- Email: [email protected]
Reconstruction of large mandibular and surrounding soft-tissue defects using distraction with bone transport
Int. J. Oral Maxillofac. Surg. 2012; 41: 1215–1222 http://dx.doi.org/10.1016/j.ijom.2012.03.020, available online at http://www.sciencedirect.com
Clinical Paper Reconstructive Surgery
Reconstruction of large mandibular and surrounding soft-tissue defects using distraction with bone transport
N. Zwetyenga1,2,, F. Siberchicot3, A. Emparanza3 1 Department of Maxillofacial Surgery, Plastic and Reconstructive Surgery, Hand Surgery, Universite´ de Bourgogne, Dijon, France; 2EA 4268: Intervention, innovation, imaging and engineering in health (I4S) Place Saint Jacques 25 030 Besanc¸on Cedex, France; 3 Department of Maxillofacial and Plastic Surgery, Hoˆpital Pellegrin, Universite´ Victor Se´galen-Bordeaux, France
N. Zwetyenga, F. Siberchicot, A. Emparanza: Reconstruction of large mandibular and surrounding soft-tissue defects using distraction with bone transport. Int. J. Oral Maxillofac. Surg. 2012; 41: 1215–1222. # 2012 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Abstract. Reconstruction of large bone and soft-tissue defects of the inferior third of the face is possible using various surgical techniques. Patients who require these procedures need to be in good general health, may have sequelae linked to donor sites, and require several interventions to achieve good aesthetic and functional results. The aim of this study was to report outcomes in patients with large mandibular and soft-tissue defects treated using osteogenic distraction with bone transport. Between 2001 and 2008, 14 patients had distraction with bone transport. Most patients were men (92.1%). The mean age was 43.1 years. The average mandibular bone reconstruction was 13.6 cm. The mean duration of distraction was 2.3 months. No infections occurred, and in all cases reconstruction of soft tissues was obtained. Two patients had non-union and underwent reconstruction using an iliac bone graft. Patients with sufficient bone height (57.1%) had dental implants. 44 implants were inserted, two of which were lost. 36 implants were activated. Six patients had satisfactory oral rehabilitation with implant-supported prostheses. Osteogenic distraction with bone transport allows total or partial restoration of oral function, provides an acceptable appearance, and enables patients to resume a reasonable quality of life.
The challenge of facial reconstruction following gunshot wounds is to restore an acceptable quality of life with minimal sequelae. Reconstruction of large bone and soft-tissue defects of the lower third of the face is possible using various surgical techniques, including new techniques.1–5 Free vascularised flaps are the preferred donor tissue (cutaneous, osseous 0901-5027/01001215 + 08 $36.00/0
and muscular).4,6 Patients undergoing microvascular procedures need to be in good general health and may have sequelae linked to the donor site.7,8 Good aesthetic and functional results can be achieved, but require several surgical procedures. Osteogenic distraction allows bone and soft-tissue reconstruction and has been used successfully for mandibular
Keywords: gunshot; mandible; distraction; bone. Accepted for publication 20 March 2012 Available online 30 April 2012
distraction in gunshot wounds.7,9 There are two types of osteogenic distraction. The first type is osteogenic distraction without distraction bone transport, and is used in orthopaedic and maxillofacial malformation surgery. This technique can be used to lengthen bone and the adjacent soft tissues. The second type is osteogenic distraction with bone transport,
# 2012 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
1216
Zwetyenga et al.
Fig. 1. Example of peroperative aspect of mandibular and adjacent soft-tissue defects linked to gunshot.
which is used in cases of osseous defect. This latter technique makes it possible to fill the defect without changing the original length of the bone. The aim of this study was to report outcomes in patients with large mandibular and soft-tissue defects treated using osteogenic distraction with bone transport.
Fig. 2. Preoperative three-dimensional CT (3D CT) scan showing a mandibular osseous defect.
