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Re-evaluation of bone chip grafts for mandibular defects
Re-evaluation
of Bone Chip Grafts for
Mandibular A. JOHN ANLYAN, M.D. AND JOHN R
Defects*
MANIS, M.D., San Francisco, California
From The Plastic and Reconstructive Surgery Service, Saint Francis Memorial Hospital, San Francisco, California.
drains were placed in the lower wound and the skin was closed. RESULTS
I
n a previous paper [I] one of us (A. J.A.) described a technic for repairing surgically created mandibular defects with autogenous bone chip grafts. The present study is a review of the long-term results of the fifteen previously presented cases with the addition of twelve more cases.
Four of the twenty-seven patients eventually died of their disease. One of these four (case 8) healed to a solid union of the bone chips but succumbed fifteen months postoperatively to distant metastases. The interval between surgery and death in the three other patients, (cases 19, 23, and 26) was too short to give a meaningful evaluation of the grafting results. Of the three patients who died of intercurrent disease, in one (case 7) postoperative wound infection developed in the graft area which subsequently healed to an osseofibrous union, but the patient died of coronary occlusion twentytwo months later. Of the remaining two patients in this group, one (case 5) died of aspiration pneumonia in the immediate postoperative period and the other (case 20) was found to have a second primary carcinoma of the esophagus two months after an apparent curative resection of his lingual tumor. He died from the second tumor within two months of its discovery. Again, the postoperative follow-up period was not long enough for these patients to be included in the series. Three patients (cases 12, 13, and 14) had good immediate results but were lost to follow-up in the early postoperative period. Of the remaining seventeen cases, resorption of the bone chip grafts occurred in six patients, five of whom eventually had re-grafting with rib or solid iliac bone. One patient (case 2) was involved in an auto accident three months after primary procedure and suffered a fracture
MATERIAL AND METHODS Reconstruction of mandibular defects with autogenous bone chip grafts was performed in twentyseven patients between 1963 and 1966. (Table I.) The period of follow-up ranges from nine to fifty-one months. Briefly, the surgical technic used in all cases was as follows: After radical neck dissection was completed, part of the mandible was excised in continuity with the intraoral primary lesion. Simultaneously, a second surgical team made an incision over the iliac crest and removed bone chips. The chips were broken up into pieces measuring approximately 0.5 cm. and were placed in an antibiotic solution containing 1 gm. of kanamycin sulfate and 50,000 units of bacitracin. After the mucosal layer in the mouth was closed, a second back-up layer of sutures was placed using available muscle tissue in the area. The bone chips were placed in the defect created by excision of the mandibular segment. The chips were kept in place by suturing the digastric, mylohyoid, and stylohyoid muscles to the superior neck flap. When these muscles were sacrificed with the primary procedure, the levator scapulae muscle was freed at its lower end and swung up and forward to form a hammock containing the bone chips. A second layer below the chips was formed by suturing the platysma muscle in the superior flap to the strap muscles in the lower part of the neck. Two Penrose
* Presented at the Fourteenth Annual Meeting of The Society of Head and Neck Surgeons, Los Angeles, California, April 21-24, 1968. 606
The American Journal of Surgery
Bone Chip Grafts for Mandibular
Defects
TABLE I SU.XMMARY OF DATA IN TWENTY-SEVENPATIESTS WITH BONE CHIP GRAFTS FOR Cast
.\ge y-r.)
