CC
A 51-year-old male presents with concern that he has facial pressure and a growth on his face that is getting larger.
HPI
The patient has a history of an ossifying fibroma of his anterior mandible that was excised 18 years prior. He now presents with a new onset of firm swelling of the anterior mandible with increasing pressure sensation. He denies malocclusion, paresthesia, fevers, weight loss, and constitutional symptoms.
This is a benign but locally aggressive tumor, so segmental mandibulectomy with fibular free flap reconstruction and immediate implant placement with prosthetic rehabilitation was recommended. However, the patient was opposed to this approach. He did accept the alternative approach of a transoral excision with extraction of mandibular incisors and peripheral ostectomy, application of custom reconstruction plate with titanium mesh, and anterior iliac crest bone graft. After healing and graft consolidation, secondary implant placement and prosthetic rehabilitation were planned.
PMHX/PDHX/medications/allergies/SH/FH
The patient has well-controlled hypertension.
Examination
General. The patient is a well-developed and well-nourished male in no acute distress.
Maxillofacial. Gross deformation of anterior mandible and chin with three-dimensional tumor expansion from the posterior mandible bilaterally as shown in eFig. 79.1 . Cranial nerves II to XII are intact without paresthesias or dysesthesias of bilateral V3.
Intraoral. Submucosal tumor with deformation and buccolingual expansion of the anterior mandible and vestibule that extends from the mandibular first molar to the contralateral first molar as shown in eFig. 79.1 . Dentition is intact with a full complement of teeth. Class 2 to 3 mobility of the anterior mandibular incisors.
Imaging
Preoperative reconstructed panoramic radiograph from a cone-beam computed tomography (CBCT) scan as shown in Fig. 79.2 demonstrates a mixed radiolucent and radiopaque osseous lesion extending from the inferior border of anterior mandible to the alveolar ridge and from the mandibular first molar to the contralateral first molar. No pathologic fractures are present.
Labs
Baseline hemoglobin and hematocrit are obtained and found to be within normal limits. Unpredictable blood loss is possible, so it is prudent to obtain preoperative complete blood count. Further laboratory testing is dictated by the medical history.
Assessment
Incisional biopsy demonstrated an ossifying fibroma. This is a benign, recurrent tumor. Extirpation does not require a wide bony margin, but this lesion occupies the full thickness of the mandible from the alveolus to the inferior border. Tumor extirpation would result in a near-continuity defect with substantial structural mandibular loss. Segmental resection with an immediate fibula flap, dental implant, and hybrid load prosthesis versus transoral marginal resection and reconstruction with an iliac crest bone graft were offered.
The patient accepted the alternative approach of a transoral excision with extraction of mandibular incisors and peripheral ostectomy, application of custom reconstruction plate with titanium mesh as shown in eFig. 79.3 , and an anterior iliac crest bone graft to immediately restore the defect. After graft consolidation, secondary implant placement and prosthetic rehabilitation were planned.
Radiographically, the tumor extended from teeth #20 to #30. After excision of the tumor intraoperatively, the defect included the buccal cortex from canine to canine and the marrow space from first molar to first molar. Small perforations were present along the lingual cortex, but it was largely intact.
Treatment
There are many approaches to reconstructing a mandibular defect. The approach is contingent on the size of the defect, available resources, and patient preferences. In this case, iliac crest bone graft was used to reconstruct the defect via an intraoral approach with a free bone graft. The keys to success for this approach are exposure; sterile technique; and tension free, watertight, multilayer closure.
Autologous bone grafts are osteogenic, osteoconductive, and osteoinductive in nature. There are osteoinductive properties with intrinsic bone morphogenic protein and other growth factors, there is the presence of osteoprogenitor cells allowing for osteogenesis, and there are osteoconductive properties of osseous hydroxyapatite that provide the appropriate scaffolding. In addition, when a graft is autologous, then it is perhaps less immunologic without risk of foreign body reaction.
Ileum is advantageous because it can provide corticocancellous bone as well as cancellous marrow. As a rule of thumb, each 1 cm of linear bone defect requires 10 mL of harvested uncompressed bone. Whereas a single anterior ilium may provide an average of 26 mL of uncompressed corticocancellous bone, a posterior approach to ilium harvest may provide 34 mL of corticocancellous bone. However, the posterior approach does require repositioning the patient after prone posterior bone harvest, which is considered by some to be a major disadvantage. Advantages to the posterior approach include less postoperative pain and gait disturbances.
Contraindications to ilium harvest include active infection or history of trauma to the surgical site. Relative contraindications include irradiation to the skin, chemotherapy, bisphosphonate use, and long-term steroid use.
In this case, an intraoral approach with complete exposure and preparation of the recipient bed was used as shown in Fig. 79.4 . During exposure, the clinician must have closure in mind. To achieve sufficient closure, bilateral vertical releasing incisions are required. The flap is undermined, and the periosteum is scored heavily to allow for advancement. A major advantage to this approach is the avoidance of external cutaneous scars on the neck and face. However, there are risks with an intraoral approach, including the possibility of abolishing the vestibular space and graft infection or failure. Excellent exposure of the entire area to be restored is critical. In this case, to excise the tumor completely, the apices of teeth #22, #27, and #31 were shaved as shown in eFig. 79.5 . The teeth left in place were periodontally sound. As shown in Fig. 79.3 and eFig. 79.6 , a prebent Stryker 2.3-mm locking reconstruction plate with titanium mesh and an autogenous cancellous iliac crest bone graft with the addition of recombinant human bone morphogenetic protein 2 (Infuse, Medtronic) was used to immediately reconstruct the defect.
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