Materials and methods
The medical records of patients who underwent reconstruction of large mandibular and soft-tissue defects using external distraction with bone transport between 2001 and 2009 were reviewed (Fig. 1). The bone and soft-tissue defects were evaluated by preoperative computed
tomography (CT) scan with three-dimensional reconstruction (Fig. 2). From the initial trauma to the distraction protocol, all the patients were in intensive care with tracheotomy, a nasogastric tube or a gastrostomy tube. During the first 3 or 4 weeks, dressings were changed under general anaesthesia every 2 days. A mandibular reconstruction plate was inserted to avoid tissue retraction and fibrosis (Fig. 3). This phase was devoted to cleaning the necrotic tissue to allow new tissue regeneration. The surgical procedures began after this period. The first procedure began with the placement of the distraction device under general anaesthesia. First, the skin was marked and four pins were inserted percutaneously into each mandibular ramus. The horseshoe-shaped trammel of the device was placed in the axis of the bone defect and two pins were inserted vertically into the lower border of the mandible on each side of the defect. One or two planned bicortical osteotomy(ies) that preserved the internal periosteum was (were) performed through a cutaneous incision using an alternating microsaw (Figs. 3 and 4). To anticipate possible obstacles, each mobile segment was activated over a few millimetres and then returned to the original position. The period of latency to allow the formation of a neocallus was 7–10 days. The active phase began with a rate of distraction of 1 mm per day for each osteotomised segment. The device was activated for the first time by the surgeon and then by the patient using a screwdriver and a mirror. During the active phase panoramic X-rays were taken regularly (Fig. 5). The distraction was ended when the mobile segment was in contact with the fixed segment (one osteotomy
Fig. 3. 3D CT showing a mandibular reconstructive plate inserted to avoid tissue retraction and fibrosis.
Reconstruction using distraction with bone transport
1217
had appropriate postoperative antibiotic prophylaxis for 7 days. The length of the reconstructed bone was measured using a postoperative CT scan in the midline of the mandible. Fig. 10 provides a time line of the stages in the treatment. Results
13 men (92.9%) and 1 woman (7.1%) were studied. Their mean age was 43.1 years (19–66 years). The average mandibular bone defect measured 13.6 cm (2.8–24 cm). In all cases it was a suicide attempt by gunshot. One patient had one osteotomy and 13 had two osteotomies (one on each side). 13 Normed1 (Germany) and one OBL1 (France) distraction devices were inserted. The data are summarized in Table 1. The mean duration of distraction was 2.3 months (1–4 months). In all cases, the wound was closed (skin, muscle, and mucosa) (Fig. 11). One patient had partial plate exposure. No patients had postoperative infection in the site of reconstruction (no suppuration at wound margins; no drainable pus). Two patients (14.3%) had nonunion between the mobile fragments and underwent a second reconstruction procedure in which an iliac bone graft was placed in the gap. Both operations were successful. Eight patients with adequate bone height (57.1%) had mandibular oral implants in a mean time of 23 months (18– 38 months). 44 dental implants were inserted. One patient lost 2 implants (4.3% of all implants) corresponding to a percentage of osseointegration of 95.5%. 36 dental implants were activated (85.7% of 42 implants). In six patients complete oral rehabilitation was restored with implant-supported prostheses (Fig. 12). Rehabilitation of the remaining patients was in process. The mean follow-up was 77 months (range 31–116 months). Fig. 4. Peroperative (a) and postoperative (b) views after placement of the distraction device.
Discussion
on one side) or when both mobile segments were in contact (one osteotomy on each side). The second procedure was the stabilization and consolidation phase. The distal parts of the bony segments were curetted and stabilised using mandibular plates (Tekka1; Lyon, France) and the skin was closed under general anaesthesia (Fig. 6). The consolidation phase took 3
months and the distraction device was used as an external stabiliser. The third procedure was the removal of the distractor under local anaesthesia (Fig. 7). This phase was usually associated with commissuroplasty. Postoperative CT scans were performed to evaluate the bone reconstruction (Fig. 8). Oral implants were inserted up to the 18th month after the third operation (Fig. 9). All the patients
This study confirms the effectiveness of osteogenic distraction with bone transport in large mandibular and adjacent soft-tissue defects caused by gunshot. The bone reconstruction enabled implant-supported prostheses. Male predominance is classically found in the literature.7,9,10 In most cases, this type of defect is linked to a suicide attempt.7,9,10 The mean age is in keeping with data in the literature.7,10 Performing two osteotomies (one on each side) to enable double
1218
Zwetyenga et al.
