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Mandibular reconstruction in patients with oral carcinoma using autogenous mandibular implants
Mandibular reconstruction in patients with oral carcinoma using autogenous mandibular implants He’ctor Alvarado, D.M.D., A. S. Casanova-D&, M.D., Amaury Capella, M.D., Char Toro-Freire, M.D., Iv&n M. Mbquez, M.D., Marcos A. Dones, D.D.S., and Ram& Cabaiias, D.D.S.,” San Juart, Puerto Rico DEPARTMENT
OF SURGERY, SAN JUAN
CITY HOSPITAL
I
n patients suffering from oral carcinoma with invasion of the mandible and metastases to regional lymph nodes, the usual operative procedure is partial or total mandibulectomy with radical neck dissection, either unilateral or bilateral as the case may warrant. This operation is also known as a commando operation and involves the resection of the entire lesion, part of the floor of the mouth, part of the mandible, the involved cervical lymphatic chain, and at times part or most of the tongue. The result of this operation, as one can imagine, is a severe cosmetic deformity, together with a functional disability in mastication and at times in deglutition and even in speech. For many patients, the resultant bird-face appearance is a real blow to their morale and to their desire to live. The lack of masticatory function is also very depressing. For these reasons, surgeons have searched for years for a way to reconstruct the missing portion of bone before the patient’s recovery, in an attempt to minimize or avoid the cosmetic deformity. For this purpose, autogenous bone grafting is the best technique. Bone from the iliac crest and ribs have been used with some success. Weinstein and colleagues1 have used bone from the iliac crest successfully. Another technique used recently involves grafts from cadavers for the immediate reconstruction of the jaw. Plotaikov5 has used jaws preserved by rapid freezing and dehydration under high vacuum or a lyophilized jaw from a cadaver for immediate mandibular reconstruction. He has reported success in more than 200 patients. To be successful, a bone graft or implant must be covered with an adequate ‘Associate
Professor,
University
of Puerto Rico School of Dentistry.
11
12
Alvarado
Oral Surg. July, 1970
et al.
soft-tissue blanket. The radical surgical procedure performed in the mouth and jaws removes so much surrounding soft tissue and bone that not enough remains to cover the graft. Therefore, special techniques using soft tissue from neighboring structures to cover the implant have been developed in order to make immediate bone grafting possible in cancer patients. The possibility of using the same bone that is being removed for reconstruction has been considered by many surgeons, but the question of completely eliminating tumor cells has always been a problem. We have developed a technique in which the resected cancer-invaded bone is being used for reconstruction of the mandible after autoclaving for 30 minutes at 300° F. PLACEMENT AND FIXATION OF THE AUTOCLAVED MANDIBLE
The tumor and its associated periosteum are completely removed. The edentulous mandible is then trimmed according to the amount of soft tissue available to cover it, reducing it from the alveolar ridge down to the desired thickness. When the desired shape is obtained, holes are drilled through from the buccal to the lingual surfaces to permit the growth of fibrous tissue to give stability to the implant and a better chance of revascularization. After this, the mandible is autoclaved at 300° F. for 30 minutes. Meanwhile, the surgeon reconstructs and sutures the surgical wounds. When autoclaving of the mandible has been completed, it is immersed in antibiotics (lincomycin in the two casesreported here) for 5 minutes. The mandible is then placed in the surgical defect by direct wiring with a 24-gauge stainless steel wire. A perfect fit is assured, since the bone being replaced is the same that was resected. COMPLICATIONS AFTER COMMANDO
OPERATION
The more serious complications that may occur after a mandibular resection revolve around the airway. Edema with subsequent airway blockage can occur because of lack of support for the larynx when the mandibular symphysis with its muscle attachments has been resected. The support of the larynx is restored by using soft tissue from structures in the remaining oral cavity to cover the mandible. Hayes Martin, as quoted by Weinstein,l considers tracheostomy essential in patients undergoing partial or complete resection of the mandible. In the two cases on which this preliminary report is based, tracheostomy was performed prior to surgical intervention. Once internal fixation has been completed, the remaining muscle and soft tissue are used to cover the graft. In each of our cases, reconstruction of the floor of the mouth was accomplished by a ventral incision on the patient’s tongue, which permitted the tongue to be sutured to the buccal mucosa on both sides, thereby forming a soft-tissue floor. EXTERNAL FIXATION
In the case of hemimandibulectomy, the remaining side was immobilized by intermaxillary fixation left in place for 5 weeks.
