Vitallium implant for transected portion of the mandible

Vitallium

Implant for Transected of the Mandible

Portion

STANLEY L. LANE, M.D.,D.D.s., BENJAMIN HOFFMAN, D.D.S. AND JULES V. LANE, D.D.s.. New York, New York EMOVAL of segments

of the mandibIe may be a prerequisite’ for the best possibIe prognosis in the treatment of tumors of the mandibIe and adjacent structures, but the consequent structura1 and functiona resuIts are quite unsatisfactory. The usua1 drifting of the residua1 segment of the mandible, upward, inward and backward, produces a poorIy functioning masticatory apparatus and is disfiguring. During the past few wars considerabIe experience has been gained in the management and restoration of Ioss of portions of the mandibIe due to trauma. AI1 of these procedures are time-consuming, require staged operations and are economicaIIy unfeasibIe for the average civiIian patient. It is advisabIe in patients with cancer, in view of the foreshortened Iife expectancy, to attempt earIy reconstruction of the Iost part. DeIay makes the patient Iess acceptabIe to environment. EarIy peopIe in his normal reconstruction and the return of the patient to a normal existence in the shortest possibIe time is a goa we strive to attain. The idea1 time for reconstruction and anatomica restoration for norma physioIogica1 function is at the time of the origina surgery, and before soft tissue coIIapse and contractures have occurred. Many papers have been written demonstrating technics using different materiaIs in attempts to overcome the probIems incidenta to deIayed restoration of the transected mandibIe. The success of the technics has been as varied as the materiaIs used. Bone, autogenous and homoIogous, VitaIIium,@ stee1 and the inert pIastics are some of the materiaIs in use at this time. There is no doubt that in carefuIIy seIected cases autogenous bone wouId give uniformly satisfactory resuIts, yet considering the fact that Iiving bone requires a

R

American

Journal

of Surgery,

Volume

96, December,

1938

we11 vascuIarized bed virtuaIIy free from contamination for “take” of the graft, onIy a smaI1 number of cases ideaIIy Iend themseIves to this method. When radiation has been resorted to prior to surgery, or is contempIated foIIowing surgery, the viability of the autogenous graft may be seriously compromised. In these cases a high incidence of deIayed resorption and extrusion of the graft has been observed. Furthermore, if surgery requires the remova of the head of the condyIe, restoration of that part by autogenous bone is more diffrcuIt and Iess apt to be successfu1. The use of VitaIIium to repIace transected portions of the mandibIe has been described by ConIey, Winter and others. A variety of impIants are avaiIabIe. In the dentuIous patient the probIem of attachment of the prosthesis to the remaining bone presents d&uIties if bucca1 and IinguaI flanges are used. The insertion of screws to attach these ffanges may resuIt in penetration of the screws into tooth structure. These screws usuaIIy exfoIiate in a reIativeIy short time. In the edentuIous patient these ffanged prostheses may be used more successfuIIy, providing the curve of the flange is congruous with the curvature of the residua1 mandibIe. We prefer the foIIowing technic. A IateraI x-ray fiIm of the mandibIe can be utiIized to determine bone height and Iength, and a basa1 view of the skuI1 can be utiIized to determine mandibuIar curvature. CaIiper measurements from the head of the condyIe to the inferior border of the mandibIe at the site of contempIated transection are taken. These can be checked with the x-ray frIm. The head of the condyIe can be Iocated I I to 13 mm. in front of the tragus on the tragus-canthus Iine. The height of the mandibIe at the site of transection can be accurateIy measured

768

VitaIIium

ImpIant

for Transected

sharpened “outside” caIipers with the sites of contact anesthetized by IocaI anesthesia. Utilizing the curve of the mandible obtained from the basal x-ray film and measurements obtained with the calipers, a wax template can be contoured to size. The height of the mandibular template can be reduced 30 to _to per cent but left about the measured height at the point of attachment. If the coronoid process is in the portion of the mandible to be removed, it should not be incorporated into the prosthesis. A reduced wedge-shaped tenon is then added ahead of the proximat end of the prosthesis. This wil1 eventually be impacted into the cancehous portion of the remaining mandible. Three holes are drihed vcrticallv about 3 to 4 mm. posterior to the end of the implant. An appreciable bulk of the wax template can now be removed by drilling large holes in the body of the prosthesis. This is then processed in Vitallium. Following the removal of the involved portion of the mandible, the prosthesis is f>rought into place. The head of the condyle is fitted into position in the gfenoid fossa by suturing the capsular Iigaments and residua1 external ptery-goid muscle about the neck. The small tenon is now impacted into the cancellous portion of the bone. Holes are drilled in the proximal end of the mandible in line \vith the holes in the prosthesis. Twentytight gauge stainless steel wire is used to fix the implant in position. The masseter and intern11 pterygoid muscles are then sutured to the prosthesis. Closure is made over the in the conventional manner. Interimplant maxillary fixation is used to maintain the residual mandible in correct position and to minimize drift to the affected side. The use of inert, non-organic impIants for replacement in cases of mandibuIar transection has a detinite place in the armamentarium of the maxillofacia1 surgeon. Further investigation of materials and technics shouId be a rewarding endeavor. Too often intraora1 prosthetic restoration in cases of mandibular loss presents problems which could be more readiIy solved il‘ consideration to immediate reconstruction had been undertaken. The surgeon and the maxillofacia1 prosthodontist can act as a team for the treatment and rehabihtation of the patient with cancer of the head and neck. The use of impIants to repIace the resected mandibIe is one phase of this cooperation. An ideal example of the use of this type of restora-

using

Portion

of MandibIe

tion is the foIfowing case of mandibular resection, including the condyIe, for an ameIobIastoma. CASE

