- Email: [email protected]
The use of reconstruction plates to treat benign mandibular pathological lesions: A retrospective clinical study
G Model
JORMAS-180; No. of Pages 5 J Stomatol Oral Maxillofac Surg xxx (2018) xxx–xxx
Available online at
ScienceDirect www.sciencedirect.com
Original article
The use of reconstruction plates to treat benign mandibular pathological lesions: A retrospective clinical study S.C. Isler, B. Keskin Yalcin, S. Cakarer *, E. Cansiz, A. Gumusdal, C. Keskin Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Istanbul University, Istanbul, Turkey
A R T I C L E I N F O
A B S T R A C T
Article history: Received 13 February 2018 Accepted 23 April 2018
Introduction: The purpose of this retrospective clinical study was to evaluate the indications for and the utility of reconstruction plates in the management of benign mandibular pathological lesions. The complications associated with plate use were also assessed. Patients and methods: The clinical and radiological data of 23 patients (16 males, 7 females) with large, benign mandibular pathologies were evaluated. During operations, reconstruction plates were used to prevent mandibular fracture or to allow for bone reconstruction after segmental or disarticulation resection. The mean follow-up time was 11.2 months. Results: Condylar sag was observed in one patient who had undergone disarticulation resection. A reconstruction plate was removed from one patient because of pain. A plate became exposed in one patient who had undergone a disarticulation resection. Two patients reported slight paraesthesia. Screw-loosening was observed in one patient who had received a non-locking plate. Conclusion: Reconstruction plates can be safely used to manage benign mandibular lesions. Preoperative bending of the plates on individualised models is useful for reducing the time required for plate adaptation during operation. Locking reconstruction plates are preferable for preventing screwloosening. All complications can be managed with careful follow up.
C 2018 Published by Elsevier Masson SAS.
Keywords: Mandibular reconstruction Reconstruction plate Pathological fracture Resection Curettage
1. Introduction Mandibular reconstruction plates are used during mandibular defect reconstruction to improve functional and aesthetic outcomes after resection of malignant and benign tumours [1]. Reconstruction plates are also used to manage complex mandibular fractures or to prevent pathological fracture after marginal resection or broad curettage of benign, aggressive jaw lesions [2]. Since the early 1980s, the standard of care for restoration of mandibular continuity has been the placement of rigid reconstruction plates combined with simultaneous or delayed osseous reconstruction [3]. Titanium plates have replaced stainless steel plates, the plate profiles have been reduced, and the use of locking screws has greatly facilitated osseous reconstruction [4]. Some complications associated with the use of reconstruction plates in patients who have undergone malignant tumour resections have been reported. However, little information is available on the utility of the reconstruction plates used to manage benign
* Corresponding author. E-mail address: [email protected] (S. Cakarer).
mandibular lesions. Therefore, we evaluated the clinical outcomes of reconstructions plates to manage benign lesions.
2. Materials and methods Data on 23 patients who received reconstruction plates before and after complete removal of benign, mandibular pathological lesions at the Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Istanbul University, from January 2015 through December 2017 were retrospectively reviewed. The study was approved by our institutional Ethics Committee. The same surgical team performed all operations. We evaluated intraand post-operative complications. Patients who received reconstruction plates during resection of malignant mandibular tumours or for management of mandibular fractures were excluded. The mean follow-up time was 11.2 months (range: 6– 24 months). Patients for whom the follow-up time was < 6 months were also excluded. The included patients were 16 males and 7 females aged 25–70 years (average: 42.7 years). Sixteen patients received an average of 2.7 plates, and 7 patients received 2.0 plates. Prebent plates were placed in six patients. At least three screws were placed in each side of the mandible to facilitate plate
https://doi.org/10.1016/j.jormas.2018.04.013 C 2018 Published by Elsevier Masson SAS. 2468-7855/
Please cite this article in press as: Isler SC, et al. The use of reconstruction plates to treat benign mandibular pathological lesions: A retrospective clinical study. J Stomatol Oral Maxillofac Surg (2018), https://doi.org/10.1016/j.jormas.2018.04.013
G Model
JORMAS-180; No. of Pages 5 S.C. Isler et al. / J Stomatol Oral Maxillofac Surg xxx (2018) xxx–xxx
2
adaptation. A series of radiographs was taken throughout follow up.