Fig. 5. Panoramic view during the active phase of the distraction.
distraction reduces activation time by half. Non-union occurred in two patients, and this may have been due to poor vascularisation of the extremities of the mobile
fragments. Treatment consisted in filling the gap using an iliac bone graft with miniplates. Partial exposure of the plate is not a cause of failure.
Fig. 6. Patients during the stabilization and consolidation phase.
One of the goals of oral rehabilitation is the recovery of dental function.4 Good oral rehabilitation is difficult or impossible to obtain because the reconstructed bone using free flaps is usually smaller in height than the original mandible. Several techniques have been developed to increase this height to allow the use of removable dentures or implant-supported prostheses. These include vertical osteogenesis, the ‘double-barrel technique’ and onlay grafting, but these techniques cause a number of complications.8,11,12 In osteogenic distraction with bone transport, bone height is sufficient to allow the insertion of dental implants without previous preimplant surgery.7 Implants are very well osseointegrated in this new bone because distraction provides vascularised bone surrounded by muscles and mucosa. Several patients in this series received an implant-supported prosthesis. This percentage will improve progressively. In the literature, there are no reports of the
Reconstruction using distraction with bone transport
1219
Fig. 8. 3D CT scan showing bone reconstruction.
long-term success rate of implant survival in distracted bone. The present authors agree with those who advocate the use of osteogenic and soft-tissue distraction (skin, muscles, vessels and nerves) to achieve aesthetic results (as it avoids the patchwork appearance of the free flap technique, and provides the same quality of soft tissue) that are far better than those obtained by skeletal surgery, or by soft tissue surgery carried out independently, or using a combination of the two.7,13 Another advantage is the possibility of performing osteogenic distraction with bone transport in cases of chronic infection.10 Patients with gunshot wounds have to stay in intensive care units for a long time and they usually contract one or more infections with multi-resistant bacteria. In this series, no patients had an acute
Fig. 7. Patient just after the removal of the distraction device (a) and 1 month later (b).
Fig. 9. Panoramic X-ray showing intra-oral implants.
1220
Zwetyenga et al. Injury
Initial management
Intensive care
Dressings general anaesthesia
Distractor placement
Latency
Active
General anaesthesia
General anaesthesia
3 to 4 weeks
Stabilization-consolidation
7 to 10 days
Fig. 10. Time line for the treatment stages.
Fig. 11. Examples of post-distraction reconstruction results.
Variable
Removal
Local anaesthesia
3 months
Oral Implants Local anaesthesia
Up to 18 months
Reconstruction using distraction with bone transport
1221
Fig. 12. Patient with oral rehabilitation with implant-supported prostheses.
infection, which confirms the reliability of this technique. Compared to microsurgery, this technique is advantageous because it is a reliable, minimally invasive procedure, with a short operation time, a low risk of complications, no donor site morbidity, and is suitable for older or weak patients. It also gives better aesthetic results, and the bone regenerated can sup-
port intra-oral implant rehabilitation. The main drawbacks are the duration of the treatment and the need to wear a cumbersome device for months. Osteogenic distraction with bone transport allows total or partial restoration of oral function, provides an acceptable appearance, and enables patients to resume a reasonable quality of life. This
technique must be considered when surgeons are faced with a severe lower face defect. Both bone and soft tissues can be obtained in sufficient quality and quantity to allow implant-supported prosthesis. Osteogenic distraction improves both bone and adjacent soft tissues, therefore the authors call it histogenic distraction.
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Zwetyenga et al.