Manclibular
reconshction
with
autogenous implants
13
In the case of ,mandibulectomy, the “new” mandible was not immobilized and the results were good. Whether the success was due to the fact that movement was not abolished cannot be ascertained, but that possibility should be taken into serious consideration. In a study by Walker, as quoted by Weinstein,l in which patients with fractures had immobilization appliances for only 2 weeks with movements allowed afterward, the patients seemed to heal faster t,han those in whom immobilization was continued for 6 weeks. An explanation for the stimulation of growth by mandibular movements is found in the work of Basset, according to Weinstein1 He has shown that collagen and hyaluronic acid crystals in bone have piezoelectric properties; that is, when they are subjected to mechanical stimulus, such as stress or handling, they generate electricity. Such electricity results in the production of bone. Basset has caused bone production in animals by the induction of weak, artificially induced direct currents. Bone, therefore, acts as an extremely sensitive piezoelectric gauge, responding to the slightest jar or deformation. Pressure from muscles and jaws, wheg they are brought together, will stimulate mandibular bone growth. Of the two cases reported here, one failed because of postoperative infection with loss of soft tissue and subsequent uncovering of the implant. CASE REPORTS CASE
1
48-year-old man with squamous-cell carcinoma of the left lower gingiva, irradiated from May 22 to July ‘7, 1967, with 6,000 r, was presented to the Tumor Board at the San Juan City Hospital on Jan. 23, 1968. The original lesion in the gingiva persisted, with an extension of the ulceration to the left border of the tongue, extending down to the floor of the mouth and tonsillar pillar on that side. The patient drank heavily and smoked two to three packs of cigarettes daily. The family history revealed that the patient’s father had died of carcinoma of the oral cavity. Physical examination disclosed mild to moderate dysphagia. The patient had very poor oral hygiene. There was induration of the gingiva on the left side of the mandible and neck and limitation of tongue protrusion. Mirror laryngoscopy showed edema of the laryngeal structures. There was swelling in the cervical and submandibular regions, without definite clinically palpable nodes. Roentgenograms of the mandible disclosed some irregularity of the alveolar ridge but no gross evidence of tumor invasion, even though, on clinical grounds, it was thought to be present. The decision of the Board in this case was that a hemimandibulectomy should be performed, with radical neck dissection on the affected side (commando procedure). This procedure was carried out on Feb. 29, 1968, under endotracheal anesthesia. A subtotal hemimandibulectomy was performed. The ramus was divided about M inch under the neck of th’e condyle, with preservation of the coronoid process. A
Mandibular
replacement
The part of the mandible resected (from the ramus, M inch from the condyle to the symphysis, crossing the midline about M inch) was cleansed of its soft-tissue covering. It was then reduced to about $$ inch from the alveolar ridge, and holes were drilled through buccoliugually. It was then autoclaved at 300” F. for 30 minutes and subsequently placed in a lincomycin bath for 5 minutes. The graft was placed in the defect by direct wirin&-n+& a 26-gauge stainless steel wire, and the implant and surrounding tissues were then i,rrigat$d
14
Alvarado et al.
