Mandibular Reconstruction With Pediculated Osteotomized Segments

Statement of the problem: Mandibular bone discontinuity defects have been a challenge in craniofacial reconstruction throughout the years. Free bone grafts, microvascular flaps, combined freeze dried mandibles and blood morphogenetic proteins with autologous cancellous bone grafts have been used with high success, utilizing mostly an extraoral approach; however there are still some issues: morbidity, predictability and limitations because of recovery time and surgical costs.

Local pediculated  ostetomized segments could be used intraorally  to treat particular well-planned clinical situations of  4 to 8 centimeters bone discontinuity defects. Muscles and soft tissues attached to the sagittal split ramus distal segment and sagittal symphyseal medial segment can be mobilized and fixed to a reconstruction plate with 2.7 mm screws and obtain bone continuity with no facial disfigurement.

Materials and Methods: 6 patients ages 28.4 to 47.6 (Average 36. 5 years old) with bone discontinuity defects of 6 cm, from 2 to 8 centimeters average: 4 cms after bone resection in tumor surgery, trauma or infection; underwent mandibular reconstruction via local osteotomized bony segments, maintaining the soft tissues attached and repositioned to a reconstruction plate utilizing 2.7 mm screws. Those patients requiring mandibular body reconstruction up to 4 cms were treated by unilateral mandibular sagittal split osteotomy alone; obtaining a distal segment as big as possible by performing the horizontal osteotomy above the lingula, projecting the osteotomy towards the posterior border of the mandible, carefully separating the mandibular split, maintaining the medial soft tissues attached for vascularity. A Carroll-Girard screw is utilized laterally to fix the medial segment and facilitate the split; immediately after, holes are made in the distal fragment and anterior mandible to use a 0.024” wire to unite the anterior and posterior segments by torching the wire, until full bone contact is visualized. 2.7 mm reconstruction screws are used to fixate the bone fragment to the reconstruction plate. For major defects, the sagittal split osteotomy was combined with symphyseal mandibular osteotomy, repositioning the lingual osteotomized segment posteriorly until adequate contact is obtained and fixed to the reconstruction plate.

Methods of data analysis: Clinical analysis, photographs and radiographs (Panoramic, lateral and P-A cephalic) were used to evaluate the bone continuity, facial esthetics and mandibular function.

Results: A wide sagittal split mandibular osteotomy allowed mandibular reconstruction of 2 to 4 cm in 4 patients and combining ramus mandibular osteotomy and symphyseal sagittal split bone discontinuity defects of 6 to 8 cm in two patients. Soft tissues were attached to the bony segments at the end of the surgeries, securing vascularity to the bony segments and permitted a faster healing process.

Conclusions: All patients were adequately reconstructed, obtaining full bone continuity by transporting and rigidly fixating the pediculated osteotomized segments to the reconstruction plate; those patients requiring up to 4 cm of bone were treated by sagittal split osteotomy and those with major defects up to 8 cm underwent anterior and posterior sagittal split osteotomies, the mobilized segments were secured to the reconstruction plate by means of multiple screws; eliminating the need of iliac crest, parietal or fibula bone grafts.

References:

Verdaguer J, Soler F, Fernandez J, Acero J: Sliding osteotomies in mandibular reconstruction. Plast Reconstr Surg. 2001; 15;107(5):1107-14

Bathena HM: Mandibular reconstruction with local live vascularised bone transfer. Acta Chir Plast. 2004;46(3):76:80