3. Results The clinical records of 23 patients, 16 males and 7 females aged 25–70 years, were reviewed. The mean patient age was 42.7 years, and the mean follow-up period was 11.2 months. Patients’ demographic and clinical characteristics are presented in Table 1. Most diagnoses were keratocysts. No recurrence was noted in any patient during follow up. Fifteen (65.2%) patients had undergone curettage of pathological lesions. Fig. 1 shows a patient with a large keratocyst of the mandible who received a reconstruction plate to prevent a possible pathological fracture and to provide bony support in case the lesion recurred, which would trigger a requirement for segmental mandibular resection. Four patients (17.3%) underwent disarticulation resections and had defects of the ramus, angle, and body. Four patients (17.3%) underwent segmental resections. Postoperative complications
associated with the plates occurred in 6 of the 23 patients (26%) (one instance of condylar sag, one plate removal, two cases of paraesthesia, one screw-loosening, and one plate exposure). The patient with the condylar sag did not report any clinically significant complaints and refused secondary reconstruction. Therefore, the plate was not removed. A plate was removed from one patient (4.3%) because of constant pain. In this patient, the plate had been used to prevent pathological fracture after keratocyst curettage. The plate was removed after 8 months, at which time the residual basal bone was completely healed and there was no risk of pathological fracture. Therefore, we did not replace the plate. Two patients complained of slight paraesthesia after keratocyst curettage, but plate removal was not required because the complaints subsided 6 months after the operations. A computed tomography (CT) scan revealed loosening of two screws in a patient with defects in the body, angle, and ramus (caused by removal of an ameloblastoma) 2 years after surgical resection. The plate used in this patient was non-locking. The patient did not voice any clinically significant complaints, and plate stability was not compromised; thus, the plate was not
Table 1 Demographic and clinical data of the study. Patient No
Age
Sex
Diagnosis
Approach
Management
Complication
Profile and screw type of the plate
Follow-up (months)
1
63
Male
Keratocyst
Extraoral
Disarticulation resection
Condylar sag
24
2
31
Male
Keratocyst
Intraoral
Curettage
None
3
30
Female
Keratocyst
Extraoral
Curettage
Paresthesia
4
62
Male
Keratocyst
Intraoral
Curettage
None
5
65
Male
Keratocyst
Extraoral
Curettage
Paresthesia
6
30
Male
Odontogenic myxoma
Intraoral
Curettage
None
7
53
Female
Ameloblastoma
Intraoral
Curettage
None
8
35
Female
Keratocyst
Extraoral
Curettage and mandibular switching
None
9
55
Male
Ameloblastoma
Extraoral
Disarticulation resection
Plate exposure
10
70
Female
Ameloblastoma
Extraoral
Segmental resection
None
11
29
Male
Ameloblastic odontoma
Extraoral
Disarticulation resection
None
12
35
Female
Keratocyst
Extraoral
Curettage
None
13
66
Male
Keratocyst
Intraoral
Curettage
None
14
41
Male
Keratocyst
Extraoral
Curettage
None
15
44
Male
Keratocyst
Extraoral
Segmental resection
None
16
25
Male
Keratocyst
Intraoral
Curettage
Removal of plate due to pain
2.7 mm Locking plate 2.0 mm Locking plate 2.0 mm Locking plate 2.0 mm Locking plate 2.7 mm Locking plate 2.7 mm Locking plate 2.0 mm Locking plate 2.7 mm Locking plate 2.7 mm Locking plate 2.7 mm Locking plate 2.7 mm Locking plate 2.0 mm Locking plate 2.0 mm Locking plate 2.7 mm Locking plate 2.7 mm Locking plate 2.7 mm Locking plate
17
45
Female
Keratocyst
Extraoral
Curettage with mandibular switching
None
18
36
Female
Fibroosseous lesion
Intraoral
Curettage
None
19
27
Male
Local infection
Intraoral
Curettage
None
20
34
Male
Local infection
Extraoral
Curettage
None
21
41
Male
Ossifying fibroma
Intraoral
Segmental resection
None
22
60
Male
Ameloblastoma
Extraoral
Disarticulation resection
Screw loosening
23
41
Male
Previous infection
Extraoral
Segmental resection
None
2.7 mm Locking plate 2.0 mm Locking plate 2.7 mm Locking plate 2.7 mm Locking plate 2.7 mm Non -Locking plate 2.7 mm Non-Locking plate 2.7 mm Non-Locking plate
10 12 12 16 30 10 10 12 6 12 6 6 6 12 8
6 6 6 6 12 24 6
Please cite this article in press as: Isler SC, et al. The use of reconstruction plates to treat benign mandibular pathological lesions: A retrospective clinical study. J Stomatol Oral Maxillofac Surg (2018), https://doi.org/10.1016/j.jormas.2018.04.013
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JORMAS-180; No. of Pages 5 S.C. Isler et al. / J Stomatol Oral Maxillofac Surg xxx (2018) xxx–xxx
removed. One plate became exposed at the angle of the mandible in a patient who had undergone a disarticulation resection. The plate was revised under general anaesthesia, the surgical site and the plate were cleaned, and the plate was rebent to form an angular match to the lingual region to avoid further exposure. Three-dimensional (3D) individualised models were used during operations on six patients. Figs. 2 and 3 show the management of patient no. 10 (Table 1); the reconstruction plates were prebent on a 3D model built by reference to the cone beam CT scan of the mandible [5]. Two patients underwent curettage of the mandibular ramus because of the presence of keratocysts. These patients had
Fig. 1. Placed reconstruction plate after the enucleation of a large keratocyst.
3
previously undergone surgical operations treating the keratocysts at another centre. CBCT revealed recurrent keratocystic lesions in the lingual region of the mandible. Therefore, we completely exposed the buccal and lingual parts of the mandibular ramus using the mandibular swing technique; we left the condylar part intact. The lingual part of the ramus was completely curetted, and a reconstruction plate was used to provide bony support and allow for possible segmental resection in the future (Figs. 4 and 5). 4. Discussion We retrospectively evaluated complications associated with the use of reconstruction plates to manage benign mandibular lesions; we now move on to a review of the literature. One reported complication is condylar sag, which is defined as an immediate or late change in the condylar position within the glenoid fossa after surgical establishment of a preplanned occlusion and rigid fixation of bone fragments, triggering changes in the occlusion [6]. In the present study, four patients who had undergone disarticulation resections received reconstruction plates with condylar heads that were fixed to the plates with screws. One such patient developed condylar sag evident on the panoramic radiograph taken after the operation. This patient lacked teeth in the intact portion of the mandible and did not receive radiotherapy. The patient remained functional and asymptomatic despite the radiographic change. We did not encounter a plate fracture or exposure problem. The patient was comfortable, did not complain about the occlusion, and refused a second permanent reconstruction operation. Therefore, the plate was not removed; 2 years later, the patient continued to voice no complaints. Although the technique is useful for adults, it is not
Fig. 2. Prebended reconstruction plate on the model provided by CT scan of the mandible. Fig. 4. The intraoperative view of the medial part of the ramus mandible after the curettage of the keratocyst.
