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The Feasibility of Rib Grafts in Long Span Mandibular Defects Reconstruction: a Long Term Follow Up

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The Feasibility of Rib Grafts in Long Span Mandibular Defects Reconstruction: a Long Term Follow Up Journal of Cranio-Maxillo-Facial Surgery 47 (2019) 15e22 Contents lists available at ScienceDirect Journal of Cranio-Maxillo-Facial Surgery journal homepage: www.jcmfs.com The feasibility of rib grafts in long span mandibular defects reconstruction: A long term follow up * Ahmed M.A. Habib , Shady A. Hassan Department of Maxillofacial and Plastic Surgery, Faculty of Dentistry, Alexandria University, Egypt article info abstract Article history: Aims: To evaluate the efficiency of reconstruction of long span mandibular defects using split rib bundle Paper received 10 June 2018 bone graft. Accepted 2 November 2018 Materials and methods: Six hundred patients with long span mandibular defects (more than 6 cm long), Available online 10 November 2018 following resection of aggressive mandibular tumours, were reconstructed with split rib bundle bone graft technique. Immediate reconstruction was performed in all patients. A reconstruction plate was used to Keywords: support the graft. Two ribs were harvested from the right side of the chest, split into four halves and used to Reconstruction restore the continuity of the mandible. The inclusion criterion was post-surgical mandibular bony defects Mandible fi Split rib without soft tissue de ciency. Defects with a history of previous or need of future irradiation were excluded. Results: The appearance of the patients was accepted in 550 patients. Functional reconstruction was done in 320 patients by osseointegrated dental implants (after 15 months), and removable prosthesis in 150 patients. Infection was minor in 31 patients, moderate in 47 patients and severe in 42 patients. Partial loss of graft, up to 25%, due to moderate infection was reported. Total or near total loss of graft due to severe infection was corrected by reoperation six months later. Conclusions: This technique is simple, safe, and can be effectively used to reconstruct long-span mandibular defects with minimal complications in selected patients. © 2018 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved. 1. Introduction cost of second surgery and allow the patient to return to work as soon as possible (Ahmad and Choudhary, 2013). Mandibular reconstruction has both functional and aesthetic With advancement of microvascular free tissue transfer, vascu- purposes; it provides skeletal support to the lips, the floor of the larized bone flaps (VBFs) are currently the criterion standard for mouth, and the tongue to restore oral continence, swallowing, reconstruction of mandibular defects in the developed world control of saliva, and speech. Proper mandibular reconstruction (Whitman et al., 1997; Reinert, 2000; Baker et al., 2001). furthermore should provide adequate bone stock for dental reha- Nonetheless, in developing countries, VBFs are not the first bilitation either by insertion of a good denture or osseointegrated choice for mandibular bony defect reconstruction because of the dental implants. Also, it is performed to restore the contour of the lack of financial resources and trained surgical team. Thus, non- lower facial appearance and avoid the retrogenic and retrognathic vascularized bone grafts (NVBGs), either from iliac crest or rib, profile (Baker et al., 2001). still play an important role in mandibular reconstruction in the Mandibular reconstruction can be performed either primary developing world (Habib, 2016). simultaneously with resection or secondary at a later surgery after When enough soft tissue coverage is present after resection, confirmation of nonrecurrence of pathology. In developing coun- split ribs can be used to reconstruct mandibular defects in a three- tries, it is preferred to do primary reconstruction to decrease the dimensional way (horizontal, vertical, and bucco-lingual) as it is easily contoured to match the original mandibular configuration (El-Skeikh et al., 1992). In this article, the authors show their experience with the use of non-vascularised split rib bundle graft for mandibular reconstruc- * Corresponding author. Faculty of Dentistry, Alexandria University, 26A Fawzy fi Moaz Street, Smouha, Alexandria, Egypt. tion, describing its indications, limitations, modi ed surgical E-mail address: [email protected] (A.M.A. Habib). technique, and possible complications. https://doi.org/10.1016/j.jcms.2018.11.002 1010-5182/© 2018 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved. 16 A.M.A. Habib, S.A. Hassan / Journal of Cranio-Maxillo-Facial Surgery 47 (2019) 15e22 2. Materials and methods Maxillo-mandibular fixation (MMF) was adopted using com- plete upper arch bar and segmental lower arch bar applied to