Table 1. Summary of patient data. No./age/sex
Bone defect
Distractor
Osteotomy
17 cm 14 cm 16 cm 24 cm 13 cm 14 cm 2.8 cm 12 cm 9 cm 7 cm 21 cm 17 cm 13 cm 11 cm
Normed1 Normed1 Normed1 Normed1 Normed1 Normed1 Normed1 Normed1 Normed1 Normed1 OBL1 Normed1 Normed1 Normed1
Bilateral Bilateral Bilateral Bilateral Bilateral Bilateral Unilateral Bilateral Bilateral Bilateral Bilateral Bilateral Bilateral Bilateral
1/34/M 2/42/M 3/19/M 4/24/M 5/42/M 6/62/M 7/47/M 8/50/M 9/66/M 10/55/M 11/39/M 12/53/M 13/44/M 14/26/W
Event
Follow-up (months)
Iliac bone graft
Iliac bone graft
Implant-supported prostheses Implant-supported prostheses Implant-supported prostheses Implant-supported prostheses Implant-supported prostheses Implant-supported prostheses Oral implants (84) Oral implants (78) Amovible prosthesis (72) Amovible prosthesis (53) Amovible prosthesis (52) Amovible prosthesis (54) Amovible prosthesis (53) Amovible prosthesis (31)
(116) (108) (105) (96) (92) (84)
M, men; W, women.
Funding
None. Competing interests
None declared. Ethical approval
Not required. References 1. Goodger NM, Wang J, Smagalski GW, Hepwoth B. Methylmethacrylate as a space maintainer in mandibular reconstruction. J Oral Maxillofac Surg 2005;63:1048–51. 2. Heliotis M, Lavery KM, Ripamonti U, Tsiridis E, di Silvio L. Transformation of a prefabricated hydroxyapatite/osteogenic protein-1 implant into a vascularised pedicled bone flap in the human chest. Int J Oral Maxillofac Surg 2006;35:265–9. 3. Warnke PH, Wiltfang J, Springer I, Acil Y, Bolte H, Kosmahl M, et al. Man as living bioreactor: fate of an exogenously prepared customized tissue-engineered mandible. Biomaterials 2006;17:3163–7. 4. Zwetyenga N. Overview and perspective of mandibular reconstruction. Rev Stomatol Chir Maxillofac 2009;110:185–7.
5. Zwetyenga N, Catros S, Emparanza A, Deminiere C, Siberchicot F, Fricain JC. Mandibular reconstruction using induced membranes with autologous cancellous bone graft and HA-betaTCP: animal model study and preliminary results in patients. Int J Oral Maxillofac Surg 2009;38:1289–697. 6. Ho¨lzle F, Kesting MR, Ho¨lzle G, Watola A, Loeffelbein DJ, Ervens J, et al. Clinical outcome and patient satisfaction after mandibular reconstruction with free fibula flaps. Int J Oral Maxillofac Surg 2007;36:802–6. 7. Labbe D, Nicolas J, Kaluzinski E, Soubeyran E, Sabin P, Compere JF, et al. Gunshot wounds: reconstruction of the lower face by osteogenic distraction. Plast Reconstr Surg 2005;116:1596–603. Comment in Plast Reconstr Surg 2006;118:1271–2; author reply 1272–3. 8. Vu DD, Schmidt BL. Quality of life evaluation for patients receiving vascularized versus nonvascularized bone graft reconstruction of segmental mandibular defects. J Oral Maxillofac Surg 2008; 66: 1856–63. 9. Zwetyenga N, Emparanza A, Ricard AS, Gindre A, El-Bouihi M, Majoufre-Lefebvre C, et al. Large mandibular and soft-tissues defects: the use osteogenic distraction with bone transport. In: Diner PA, Arnaud E, Vasquez MP, editors. Maxillofacial and craniofacial distraction. Medimond, international proceedings. 2006:119.
10. Labbe D, Nicolas J, Kaluzinski E, Soubeyran E, Delcampe P, Sabin P, et al. Gunshot wounds: two cases of midface reconstruction by osteogenic distraction. J Plast Reconstr Aesthet Surg 2009;62:1174–80. 11. Bahr W, Stoll P, Wa¨chter R. Use of the ‘‘double barrel’’ free vascularized fibula in mandibular reconstruction. J Oral Maxillofac Surg 1998;56:38–44. 12. Lizio G, Corinaldesi G, Pieri F, Marchetti C. Problems with dental implants that were placed on vertically distracted fibular free flaps after resection: a report of six cases. Br J Oral Maxillofac Surg 2009;47:455–60. 13. Molina F, Ortiz Monasterio FO. Mandibular elongation and remodeling by distraction: a farewell to major osteotomies. Plast Reconstr Surg 1995;96:825–40. discussion 841–2.
