To replace large defects, Fries,
Marble, and Snell73 used a hollowed freeze-dried cadaver mandible filled with autogenous chips, and Mainous and co-workers74 used a freshfrozen, surface-decalcified cadaver mandible; both groups reported good initial results. ■ Replantation: Boiling or autoclaving of dis eased bone can sterilize and perhaps make the segment suitable for replantation into the orig inal defect. A review of this subject by Harding76 reveals that after several early successful at tempts,77,78 mention of heated bone grafts in the literature diminished primarily as a result of the development of new antibiotics and freezing pro cesses. There seems to have been no revival of interest in this type of bone graft in recent years but, as Harding points out, there may be a place for replantation in avulsive mandibular sur gery. Although not a true implant procedure, a tech nique of cauterizing bone in situ, used by Blair, Brown, and Byars,79 did stabilize the fragments during healing. The procedure was accompanied by continuous draining sequestration and a re sidual fistula. ■ H eterografts: Probably the first reported graft of animal bone to a human was recorded in 1668; a skull graft from a dog was used to replace a similar defect in a Russian soldier.80 In 1913, Konig81 replaced hemimandibles in two patients with ivory; one of these heterografts was suc cessful after two years. Krause used ivory as a temporary mandibular splint; it was later re placed with a bone graft.63 Other early accounts o f animal grafts used in humans involved cow and deer horns, rabbit, sheep, ox, or horse bone, walrus tusk and, most commonly, bovine bone.10,63 Opinions about the use of heterografts, the most common of which is particulate-treated or frozen despeciated bovine bone,82 cover a wide range; some consider a heterograft equal to an autogenous graft,63,77 whereas others believe a heterograft is not currently appropriate for use. 57,58 perhaps the most extensive series on man dibular heterografts is a collection of 20 such cases by Bell,52 who used despeciated bone (calf bone stored in bovine plasma) and anorganic bone (calf bone treated with ethyl diamine),82 with generally poor results. ■ Cartilage grafts: Cartilage implants, either viable or preserved, can be used to repair cos metic defects in the face and jaws, but they lack
s
Fig 5 ■ Hard rubber hemimandible with irrigating channels. (Reprinted from Martin, O. In Scudder, C.L. Philadelphia, W. B. Saunders Co., 1912, p 356.)
the strength necessary to support mandibular fragments.57 Although Byars83,84 mentions the use of cartilage grafts in conjunction with auto genous bone as a cosmetic supplement or alone in augmenting a severe micrognathic situation, generally this material has seldom been used in supportive mandibular reconstruction.
Alloplastic implants Alloplastic materials are found outside the hu man body, either in nature or as synthetics. Those that have been used as mandibular replacements can be divided into three groups: medical pol ymers, ceramics, and metals.85 The ready avail ability o f many allop lasts, along with modern research and technology related to their use, have made them the most promising materials for mandibular replacements. ■ M edical polym ers: Polymers as mandibular implants are infrequently mentioned in the early literature. Celluloid86 and gutta-percha4 were used around the turn of the century to stabilize hemimandibles and segmentally removed man dibles. Hard or vulcanized rubber was used as a permanent or temporary mandibular replace ment as early as 1890.87 Some of these prostheses could be removed for cleaning; others were made with irrigating channels and an intra oral communication for the passage of fluid (Fig 5). Polyethylenes, polyurethanes, and polyethylParel— Drane— W illiam s: MANDIBULAR REPLACEMENTS ■ 123
Fig 6 ■ Contoured and wire-stabilized silicone prosthesis. (Re
ments4,115 and was once used to replace an en tire mandible.114 The ability to vary pore size and allow for tis sue ingrowth116 makes Teflon a desirable im plant coating. Homsy, Kent, and H inds117,118 have reported on the use of Teflon in combina tion with pyrolytic graphite to produce a coat ing known as Proplast.§ This has been used for ridge augmentation, temporomandibular joint repair, and once as a segmental prosthesis.118
printed from McQuarrie, D.G. Arch Surg 102:447, 1971.)