1
Procedure
Squamous cell carcinoma of mouth
of floor
Adamantinoma
31
3
56
Left commando
G/4/64)
4
53
Left commando
@/30/64)
5
63
Right commando
6
6G
Left commando
7
64
Right commando
x
“7 01
Partial mandibulectomy (g/22/64)
Osteogenic sarcoma of left mandible
9
50
Right commando
(g/30/64)
10
60
Right commando
(10/12/64)
11
65
Right commando
(12/11/64)
12
66
Right commando
(3/3 /65 j
Squamous tongue Squamous tongue Squamous tonsillar Squamous alveolar
13
50
Right commando
(3/ 15/65)
14
50
Left commando
15
43
16
65
.-interior mandibular and floor of mouth resection; bilateral radical neck dissection (6/18/65) Right commando (l/25/66)
17
54
Left commando
(3/15/66)
18
73
Left commando
(3/31/66)
19
58
20
40
Resection of anterior part of mandible and floor of mouth ; bilateral radical neck dissection (5/13/66) Left commando (5/30/66)
21
42
Left commando
Vol. 116, October 1968
(5/15/64)
(8/28/64)
(3/31/65)
(8/19/66)
Squamous cell carcinoma of tongue Squamous cell carcinoma of gingiva Squamous cell carcinoma of alveolar ridge Squamous cell carcinoma alveolar ridge
of
Squamous cell carcinoma alveolar ridge
of
cell carcinoma
of
cell carcinoma
of
cell carcinoma of right pillar cell carcinoma of right ridge
Squamous cell carcinoma tonsillar pillar
of right
Squamous cell carcinoma of mandible and hard palate Squamous cell carcinoma of mouth
of floor
Squamous cell carcinoma of alveolar ridge Squamous cell carcinoma of tongue Squamous cell carcinoma of tongue Squamous cell carcinoma of floor of mouth
Squamous tongue
cell carcinoma
Squamous gingiva
cell carcinoma
DEFECTS
Result
2
(5/14,‘64)
MANDIBULAR
Diagnosis
and Date
Bilateral neck dissection; anterior mandibulectomy; resection of floor of mouth (12/27/63) Partial mandibulectomy (2/25/64)
(illi
of
of left
Good functional and cosmetic result; no evidence of recurrence; osseofibrous union Auto accident 3 mo. postoperatively with fracture of graft area rib and resorption of chips; graft Osseofibrous union Bone chips united; good cosmetic and functional result Bone chips infected, then removed; patient died 2 wk. later of pneumonia Re-exploration necessary for postoperative hemorrhage; wound became infected and bone chips were removed; iliac graft Infected graft which subsequently healed ; patient died of coronary occlusion Healed with solid jaw; patient died of widespread metastases 15 mo. postoperatively Gradual resorption of chips; rib graft 3 yr. later Solid bony union Osseofibrous
union
Good immediate postoperative result; then lost to follow-up study Good immediate postoperative result; then lost to follow-up study Good immediate postoperative result; then lost to follow-up study Bone chips resorbed; rib graft; recurrence of tumor; repeat resection with immediate rib graft Osseofibrous union Osseofibrous
union
Osseofibrous
union
Patient died of distant metastatrs
Separate primary carcinoma of esophagus discovered 2 mo. later; patient died. Osseofibrous union
Anlyan
608
and Manis
TABLE I (continued) Procedure
and Date
Case
Age (yr.)
22
58
23
73
Resection of anterior part of mandible and floor of mouth with bilateral radical neck dissection (S/23/66) Left commando (g/30/66)
24
53
Right commando
25
60
Left commando
(10/24/66)
26
80
Left commando
(11/14/66)
27
56
Right commando
(10/14/66)
(4/24/67)
Diagnosis
Epidermoid mouth
carcinoma
Squamous tongue Squamous tonsillar Squamous gingiva Squamous gingiva Squamous tongue
cell carcinoma
through a radiologically solid graft and then went on to resorption of most of this chip graft. The patient in case 15, whose tumor recurred after rib grafting, had successful re-resection and re-grafting, again with rib. In the remaining eleven cases, two patients healed to a clinically and a radiologically solid bony union. (Fig. 1.) The other nine patients healed to a clinically stable mandible but solid bony union was not radiographically evident. (Fig. 2.) This osseofibrous union has been both functionally and aesthetically satisfactory. These patients are pain-free, able to wear dentures, chew effectively, and have a very acceptable appearance. (Fig. 3.) Significant postoperative infection occurred in three patients, necessitating removal of the
A
Result
of floor of
of
Bone chips resorbed;
iliac graft
Patient died of metastases
cell carcinoma of right pillar cell carcinoma of left
Osseofibrous
cell carcinoma
Died of recurrent tumor
cell carcinoma
of left of
Resorption
union of bone chip grafts
Osseofibrous union
FIG. 1. Case 10. Roentgenogram demonstrating union of bone chips three years after surgery.
solid
B
FIG. 2. Case 3. A, roentgenogram showing bone chip grafts six months after surgery. B, same patient thirty-five months later showing osseofibrous union. The American
Journal
of Surgery
Bone Chip Grafts for Mandibular
bone chips in two instances (cases 5 and 6j. The remaining patient (case '7)healed to an osseofibrous union after appropriate drainage and antibiotic therapy. COMMENTS
In our experience, it has not been necessary for solid bony union to exist for adequate mandibular stability, as evidenced by the nine patients with osseofibrous union. In these cases, good cosmetic and functional results were obtained, enabling the patients to accept dentures and chew adequately. In the six patients lvho demonstrated resorption of the bone chip grafts, the fibrosis which did occur in the interim helped stabilize the remaining mandible in a satisfactory position so that subsequent
Vol. 116. October 1968
Defects
fiO!)
solid bone grafting could be more easily accomplished. SUMMARY
Twenty-seven cases of immediate reconstruction of mandibular defects with autogenous bone chip grafts are presented. Four patients died of recurrent disease, and three patients died of intercurrent disease. Three patients were lost to follow-up study. Solid bony union occurred in three cases and osseofibrous union occurred in ten. Six patients had resorption of their grafts. REFERENCE 1. ASLYAN,
Am.