Fig. 3. Placement of the reconstruction plate before segmental resection of the mandible.
Fig. 5. The placement of the reconstruction plate and miniplate after the curettage.
Please cite this article in press as: Isler SC, et al. The use of reconstruction plates to treat benign mandibular pathological lesions: A retrospective clinical study. J Stomatol Oral Maxillofac Surg (2018), https://doi.org/10.1016/j.jormas.2018.04.013
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S.C. Isler et al. / J Stomatol Oral Maxillofac Surg xxx (2018) xxx–xxx
appropriate for children (a prosthesis cannot grow) [7]. Appropriate correction of angles and the ramus during operation is very important to reduce the incidence of condylar sag. We strongly advise 3D planning of operations for those who have undergone disarticulation resections. Another common complication is plate failure, which is caused principally by plate fracture and screw-loosening [1]. Van der Rijt et al. reported that smokers and diabetic patients were at higher risk of plate failure after mandibular reconstruction using a mean of 2.7 reconstruction plates [8]. In the present study, 68% of patients received such plates. One reported continuous pain, and the plate was removed. The patient was not a diabetic or a smoker. The plate failure rate ranged from 20% to 80% in the literature [9]. Spencer at al. reported that most plate losses developed when either anterior or large lateral defects (including the condyle) were bridged in patients who received either pre- or post-operative radiotherapy [10]. The plate failure (fracture or removal) rate of the present study was 4.34%. Only one plate was removed because of continuous pain. This is lower than the rate in the literature because all our patients had benign pathologies and, thus, none received radiotherapy. Therefore, within the limits of our study, we suggest that the survival rate of reconstruction plates used to treat benign mandibular pathologies is greater than that of plates placed in patients recovering from malignancies. Reconstruction plates allow for mandibular reconstruction and function and can also be valuable for preventing possible pathological fractures after the removal of large, benign, cystic jaw lesions [1,2]. In the present study, 65.2% of patients with keratocysts, odontogenic myxomas, fibro-osseous lesions, and local infections received plates to prevent pathological fractures after lesional curettage. One patient (4.34%) reported pain associated with the plate, and two (8.69%) complained of slight paraesthesia. Screw-loosening is a complication of reconstruction plate placement. The proximal mandibular stump is exposed to higher moments and shear forces. Radiation therapy may adversely affect the rigidity of the bone-to-metal interface [10], but radiotherapy was not in play in this study. The patient with an ameloblastoma who underwent a disarticulation resection exhibited screwloosening in the area of the mandibular symphysis. Arias-Gallo et al. reported that screw-loosening was provoked principally by failure of condylar stump fixation; condylar rotation was radiologically evident [11]. Our patient was the only patient to receive non-locking screws. All remaining patients received locking screws that did not loosen. Within the limitations of our present study, we suggest that at least four screws be placed in each stump and that locking, load-bearing reconstruction plates be employed to prevent screw-loosening. Radiation therapy and the use of plates crossing the midline of the mandible have been reported to be significant risk factors for plate exposure [12]. Yao et al. found that a greater surgical defect size may also trigger plate-related complications. Patients with segmental mandibulectomy defects were more likely to develop plate exposure [13]. The size of the mandibular defect and the need to cross the midline significantly affect plate exposure. Frequent torsion and the presence of opposing teeth seemed to be risk factors for plate fracture [14]. In the present study, one patient (with an ameloblastoma and a disarticulation defect) developed plate exposure. The patient was dentulous on the opposite side, consistent with literature reports. The plate was removed and the exposed area cleaned. The plate was re-oriented medially to afford better bone fixation. A pectoralis major flap was also placed on the exposed region to prevent re-exposure. Radiation therapy may increase the amount of poorly vascularised scar tissue, increasing the possibility of plate exposure. No patient in our study received radiotherapy.