Oral surg. July, 1970
with lincomycin. In order to cover the mandible completely with soft tissue, the remaining tongue was split open along the midline on the undersurface and the left side was used to cover the graft as it was sutured to the cheek. The mandible was then immobilized by intermaxillary fixation. Postoperative
care
Postoperative medication included intravenous fluids, ampicillin, and heavy doses of lincomycin. Administration of a liquid diet through a feeding tube was started as soon as it could be tolerated. Recovery was satisfactory until 6 weeks later, when dehiscence of the soft tissues over the implant was demonstrated. On March 12, 1968, the patient was taken back to the operating room, where a sliding flap was mobilized to cover the implant again. During the following weeks the patient complained of inability to swallow, and a gastrostomy was performed on April 10, 1968. After fully recovering from his operations, he was discharged from the hospital and followed up in the Outpatient Clinic. Follow-up
Roentgenograms of the mandible taken 2, 4, 8, and 16 weeks after the operation showed no evidence of recurrence. Recovery was again satisfactory after the last operation until May 3, 1968, when the patient came to the Oral Surgery Clinic. At this time there was suppuration from the operative area, and the infected implant was exposed. The patient was admitted to the hospital and, after the infection was brought under control, the implant and a piece of gingiva were removed and examined histopathologically. The pathologist’s report was as follows : A. Portions of bone (mandible) with necrosis; no osteoblastic activity observed. B. Squamous-cell mucosa with inflammatory changes. CASE 2
On Feb. 8, 1968, a 45-year-old white man, an agronomist, came to the Oral Surgery Clinic for evaluation and treatment of a large lesion in the anterior area of the floor of the mouth extending into the alveolar ridge crossing the midline. He had been referred by a private dentist. The teeth in the area were floating, and the tumor mass extended also into the right submaxillary region. The primary lesion was ulcerated, cauliflower-like in
A
Fig. 1. 8, Preoperative lateral oblique roentgenogram lateral oblique left side of mandible. B, Preoperative lytil c lesion on right side of masdible.
showing metastatie lytic lesion on roentgenogram showing metasta ttic
Volume Number
30 1
Maltdibular
reconstruction
with
autogenous implants
15
appearance, and very friable. A biopsy was performed immediately and revealed a welldifferentiated epidermoid carcinoma. Roentgenograms of the mandible showed evidence of lytic lesions on the left side of the mandible compatible with direct extensions of the clinically described carcinoma of the floor of the mouth (Fig. 1). The patient gave a history of smoking one to three packs of cigarettes daily. The case was presented to the Tumor Board, which decided upon radical surgery (bilateral commando operation) preceded by radiotherapy. A full-mouth extraction with radical alveolectomy was performed in preparation for radiotherapy. The patient was admitted to the hospital and, on March 13, 1968, a commando operation was performed with subtotal mandibulectomy. The condyles and part of the right and left
Pig. 1. Postoperative
posteroanterior
roentgenogram
of implant,
June 6,1968.
B
A
Pig. 9. A, Postoperative 1968. B, Postoperative lateral
lateral oblique roentgenogram oblique roentgenogram of right
of left side of implant, June 6, side of implant, Sept. 9,1968.
Alvarado
16
Oral Surg. July, 1970
et al.
rami of the mandible were left in place. The tumor was removed, and the mandible was left devoid of soft tissue. The mandible was then reduced about 1 inch from the alveolar ridge, and holes were drilled buccolingually throughout the entire mandible (Pigs. 2 and 3). The previously mentioned procedure was followed to eliminate cancerous cells in the mandible. A right radical neck dissection was performed at this time, followed in 4 weeks by a left radical neck dissection. The postoperative medications given included intravenous fluids, multivitamin therapy, ampicillin, and lincomycin. Recovery was uneventful, and 2 months after the second surgical intervention the patient was discharged in good condition.
Fig. 4. Postoperative
posteroanterior
roentgenogram
of implant,
Sept. 9, 1968.
A
Fig. 5. A, Postoperative lateral oblique roentgenogram of left side of implant, Sept. 9, 1968. B, Postoperative lateral oblique roentgenogram of right side of implant, Sept. 9, 1968.
Volume Number
30 1
Mandiibular
reconstruction
with
autogenous implants
17
Follow-up
The patient’s progress was followed closely until October, 1968. Postoperative roentgenograms were taken at various intervals and were read as negative for recurrence of malignancy (Figs. 4 and 5). An x-ray report on April 18, 1969, disclosed evidence of a previous autogenous mandibular implant with no sign of recurrence, rejection, lysis, or inflammatory changes. Adequate osseous continuity was present (Figs. 6 and 7). As of this date, the patient has gone back to work, and, although he cannot speak very clearly because part of his tongue was used to cover the graft, he has returned to society rehabilitated and with a great desire to live (Figs. 8 to 10).
Fig. 6. Postoperative
A
posteroanterior
roentgenogram
of implant,
Feb. 18, 1969.