Address: Narcisse Zwetyenga Department of Maxillofacial Surgery Plastic and Reconstructive Surgery Hand Surgery Boulevard de Lattre de Tassigny Centre Hospitalier Universitaire Universite´ de Bourgogne 21000 Dijon France Tel.: +33 6 24 57 87 06/3 80 29 37 57 fax: +33 3 80 29 35 86 E-mail: [email protected]
Clinical Paper Reconstructive Surgery
Reconstruction of large mandibular and surrounding soft-tissue defects using distraction with bone transport
N. Zwetyenga1,2,, F. Siberchicot3, A. Emparanza3 1 Department of Maxillofacial Surgery, Plastic and Reconstructive Surgery, Hand Surgery, Universite´ de Bourgogne, Dijon, France; 2EA 4268: Intervention, innovation, imaging and engineering in health (I4S) Place Saint Jacques 25 030 Besanc¸on Cedex, France; 3 Department of Maxillofacial and Plastic Surgery, Hoˆpital Pellegrin, Universite´ Victor Se´galen-Bordeaux, France
N. Zwetyenga, F. Siberchicot, A. Emparanza: Reconstruction of large mandibular and surrounding soft-tissue defects using distraction with bone transport. Int. J. Oral Maxillofac. Surg. 2012; 41: 1215–1222. # 2012 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Abstract. Reconstruction of large bone and soft-tissue defects of the inferior third of the face is possible using various surgical techniques. Patients who require these procedures need to be in good general health, may have sequelae linked to donor sites, and require several interventions to achieve good aesthetic and functional results. The aim of this study was to report outcomes in patients with large mandibular and soft-tissue defects treated using osteogenic distraction with bone transport. Between 2001 and 2008, 14 patients had distraction with bone transport. Most patients were men (92.1%). The mean age was 43.1 years. The average mandibular bone reconstruction was 13.6 cm. The mean duration of distraction was 2.3 months. No infections occurred, and in all cases reconstruction of soft tissues was obtained. Two patients had non-union and underwent reconstruction using an iliac bone graft. Patients with sufficient bone height (57.1%) had dental implants. 44 implants were inserted, two of which were lost. 36 implants were activated. Six patients had satisfactory oral rehabilitation with implant-supported prostheses. Osteogenic distraction with bone transport allows total or partial restoration of oral function, provides an acceptable appearance, and enables patients to resume a reasonable quality of life.
The challenge of facial reconstruction following gunshot wounds is to restore an acceptable quality of life with minimal sequelae. Reconstruction of large bone and soft-tissue defects of the lower third of the face is possible using various surgical techniques, including new techniques.1–5 Free vascularised flaps are the preferred donor tissue (cutaneous, osseous 0901-5027/01001215 + 08 $36.00/0
and muscular).4,6 Patients undergoing microvascular procedures need to be in good general health and may have sequelae linked to the donor site.7,8 Good aesthetic and functional results can be achieved, but require several surgical procedures. Osteogenic distraction allows bone and soft-tissue reconstruction and has been used successfully for mandibular
Keywords: gunshot; mandible; distraction; bone. Accepted for publication 20 March 2012 Available online 30 April 2012
distraction in gunshot wounds.7,9 There are two types of osteogenic distraction. The first type is osteogenic distraction without distraction bone transport, and is used in orthopaedic and maxillofacial malformation surgery. This technique can be used to lengthen bone and the adjacent soft tissues. The second type is osteogenic distraction with bone transport,
# 2012 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
1216
Zwetyenga et al.
Fig. 1. Example of peroperative aspect of mandibular and adjacent soft-tissue defects linked to gunshot.
which is used in cases of osseous defect. This latter technique makes it possible to fill the defect without changing the original length of the bone. The aim of this study was to report outcomes in patients with large mandibular and soft-tissue defects treated using osteogenic distraction with bone transport.
Fig. 2. Preoperative three-dimensional CT (3D CT) scan showing a mandibular osseous defect.
