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Reimplantation of the mandibular condyle in cases of intraoral resection and reconstruction of the mandible
d. rnax.-fac. Surg. 7 (1979) 1-5
Reimplantation of the Mandibular Condyle in Cases of Intraoral Resection and Reconstruction of the Mandible* Giuseppe Rossi, Gabriele ARRIGONI
Department o[ Oral and Maxillo-Facial Surgery (Head: Prof. G. Rossi, M.D., D.M.D.), Ospedali Civili Riuniti, Venezia, Italy
Summary A new technique for the reconstruction of the disarticulated ramus is presented. From an intra-oral approach tile mandible is resected, and if the posterior part of the ramus and the neck of the condyle are not involved by the tumour, this part is preserved. It is then fixed to the bone graft from the iliac crest bridging the remaining defect. The procedure is outlined, based on the experience of 4 cases which have been success fully operated on according to this technique. The earliest of them has been followed-up for seven years.
Key-Words: Reconstruction of mandible; Reconstruction of temporo-mandibular joint; Composite graft of mandible; Condyle reimplantation; Mandibular tumours.
Introduction In cases of mandibular resection for benign or malignant turnouts no real problems exist in the surgical intervention through an intra-oral approach and immediate replacement of the specimen by a bone graft. Still, some questions remain regarding the reconstruction of an efficient temporo-mandibular jo~int. Having studied the problem, the authors can now illustrate their technique, which consists of the reimplantation of the condyle and the posterior border of the ramus inserted into the iliac crest bone graft.
and the capsule of the joint from the bone. The articular disc is left in the joint. A n X - r a y of the specimen is taken to show the exact extent of the turnout in the bone and particularly to make sure that it has not reached the posterior margin of the ramus and the neck of the condyle. The resected part is faithfully reproduced on a tin-foil mould or a thin sheet of auminium. The bone graft is then taken from the iliac crest. Iliac crest is preferred to any other graft because of its form and its richness in spongiosa. The condyle and the posterior border of the ramus are then removed from the resected hemi-mandible. The bone graft is then shaped and the condyle is fixed to it with wire ligatures in such a manner that the exact length, inclination and angulation of the removed part is achieved (Fig. 1). In order to improve the conditions for the "take" of the graft it is advisable to bur some small holes through the cortical layer of the condyle and the ramus to obtain bleeding points. The composite transplant is then placed into its bed which has been carefully prepared and is firmly fixed to the mandibular stump by wire ligatures. The closure of the mucosa is obtained by two-layer suturing. Intermaxillary fixation is maintained for a period of six weeks, and afterwards articular mobility has to be re-established through passive and active exercises until muscular balance is attained.
Method In the cases which will be presented, mandibular resection was indicated for benign or locally malignant turnouts. The operation is performed under general anaesthesia with nasal intubation. Through an intra-oral approach hemimandibulectomy is carried out including removal of the condyle paying particular attention to the fact that laceration is avoided, when dissecting the muscle * Paper read at the 3rd Congress of the E.A.M.F.S. London, September 1976. 0301-0503/79 1300-0001 $ 03.00 1 J. max.-fac. Surg. 1/79
Results The results are shown by briefly outlining 2 cases:
Case Report Case 1: G.F. 42-year-old woman. Diagnosis: Relapse of a extensive ameloblastoma of the right hemimandible (F{g.2a). Therapy: In December 1970 a resection-disarticulation of the right hemimandible was carried out through an intra-oral approach. The removed part was reconstrncted with an autogenous iliac crest bone graft combined with the removed condyle,
© 1979 Georg Thieme Publishers
2
G. Rossi, G. Arrigoni
Fig. 1 a+b Technique for preparation of implant. a) The removed hemimandible and the iliac crest transplant.
Fig. 1 a
b) The resected condylar segment fixed to the shaped bone graft.