B
Fig. 7. A, Postoperative lateral oblique roentgenogram of left side of implant, Feb. 18, 1969. B, Postoperative lateral oblique roentgenogram of right side of implant, Feb. 18, 1969.
Alvarado
18
Fig. 8. Right profile
Fig.
Oral Burg. July, 1970
et al.
of patient
who did not have the benefit of our procedure.
9
Fig.
30
Pig. 9. Right profile of patient with mandibular autogenous implant. Pig. 10. Frontal photograph of patient with mandibular autogenous implant.
DISCUSSION
Cosmetic reconstruction in cases of radical mandibular surgery is extren lely important to rehabilitate the patient and, in so doing, maintain his desire ! to live and aid his return to fairly normal activity. It also helps to restore his morale and to help him keep his place in society. The resected mandible, sterilized by autoclaving at 300’ I?. for 30 minu tes, followed by immersion in an antibiotic bath for 5 minutes, seems to us to be the
Mandibular
reconstruction
with
autogelbous, i,mplan ts
19
best graft that can be used for this type of reconstruction, inasmuch as it retains the original shape and size, if not the thickness. Furthermore, it is always available at the time of operation, unless totally destroyed by the cancerous process. Like any other bone graft, the trimmed, sterilized mandible must be covered completely with living soft tissue. PERIOSTEUM
AND
BONE
REPAIR MECHANISM
Weinstein and associates,1 in their review of the literature, point out that there are at least three different concepts of bone healing: (1) bone growth from the periosteum, (2) bone growth from the osteoblasts of the graft, and (3) bone growth from the adjacent host bone. Many investigators have demonstrated the role played by the periosteum and the osteoblasts in bone healing. We shall not delve much into this, inasmuch as neither one plays any part in the procedure described here. Autoclaving destroys the osteoblasts in the graft, and the periosteoum is cleaned away from the mandible along with the tumor. The exposition of the third concept appeared in a paper by Barth3 in 1893. Barth performed experiments which showed that all elements of transplanted bone die and are slowly replaced by elements from the adjacent host bone. In 1914, Gallie took a wedge of bone from a dog’s radius, boiled it, and then replaced it. He also performed variations of this experiment, such as replacing the wedge with cat bone. The results of these experiments led him to believe that the bone graft acts as a medium or bridge for the invasion of osteoblasts from the adjacent host bone. This conclusion further supported Barth’s theory. In agreement with this viewpoint, Phemister,‘j in 1914, called the process “creeping substitution.” Later on, while working with Robertson, Gallie used boiled bone as a graft and found that the percentage of success was lower than with unboiled bone. Nevertheless, boiled bone was successful to some extent, and this was the basis for the development of our technique. The drilling of holes through the graft was added to increase stability by allowing the fibrous tissue to grow through and to provide better chances for nutrition to the invading osteoblasts. serving as a matrix for the formation of new bone from the adjacent host bone. We have used this technique in only two cases thus far. In one case the technique met with failure because of secondary infection with loss of the graft. Even with this very limited experience, the procedure seems to us to have enough advantages to be worthy of more extensive clinical trial. SUMMARY
Treatment of carcinoma of the oral cavity with extension to the mandible and neck usually requires a commando operation which results in a serious and repulsive deformity unless proper reconstruction is carried out, preferably at the time of the original operation. A technique of reconstruction, using the same resected mandible, trimmed and sterilized, is described, and the case histories of the first two patients thus treated are presented.
20
Alvarado
et al.
Oral Surg. July, 1970
REFERENCES
1. Weinstein, I., Yamanaka, H., and Fuchihata, H.: Resection and Reconstruction of the Mandible for Removal of a Central Hemangioma, ORAL SURG. 16: 2-13, 1963. 2. Bhaskar, S. N.: Synopsis of Oral Pathology, ed. 2, St. Louis, 1965, The C. V. Mosby Company. 3. Barth, A.: ijber histologische Befunde nack Knochenimplantationen, Arch. Klin. Chir. 46: 409, 1893. 4. Gallie, W. E.: The History of a Bone Graft, J. Amer. Orthop. Surg. 12: 201, 1914. 5. Borrowed Bone Quickly Rebuilds Jaw, Med. World News, p. 87, Sept., 1968. 6. Phemister, D. B.: The Fate of Transplanted Bone and Regenerative Power of Its Various Constituents, Surg. Gynec. Obstet. 19: 303, 1914.