The bite force affects both the mechanical stress imposed on (the) plate(s) and the success of reconstructive surgery. Fractures may also be caused by excessive intraoperative bending of reconstruction plates. Infections may displace such plates [15]. The association with the platef racture and defect type was not clearly explained in literature on the other hand some reports demonstrated that the plate fractures occur mostly in the discontinuity defects. [1]. In our present study, four patients (17.3%) underwent disarticulation resections and thus had defects of the ramus, angle, and body. None experienced plate facture. After such fracture, management options are limited. The plate can be removed, but the patient may require permanent reconstruction, including grafting of vascularised autogenous bone. If a patient is unsuitable for, or refuses, autologous tissue reconstruction, a new and longer plate, or a plate of a different orientation, can be placed. Peacock et al. treated three patients with fractured reconstruction plates by placing customised prostheses engaging the plates. The prostheses remained in place and afforded stable occlusion in all three patients for at least 9 months of follow-up [16]. Placement of reconstruction plates during surgery requires time and surgical skill, even when an extraoral approach is chosen to allow direct access to the reconstruction site [2]. We used 3D individualised models when treating six patients (26%). The principal disadvantage of model use is the high cost; it was not (economically) possible to make models for all patients. Plate prebending on models before surgery reduced the operation time and ensured appropriate adaptation of the plate to the mandible. Intra-oral plate adaptation is more challenging because of the difficultly accessing the surgical site, especially at the posterior of the mandible. Therefore, the authors advise using 3D planning (whenever possible) before surgery, especially for cases where an intraoral approach is preferred and for those who have undergone disarticulation resections. Patients should be informed about possible complications, and surgeons must schedule close followup visits to manage any complications that arise. All complications are manageable. Disclosure of interest The authors declare that they have no competing interest. References [1] Seol GJ, Jeon EG, Lee JS, Choi SY, Kim JW, Kwon TG, et al. Reconstruction plates used in the surgery for mandibular discontinuity defect. J Korean Assoc Oral Maxillofac Surg 2014;40:266–71. [2] Haas Jr OL, Scolari N, Meirelles Lda S, Becker OE, Melo MF, Viegas VN, et al. Intraoral technique for locking reconstruction plate fixation using an implant handpiece with adapted drills. Head Neck 2016;38:1436–9. [3] Peacock ZS, Afshar S, Lukas SJ, Kaban LB. Customized Repair of Fractured Mandibular Reconstruction Plates. J Oral Maxillofac Surg 2012;70:e563–73. [4] Knott PD, Suh JD, Nabili V, Sercarz JA, Head C, Abemayor E, et al. Evaluation of hardware-related complications in vascularized bone grafts with locking mandibular reconstruction plate fixation. Arch Otolaryngol Head Neck Surg 2007;133:1302–6. [5] Cakarer S, Soluk-Tekkesin M, Alpaslan C, editors. Ag˘ız dis¸ c¸ene cerrahisi/Kanıta Dayalı Tanı ve Tedavi Yaklas¸ımları.. Quintessence Publishing; 2018 [Chapter 15. February. Book in Turkish]. [6] Je˛drzejewski M, Smektała T, Sporniak-Tutak K, Olszewski R. Preoperative, intraoperative, and postoperative complications in orthognathic surgery: a systematic review. Clin Oral Investig 2015;19(5):969–77. [7] Ow A, Tan W, Pienkowski L. Mandibular reconstruction using a custom-made titanium prosthesis: a case report on the use of virtual surgical planning and computer-aided design/computer-aided manufacturing. Craniomaxillofac Trauma Reconstr 2016;9(3):246–50. [8] van der Rijt EE, Noorlag R, Koole R, Abbink JH, Rosenberg AJ. Predictive factors for premature loss of Martin 2.7 mandibular reconstruction plates. Br J Oral Maxillofac Surg 2015;53(2):121–5. [9] Bagheri SC. Clinical Review of Oral and Maxillofacial Surgery-E-Book. In: Chapter 12: reconstructive oral and maxillofacial surgery Second ed, Mosby: Elsevier; 2008. p. 396.
Please cite this article in press as: Isler SC, et al. The use of reconstruction plates to treat benign mandibular pathological lesions: A retrospective clinical study. J Stomatol Oral Maxillofac Surg (2018), https://doi.org/10.1016/j.jormas.2018.04.013
G Model
JORMAS-180; No. of Pages 5 S.C. Isler et al. / J Stomatol Oral Maxillofac Surg xxx (2018) xxx–xxx [10] Spencer KR, Sizeland A, Taylor GI, Weisenfeld D. The use of titanium mandibular reconstruction plates in patients with oral cancer. Int J Oral Maxillofac Surg 1999;28:288–90. ˜ o[11] Arias-Gallo J, Maremonti P, Gonza´lez-Otero T, Go´mez-Garcı´a E, Burguen Garcı´a M, Chamorro Pons M, et al. Long term results of reconstruction plates in lateral mandibular defects. Revision of nine cases. Auris Nasus Larynx 2004;31(1):57–63. [12] Iwasawa M, Mishima Y, Ohtsubo M. Prevention of mandible reconstruction plate exposure by costal cartilage wrapping. Plast Reconstr Surg Glob Open 2017;4:e1438 [5(8)]. [13] Yao CM, Ziai H, Tsang G, Copeland A, Brown D, Irish JC, et al. Surgical site infections following oral cavity cancer resection and reconstruction is a
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risk factor for plate exposure. J Otolaryngol Head Neck Surg 2017;8:30 [46(1)]. [14] Markwardt J, Pfeifer G, Eckelt U, Reitemeier B. Analysis of complications after reconstruction of bone defects involving complete mandibular resection using finite element modelling. Onkologie 2007;30(3):121–6. [15] Hasegawa T, Saito I, Takeda D, Iwata E, Yonezawa N, Kakei Y, et al. Risk factors and surgical refinements of postresective mandibular reconstruction: a retrospective study. J Craniomaxillofac Surg 2015;43(7):1094–8. [16] Peacock ZS, Afshar S, Lukas SJ, Kaban LB. Customized repair of fractured mandibular reconstruction plates. J Oral Maxillofac Surg 2012;70(10): e563–73.