Fig. 1 b
Fig. 2 a
Fig. 2 b
Fig. 2 a + b Recurrence of ameloblastoma(case 1). a) Angle and body of mandible invaded by tumour. b) Postoperative view showing the reconstruction from the midline to the ramus by iliac crest and the reimplanted condyle,
by the technique outlined above (Fig. 2 b). After intermaxillary fixation for six weeks and subsequent reestablishment of functional activity, the clinical and radiological controls one year later confirmed the excellent result of the operation with restoration of normal articular activity and normal facial contour. The patient has been followed-up for a period of six years. Case 2: 41-year-old woman. Diagnosis: Cystic amelobastoma of the left angle area (Fig. 3a). Resectiondisarticulation from an intra-oral approach was carried out in January 1976. An iliac crest graft was
used for reconstruction (Fig. 3 b), and intermaxillary fixation to an upper denture was maintained for 2 months. After subsequent articular exercis.es a good resuIt is observed. This technique has been used in 4 cases. They have been followed-up for 6, 5, 2 and 1 year respectively. I n all 4 cases, very satisfactory results were obtained. Function in the temporo-mandibular joint is good a n d facial contour in all cases normal. No graft was lost.
Reimplantation of the Mandibular Condyle in Cases of Intraoral Resection
.3
Fig. 3 a
Fig. 3 b Fig. 3 a + b Cystic ameloblastoma of the angle area. a) X-ray showing the tumour and the uninvolved posterior border of the ramus and the condylar neck. b) X-ray immediately after reconstruction with a combined graft.
Discussion In the last 20 years the technical modalities of autogenous bone grafting have been seriously revised to such an extent that certain concepts considered up to now as indisputable, such as the complete sterilization of the transplantation bed and also the belief that a period of time has to
pass after surgical ablation before bone grafting, ha~e changed radically (Conlay 1953). Obwegeser (1960), 1963, 1965, 1966) perfected techniques for resection and simultaneous reconstruction with bone grafts during the same operation via an intra-oral approach. This technique offers unquestionable aesthetic and psychological
4
G. Rossi, G. Arrigoni
advantages and avoids a second operation. These new methods, by now well classified and recommended, especially for benign and locally malignant tumours requiring extensive resections, have been rapidly accepted and are now currently used. We ourselves have been using these techniques for 10 years (Rossi et al. 1969, 1970) and have had excellent results. Still, whenever resection-disarticulation was necessary, a supplementary problem remains. There are no real difficulties in the operation through the intra-oral approach and neither for the immediate reconstruction by a bone graft (Obwegeser 1963, 1965, 1966, Celesnik 1963, Cernea et al. 1966, Sailer 1974, Stea 1974), but some questions remain regarding the reconstruction of an efficient temporo-mandibular joint which is obtained by a pseudo-arthrosis between the extremity of the bone graft and the articular cavity (Obwegeser 1963, Dingmann and Grabb 1964, Freihofer and Perko 1976). We therefore tried to save the condyle, if uninvolved by the tumour, and to re-insert it as a free bone graft together with the iliac crest graft for the reconstruction of the mandible. Accepting fully the principles enunciated by Obwegeser (1960, 1963, 1965, 1966) we prefer the intraoral approach. We have carried out 29 such grafts in the last 10 years. 29 have been successful. In 4 of these we applied the technique demonstrated above for reconstruction of the temporo-mandibular joint. This success allows us to affirm that this is an efficient technique for re-establishment of good temporo-mandibular function thanks to normal morphology. The possibility of taking the removed section of the mandible as a model, allows the copying its shape exactly and with great precision. If the disc and the capsule of the joint can be saved, the muscles re-insert in a practically normal anatomical position. This is proved by the fact that not only opening movements but protrusion and lateral movements are also possible even after many years. Since two of the cases are relatively recent, we will have to wait some further time before a detailed follow-up report can give significant information. An obvious condition for obtaining such a result is the correct re-positioning of the condyle in the glenoid fossa. In one of our cases w,,e encountered some difficulty in doing so. We have therefore passed the ends of a bent steel wire from the oral
cavity to the preauricular, infrazygomatic area. The neck of the condyle was then placed in the wire sling and pulling the wire from the exterior we have placed the condyle in the fossa and were able to fix it in its anatomical position. It is our belief that this technique is absolutely indicated in cases of resection-disarticulation in which the condyle and the superior part of the ramus are unaffected by the tumour. However, a relative indication is seen also for cases where it would not be strictly necessary to proceed to a disarticulation, but in which the proximal resection is so high that a stable union between the condyle-bearing segment and the bone graft seems difficult. Although no such case has been observed by the authors in recent years, it seems that a disarticulation and reconstruction as described above would give a better result without any significant limitation of functional activity. Conclusion
In cases in which resection of the mandible has to be combined with disarticulation of the temporo-mandibular joint, the condyle and posterior part of the ramus should be preserved if they are not invaded by the tumour. A reconstruction with a combined graft of the removed condyle and an iliac bone graft will give an almost normal and lasting functional and aesthetic result, because of the practically normal anatomical reconstruction of the temporo-mandibular .joint obtained.