Materials and methods
The medical records of patients who underwent reconstruction of large mandibular and soft-tissue defects using external distraction with bone transport between 2001 and 2009 were reviewed (Fig. 1). The bone and soft-tissue defects were evaluated by preoperative computed
tomography (CT) scan with three-dimensional reconstruction (Fig. 2). From the initial trauma to the distraction protocol, all the patients were in intensive care with tracheotomy, a nasogastric tube or a gastrostomy tube. During the first 3 or 4 weeks, dressings were changed under general anaesthesia every 2 days. A mandibular reconstruction plate was inserted to avoid tissue retraction and fibrosis (Fig. 3). This phase was devoted to cleaning the necrotic tissue to allow new tissue regeneration. The surgical procedures began after this period. The first procedure began with the placement of the distraction device under general anaesthesia. First, the skin was marked and four pins were inserted percutaneously into each mandibular ramus. The horseshoe-shaped trammel of the device was placed in the axis of the bone defect and two pins were inserted vertically into the lower border of the mandible on each side of the defect. One or two planned bicortical osteotomy(ies) that preserved the internal periosteum was (were) performed through a cutaneous incision using an alternating microsaw (Figs. 3 and 4). To anticipate possible obstacles, each mobile segment was activated over a few millimetres and then returned to the original position. The period of latency to allow the formation of a neocallus was 7–10 days. The active phase began with a rate of distraction of 1 mm per day for each osteotomised segment. The device was activated for the first time by the surgeon and then by the patient using a screwdriver and a mirror. During the active phase panoramic X-rays were taken regularly (Fig. 5). The distraction was ended when the mobile segment was in contact with the fixed segment (one osteotomy
Fig. 3. 3D CT showing a mandibular reconstructive plate inserted to avoid tissue retraction and fibrosis.
Reconstruction using distraction with bone transport
1217
had appropriate postoperative antibiotic prophylaxis for 7 days. The length of the reconstructed bone was measured using a postoperative CT scan in the midline of the mandible. Fig. 10 provides a time line of the stages in the treatment. Results
13 men (92.9%) and 1 woman (7.1%) were studied. Their mean age was 43.1 years (19–66 years). The average mandibular bone defect measured 13.6 cm (2.8–24 cm). In all cases it was a suicide attempt by gunshot. One patient had one osteotomy and 13 had two osteotomies (one on each side). 13 Normed1 (Germany) and one OBL1 (France) distraction devices were inserted. The data are summarized in Table 1. The mean duration of distraction was 2.3 months (1–4 months). In all cases, the wound was closed (skin, muscle, and mucosa) (Fig. 11). One patient had partial plate exposure. No patients had postoperative infection in the site of reconstruction (no suppuration at wound margins; no drainable pus). Two patients (14.3%) had nonunion between the mobile fragments and underwent a second reconstruction procedure in which an iliac bone graft was placed in the gap. Both operations were successful. Eight patients with adequate bone height (57.1%) had mandibular oral implants in a mean time of 23 months (18– 38 months). 44 dental implants were inserted. One patient lost 2 implants (4.3% of all implants) corresponding to a percentage of osseointegration of 95.5%. 36 dental implants were activated (85.7% of 42 implants). In six patients complete oral rehabilitation was restored with implant-supported prostheses (Fig. 12). Rehabilitation of the remaining patients was in process. The mean follow-up was 77 months (range 31–116 months). Fig. 4. Peroperative (a) and postoperative (b) views after placement of the distraction device.
Discussion
on one side) or when both mobile segments were in contact (one osteotomy on each side). The second procedure was the stabilization and consolidation phase. The distal parts of the bony segments were curetted and stabilised using mandibular plates (Tekka1; Lyon, France) and the skin was closed under general anaesthesia (Fig. 6). The consolidation phase took 3
months and the distraction device was used as an external stabiliser. The third procedure was the removal of the distractor under local anaesthesia (Fig. 7). This phase was usually associated with commissuroplasty. Postoperative CT scans were performed to evaluate the bone reconstruction (Fig. 8). Oral implants were inserted up to the 18th month after the third operation (Fig. 9). All the patients
This study confirms the effectiveness of osteogenic distraction with bone transport in large mandibular and adjacent soft-tissue defects caused by gunshot. The bone reconstruction enabled implant-supported prostheses. Male predominance is classically found in the literature.7,9,10 In most cases, this type of defect is linked to a suicide attempt.7,9,10 The mean age is in keeping with data in the literature.7,10 Performing two osteotomies (one on each side) to enable double
1218
Zwetyenga et al.
