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TMJ reconstruction
A-V Mandibular Reconstruction Following Ablative Surgery A - V Mandibular Reconstruction Following Ablative Surgery
1. Free Composite Tissue Flaps for Mandibular Reconstruction
Qiu, W.L. Department of Oral & Maxillofacial Surgery, Shanghai Second Medical University, Shanghai, 200011, P.R. China Surgical ablation of oral cancers involving the mandible normally leads to loss of part of the mandibular bone and its surrounding mucosa or even the facial skin. These forms of complex deficits should ideally be replaced by composite flaps of bone and soft tissues. Free flaps are considered as the modern standard of reconstruction because of their low complication rate and versatility. The aim of this study is to report our clinical experience with the use of free osseo-muscular and osseo-musculocutaneous flaps for mandibular reconstruction. A total of 979 free microvascular flaps were performed in our department between 1979 and 1996. Among these, 134 were free osseomuscular or osseo-musculocutaneous flaps that had been used for mandibular reconstruction. Deep circumflex groin flaps with the iliac bone were most commonly used (88/134). The others were vascularized rib-pectoralis major myocutaneous, rib-latissiumus dorsi myocutaneous and scapularmyocutaneous flaps. Fibular flaps were increasingly performed because of their ability to accept osseointegrated implants for dental rehabilitation. The overall success rate in maintaining vascularization of the flaps during healing was 91% (122/134). The success rate has improved to 100% in the last 7 years (1989-1996) with increasing experience in microvascular surgery. Complex mandibular defects can now be reliably reconstructed by free microvascular bone flaps and their associated musculocutaneous components.
2. Use of Microvascular Free Grafts
Reuther, J. Clinic of Oral and Maxillofacial Surgery JuliusMaximilians-University, Wiirzburg, Germany The mandible assists vital functions such as breathing and speaking as well as chewing and swallowing. Depending on extension and location of bone loss mandibular resection causes severe functional and aesthetic disturbances. Routinely we use "The Wiirzburg" plate system together with free iliac bone grafts for mandibular reconstruction. In case of poor soft tissues especially following irradiation or infection, microsurgically revascularized bone grafts are indicated. For defects in the area of the mandibular angle and the ascending ramus we favour the iliac bone graft with nourishment of the deep circumflex iliac artery and vein as described by TAYLORin 1979.
19
For large bony defects we prefer the fibular graft with nourishment via the peroneal vessels, which was introduced as early as in 1973 by UEBA. The fibula has a number of characteristics that make it an attractive alternative for mandibular reconstruction: It has an adequate length and due to its vascularization it has a great flexibility and its cross-section is similar to the edentulous mandible. In patients where bone loss is combined with severe soft tissue defects, particularly in the chin region, we prefer grafts from the scapular area. The bone as well as the fasciocutaneous scapular and parascapular flap is based on the circumflex scapular vessels. The main advantage of these combined grafts is, that the bone and the skin paddles can be rotated against each other with nearly no limitation. The addition of the musculocutaneous latissimus dorsi flap offers the possibility for transplanting a combination of four independent flaps based on one vascular pedicle, the subscapular system, in about 98% of patients. In view of our experience of more than 600 free microsurgically revascularized grafts, these techniques will be discussed.
3. T M J Reconstruction
Williams, J. Maxillofacial Unit, St Richard's Hospital, Chichester, UK Treatment options to be considered: 1) No treatment 2) Reconstruction a) Developing child b) Adult 1) No treatment - Occlusion must be stable even if minimally deformed - Patient unsuitable for other forms of surgery 2) Reconstruction a) Developing child i) Post-traumatic deformity - usually associated with ankylosis - Staged reconstruction One-stage reconstruction prevention of secondary deformity cancum oris ii) Acquired deformity-Inflammatory disease osteomyelitis -Still's Disease - Correction of secondary deformity-unilateral/ bilateral Maintenance of growth potential Restoration and maintenance of function b) Adult Ablation surgery may involve such a variety of tissue in addition to the joint itself that a wide variety of treatment options must be contemplated before a technique is selected. These options include: i) Bone grafts - Cortical - Cancellous - Cortico-cancellous
20
A-V Mandibular Reconstruction Following Ablative Surgery
Periosteal and osteoperiosteal grafts Segments of shafts of long bones - Segments of long bones containing a growth cartilage - Whole bone grafts - Osteoarticular grafts - Pedicle bone grafts - Free vascularised bone grafts ii) Cartilage grafts - Autografts - Stored allografts and xenografts - Living and dead osteoarticular allografts iii) Bone substitutes - Polymers - Bioinert alumina ceramics - Bioactive glass ceramics - Bioactive non-glass ceramics - Corals - Hydroxyapatite - Tricalcium phosphate - Calcite - Collagen - Carbon fibre iv) Metallic implants - Titanium mesh - Titanium struts ~) Combined techniques Discussion centres around the relative values and successes of different techniques. From this will be evolved a logical suggestion for the management of reconstruction of the TMJ. -
4.