References
Cele~,nik, F.: Intra-oral osteoplastic operations. Acta clair, plast. 5 (1963) 266 Cernea, P. e coll.: "Reconstitution mandibulaire, apr6s r6section par greffe oss6use immediate, sans blocage bimaxillaire." Rev. de Stomat. 67, 12 (1966) 672 Conley, ].: A Technique of Immediate Bone Grafting in the Treatment of Benign and Malignant Tumours of the Mandible and a Review of Seventeen Consecutive Cases. Cancer 6 (1953) 568 Dingman, R. 0., W. C. Grabb: Reconstruction of Both Mandibular Condyles with Metatarsal Bone Grafts. Plast. reconstr. Surg. 34 (1964) 441 Freihofer, H. P. jr., M. A. Perko: Simultaneous Reconstruction of the Area of the Temporo-Mandibular Joint Including the Ramus of the Mandible in a Posttraumatic case. J. max.-fac. Surg. 2 (1976) 124
Reconstructive Surgery of the Mandible by Means of Metal Plates
Obwegeser, H. L.: Aktives chirurgisches Vorgehen bei der Osteomyelitis mandibulae. Ost. Z. Stomat. 57 (1960) 216 Obwegeser, H. L.: Probleme und M6glichkeiten der Unterkieferresektion und gleichzeitigen Rekonstruktion auf dem oralen Operationsweg. Schweiz. Ms&r. Zahlheilk. 73 (1963) 830 Obwegeser, H. L.: Erfahrungen mit der einzeitigen Unterkieferresektion und -rekonstruktion auf dem oralen Operationsweg. Ust. Z. Stomat. 62 (1965) 261 Obwegeser, H. L.: Simultaneous resection and reconstruction of parts of the mandible via the intraoral route in patients with and without gross infections. Oral Surg. 21 (1966) 693 Rossi, G., et al.: I1 trapianto osseo autoplastico immediato per via endorale nella ricostruzione delle per-
5
dite di sostanza dei mascellari. Riv. It. di Stomat, 9 (1969) 837 Rossi, G.: The immediate autogenous bone graft by the intraoral route. Min. Stomat. 11 (1970) 418 Sailer, H. F.: Experiences with Intra-oral Partial Resection and Simultaneous Reconstruction of the Mandible in Preoperatively Non-Infected Cases. J. max.-fae. Surg. 2 (1974) 173 Stga, G.: Notre exp6rience de la r6section mandibulaire par vole endobuccale et la transplantation immfdiate d'os autoghne. Rev. de Stomat. 75 (1974) 55 Prof. G. Rossi, M.D., D.M.D., Dept. of Oral and Maxillo-Facial Surgery Ospedali Riuniti Venezla, Italy
J. max.-fac, Surg. 7 (1979)5-10
Reconstructive Surgery of the Mandible by Means of Metal Plates Mi&ael SONNENBURG-,Ingrid SONNENBURG Department of Surgical Stomatology and Maxillo-Facial Surgery (Head: Prof. A. Andrii, M.D., D.D.S.) Clinic of Stomatology, Wilhelm-Pieck-University of Rostock, GDR
Summary Reconstructive operations for defects of the mandible arising as a consequence of tumour operations and after trauma, add considerably to the improvement of aesthetics and mastieatory function. Here, we have found methods of stable osteosynthesis for transplant fixation to be very useful. The most favourable results were achieved by the application of special mandibular plates. Only homologous spongy bone of the crest of ilium was used as the transplant material. The primary temporary bridging of the defect by alloplastic material after mandibular resection in cancer therapy proved very advantageous. The results of treatment permit practical conclusions.