OF SURGERY, SAN JUAN
CITY HOSPITAL
I
n patients suffering from oral carcinoma with invasion of the mandible and metastases to regional lymph nodes, the usual operative procedure is partial or total mandibulectomy with radical neck dissection, either unilateral or bilateral as the case may warrant. This operation is also known as a commando operation and involves the resection of the entire lesion, part of the floor of the mouth, part of the mandible, the involved cervical lymphatic chain, and at times part or most of the tongue. The result of this operation, as one can imagine, is a severe cosmetic deformity, together with a functional disability in mastication and at times in deglutition and even in speech. For many patients, the resultant bird-face appearance is a real blow to their morale and to their desire to live. The lack of masticatory function is also very depressing. For these reasons, surgeons have searched for years for a way to reconstruct the missing portion of bone before the patient’s recovery, in an attempt to minimize or avoid the cosmetic deformity. For this purpose, autogenous bone grafting is the best technique. Bone from the iliac crest and ribs have been used with some success. Weinstein and colleagues1 have used bone from the iliac crest successfully. Another technique used recently involves grafts from cadavers for the immediate reconstruction of the jaw. Plotaikov5 has used jaws preserved by rapid freezing and dehydration under high vacuum or a lyophilized jaw from a cadaver for immediate mandibular reconstruction. He has reported success in more than 200 patients. To be successful, a bone graft or implant must be covered with an adequate ‘Associate
Professor,
University
of Puerto Rico School of Dentistry.
11
12
Alvarado
Oral Surg. July, 1970
et al.
soft-tissue blanket. The radical surgical procedure performed in the mouth and jaws removes so much surrounding soft tissue and bone that not enough remains to cover the graft. Therefore, special techniques using soft tissue from neighboring structures to cover the implant have been developed in order to make immediate bone grafting possible in cancer patients. The possibility of using the same bone that is being removed for reconstruction has been considered by many surgeons, but the question of completely eliminating tumor cells has always been a problem. We have developed a technique in which the resected cancer-invaded bone is being used for reconstruction of the mandible after autoclaving for 30 minutes at 300° F. PLACEMENT AND FIXATION OF THE AUTOCLAVED MANDIBLE
The tumor and its associated periosteum are completely removed. The edentulous mandible is then trimmed according to the amount of soft tissue available to cover it, reducing it from the alveolar ridge down to the desired thickness. When the desired shape is obtained, holes are drilled through from the buccal to the lingual surfaces to permit the growth of fibrous tissue to give stability to the implant and a better chance of revascularization. After this, the mandible is autoclaved at 300° F. for 30 minutes. Meanwhile, the surgeon reconstructs and sutures the surgical wounds. When autoclaving of the mandible has been completed, it is immersed in antibiotics (lincomycin in the two casesreported here) for 5 minutes. The mandible is then placed in the surgical defect by direct wiring with a 24-gauge stainless steel wire. A perfect fit is assured, since the bone being replaced is the same that was resected. COMPLICATIONS AFTER COMMANDO
OPERATION
The more serious complications that may occur after a mandibular resection revolve around the airway. Edema with subsequent airway blockage can occur because of lack of support for the larynx when the mandibular symphysis with its muscle attachments has been resected. The support of the larynx is restored by using soft tissue from structures in the remaining oral cavity to cover the mandible. Hayes Martin, as quoted by Weinstein,l considers tracheostomy essential in patients undergoing partial or complete resection of the mandible. In the two cases on which this preliminary report is based, tracheostomy was performed prior to surgical intervention. Once internal fixation has been completed, the remaining muscle and soft tissue are used to cover the graft. In each of our cases, reconstruction of the floor of the mouth was accomplished by a ventral incision on the patient’s tongue, which permitted the tongue to be sutured to the buccal mucosa on both sides, thereby forming a soft-tissue floor. EXTERNAL FIXATION
In the case of hemimandibulectomy, the remaining side was immobilized by intermaxillary fixation left in place for 5 weeks.