Endosteal
Implants
in the
Reconstructed
Mandible
Cawood, J. L Department of Oral and Maxillofacial Surgery, Countess of Chester Hospital, Chester, England Oral reconstruction has brought about a revolution the use of free vascularised flaps following ablative surgery. However, anatomical changes together with impaired movement and sensation within the oral cavity following reconstruc-
tion, limits restoration of oral function and adversely affects the psychological wellbeing of the patient. Oral rehabilitation can be improved with the use of endosseous implants to enhance prosthetic replacement of the dentition. The benefits of an implant retained prosthesis include improved facial appearance, improved oral function with clearer speech, more efficient mastication and a gain in selfesteem and confidence. Patients who have undergone free flap reconstruction pose special problems in relation to the use of implants. Consideration should be given to the individual patient, surgical factors relating to both hard and soft tissues and prosthodontic requirements. Other factors are the effect of radiotherapy and timing of treatment. This presentation will address these various factors and discuss the concept of pre-implant surgery to obtain the most favourable peri-implant environment to achieve optimal oral rehabilitation following ablative surgery.
5.
Indications
and
Techniques
for Nerve
Reconstruction
Schmelzeisen, R. Department of Oral and Maxillofacial Surgery, Medical University of Hannover, Hannover, Germany There are currently well established indications for microsurgical reconstruction of motor and sensitive nerves in the head and neck area. Surgical procedures always follow a strict order, beginning with external neurolysis. In cases of complete separation of the nerve stumps or when tensionless coaptation of the nerve ends can not be achieved, nerve grafts from suitable donor sites, for example the sural nerve, have to be interposed. Good functional results can be obtained following reconstruction of motor nerves, such as the accessory or facial nerve. In contrast, reconstruction of sensory nerves has a lower success rate averaging 50% but very often a subjective improvement of symptoms can be achieved. Taste is very unlikely to be recovered in lingual nerve reconstruction. Facial nerve reconstruction offers a predictable functional and aesthetic result, in long-standing facial palsy with atrophy of the facial musculature, neurovascularly reanastomosed muscle grafts offer a good option.
1. Free Composite Tissue Flaps for Mandibular Reconstruction
Qiu, W.L. Department of Oral & Maxillofacial Surgery, Shanghai Second Medical University, Shanghai, 200011, P.R. China Surgical ablation of oral cancers involving the mandible normally leads to loss of part of the mandibular bone and its surrounding mucosa or even the facial skin. These forms of complex deficits should ideally be replaced by composite flaps of bone and soft tissues. Free flaps are considered as the modern standard of reconstruction because of their low complication rate and versatility. The aim of this study is to report our clinical experience with the use of free osseo-muscular and osseo-musculocutaneous flaps for mandibular reconstruction. A total of 979 free microvascular flaps were performed in our department between 1979 and 1996. Among these, 134 were free osseomuscular or osseo-musculocutaneous flaps that had been used for mandibular reconstruction. Deep circumflex groin flaps with the iliac bone were most commonly used (88/134). The others were vascularized rib-pectoralis major myocutaneous, rib-latissiumus dorsi myocutaneous and scapularmyocutaneous flaps. Fibular flaps were increasingly performed because of their ability to accept osseointegrated implants for dental rehabilitation. The overall success rate in maintaining vascularization of the flaps during healing was 91% (122/134). The success rate has improved to 100% in the last 7 years (1989-1996) with increasing experience in microvascular surgery. Complex mandibular defects can now be reliably reconstructed by free microvascular bone flaps and their associated musculocutaneous components.
2. Use of Microvascular Free Grafts
Reuther, J. Clinic of Oral and Maxillofacial Surgery JuliusMaximilians-University, Wiirzburg, Germany The mandible assists vital functions such as breathing and speaking as well as chewing and swallowing. Depending on extension and location of bone loss mandibular resection causes severe functional and aesthetic disturbances. Routinely we use "The Wiirzburg" plate system together with free iliac bone grafts for mandibular reconstruction. In case of poor soft tissues especially following irradiation or infection, microsurgically revascularized bone grafts are indicated. For defects in the area of the mandibular angle and the ascending ramus we favour the iliac bone graft with nourishment of the deep circumflex iliac artery and vein as described by TAYLORin 1979.