Key-Words: Mandibular defects; Stable osteosynthesis; Primary and secondary osteoplasties. Introduction Surgically or traumatically acquired defects of the mandible lead, depending on their position and size, to deformities, and disturbances of masticatory 0301-0503/79 1300-0005 $ 03.00
function, breathing, swallowing and articulation in different degrees. The patients are physically and psychologically handicapped (Pape and Koberg 1968). This is why speedy reconstruction of the mandible is really necessary from an aesthetic and functional point of view. T o d a y a temporary bridging of the defect by alloplastic material is advised when resecting the mandible in cases of malignancy. For definitive reconstruction primary or secondary osteoplasties are performed depending on the aetiology. Autogenous bone is best suited as a transplant (Weiss 1966). The fixation of transplants by stable osteosynthesis methods have essentially added to the improvement of the results of osteoplasty operations in the reconstruction of mandibular defects (Hutzschenreuther 1972, Luhr 1973, Ducker et al. 1976, Schargus et al. 1976, Becker 1977, Ewers and ]oos 1977, Reuther and Hausamen 1977). This problem is to be investigated here.
© 1979 Georg Thieme Publishers
Reimplantation of the Mandibular Condyle in Cases of Intraoral Resection and Reconstruction of the Mandible* Giuseppe Rossi, Gabriele ARRIGONI
Department o[ Oral and Maxillo-Facial Surgery (Head: Prof. G. Rossi, M.D., D.M.D.), Ospedali Civili Riuniti, Venezia, Italy
Summary A new technique for the reconstruction of the disarticulated ramus is presented. From an intra-oral approach tile mandible is resected, and if the posterior part of the ramus and the neck of the condyle are not involved by the tumour, this part is preserved. It is then fixed to the bone graft from the iliac crest bridging the remaining defect. The procedure is outlined, based on the experience of 4 cases which have been success fully operated on according to this technique. The earliest of them has been followed-up for seven years.
Key-Words: Reconstruction of mandible; Reconstruction of temporo-mandibular joint; Composite graft of mandible; Condyle reimplantation; Mandibular tumours.
Introduction In cases of mandibular resection for benign or malignant turnouts no real problems exist in the surgical intervention through an intra-oral approach and immediate replacement of the specimen by a bone graft. Still, some questions remain regarding the reconstruction of an efficient temporo-mandibular jo~int. Having studied the problem, the authors can now illustrate their technique, which consists of the reimplantation of the condyle and the posterior border of the ramus inserted into the iliac crest bone graft.