the We did a prospective observational clinical study involving 600 remaining lower teeth (if any) or by MMF screws fixed to the patients of both sexes and different ages requiring mandibular maxilla and pathological free part of the mandible. reconstruction treated in our department between 2007 and 2017 with mandibular defects. C Surgical Approach and Resection Inclusion Criteria: The operation was done through a combined intra-oral lower 1. Patients with benign mandibular tumours planned to be sulcus and extra-oral extended submandibular incisions for lateral managed by segmental mandibulectomy. mandibular resections and a combined intra-oral lower sulcus and 2. Patients with adequate soft tissue coverage after mandibular transverse collar incision for midline mandibular resections. resection. A reconstruction plate was adapted to the mandible before 3. Patients with malignant tumours those are radio-resistant. resection of the lesion, if this was possible, and at least three holes were drilled on each side of the proposed defect edge. Then the Exclusion Criteria: screws were removed, and the plate was put aside. Figs. 1e11. In some patients, where the shape of the mandible was not 1. Patients not suitable for general anaesthesia because of severe significantly changed, the plate was kept in place and the mandible systemic medical problems. was resected using fine fissure bur. The advantages of this modifi- 2. Patients with soft tissue deficiency after resection, which are cation in the resection technique are keeping patient's own oc- better treated by free osseo-cutaneous flaps. clusion and reducing the time of surgery. 3. Patients planned to have postoperative radiotherapy or with When the lesion extends to the angle of the mandible, resection history of head and neck radiotherapy. of the coronoid process (even if not involved in the pathological 4. Patients with obvious preoperative infections at the site of process) was performed to prevent the upward pull of the tem- surgical resection. poralis muscle that leads to displacement of the proximal segment 5. Patients with recurrent lesions where wider resection will upwards and inwards. If the lesion approximates or involves the necessitate free composite flap reconstruction. condyle, disarticulation of the temporomandibular joint was per- 6. Patients with mammary implants for fear of intraoperative formed leaving the articular disc in place. injury to the implant or post-operative infection/exposure of the implant. D Preparation of the Mandibular stumps: 7. Patients with post gunshot mandibular defects because of the compromised vascularity at the site of injury. They are better The proximal and distal sharp upper edges of the mandibular treated by free osseo-cutaneous flaps. stumps were reduced and smoothed to facilitate watertight and 8. When immediate dental implant placement is being considered. tensionless mucosal closure at these critical areas. Also, this pre- vents the sharp mandibular stumps from penetrating the overlying All patients were primarily reconstructed for extensive mucosa. mandibular defects after ablation of aggressive mandibular tu- The outer cortices of the mandible at the recipient sites were mours using split rib bundle graft (SRBG). removed using a rose-head bur, in the form of a box to expose the The surgical data including the lesions, pathology, location, size, spongiosa, and helped bony union and graft take. the method of reconstruction, and complications are given in Table 1. E Harvesting the Rib Graft, and Making the Bundle: The patient's medical, demographic, surgical, pathological va- rieties and follow up data were collected (Table 1). A pillow was put under the ipsilateral chest wall facilitating The types of mandibular defects met in this study are: harvesting a long segment of the rib. Through a curved submammary incision, two alternating ribs, 1. Hemimandibular defect (body, ramus, condyle, and coronoid), usually the fourth and sixth or the fifth and seventh, were har- 120 patients vested from either side of the chest wall. 2. Hemimandibular defects sparing the condyle, 320 patients We prefer the right side, unless a graft had previously been 3. Hemimandibular defects extending beyond the midline, 119 taken from that side. patients When a costochondral graft was desired to replace a resected 4. Subtotal defect (from angle to angle), 21 patients mandibular condyle, a sheet of periosteum and perichondrium was 5. Near-Total Mandibular defect, 20 patients kept attached to the anterior surface of the costochondral junction of the graft, to minimize the risk of separation at that critical area. After confirming that the pleura was intact, the wound was closed 2.1. Surgical technique in layers. The ribs were split, using fine osteotome and manual pressure A Preparation of the Oral Cavity; on an instrument table,
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