J. A. Reconstruction of mandibular J. .%rg., 110: 564, 1965.
defects.
of Bone Chip Grafts for
Mandibular A. JOHN ANLYAN, M.D. AND JOHN R
Defects*
MANIS, M.D., San Francisco, California
From The Plastic and Reconstructive Surgery Service, Saint Francis Memorial Hospital, San Francisco, California.
drains were placed in the lower wound and the skin was closed. RESULTS
I
n a previous paper [I] one of us (A. J.A.) described a technic for repairing surgically created mandibular defects with autogenous bone chip grafts. The present study is a review of the long-term results of the fifteen previously presented cases with the addition of twelve more cases.
Four of the twenty-seven patients eventually died of their disease. One of these four (case 8) healed to a solid union of the bone chips but succumbed fifteen months postoperatively to distant metastases. The interval between surgery and death in the three other patients, (cases 19, 23, and 26) was too short to give a meaningful evaluation of the grafting results. Of the three patients who died of intercurrent disease, in one (case 7) postoperative wound infection developed in the graft area which subsequently healed to an osseofibrous union, but the patient died of coronary occlusion twentytwo months later. Of the remaining two patients in this group, one (case 5) died of aspiration pneumonia in the immediate postoperative period and the other (case 20) was found to have a second primary carcinoma of the esophagus two months after an apparent curative resection of his lingual tumor. He died from the second tumor within two months of its discovery. Again, the postoperative follow-up period was not long enough for these patients to be included in the series. Three patients (cases 12, 13, and 14) had good immediate results but were lost to follow-up in the early postoperative period. Of the remaining seventeen cases, resorption of the bone chip grafts occurred in six patients, five of whom eventually had re-grafting with rib or solid iliac bone. One patient (case 2) was involved in an auto accident three months after primary procedure and suffered a fracture
MATERIAL AND METHODS Reconstruction of mandibular defects with autogenous bone chip grafts was performed in twentyseven patients between 1963 and 1966. (Table I.) The period of follow-up ranges from nine to fifty-one months. Briefly, the surgical technic used in all cases was as follows: After radical neck dissection was completed, part of the mandible was excised in continuity with the intraoral primary lesion. Simultaneously, a second surgical team made an incision over the iliac crest and removed bone chips. The chips were broken up into pieces measuring approximately 0.5 cm. and were placed in an antibiotic solution containing 1 gm. of kanamycin sulfate and 50,000 units of bacitracin. After the mucosal layer in the mouth was closed, a second back-up layer of sutures was placed using available muscle tissue in the area. The bone chips were placed in the defect created by excision of the mandibular segment. The chips were kept in place by suturing the digastric, mylohyoid, and stylohyoid muscles to the superior neck flap. When these muscles were sacrificed with the primary procedure, the levator scapulae muscle was freed at its lower end and swung up and forward to form a hammock containing the bone chips. A second layer below the chips was formed by suturing the platysma muscle in the superior flap to the strap muscles in the lower part of the neck. Two Penrose
* Presented at the Fourteenth Annual Meeting of The Society of Head and Neck Surgeons, Los Angeles, California, April 21-24, 1968. 606
The American Journal of Surgery
Bone Chip Grafts for Mandibular
Defects
TABLE I SU.XMMARY OF DATA IN TWENTY-SEVENPATIESTS WITH BONE CHIP GRAFTS FOR Cast
.\ge y-r.)
1
Procedure
Squamous cell carcinoma of mouth
of floor
Adamantinoma
31
3
56
Left commando
G/4/64)
4
53
Left commando
@/30/64)
5
63
Right commando
6
6G
Left commando
7
64
Right commando
x
“7 01
Partial mandibulectomy (g/22/64)
Osteogenic sarcoma of left mandible
9
50
Right commando
(g/30/64)
10
60
Right commando
(10/12/64)
11
65
Right commando
(12/11/64)
12
66
Right commando
(3/3 /65 j
Squamous tongue Squamous tongue Squamous tonsillar Squamous alveolar
13
50
Right commando
(3/ 15/65)
14
50
Left commando
15
43
16
65
.-interior mandibular and floor of mouth resection; bilateral radical neck dissection (6/18/65) Right commando (l/25/66)
17
54
Left commando
(3/15/66)
18
73
Left commando
(3/31/66)
19
58
20
40
Resection of anterior part of mandible and floor of mouth ; bilateral radical neck dissection (5/13/66) Left commando (5/30/66)
21
42
Left commando
Vol. 116, October 1968
(5/15/64)
(8/28/64)
(3/31/65)
(8/19/66)
Squamous cell carcinoma of tongue Squamous cell carcinoma of gingiva Squamous cell carcinoma of alveolar ridge Squamous cell carcinoma alveolar ridge
of
Squamous cell carcinoma alveolar ridge