and the capsule of the joint from the bone. The articular disc is left in the joint. A n X - r a y of the specimen is taken to show the exact extent of the turnout in the bone and particularly to make sure that it has not reached the posterior margin of the ramus and the neck of the condyle. The resected part is faithfully reproduced on a tin-foil mould or a thin sheet of auminium. The bone graft is then taken from the iliac crest. Iliac crest is preferred to any other graft because of its form and its richness in spongiosa. The condyle and the posterior border of the ramus are then removed from the resected hemi-mandible. The bone graft is then shaped and the condyle is fixed to it with wire ligatures in such a manner that the exact length, inclination and angulation of the removed part is achieved (Fig. 1). In order to improve the conditions for the "take" of the graft it is advisable to bur some small holes through the cortical layer of the condyle and the ramus to obtain bleeding points. The composite transplant is then placed into its bed which has been carefully prepared and is firmly fixed to the mandibular stump by wire ligatures. The closure of the mucosa is obtained by two-layer suturing. Intermaxillary fixation is maintained for a period of six weeks, and afterwards articular mobility has to be re-established through passive and active exercises until muscular balance is attained.
Method In the cases which will be presented, mandibular resection was indicated for benign or locally malignant turnouts. The operation is performed under general anaesthesia with nasal intubation. Through an intra-oral approach hemimandibulectomy is carried out including removal of the condyle paying particular attention to the fact that laceration is avoided, when dissecting the muscle * Paper read at the 3rd Congress of the E.A.M.F.S. London, September 1976. 0301-0503/79 1300-0001 $ 03.00 1 J. max.-fac. Surg. 1/79
Results The results are shown by briefly outlining 2 cases:
Case Report Case 1: G.F. 42-year-old woman. Diagnosis: Relapse of a extensive ameloblastoma of the right hemimandible (F{g.2a). Therapy: In December 1970 a resection-disarticulation of the right hemimandible was carried out through an intra-oral approach. The removed part was reconstrncted with an autogenous iliac crest bone graft combined with the removed condyle,
© 1979 Georg Thieme Publishers
2
G. Rossi, G. Arrigoni
Fig. 1 a+b Technique for preparation of implant. a) The removed hemimandible and the iliac crest transplant.
Fig. 1 a
b) The resected condylar segment fixed to the shaped bone graft.
Fig. 1 b
Fig. 2 a
Fig. 2 b
Fig. 2 a + b Recurrence of ameloblastoma(case 1). a) Angle and body of mandible invaded by tumour. b) Postoperative view showing the reconstruction from the midline to the ramus by iliac crest and the reimplanted condyle,
by the technique outlined above (Fig. 2 b). After intermaxillary fixation for six weeks and subsequent reestablishment of functional activity, the clinical and radiological controls one year later confirmed the excellent result of the operation with restoration of normal articular activity and normal facial contour. The patient has been followed-up for a period of six years. Case 2: 41-year-old woman. Diagnosis: Cystic amelobastoma of the left angle area (Fig. 3a). Resectiondisarticulation from an intra-oral approach was carried out in January 1976. An iliac crest graft was
used for reconstruction (Fig. 3 b), and intermaxillary fixation to an upper denture was maintained for 2 months. After subsequent articular exercis.es a good resuIt is observed. This technique has been used in 4 cases. They have been followed-up for 6, 5, 2 and 1 year respectively. I n all 4 cases, very satisfactory results were obtained. Function in the temporo-mandibular joint is good a n d facial contour in all cases normal. No graft was lost.
Reimplantation of the Mandibular Condyle in Cases of Intraoral Resection
.3
Fig. 3 a
Fig. 3 b Fig. 3 a + b Cystic ameloblastoma of the angle area. a) X-ray showing the tumour and the uninvolved posterior border of the ramus and the condylar neck. b) X-ray immediately after reconstruction with a combined graft.