Fig. 5. Panoramic view during the active phase of the distraction.
distraction reduces activation time by half. Non-union occurred in two patients, and this may have been due to poor vascularisation of the extremities of the mobile
fragments. Treatment consisted in filling the gap using an iliac bone graft with miniplates. Partial exposure of the plate is not a cause of failure.
Fig. 6. Patients during the stabilization and consolidation phase.
One of the goals of oral rehabilitation is the recovery of dental function.4 Good oral rehabilitation is difficult or impossible to obtain because the reconstructed bone using free flaps is usually smaller in height than the original mandible. Several techniques have been developed to increase this height to allow the use of removable dentures or implant-supported prostheses. These include vertical osteogenesis, the ‘double-barrel technique’ and onlay grafting, but these techniques cause a number of complications.8,11,12 In osteogenic distraction with bone transport, bone height is sufficient to allow the insertion of dental implants without previous preimplant surgery.7 Implants are very well osseointegrated in this new bone because distraction provides vascularised bone surrounded by muscles and mucosa. Several patients in this series received an implant-supported prosthesis. This percentage will improve progressively. In the literature, there are no reports of the
Reconstruction using distraction with bone transport
1219
Fig. 8. 3D CT scan showing bone reconstruction.
long-term success rate of implant survival in distracted bone. The present authors agree with those who advocate the use of osteogenic and soft-tissue distraction (skin, muscles, vessels and nerves) to achieve aesthetic results (as it avoids the patchwork appearance of the free flap technique, and provides the same quality of soft tissue) that are far better than those obtained by skeletal surgery, or by soft tissue surgery carried out independently, or using a combination of the two.7,13 Another advantage is the possibility of performing osteogenic distraction with bone transport in cases of chronic infection.10 Patients with gunshot wounds have to stay in intensive care units for a long time and they usually contract one or more infections with multi-resistant bacteria. In this series, no patients had an acute
Fig. 7. Patient just after the removal of the distraction device (a) and 1 month later (b).
Fig. 9. Panoramic X-ray showing intra-oral implants.
1220
Zwetyenga et al. Injury
Initial management
Intensive care
Dressings general anaesthesia
Distractor placement
Latency
Active
General anaesthesia
General anaesthesia
3 to 4 weeks
Stabilization-consolidation
7 to 10 days
Fig. 10. Time line for the treatment stages.
Fig. 11. Examples of post-distraction reconstruction results.
Variable
Removal
Local anaesthesia
3 months
Oral Implants Local anaesthesia
Up to 18 months
Reconstruction using distraction with bone transport
1221
Fig. 12. Patient with oral rehabilitation with implant-supported prostheses.
infection, which confirms the reliability of this technique. Compared to microsurgery, this technique is advantageous because it is a reliable, minimally invasive procedure, with a short operation time, a low risk of complications, no donor site morbidity, and is suitable for older or weak patients. It also gives better aesthetic results, and the bone regenerated can sup-
port intra-oral implant rehabilitation. The main drawbacks are the duration of the treatment and the need to wear a cumbersome device for months. Osteogenic distraction with bone transport allows total or partial restoration of oral function, provides an acceptable appearance, and enables patients to resume a reasonable quality of life. This
technique must be considered when surgeons are faced with a severe lower face defect. Both bone and soft tissues can be obtained in sufficient quality and quantity to allow implant-supported prosthesis. Osteogenic distraction improves both bone and adjacent soft tissues, therefore the authors call it histogenic distraction.
1222
Zwetyenga et al.