of
cell carcinoma
of
cell carcinoma
of
cell carcinoma of right pillar cell carcinoma of right ridge
Squamous cell carcinoma tonsillar pillar
of right
Squamous cell carcinoma of mandible and hard palate Squamous cell carcinoma of mouth
of floor
Squamous cell carcinoma of alveolar ridge Squamous cell carcinoma of tongue Squamous cell carcinoma of tongue Squamous cell carcinoma of floor of mouth
Squamous tongue
cell carcinoma
Squamous gingiva
cell carcinoma
DEFECTS
Result
2
(5/14,‘64)
MANDIBULAR
Diagnosis
and Date
Bilateral neck dissection; anterior mandibulectomy; resection of floor of mouth (12/27/63) Partial mandibulectomy (2/25/64)
(illi
of
of left
Good functional and cosmetic result; no evidence of recurrence; osseofibrous union Auto accident 3 mo. postoperatively with fracture of graft area rib and resorption of chips; graft Osseofibrous union Bone chips united; good cosmetic and functional result Bone chips infected, then removed; patient died 2 wk. later of pneumonia Re-exploration necessary for postoperative hemorrhage; wound became infected and bone chips were removed; iliac graft Infected graft which subsequently healed ; patient died of coronary occlusion Healed with solid jaw; patient died of widespread metastases 15 mo. postoperatively Gradual resorption of chips; rib graft 3 yr. later Solid bony union Osseofibrous
union
Good immediate postoperative result; then lost to follow-up study Good immediate postoperative result; then lost to follow-up study Good immediate postoperative result; then lost to follow-up study Bone chips resorbed; rib graft; recurrence of tumor; repeat resection with immediate rib graft Osseofibrous union Osseofibrous
union
Osseofibrous
union
Patient died of distant metastatrs
Separate primary carcinoma of esophagus discovered 2 mo. later; patient died. Osseofibrous union
Anlyan
608
and Manis
TABLE I (continued) Procedure
and Date
Case
Age (yr.)
22
58
23
73
Resection of anterior part of mandible and floor of mouth with bilateral radical neck dissection (S/23/66) Left commando (g/30/66)
24
53
Right commando
25
60
Left commando
(10/24/66)
26
80
Left commando
(11/14/66)
27
56
Right commando
(10/14/66)
(4/24/67)
Diagnosis
Epidermoid mouth
carcinoma
Squamous tongue Squamous tonsillar Squamous gingiva Squamous gingiva Squamous tongue
cell carcinoma
through a radiologically solid graft and then went on to resorption of most of this chip graft. The patient in case 15, whose tumor recurred after rib grafting, had successful re-resection and re-grafting, again with rib. In the remaining eleven cases, two patients healed to a clinically and a radiologically solid bony union. (Fig. 1.) The other nine patients healed to a clinically stable mandible but solid bony union was not radiographically evident. (Fig. 2.) This osseofibrous union has been both functionally and aesthetically satisfactory. These patients are pain-free, able to wear dentures, chew effectively, and have a very acceptable appearance. (Fig. 3.) Significant postoperative infection occurred in three patients, necessitating removal of the
A
Result
of floor of
of
Bone chips resorbed;
iliac graft
Patient died of metastases
cell carcinoma of right pillar cell carcinoma of left
Osseofibrous
cell carcinoma
Died of recurrent tumor
cell carcinoma
of left of
Resorption
union of bone chip grafts
Osseofibrous union
FIG. 1. Case 10. Roentgenogram demonstrating union of bone chips three years after surgery.
solid
B
FIG. 2. Case 3. A, roentgenogram showing bone chip grafts six months after surgery. B, same patient thirty-five months later showing osseofibrous union. The American
Journal
of Surgery
Bone Chip Grafts for Mandibular
bone chips in two instances (cases 5 and 6j. The remaining patient (case '7)healed to an osseofibrous union after appropriate drainage and antibiotic therapy. COMMENTS
In our experience, it has not been necessary for solid bony union to exist for adequate mandibular stability, as evidenced by the nine patients with osseofibrous union. In these cases, good cosmetic and functional results were obtained, enabling the patients to accept dentures and chew adequately. In the six patients lvho demonstrated resorption of the bone chip grafts, the fibrosis which did occur in the interim helped stabilize the remaining mandible in a satisfactory position so that subsequent
Vol. 116. October 1968
Defects
fiO!)
solid bone grafting could be more easily accomplished. SUMMARY
Twenty-seven cases of immediate reconstruction of mandibular defects with autogenous bone chip grafts are presented. Four patients died of recurrent disease, and three patients died of intercurrent disease. Three patients were lost to follow-up study. Solid bony union occurred in three cases and osseofibrous union occurred in ten. Six patients had resorption of their grafts. REFERENCE 1. ASLYAN,
Am.
J. A. Reconstruction of mandibular J. .%rg., 110: 564, 1965.
defects.