Discussion In the last 20 years the technical modalities of autogenous bone grafting have been seriously revised to such an extent that certain concepts considered up to now as indisputable, such as the complete sterilization of the transplantation bed and also the belief that a period of time has to
pass after surgical ablation before bone grafting, ha~e changed radically (Conlay 1953). Obwegeser (1960), 1963, 1965, 1966) perfected techniques for resection and simultaneous reconstruction with bone grafts during the same operation via an intra-oral approach. This technique offers unquestionable aesthetic and psychological
4
G. Rossi, G. Arrigoni
advantages and avoids a second operation. These new methods, by now well classified and recommended, especially for benign and locally malignant tumours requiring extensive resections, have been rapidly accepted and are now currently used. We ourselves have been using these techniques for 10 years (Rossi et al. 1969, 1970) and have had excellent results. Still, whenever resection-disarticulation was necessary, a supplementary problem remains. There are no real difficulties in the operation through the intra-oral approach and neither for the immediate reconstruction by a bone graft (Obwegeser 1963, 1965, 1966, Celesnik 1963, Cernea et al. 1966, Sailer 1974, Stea 1974), but some questions remain regarding the reconstruction of an efficient temporo-mandibular joint which is obtained by a pseudo-arthrosis between the extremity of the bone graft and the articular cavity (Obwegeser 1963, Dingmann and Grabb 1964, Freihofer and Perko 1976). We therefore tried to save the condyle, if uninvolved by the tumour, and to re-insert it as a free bone graft together with the iliac crest graft for the reconstruction of the mandible. Accepting fully the principles enunciated by Obwegeser (1960, 1963, 1965, 1966) we prefer the intraoral approach. We have carried out 29 such grafts in the last 10 years. 29 have been successful. In 4 of these we applied the technique demonstrated above for reconstruction of the temporo-mandibular joint. This success allows us to affirm that this is an efficient technique for re-establishment of good temporo-mandibular function thanks to normal morphology. The possibility of taking the removed section of the mandible as a model, allows the copying its shape exactly and with great precision. If the disc and the capsule of the joint can be saved, the muscles re-insert in a practically normal anatomical position. This is proved by the fact that not only opening movements but protrusion and lateral movements are also possible even after many years. Since two of the cases are relatively recent, we will have to wait some further time before a detailed follow-up report can give significant information. An obvious condition for obtaining such a result is the correct re-positioning of the condyle in the glenoid fossa. In one of our cases w,,e encountered some difficulty in doing so. We have therefore passed the ends of a bent steel wire from the oral
cavity to the preauricular, infrazygomatic area. The neck of the condyle was then placed in the wire sling and pulling the wire from the exterior we have placed the condyle in the fossa and were able to fix it in its anatomical position. It is our belief that this technique is absolutely indicated in cases of resection-disarticulation in which the condyle and the superior part of the ramus are unaffected by the tumour. However, a relative indication is seen also for cases where it would not be strictly necessary to proceed to a disarticulation, but in which the proximal resection is so high that a stable union between the condyle-bearing segment and the bone graft seems difficult. Although no such case has been observed by the authors in recent years, it seems that a disarticulation and reconstruction as described above would give a better result without any significant limitation of functional activity. Conclusion
In cases in which resection of the mandible has to be combined with disarticulation of the temporo-mandibular joint, the condyle and posterior part of the ramus should be preserved if they are not invaded by the tumour. A reconstruction with a combined graft of the removed condyle and an iliac bone graft will give an almost normal and lasting functional and aesthetic result, because of the practically normal anatomical reconstruction of the temporo-mandibular .joint obtained.