Manclibular
reconshction
with
autogenous implants
13
In the case of ,mandibulectomy, the “new” mandible was not immobilized and the results were good. Whether the success was due to the fact that movement was not abolished cannot be ascertained, but that possibility should be taken into serious consideration. In a study by Walker, as quoted by Weinstein,l in which patients with fractures had immobilization appliances for only 2 weeks with movements allowed afterward, the patients seemed to heal faster t,han those in whom immobilization was continued for 6 weeks. An explanation for the stimulation of growth by mandibular movements is found in the work of Basset, according to Weinstein1 He has shown that collagen and hyaluronic acid crystals in bone have piezoelectric properties; that is, when they are subjected to mechanical stimulus, such as stress or handling, they generate electricity. Such electricity results in the production of bone. Basset has caused bone production in animals by the induction of weak, artificially induced direct currents. Bone, therefore, acts as an extremely sensitive piezoelectric gauge, responding to the slightest jar or deformation. Pressure from muscles and jaws, wheg they are brought together, will stimulate mandibular bone growth. Of the two cases reported here, one failed because of postoperative infection with loss of soft tissue and subsequent uncovering of the implant. CASE REPORTS CASE
1
48-year-old man with squamous-cell carcinoma of the left lower gingiva, irradiated from May 22 to July ‘7, 1967, with 6,000 r, was presented to the Tumor Board at the San Juan City Hospital on Jan. 23, 1968. The original lesion in the gingiva persisted, with an extension of the ulceration to the left border of the tongue, extending down to the floor of the mouth and tonsillar pillar on that side. The patient drank heavily and smoked two to three packs of cigarettes daily. The family history revealed that the patient’s father had died of carcinoma of the oral cavity. Physical examination disclosed mild to moderate dysphagia. The patient had very poor oral hygiene. There was induration of the gingiva on the left side of the mandible and neck and limitation of tongue protrusion. Mirror laryngoscopy showed edema of the laryngeal structures. There was swelling in the cervical and submandibular regions, without definite clinically palpable nodes. Roentgenograms of the mandible disclosed some irregularity of the alveolar ridge but no gross evidence of tumor invasion, even though, on clinical grounds, it was thought to be present. The decision of the Board in this case was that a hemimandibulectomy should be performed, with radical neck dissection on the affected side (commando procedure). This procedure was carried out on Feb. 29, 1968, under endotracheal anesthesia. A subtotal hemimandibulectomy was performed. The ramus was divided about M inch under the neck of th’e condyle, with preservation of the coronoid process. A
Mandibular
replacement
The part of the mandible resected (from the ramus, M inch from the condyle to the symphysis, crossing the midline about M inch) was cleansed of its soft-tissue covering. It was then reduced to about $$ inch from the alveolar ridge, and holes were drilled through buccoliugually. It was then autoclaved at 300” F. for 30 minutes and subsequently placed in a lincomycin bath for 5 minutes. The graft was placed in the defect by direct wirin&-n+& a 26-gauge stainless steel wire, and the implant and surrounding tissues were then i,rrigat$d
14
Alvarado et al.
Oral surg. July, 1970
with lincomycin. In order to cover the mandible completely with soft tissue, the remaining tongue was split open along the midline on the undersurface and the left side was used to cover the graft as it was sutured to the cheek. The mandible was then immobilized by intermaxillary fixation. Postoperative
care
Postoperative medication included intravenous fluids, ampicillin, and heavy doses of lincomycin. Administration of a liquid diet through a feeding tube was started as soon as it could be tolerated. Recovery was satisfactory until 6 weeks later, when dehiscence of the soft tissues over the implant was demonstrated. On March 12, 1968, the patient was taken back to the operating room, where a sliding flap was mobilized to cover the implant again. During the following weeks the patient complained of inability to swallow, and a gastrostomy was performed on April 10, 1968. After fully recovering from his operations, he was discharged from the hospital and followed up in the Outpatient Clinic. Follow-up
Roentgenograms of the mandible taken 2, 4, 8, and 16 weeks after the operation showed no evidence of recurrence. Recovery was again satisfactory after the last operation until May 3, 1968, when the patient came to the Oral Surgery Clinic. At this time there was suppuration from the operative area, and the infected implant was exposed. The patient was admitted to the hospital and, after the infection was brought under control, the implant and a piece of gingiva were removed and examined histopathologically. The pathologist’s report was as follows : A. Portions of bone (mandible) with necrosis; no osteoblastic activity observed. B. Squamous-cell mucosa with inflammatory changes. CASE 2
On Feb. 8, 1968, a 45-year-old white man, an agronomist, came to the Oral Surgery Clinic for evaluation and treatment of a large lesion in the anterior area of the floor of the mouth extending into the alveolar ridge crossing the midline. He had been referred by a private dentist. The teeth in the area were floating, and the tumor mass extended also into the right submaxillary region. The primary lesion was ulcerated, cauliflower-like in
A
Fig. 1. 8, Preoperative lateral oblique roentgenogram lateral oblique left side of mandible. B, Preoperative lytil c lesion on right side of masdible.