Please cite this article in press as: Isler SC, et al. The use of reconstruction plates to treat benign mandibular pathological lesions: A retrospective clinical study. J Stomatol Oral Maxillofac Surg (2018), https://doi.org/10.1016/j.jormas.2018.04.013
JORMAS-180; No. of Pages 5 J Stomatol Oral Maxillofac Surg xxx (2018) xxx–xxx
Available online at
ScienceDirect www.sciencedirect.com
Original article
The use of reconstruction plates to treat benign mandibular pathological lesions: A retrospective clinical study S.C. Isler, B. Keskin Yalcin, S. Cakarer *, E. Cansiz, A. Gumusdal, C. Keskin Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Istanbul University, Istanbul, Turkey
A R T I C L E I N F O
A B S T R A C T
Article history: Received 13 February 2018 Accepted 23 April 2018
Introduction: The purpose of this retrospective clinical study was to evaluate the indications for and the utility of reconstruction plates in the management of benign mandibular pathological lesions. The complications associated with plate use were also assessed. Patients and methods: The clinical and radiological data of 23 patients (16 males, 7 females) with large, benign mandibular pathologies were evaluated. During operations, reconstruction plates were used to prevent mandibular fracture or to allow for bone reconstruction after segmental or disarticulation resection. The mean follow-up time was 11.2 months. Results: Condylar sag was observed in one patient who had undergone disarticulation resection. A reconstruction plate was removed from one patient because of pain. A plate became exposed in one patient who had undergone a disarticulation resection. Two patients reported slight paraesthesia. Screw-loosening was observed in one patient who had received a non-locking plate. Conclusion: Reconstruction plates can be safely used to manage benign mandibular lesions. Preoperative bending of the plates on individualised models is useful for reducing the time required for plate adaptation during operation. Locking reconstruction plates are preferable for preventing screwloosening. All complications can be managed with careful follow up.
C 2018 Published by Elsevier Masson SAS.
Keywords: Mandibular reconstruction Reconstruction plate Pathological fracture Resection Curettage
1. Introduction Mandibular reconstruction plates are used during mandibular defect reconstruction to improve functional and aesthetic outcomes after resection of malignant and benign tumours [1]. Reconstruction plates are also used to manage complex mandibular fractures or to prevent pathological fracture after marginal resection or broad curettage of benign, aggressive jaw lesions [2]. Since the early 1980s, the standard of care for restoration of mandibular continuity has been the placement of rigid reconstruction plates combined with simultaneous or delayed osseous reconstruction [3]. Titanium plates have replaced stainless steel plates, the plate profiles have been reduced, and the use of locking screws has greatly facilitated osseous reconstruction [4]. Some complications associated with the use of reconstruction plates in patients who have undergone malignant tumour resections have been reported. However, little information is available on the utility of the reconstruction plates used to manage benign
* Corresponding author. E-mail address: [email protected] (S. Cakarer).
mandibular lesions. Therefore, we evaluated the clinical outcomes of reconstructions plates to manage benign lesions.
2. Materials and methods Data on 23 patients who received reconstruction plates before and after complete removal of benign, mandibular pathological lesions at the Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Istanbul University, from January 2015 through December 2017 were retrospectively reviewed. The study was approved by our institutional Ethics Committee. The same surgical team performed all operations. We evaluated intraand post-operative complications. Patients who received reconstruction plates during resection of malignant mandibular tumours or for management of mandibular fractures were excluded. The mean follow-up time was 11.2 months (range: 6– 24 months). Patients for whom the follow-up time was < 6 months were also excluded. The included patients were 16 males and 7 females aged 25–70 years (average: 42.7 years). Sixteen patients received an average of 2.7 plates, and 7 patients received 2.0 plates. Prebent plates were placed in six patients. At least three screws were placed in each side of the mandible to facilitate plate
https://doi.org/10.1016/j.jormas.2018.04.013 C 2018 Published by Elsevier Masson SAS. 2468-7855/
Please cite this article in press as: Isler SC, et al. The use of reconstruction plates to treat benign mandibular pathological lesions: A retrospective clinical study. J Stomatol Oral Maxillofac Surg (2018), https://doi.org/10.1016/j.jormas.2018.04.013
G Model
JORMAS-180; No. of Pages 5 S.C. Isler et al. / J Stomatol Oral Maxillofac Surg xxx (2018) xxx–xxx
2
adaptation. A series of radiographs was taken throughout follow up.