ene derivatives (Dacron*) have been used wide ly as surgical implants,3,88,89 but these usually lack sufficient inherent strength to serve alone as segmental mandibular replacements. Poly vinyl alcohol sponge and gelatinous sponge (G elfoam t) have been used primarily for bone augmentation,90,91 as defect fillers,92,93 for oblit eration o f undercuts,94,95 or as vehicles for med ication.96 Pennisi, Shadish, and C ox97 and Struthers98 found polyvinyl sponge to be inadequate by it self to prevent fragment collapse and to provide function; Hefner and others99 reported better results with an acrylate amide sponge. Acrylics have been used since the early 1940s for bone replacements in many parts o f the body. Various techniques and designs have been pro posed, involving one-stage100,101 and two-stage 1 0 2 . 1 0 3 techniques, a variety of shapes,104 and acrylic-metal combinations.100,101 Studies using acrylics with both humans and animals have produced conflicting success rates according to early and recent investigators.104'106 Silicone rubber (Silastict) is probably the most widely used medical implant. A great deal of clinical and histologic evidence shows that sili cones (medical grade) can be tolerated safely in nearly every region of the body. Generally speaking, silicone by itself does not provide the stability required o f a mandibular implant.107 For silicone used in combination with a second more stable material such as D acron,107,108 steel wires109 (Fig 6) or metal plates and screw s,110 good results have been reported. Small silicone blocks have been used to correct bilateral ankyl o s is ,111 and (for many years) to correct cosmetic deformities of the chin. Liquid silicone, although restricted as an injectable by the U S Food and Drug Administration, has been used to augment ridges and to correct contour.112,113 Teflon* is one o f the most inert polymers avail able for implantation,114 and one of the most ver satile. It has been used in segmental replace 124 ■ JADA, Vol. 94, January 1977
■ C eram ics: As early as 1892, plaster of Paris was used to fill cystic defects in the mandible,119 and subsequent investigators reported good re sults using plaster as an included defect filler.120' 122 Reviews o f the subject by Bahn96 and by others70,123'125 point out that although autogen ous bone is still the preferred material, plaster of Paris may be more rapidly absorbed and replaced by bone than most other implant materials. Variations in pore size of certain ceramic ma terials, such as aluminum oxide and calcium aluminate, can control hard (100 nm) or soft tissue (20 to 100 nm) ingrowth.119,126,127 The addition of bone chips to the matrix also may enhance hard tissue proliferation.128 These ma terials are highly insoluble (as opposed to plas ter) and are promising as ridge augmentations and as segmental replacements in animals85 and in humans.129"131 An epoxy-impregnated porous aluminal silica and calcium carbonate known as CerosiumH has been described recently as having the same strength and modulus of elasticity as bone.129'130 Although there is some debate regarding the toxicity and pore size of Cerosium,113 good clin ical results have been reported for a small num ber of patients. ■ M etals: Metals for use as mandibular replace ments came into prominence around the turn of the century, with several interesting applica tions. Anterior replacements were attempted during that time with best results in gold, alum inum, silver, and bronze.127,131,132 Carruthers127 noted that implants o f iron, steel, copper, zinc, and nickel steel wire were less successful. Per haps the longest surviving metal implant was a silver, anatomically shaped hemimandible placed in 1903,133 and reported by Robinson134 to be broken but in place and functioning 51 years after implantation. Undoubtedly the earliest and most consistent ly used application o f metals in the mandible was in the form o f wires.87,135 There have been re-
Fig 7 ■ Intraoral-extraoral wire stabilization by Hahl, 1900. (Re printed from Scudder, C.L. Philadelphia, W. B. Saunders Co., 1912, p 325.)
Washer
Fig 8 ■ Modified wire reconstruction to prevent erosion. (Re printed from Mladick, R.A., and others. Plast Recontr Surg 49: 228, 1973.)