showing metastatie lytic lesion on roentgenogram showing metasta ttic
Volume Number
30 1
Maltdibular
reconstruction
with
autogenous implants
15
appearance, and very friable. A biopsy was performed immediately and revealed a welldifferentiated epidermoid carcinoma. Roentgenograms of the mandible showed evidence of lytic lesions on the left side of the mandible compatible with direct extensions of the clinically described carcinoma of the floor of the mouth (Fig. 1). The patient gave a history of smoking one to three packs of cigarettes daily. The case was presented to the Tumor Board, which decided upon radical surgery (bilateral commando operation) preceded by radiotherapy. A full-mouth extraction with radical alveolectomy was performed in preparation for radiotherapy. The patient was admitted to the hospital and, on March 13, 1968, a commando operation was performed with subtotal mandibulectomy. The condyles and part of the right and left
Pig. 1. Postoperative
posteroanterior
roentgenogram
of implant,
June 6,1968.
B
A
Pig. 9. A, Postoperative 1968. B, Postoperative lateral
lateral oblique roentgenogram oblique roentgenogram of right
of left side of implant, June 6, side of implant, Sept. 9,1968.
Alvarado
16
Oral Surg. July, 1970
et al.
rami of the mandible were left in place. The tumor was removed, and the mandible was left devoid of soft tissue. The mandible was then reduced about 1 inch from the alveolar ridge, and holes were drilled buccolingually throughout the entire mandible (Pigs. 2 and 3). The previously mentioned procedure was followed to eliminate cancerous cells in the mandible. A right radical neck dissection was performed at this time, followed in 4 weeks by a left radical neck dissection. The postoperative medications given included intravenous fluids, multivitamin therapy, ampicillin, and lincomycin. Recovery was uneventful, and 2 months after the second surgical intervention the patient was discharged in good condition.
Fig. 4. Postoperative
posteroanterior
roentgenogram
of implant,
Sept. 9, 1968.
A
Fig. 5. A, Postoperative lateral oblique roentgenogram of left side of implant, Sept. 9, 1968. B, Postoperative lateral oblique roentgenogram of right side of implant, Sept. 9, 1968.
Volume Number
30 1
Mandiibular
reconstruction
with
autogenous implants
17
Follow-up
The patient’s progress was followed closely until October, 1968. Postoperative roentgenograms were taken at various intervals and were read as negative for recurrence of malignancy (Figs. 4 and 5). An x-ray report on April 18, 1969, disclosed evidence of a previous autogenous mandibular implant with no sign of recurrence, rejection, lysis, or inflammatory changes. Adequate osseous continuity was present (Figs. 6 and 7). As of this date, the patient has gone back to work, and, although he cannot speak very clearly because part of his tongue was used to cover the graft, he has returned to society rehabilitated and with a great desire to live (Figs. 8 to 10).
Fig. 6. Postoperative
A
posteroanterior
roentgenogram
of implant,
Feb. 18, 1969.
B
Fig. 7. A, Postoperative lateral oblique roentgenogram of left side of implant, Feb. 18, 1969. B, Postoperative lateral oblique roentgenogram of right side of implant, Feb. 18, 1969.