Table 1. Summary of patient data. No./age/sex
Bone defect
Distractor
Osteotomy
17 cm 14 cm 16 cm 24 cm 13 cm 14 cm 2.8 cm 12 cm 9 cm 7 cm 21 cm 17 cm 13 cm 11 cm
Normed1 Normed1 Normed1 Normed1 Normed1 Normed1 Normed1 Normed1 Normed1 Normed1 OBL1 Normed1 Normed1 Normed1
Bilateral Bilateral Bilateral Bilateral Bilateral Bilateral Unilateral Bilateral Bilateral Bilateral Bilateral Bilateral Bilateral Bilateral
1/34/M 2/42/M 3/19/M 4/24/M 5/42/M 6/62/M 7/47/M 8/50/M 9/66/M 10/55/M 11/39/M 12/53/M 13/44/M 14/26/W
Event
Follow-up (months)
Iliac bone graft
Iliac bone graft
Implant-supported prostheses Implant-supported prostheses Implant-supported prostheses Implant-supported prostheses Implant-supported prostheses Implant-supported prostheses Oral implants (84) Oral implants (78) Amovible prosthesis (72) Amovible prosthesis (53) Amovible prosthesis (52) Amovible prosthesis (54) Amovible prosthesis (53) Amovible prosthesis (31)
(116) (108) (105) (96) (92) (84)
M, men; W, women.
Funding
None. Competing interests
None declared. Ethical approval
Not required. References 1. Goodger NM, Wang J, Smagalski GW, Hepwoth B. Methylmethacrylate as a space maintainer in mandibular reconstruction. J Oral Maxillofac Surg 2005;63:1048–51. 2. Heliotis M, Lavery KM, Ripamonti U, Tsiridis E, di Silvio L. Transformation of a prefabricated hydroxyapatite/osteogenic protein-1 implant into a vascularised pedicled bone flap in the human chest. Int J Oral Maxillofac Surg 2006;35:265–9. 3. Warnke PH, Wiltfang J, Springer I, Acil Y, Bolte H, Kosmahl M, et al. Man as living bioreactor: fate of an exogenously prepared customized tissue-engineered mandible. Biomaterials 2006;17:3163–7. 4. Zwetyenga N. Overview and perspective of mandibular reconstruction. Rev Stomatol Chir Maxillofac 2009;110:185–7.
5. Zwetyenga N, Catros S, Emparanza A, Deminiere C, Siberchicot F, Fricain JC. Mandibular reconstruction using induced membranes with autologous cancellous bone graft and HA-betaTCP: animal model study and preliminary results in patients. Int J Oral Maxillofac Surg 2009;38:1289–697. 6. Ho¨lzle F, Kesting MR, Ho¨lzle G, Watola A, Loeffelbein DJ, Ervens J, et al. Clinical outcome and patient satisfaction after mandibular reconstruction with free fibula flaps. Int J Oral Maxillofac Surg 2007;36:802–6. 7. Labbe D, Nicolas J, Kaluzinski E, Soubeyran E, Sabin P, Compere JF, et al. Gunshot wounds: reconstruction of the lower face by osteogenic distraction. Plast Reconstr Surg 2005;116:1596–603. Comment in Plast Reconstr Surg 2006;118:1271–2; author reply 1272–3. 8. Vu DD, Schmidt BL. Quality of life evaluation for patients receiving vascularized versus nonvascularized bone graft reconstruction of segmental mandibular defects. J Oral Maxillofac Surg 2008; 66: 1856–63. 9. Zwetyenga N, Emparanza A, Ricard AS, Gindre A, El-Bouihi M, Majoufre-Lefebvre C, et al. Large mandibular and soft-tissues defects: the use osteogenic distraction with bone transport. In: Diner PA, Arnaud E, Vasquez MP, editors. Maxillofacial and craniofacial distraction. Medimond, international proceedings. 2006:119.
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Address: Narcisse Zwetyenga Department of Maxillofacial Surgery Plastic and Reconstructive Surgery Hand Surgery Boulevard de Lattre de Tassigny Centre Hospitalier Universitaire Universite´ de Bourgogne 21000 Dijon France Tel.: +33 6 24 57 87 06/3 80 29 37 57 fax: +33 3 80 29 35 86 E-mail: [email protected]