References
Cele~,nik, F.: Intra-oral osteoplastic operations. Acta clair, plast. 5 (1963) 266 Cernea, P. e coll.: "Reconstitution mandibulaire, apr6s r6section par greffe oss6use immediate, sans blocage bimaxillaire." Rev. de Stomat. 67, 12 (1966) 672 Conley, ].: A Technique of Immediate Bone Grafting in the Treatment of Benign and Malignant Tumours of the Mandible and a Review of Seventeen Consecutive Cases. Cancer 6 (1953) 568 Dingman, R. 0., W. C. Grabb: Reconstruction of Both Mandibular Condyles with Metatarsal Bone Grafts. Plast. reconstr. Surg. 34 (1964) 441 Freihofer, H. P. jr., M. A. Perko: Simultaneous Reconstruction of the Area of the Temporo-Mandibular Joint Including the Ramus of the Mandible in a Posttraumatic case. J. max.-fac. Surg. 2 (1976) 124
Reconstructive Surgery of the Mandible by Means of Metal Plates
Obwegeser, H. L.: Aktives chirurgisches Vorgehen bei der Osteomyelitis mandibulae. Ost. Z. Stomat. 57 (1960) 216 Obwegeser, H. L.: Probleme und M6glichkeiten der Unterkieferresektion und gleichzeitigen Rekonstruktion auf dem oralen Operationsweg. Schweiz. Ms&r. Zahlheilk. 73 (1963) 830 Obwegeser, H. L.: Erfahrungen mit der einzeitigen Unterkieferresektion und -rekonstruktion auf dem oralen Operationsweg. Ust. Z. Stomat. 62 (1965) 261 Obwegeser, H. L.: Simultaneous resection and reconstruction of parts of the mandible via the intraoral route in patients with and without gross infections. Oral Surg. 21 (1966) 693 Rossi, G., et al.: I1 trapianto osseo autoplastico immediato per via endorale nella ricostruzione delle per-
5
dite di sostanza dei mascellari. Riv. It. di Stomat, 9 (1969) 837 Rossi, G.: The immediate autogenous bone graft by the intraoral route. Min. Stomat. 11 (1970) 418 Sailer, H. F.: Experiences with Intra-oral Partial Resection and Simultaneous Reconstruction of the Mandible in Preoperatively Non-Infected Cases. J. max.-fae. Surg. 2 (1974) 173 Stga, G.: Notre exp6rience de la r6section mandibulaire par vole endobuccale et la transplantation immfdiate d'os autoghne. Rev. de Stomat. 75 (1974) 55 Prof. G. Rossi, M.D., D.M.D., Dept. of Oral and Maxillo-Facial Surgery Ospedali Riuniti Venezla, Italy
J. max.-fac, Surg. 7 (1979)5-10
Reconstructive Surgery of the Mandible by Means of Metal Plates Mi&ael SONNENBURG-,Ingrid SONNENBURG Department of Surgical Stomatology and Maxillo-Facial Surgery (Head: Prof. A. Andrii, M.D., D.D.S.) Clinic of Stomatology, Wilhelm-Pieck-University of Rostock, GDR
Summary Reconstructive operations for defects of the mandible arising as a consequence of tumour operations and after trauma, add considerably to the improvement of aesthetics and mastieatory function. Here, we have found methods of stable osteosynthesis for transplant fixation to be very useful. The most favourable results were achieved by the application of special mandibular plates. Only homologous spongy bone of the crest of ilium was used as the transplant material. The primary temporary bridging of the defect by alloplastic material after mandibular resection in cancer therapy proved very advantageous. The results of treatment permit practical conclusions.
Key-Words: Mandibular defects; Stable osteosynthesis; Primary and secondary osteoplasties. Introduction Surgically or traumatically acquired defects of the mandible lead, depending on their position and size, to deformities, and disturbances of masticatory 0301-0503/79 1300-0005 $ 03.00
function, breathing, swallowing and articulation in different degrees. The patients are physically and psychologically handicapped (Pape and Koberg 1968). This is why speedy reconstruction of the mandible is really necessary from an aesthetic and functional point of view. T o d a y a temporary bridging of the defect by alloplastic material is advised when resecting the mandible in cases of malignancy. For definitive reconstruction primary or secondary osteoplasties are performed depending on the aetiology. Autogenous bone is best suited as a transplant (Weiss 1966). The fixation of transplants by stable osteosynthesis methods have essentially added to the improvement of the results of osteoplasty operations in the reconstruction of mandibular defects (Hutzschenreuther 1972, Luhr 1973, Ducker et al. 1976, Schargus et al. 1976, Becker 1977, Ewers and ]oos 1977, Reuther and Hausamen 1977). This problem is to be investigated here.
© 1979 Georg Thieme Publishers