ports o f wires twisted to form an angle or articu lar surface,136,137 embedded in the resected stump, and brought through the oral mucosa to attach to the teeth for added support87 (Fig 7). The literature tends to support the use of a wire or a pin splint as a temporary prosthesis to prevent initial fragment collapse and fibrosis83, 84,138-140. retention figures for pin splints range from 66% used permanently to 85% that required removal141'143 at a later date. Interestingly, one study reported a 62% long-range success rate using pin splints on irradiated patients.137 Recent modifications of techniques with wire seem to have lessened the initial failure rate of these prostheses. By using threaded wires and
bolt-sleeve assembly144,145 (Fig 8), precast thim ble seat,146 or a tubular threaded sleeve coup ling,139 several investigators have reported up to a 100% rate of retention over a five-year per io d .146 Cast metal implants became more widely used after 1936, largely because of the work o f Ven able and Stuck.147 Their investigations led to widespread use o f cobalt-chromium and related alloys for skeletal reconstruction; many of the alloys used for implantation have been histori cally reviewed by W eisman.148 The increasing success and apparent biocom patibility of these metals led to a wide variety of applications for mandibular replacements. Vital lium** and 18-8 stainless steel plates were used for fixation in conjunction with or instead o f bone grafts.148'152 The first hemimandibular replace ment was done in 1948153 and was reportedly successful after five years154; the first report of such an operation involving the use of Vitallium appeared in the literature in 1951.155 In 1956, the first total replacement of a mandible with a Vital lium appliance was reported.156 Others have had success in spanning large defects157,158 or by welding like metal pieces to form articular pro c e sse s.159 Space-age research has resulted in an in creased use o f titanium as an implant material. It is as biocompatible as Vitallium and can be used as a fixating plate,160 or in kits as a malle able (titanium 130) or a rigid (titanium 160) repro duction of the segments to be replaced161 (Fig 9). Collapsible, tubular, Vitallium mesh pros theses have been used widely, mostly as a result of the near 90% success rate reported by Hahn and Corgill162,163 in mandibular reconstruction. Stainless steel mesh is more easily formed and can provide a convenient method of holding a bone graft or supporting residual bone en d s.164' 166
Tantalum, another basic element, is used in sheet or mesh form as an aid in mandibular re construction. Although this material is difficult to fabricate in a form strong enough to be perm anently self-supporting, it can be valuable in sup porting a bone graft or as a temporary splint.41,167 Holland168 and Thoma169 described the use of a tantalum mesh for ridge augmentation, but their results were not totally satisfactory. The problem of fixation is considered by many to be the key to the long-range success o f metallic implants. Classically, bone screws have been Parel— Drane—W illiams: MANDIBULAR REPLACEMENTS ■ 125
Fig 9 ■ Titanium kit combinations. (Reprinted from Bowerman, J.E., and Controy, B. Br J Oral Surg 6:223, 1969.)
used to secure skeletal prostheses, but some recent alternatives have been offered. A pre milled bolt sleeve assembly that reduces surface bulk has been described by Guerra.170 Others have suggested cementing the metal end with acrylic,171 or making custom bone-end Vitallium castings during the operation.172
Discussion It is difficult to draw conclusions on the basis of a literature review, particularly of a field in which the diversity of method and opinion is so great. Around the mid-1930s, however, there seems to have been a shift in emphasis from re pair with autogenous bone to experimentation and widespread use of alloplastic materials. Several factors may have been responsible for this subtle change of thought. First, a number of new approaches to mandibular reconstruction were made possible when certain metallic alloys were shown to be biocompatible. Surgeons also were searching for a way to avoid the functional deficit left by trauma to the donor site, particu larly if large bone grafts were used. The intro duction of rigid implants with less bulk may have increased the use of alloplastic materials for re construction in patients with cancer, especially if removal of the tissue affected by the malignant disease compromised the amount of soft tissue available for closure. Although there appear to be some recent exceptions, the general failure of 126 ■ JADA, Vol. 94, January 1977
homografts and heterografts to repair mandibular defects may have contributed to the increased use of alloplastic materials. There seems to be universal agreement that autogenous bone is by far the best substitute for missing mandibular bone when an implant is be ing considered. The limited availability of prop erly shaped bone, particularly for defects involv ing curved surfaces, may compromise the use of many autogenous grafts. Theoretically, allo plastic materials seem to be ideal for many re constructive problems but the diversity of ma terials in use and the variety of success rates re ported have not established any particular allo plastic substance as the preferred material.
Dr. Parel is associate professor, department of prosthodontics, and head, division of maxillofacial prosthetics, University of Texas Dental School, 7703 Floyd Curl Dr, San Antonio, 78229. Dr. Drane is director, Regional Maxillofacial Restorative Center at the M. D. Anderson Hospital and Tumor Institute and the Uni versity of Texas Dental Branch, Houston. Dr. Williams is a pros thodontist, Air Force Base Hospital, Okinawa. Address requests for reprints to Dr. Parel. ‘ DuPont, Los Angeles, 90022. tUpjohn Co., Kalamazoo, Mich 49001. tDow Corning, Midland, Mich 48640. §Smith-Kllne Surgical Specialties, Philadelphia, 19101. HBaxter Laboratories, Morton Grove, III 60053. **Howmedica, Inc., Chicago, 60632. 1. Sims, J.M. Osteosarcoma of the lower jaw. Am J Med Sei 1847. 2. Bergenfeldt, E. Prosthetic treatment of defects of the man dible following unilateral exarticulation. Acta Chlr Scand 64:473, 1929.
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