3. Results The clinical records of 23 patients, 16 males and 7 females aged 25–70 years, were reviewed. The mean patient age was 42.7 years, and the mean follow-up period was 11.2 months. Patients’ demographic and clinical characteristics are presented in Table 1. Most diagnoses were keratocysts. No recurrence was noted in any patient during follow up. Fifteen (65.2%) patients had undergone curettage of pathological lesions. Fig. 1 shows a patient with a large keratocyst of the mandible who received a reconstruction plate to prevent a possible pathological fracture and to provide bony support in case the lesion recurred, which would trigger a requirement for segmental mandibular resection. Four patients (17.3%) underwent disarticulation resections and had defects of the ramus, angle, and body. Four patients (17.3%) underwent segmental resections. Postoperative complications
associated with the plates occurred in 6 of the 23 patients (26%) (one instance of condylar sag, one plate removal, two cases of paraesthesia, one screw-loosening, and one plate exposure). The patient with the condylar sag did not report any clinically significant complaints and refused secondary reconstruction. Therefore, the plate was not removed. A plate was removed from one patient (4.3%) because of constant pain. In this patient, the plate had been used to prevent pathological fracture after keratocyst curettage. The plate was removed after 8 months, at which time the residual basal bone was completely healed and there was no risk of pathological fracture. Therefore, we did not replace the plate. Two patients complained of slight paraesthesia after keratocyst curettage, but plate removal was not required because the complaints subsided 6 months after the operations. A computed tomography (CT) scan revealed loosening of two screws in a patient with defects in the body, angle, and ramus (caused by removal of an ameloblastoma) 2 years after surgical resection. The plate used in this patient was non-locking. The patient did not voice any clinically significant complaints, and plate stability was not compromised; thus, the plate was not
Table 1 Demographic and clinical data of the study. Patient No
Age
Sex
Diagnosis
Approach
Management
Complication
Profile and screw type of the plate
Follow-up (months)
1
63
Male
Keratocyst
Extraoral
Disarticulation resection
Condylar sag
24
2
31
Male
Keratocyst
Intraoral
Curettage
None
3
30
Female
Keratocyst
Extraoral
Curettage
Paresthesia
4
62
Male
Keratocyst
Intraoral
Curettage
None
5
65
Male
Keratocyst
Extraoral
Curettage
Paresthesia
6
30
Male
Odontogenic myxoma
Intraoral
Curettage
None
7
53
Female
Ameloblastoma
Intraoral
Curettage
None
8
35
Female
Keratocyst
Extraoral
Curettage and mandibular switching
None
9
55
Male
Ameloblastoma
Extraoral
Disarticulation resection
Plate exposure
10
70
Female
Ameloblastoma
Extraoral
Segmental resection
None
11
29
Male
Ameloblastic odontoma
Extraoral
Disarticulation resection
None
12
35
Female
Keratocyst
Extraoral
Curettage
None
13
66
Male
Keratocyst
Intraoral
Curettage
None
14
41
Male
Keratocyst
Extraoral
Curettage
None
15
44
Male
Keratocyst
Extraoral
Segmental resection
None
16
25
Male
Keratocyst
Intraoral
Curettage
Removal of plate due to pain
2.7 mm Locking plate 2.0 mm Locking plate 2.0 mm Locking plate 2.0 mm Locking plate 2.7 mm Locking plate 2.7 mm Locking plate 2.0 mm Locking plate 2.7 mm Locking plate 2.7 mm Locking plate 2.7 mm Locking plate 2.7 mm Locking plate 2.0 mm Locking plate 2.0 mm Locking plate 2.7 mm Locking plate 2.7 mm Locking plate 2.7 mm Locking plate
17
45
Female
Keratocyst
Extraoral
Curettage with mandibular switching
None
18
36
Female
Fibroosseous lesion
Intraoral
Curettage
None
19
27
Male
Local infection
Intraoral
Curettage
None
20
34
Male
Local infection
Extraoral
Curettage
None
21
41
Male
Ossifying fibroma
Intraoral
Segmental resection
None
22
60
Male
Ameloblastoma
Extraoral
Disarticulation resection
Screw loosening
23
41
Male
Previous infection
Extraoral
Segmental resection
None
2.7 mm Locking plate 2.0 mm Locking plate 2.7 mm Locking plate 2.7 mm Locking plate 2.7 mm Non -Locking plate 2.7 mm Non-Locking plate 2.7 mm Non-Locking plate
10 12 12 16 30 10 10 12 6 12 6 6 6 12 8
6 6 6 6 12 24 6
Please cite this article in press as: Isler SC, et al. The use of reconstruction plates to treat benign mandibular pathological lesions: A retrospective clinical study. J Stomatol Oral Maxillofac Surg (2018), https://doi.org/10.1016/j.jormas.2018.04.013
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removed. One plate became exposed at the angle of the mandible in a patient who had undergone a disarticulation resection. The plate was revised under general anaesthesia, the surgical site and the plate were cleaned, and the plate was rebent to form an angular match to the lingual region to avoid further exposure. Three-dimensional (3D) individualised models were used during operations on six patients. Figs. 2 and 3 show the management of patient no. 10 (Table 1); the reconstruction plates were prebent on a 3D model built by reference to the cone beam CT scan of the mandible [5]. Two patients underwent curettage of the mandibular ramus because of the presence of keratocysts. These patients had
Fig. 1. Placed reconstruction plate after the enucleation of a large keratocyst.