19
For large bony defects we prefer the fibular graft with nourishment via the peroneal vessels, which was introduced as early as in 1973 by UEBA. The fibula has a number of characteristics that make it an attractive alternative for mandibular reconstruction: It has an adequate length and due to its vascularization it has a great flexibility and its cross-section is similar to the edentulous mandible. In patients where bone loss is combined with severe soft tissue defects, particularly in the chin region, we prefer grafts from the scapular area. The bone as well as the fasciocutaneous scapular and parascapular flap is based on the circumflex scapular vessels. The main advantage of these combined grafts is, that the bone and the skin paddles can be rotated against each other with nearly no limitation. The addition of the musculocutaneous latissimus dorsi flap offers the possibility for transplanting a combination of four independent flaps based on one vascular pedicle, the subscapular system, in about 98% of patients. In view of our experience of more than 600 free microsurgically revascularized grafts, these techniques will be discussed.
3. T M J Reconstruction
Williams, J. Maxillofacial Unit, St Richard's Hospital, Chichester, UK Treatment options to be considered: 1) No treatment 2) Reconstruction a) Developing child b) Adult 1) No treatment - Occlusion must be stable even if minimally deformed - Patient unsuitable for other forms of surgery 2) Reconstruction a) Developing child i) Post-traumatic deformity - usually associated with ankylosis - Staged reconstruction One-stage reconstruction prevention of secondary deformity cancum oris ii) Acquired deformity-Inflammatory disease osteomyelitis -Still's Disease - Correction of secondary deformity-unilateral/ bilateral Maintenance of growth potential Restoration and maintenance of function b) Adult Ablation surgery may involve such a variety of tissue in addition to the joint itself that a wide variety of treatment options must be contemplated before a technique is selected. These options include: i) Bone grafts - Cortical - Cancellous - Cortico-cancellous
20
A-V Mandibular Reconstruction Following Ablative Surgery
Periosteal and osteoperiosteal grafts Segments of shafts of long bones - Segments of long bones containing a growth cartilage - Whole bone grafts - Osteoarticular grafts - Pedicle bone grafts - Free vascularised bone grafts ii) Cartilage grafts - Autografts - Stored allografts and xenografts - Living and dead osteoarticular allografts iii) Bone substitutes - Polymers - Bioinert alumina ceramics - Bioactive glass ceramics - Bioactive non-glass ceramics - Corals - Hydroxyapatite - Tricalcium phosphate - Calcite - Collagen - Carbon fibre iv) Metallic implants - Titanium mesh - Titanium struts ~) Combined techniques Discussion centres around the relative values and successes of different techniques. From this will be evolved a logical suggestion for the management of reconstruction of the TMJ. -
4.
Endosteal
Implants
in the
Reconstructed
Mandible
Cawood, J. L Department of Oral and Maxillofacial Surgery, Countess of Chester Hospital, Chester, England Oral reconstruction has brought about a revolution the use of free vascularised flaps following ablative surgery. However, anatomical changes together with impaired movement and sensation within the oral cavity following reconstruc-
tion, limits restoration of oral function and adversely affects the psychological wellbeing of the patient. Oral rehabilitation can be improved with the use of endosseous implants to enhance prosthetic replacement of the dentition. The benefits of an implant retained prosthesis include improved facial appearance, improved oral function with clearer speech, more efficient mastication and a gain in selfesteem and confidence. Patients who have undergone free flap reconstruction pose special problems in relation to the use of implants. Consideration should be given to the individual patient, surgical factors relating to both hard and soft tissues and prosthodontic requirements. Other factors are the effect of radiotherapy and timing of treatment. This presentation will address these various factors and discuss the concept of pre-implant surgery to obtain the most favourable peri-implant environment to achieve optimal oral rehabilitation following ablative surgery.
5.
Indications
and
Techniques
for Nerve
Reconstruction
Schmelzeisen, R. Department of Oral and Maxillofacial Surgery, Medical University of Hannover, Hannover, Germany There are currently well established indications for microsurgical reconstruction of motor and sensitive nerves in the head and neck area. Surgical procedures always follow a strict order, beginning with external neurolysis. In cases of complete separation of the nerve stumps or when tensionless coaptation of the nerve ends can not be achieved, nerve grafts from suitable donor sites, for example the sural nerve, have to be interposed. Good functional results can be obtained following reconstruction of motor nerves, such as the accessory or facial nerve. In contrast, reconstruction of sensory nerves has a lower success rate averaging 50% but very often a subjective improvement of symptoms can be achieved. Taste is very unlikely to be recovered in lingual nerve reconstruction. Facial nerve reconstruction offers a predictable functional and aesthetic result, in long-standing facial palsy with atrophy of the facial musculature, neurovascularly reanastomosed muscle grafts offer a good option.