REPORT

Miss I. O., a twenty-four year old schoolteacher, was well until twenty months prior to surgery, at which time she noted enlarged right submaxillary lymph nodes. She went to her local physician vvho found nothing abnormal on physica examination. Four months later she went to her local dentist who, on intraoral x-ray of the right mandibular molar teeth, discovered a multiloculated radiolucency of the mandible. In January, 1957, she was referred to an oraI surgeon. Biopsy proved the lesion was an ameIoblastoma. The entire area was curetted and packed with gauze. This was gradually removed over a six-week period after which time the mucosa and mandible were apparcntly fully healed. Some evidence of recurrence 1957, but no external was noted in October, growth was noted until March, rq@, when the right side of the mandible began to enlarge. (Fig. I.) A Vitalhum implant was made according to the described technic and on April I, 1058, the patient was operated upon. A right submaxillary incision was made and the mandibular branch of the facial nerve was located and retracted. Several firm submaxillary nodes were dissected free from the salivary gland and left attached to the lower border of the mandible. The mandibular first bicuspid vvas rcmovcd and the mandible transected at this point. An incision was made through the mucous membrane of the mouth on both sides of the gingiva, ancl the tht mandible was dissected free *transecting masseter, internal pterygoid and temporal muscles. The entire mandible was freed up to its neck, and the external pterygoid muscle was transectecl. The caps& of the temporomandibular joint was

FIG. r. X-ray of mnndibIe showing extent of I&m.

Lane, Hoffman and Lane

FIG. 3. VitaIIium FIG. 2. Resected

mandibIe with VitaIlium repIacement.

repIacement

of the mandibIe.

the folIowing day using arch wires. The patient was given peniciIIin and streptomycin postoperaHer postoperative course was entirety tiveIy. uneventful and she was discharged on the fifth postoperative day. The resuItant cosmetic and functional resuIt was exceIIent. (Fig. 4.) The pathoIogic report, as expected, was ameIobIastoma and hyperpIastic lymph nodes. SUMMARY

Fro. 4. Postoperative

EarIy reconstruction is indicated in surgery of the mandibIe. This is an aid in preventing deformities and scar contracture. A technic is presented using a preformed, specially constructed VitalIium prosthesis which is inserted at the time of the surgica1 resection. This is particuIarIy indicated in cases in which the head of the condyIe is to be removed.

view of patient.

REFERENCES

incised and dissected as a cuff, freeing the head of the condyIe. The mandible with the attached submaxilrary Iymph nodes and gingivat mucosa membrane was removed. (Fig. 2.) The mucous of the mouth was sutured, compIeteIy closing the ora cavity from the wound. The head of the VitaIIium impIant was inserted into the gIenoid fossa, and the cuff of the joint capsuIe was sutured about it. The other end of the impIant was inserted into the marrow of the mandibIe in the first bicuspid area, and three hoIes were driIIed through the cortex of the mandibIe. The impIant was fixed to the bone by three No. 28 gauge steel wires. The center was threaded through the hoIe in the extension inserted into the marrow cavity of the mandibIe. The cut masseter and interna pterygoid muscIes were then sutured to the implant. The wound was cIosed in Iayers without drainage and a pressure dressing was applied. (Fig. 3.) IntermaxiIIary fixation was instituted

I. BYARS,L. T. and SARNAT,B. G. Surgery of mandibIe; ameIobIastoma. Surg., Gynec. 4~ Ok., 81: 575,x945. 2. CONLEY, J. J. Use of VitaIIium prosthesis and impIants in reconstruction of mandibular arch, J. Plast. ti Reconstruct. Surg., 8: 150, 1951.

3. FREEMAN, B. Use of Vitallium plates to maintain function folIowing resection of mandible. J. Plast. & Reconstruct. Surg., 3: 73, 1948. 4. HEALY, M. J., SUDAY, J. L., NIEBEL, H. H., HOFFMAN, B. M. and DUVAL, M. K. Use of acrylic

implants in one stage reconstruction of mandible. Surg., Gynec. * Obst., 98: 395, 1954. 5. MARINO, H., TURCO, N. B. and CRAVIOTTO, M. Immediate reconstruction of Iower jaw foIIowing surgica1 excision of Iarge tumors. J. Fhst. @ Reconstruct. Surg., 4: 36, 1949. 6. WARD, G. E., WILLIAMSON,R. S. and ROMBEN,J. 0. The use of removabIe acryIic prothesis to retain mandibuIar fragments and adjacent soft tissues in normaI position after surgical resection. J. Plast. ep Reconstruct. Surg., 4: 537, ‘949.

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