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previously undergone surgical operations treating the keratocysts at another centre. CBCT revealed recurrent keratocystic lesions in the lingual region of the mandible. Therefore, we completely exposed the buccal and lingual parts of the mandibular ramus using the mandibular swing technique; we left the condylar part intact. The lingual part of the ramus was completely curetted, and a reconstruction plate was used to provide bony support and allow for possible segmental resection in the future (Figs. 4 and 5). 4. Discussion We retrospectively evaluated complications associated with the use of reconstruction plates to manage benign mandibular lesions; we now move on to a review of the literature. One reported complication is condylar sag, which is defined as an immediate or late change in the condylar position within the glenoid fossa after surgical establishment of a preplanned occlusion and rigid fixation of bone fragments, triggering changes in the occlusion [6]. In the present study, four patients who had undergone disarticulation resections received reconstruction plates with condylar heads that were fixed to the plates with screws. One such patient developed condylar sag evident on the panoramic radiograph taken after the operation. This patient lacked teeth in the intact portion of the mandible and did not receive radiotherapy. The patient remained functional and asymptomatic despite the radiographic change. We did not encounter a plate fracture or exposure problem. The patient was comfortable, did not complain about the occlusion, and refused a second permanent reconstruction operation. Therefore, the plate was not removed; 2 years later, the patient continued to voice no complaints. Although the technique is useful for adults, it is not
Fig. 2. Prebended reconstruction plate on the model provided by CT scan of the mandible. Fig. 4. The intraoperative view of the medial part of the ramus mandible after the curettage of the keratocyst.
Fig. 3. Placement of the reconstruction plate before segmental resection of the mandible.
Fig. 5. The placement of the reconstruction plate and miniplate after the curettage.
Please cite this article in press as: Isler SC, et al. The use of reconstruction plates to treat benign mandibular pathological lesions: A retrospective clinical study. J Stomatol Oral Maxillofac Surg (2018), https://doi.org/10.1016/j.jormas.2018.04.013
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appropriate for children (a prosthesis cannot grow) [7]. Appropriate correction of angles and the ramus during operation is very important to reduce the incidence of condylar sag. We strongly advise 3D planning of operations for those who have undergone disarticulation resections. Another common complication is plate failure, which is caused principally by plate fracture and screw-loosening [1]. Van der Rijt et al. reported that smokers and diabetic patients were at higher risk of plate failure after mandibular reconstruction using a mean of 2.7 reconstruction plates [8]. In the present study, 68% of patients received such plates. One reported continuous pain, and the plate was removed. The patient was not a diabetic or a smoker. The plate failure rate ranged from 20% to 80% in the literature [9]. Spencer at al. reported that most plate losses developed when either anterior or large lateral defects (including the condyle) were bridged in patients who received either pre- or post-operative radiotherapy [10]. The plate failure (fracture or removal) rate of the present study was 4.34%. Only one plate was removed because of continuous pain. This is lower than the rate in the literature because all our patients had benign pathologies and, thus, none received radiotherapy. Therefore, within the limits of our study, we suggest that the survival rate of reconstruction plates used to treat benign mandibular pathologies is greater than that of plates placed in patients recovering from malignancies. Reconstruction plates allow for mandibular reconstruction and function and can also be valuable for preventing possible pathological fractures after the removal of large, benign, cystic jaw lesions [1,2]. In the present study, 65.2% of patients with keratocysts, odontogenic myxomas, fibro-osseous lesions, and local infections received plates to prevent pathological fractures after lesional curettage. One patient (4.34%) reported pain associated with the plate, and two (8.69%) complained of slight paraesthesia. Screw-loosening is a complication of reconstruction plate placement. The proximal mandibular stump is exposed to higher moments and shear forces. Radiation therapy may adversely affect the rigidity of the bone-to-metal interface [10], but radiotherapy was not in play in this study. The patient with an ameloblastoma who underwent a disarticulation resection exhibited screwloosening in the area of the mandibular symphysis. Arias-Gallo et al. reported that screw-loosening was provoked principally by failure of condylar stump fixation; condylar rotation was radiologically evident [11]. Our patient was the only patient to receive non-locking screws. All remaining patients received locking screws that did not loosen. Within the limitations of our present study, we suggest that at least four screws be placed in each stump and that locking, load-bearing reconstruction plates be employed to prevent screw-loosening. Radiation therapy and the use of plates crossing the midline of the mandible have been reported to be significant risk factors for plate exposure [12]. Yao et al. found that a greater surgical defect size may also trigger plate-related complications. Patients with segmental mandibulectomy defects were more likely to develop plate exposure [13]. The size of the mandibular defect and the need to cross the midline significantly affect plate exposure. Frequent torsion and the presence of opposing teeth seemed to be risk factors for plate fracture [14]. In the present study, one patient (with an ameloblastoma and a disarticulation defect) developed plate exposure. The patient was dentulous on the opposite side, consistent with literature reports. The plate was removed and the exposed area cleaned. The plate was re-oriented medially to afford better bone fixation. A pectoralis major flap was also placed on the exposed region to prevent re-exposure. Radiation therapy may increase the amount of poorly vascularised scar tissue, increasing the possibility of plate exposure. No patient in our study received radiotherapy.