Alvarado
18
Fig. 8. Right profile
Fig.
Oral Burg. July, 1970
et al.
of patient
who did not have the benefit of our procedure.
9
Fig.
30
Pig. 9. Right profile of patient with mandibular autogenous implant. Pig. 10. Frontal photograph of patient with mandibular autogenous implant.
DISCUSSION
Cosmetic reconstruction in cases of radical mandibular surgery is extren lely important to rehabilitate the patient and, in so doing, maintain his desire ! to live and aid his return to fairly normal activity. It also helps to restore his morale and to help him keep his place in society. The resected mandible, sterilized by autoclaving at 300’ I?. for 30 minu tes, followed by immersion in an antibiotic bath for 5 minutes, seems to us to be the
Mandibular
reconstruction
with
autogelbous, i,mplan ts
19
best graft that can be used for this type of reconstruction, inasmuch as it retains the original shape and size, if not the thickness. Furthermore, it is always available at the time of operation, unless totally destroyed by the cancerous process. Like any other bone graft, the trimmed, sterilized mandible must be covered completely with living soft tissue. PERIOSTEUM
AND
BONE
REPAIR MECHANISM
Weinstein and associates,1 in their review of the literature, point out that there are at least three different concepts of bone healing: (1) bone growth from the periosteum, (2) bone growth from the osteoblasts of the graft, and (3) bone growth from the adjacent host bone. Many investigators have demonstrated the role played by the periosteum and the osteoblasts in bone healing. We shall not delve much into this, inasmuch as neither one plays any part in the procedure described here. Autoclaving destroys the osteoblasts in the graft, and the periosteoum is cleaned away from the mandible along with the tumor. The exposition of the third concept appeared in a paper by Barth3 in 1893. Barth performed experiments which showed that all elements of transplanted bone die and are slowly replaced by elements from the adjacent host bone. In 1914, Gallie took a wedge of bone from a dog’s radius, boiled it, and then replaced it. He also performed variations of this experiment, such as replacing the wedge with cat bone. The results of these experiments led him to believe that the bone graft acts as a medium or bridge for the invasion of osteoblasts from the adjacent host bone. This conclusion further supported Barth’s theory. In agreement with this viewpoint, Phemister,‘j in 1914, called the process “creeping substitution.” Later on, while working with Robertson, Gallie used boiled bone as a graft and found that the percentage of success was lower than with unboiled bone. Nevertheless, boiled bone was successful to some extent, and this was the basis for the development of our technique. The drilling of holes through the graft was added to increase stability by allowing the fibrous tissue to grow through and to provide better chances for nutrition to the invading osteoblasts. serving as a matrix for the formation of new bone from the adjacent host bone. We have used this technique in only two cases thus far. In one case the technique met with failure because of secondary infection with loss of the graft. Even with this very limited experience, the procedure seems to us to have enough advantages to be worthy of more extensive clinical trial. SUMMARY
Treatment of carcinoma of the oral cavity with extension to the mandible and neck usually requires a commando operation which results in a serious and repulsive deformity unless proper reconstruction is carried out, preferably at the time of the original operation. A technique of reconstruction, using the same resected mandible, trimmed and sterilized, is described, and the case histories of the first two patients thus treated are presented.
20
Alvarado
et al.
Oral Surg. July, 1970
REFERENCES
1. Weinstein, I., Yamanaka, H., and Fuchihata, H.: Resection and Reconstruction of the Mandible for Removal of a Central Hemangioma, ORAL SURG. 16: 2-13, 1963. 2. Bhaskar, S. N.: Synopsis of Oral Pathology, ed. 2, St. Louis, 1965, The C. V. Mosby Company. 3. Barth, A.: ijber histologische Befunde nack Knochenimplantationen, Arch. Klin. Chir. 46: 409, 1893. 4. Gallie, W. E.: The History of a Bone Graft, J. Amer. Orthop. Surg. 12: 201, 1914. 5. Borrowed Bone Quickly Rebuilds Jaw, Med. World News, p. 87, Sept., 1968. 6. Phemister, D. B.: The Fate of Transplanted Bone and Regenerative Power of Its Various Constituents, Surg. Gynec. Obstet. 19: 303, 1914.