The bite force affects both the mechanical stress imposed on (the) plate(s) and the success of reconstructive surgery. Fractures may also be caused by excessive intraoperative bending of reconstruction plates. Infections may displace such plates [15]. The association with the platef racture and defect type was not clearly explained in literature on the other hand some reports demonstrated that the plate fractures occur mostly in the discontinuity defects. [1]. In our present study, four patients (17.3%) underwent disarticulation resections and thus had defects of the ramus, angle, and body. None experienced plate facture. After such fracture, management options are limited. The plate can be removed, but the patient may require permanent reconstruction, including grafting of vascularised autogenous bone. If a patient is unsuitable for, or refuses, autologous tissue reconstruction, a new and longer plate, or a plate of a different orientation, can be placed. Peacock et al. treated three patients with fractured reconstruction plates by placing customised prostheses engaging the plates. The prostheses remained in place and afforded stable occlusion in all three patients for at least 9 months of follow-up [16]. Placement of reconstruction plates during surgery requires time and surgical skill, even when an extraoral approach is chosen to allow direct access to the reconstruction site [2]. We used 3D individualised models when treating six patients (26%). The principal disadvantage of model use is the high cost; it was not (economically) possible to make models for all patients. Plate prebending on models before surgery reduced the operation time and ensured appropriate adaptation of the plate to the mandible. Intra-oral plate adaptation is more challenging because of the difficultly accessing the surgical site, especially at the posterior of the mandible. Therefore, the authors advise using 3D planning (whenever possible) before surgery, especially for cases where an intraoral approach is preferred and for those who have undergone disarticulation resections. Patients should be informed about possible complications, and surgeons must schedule close followup visits to manage any complications that arise. All complications are manageable. Disclosure of interest The authors declare that they have no competing interest. References [1] Seol GJ, Jeon EG, Lee JS, Choi SY, Kim JW, Kwon TG, et al. Reconstruction plates used in the surgery for mandibular discontinuity defect. J Korean Assoc Oral Maxillofac Surg 2014;40:266–71. [2] Haas Jr OL, Scolari N, Meirelles Lda S, Becker OE, Melo MF, Viegas VN, et al. Intraoral technique for locking reconstruction plate fixation using an implant handpiece with adapted drills. Head Neck 2016;38:1436–9. [3] Peacock ZS, Afshar S, Lukas SJ, Kaban LB. Customized Repair of Fractured Mandibular Reconstruction Plates. J Oral Maxillofac Surg 2012;70:e563–73. [4] Knott PD, Suh JD, Nabili V, Sercarz JA, Head C, Abemayor E, et al. Evaluation of hardware-related complications in vascularized bone grafts with locking mandibular reconstruction plate fixation. Arch Otolaryngol Head Neck Surg 2007;133:1302–6. [5] Cakarer S, Soluk-Tekkesin M, Alpaslan C, editors. Ag˘ız dis¸ c¸ene cerrahisi/Kanıta Dayalı Tanı ve Tedavi Yaklas¸ımları.. Quintessence Publishing; 2018 [Chapter 15. February. Book in Turkish]. [6] Je˛drzejewski M, Smektała T, Sporniak-Tutak K, Olszewski R. Preoperative, intraoperative, and postoperative complications in orthognathic surgery: a systematic review. Clin Oral Investig 2015;19(5):969–77. [7] Ow A, Tan W, Pienkowski L. Mandibular reconstruction using a custom-made titanium prosthesis: a case report on the use of virtual surgical planning and computer-aided design/computer-aided manufacturing. Craniomaxillofac Trauma Reconstr 2016;9(3):246–50. [8] van der Rijt EE, Noorlag R, Koole R, Abbink JH, Rosenberg AJ. Predictive factors for premature loss of Martin 2.7 mandibular reconstruction plates. Br J Oral Maxillofac Surg 2015;53(2):121–5. [9] Bagheri SC. Clinical Review of Oral and Maxillofacial Surgery-E-Book. In: Chapter 12: reconstructive oral and maxillofacial surgery Second ed, Mosby: Elsevier; 2008. p. 396.
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JORMAS-180; No. of Pages 5 S.C. Isler et al. / J Stomatol Oral Maxillofac Surg xxx (2018) xxx–xxx [10] Spencer KR, Sizeland A, Taylor GI, Weisenfeld D. The use of titanium mandibular reconstruction plates in patients with oral cancer. Int J Oral Maxillofac Surg 1999;28:288–90. ˜ o[11] Arias-Gallo J, Maremonti P, Gonza´lez-Otero T, Go´mez-Garcı´a E, Burguen Garcı´a M, Chamorro Pons M, et al. Long term results of reconstruction plates in lateral mandibular defects. Revision of nine cases. Auris Nasus Larynx 2004;31(1):57–63. [12] Iwasawa M, Mishima Y, Ohtsubo M. Prevention of mandible reconstruction plate exposure by costal cartilage wrapping. Plast Reconstr Surg Glob Open 2017;4:e1438 [5(8)]. [13] Yao CM, Ziai H, Tsang G, Copeland A, Brown D, Irish JC, et al. Surgical site infections following oral cavity cancer resection and reconstruction is a
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risk factor for plate exposure. J Otolaryngol Head Neck Surg 2017;8:30 [46(1)]. [14] Markwardt J, Pfeifer G, Eckelt U, Reitemeier B. Analysis of complications after reconstruction of bone defects involving complete mandibular resection using finite element modelling. Onkologie 2007;30(3):121–6. [15] Hasegawa T, Saito I, Takeda D, Iwata E, Yonezawa N, Kakei Y, et al. Risk factors and surgical refinements of postresective mandibular reconstruction: a retrospective study. J Craniomaxillofac Surg 2015;43(7):1094–8. [16] Peacock ZS, Afshar S, Lukas SJ, Kaban LB. Customized repair of fractured mandibular reconstruction plates. J Oral Maxillofac Surg 2012;70(10): e563–73.
Please cite this article in press as: Isler SC, et al. The use of reconstruction plates to treat benign mandibular pathological lesions: A retrospective clinical study. J Stomatol Oral Maxillofac Surg (2018), https://doi.org/10.1016/j.jormas.2018.04.013