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[MUSIC PLAYING]

CAN OZTURK: I'm a plastic surgeon working at the head and neck and plastic and reconstructive surgery department at Roswell Park. That's my only disclosure.

The majority of the mandibular defects result from oncogenic occlusions, such as the ameloblastoma for the tumor involving adjacent structures, such as the [INAUDIBLE] and [INAUDIBLE] mandible. The rest is osteoradionecrosis related to birth defects or traumatic defects, and congenital defects, too.

The mandible is essential for normal mastication, swallowing, and speech. It also sets the proportions that [INAUDIBLE] come to result in [INAUDIBLE] face. So our goal during reconstruction is to re-establish the facial balance and symmetry, provide a stable wound to prevent the leakage or fistula of the wound, and prevent the malocclusion, too. The ultimate goal is to create a surface for the mastication and, finally, dental restoration.

As a reconstructive surgeon, the most important thing for us is analyzing of the defects. So the surgery starts with analyzing of the defect. The missing components are important. Is it going to be just bone? Or it's going to be mucosa or the skin is damaged, too? It can change our reconstruction options. And the location is also critically important. Central locations or anterior locations-- anterior defects-- is much more worse than the lateral defects. If you don't reconstruct properly, the morbidity rate with the anterior defects are really critical.

So the main state of the mandible reconstruction consists of component stabilization with non-vascularized or vascularized bone grafts. The difference here is the vascularized bone grafts has their own blood supply-- the continuous blood supply that promotes the healing and long-term outcome. The other option is that the patients cannot receive the bone graft for some reason. The reconstruction, [INAUDIBLE] reconstruction with our local flaps, and soft tissue free flaps and the primary closure are the remaining options.

For the small gaps-- not critical bone gap, which is less than, generally, 4 cm, and if the patient doesn't have any [INAUDIBLE], and also the defect is not centrally located, then you can use the bone graft. So you can get the bone graft from iliac crest or the rib or the calvarium. And then bridge the gap. And then stabilize the bone graft with the plate. That requires healthy soft tissue envelope to be healed. And also the downside is you don't know how much amount of this graft can stay or remain after a long term. There's going to be some volume loss due to resorption of the graft.

The reconstruction plates without using any bone graft, we use it for the elderly patients with significant co-morbidities or the palliative surgeries. Generally, it's recommended for [INAUDIBLE] lateral defects. For the anterior defects, it's not good. It requires good soft tissue coverage. Otherwise, as you can see, you can see the extrusion of the plate [INAUDIBLE]. The disadvantages are, especially for the anterior defects, the exposure, infection, and even the fracture of these plates are sometimes common.

The most common reconstruction technique for the critical size bone defects-- I'm talking about at least five centimeter bone defect-- is the vascularized bone graft. What does it mean? So, different names-- we can call vascularized bone graft, free bone flap, or free flap-- it has its own blood supply. But, you see, this is the most common one we use-- the fibula, which has its own blood supply here-- this vessel We took this fibula bone and transfer it to the mandible, then hook up these vessels to the neck vessels, and then continuous blood supply.

The other ones are-- 90% to 95% of the time, we use the fibula, but the scapula, iliac crest, radius are [INAUDIBLE] flap surgery are the other options. So if there's absolute indication on central defects, you need to reconstruct these defects with some kind of bone, because otherwise the morbidity and the quality of life of these patients will be problematic.

So this is a demonstration of the fibula flaps. It always has the good quality length bone and can be adapted to [INAUDIBLE] centimeters of bone from a single fibula. It can do multiple osteotomies because the fibula flap has two dual blood supply. So you can cut the bone easily, but you keep the [INAUDIBLE] intact after the bone cut. This provides a thin skin. You can use the skin island for the [INAUDIBLE] defect with maximum skin coverage. The donor site morbidity is generally minimal. A major disadvantage is the short bone height, which may be problematic during the dental implant restoration.

This is a clinical example. The patient has a central ameloblastoma. And to the left-- close to the left, but it's included in the central location. The tumor is extracted. This is a fibula bone. As you see here, you can get all [INAUDIBLE] centimeter of the fibula bone. And this is the skin island attached to the bone. [INAUDIBLE] the osteotomies on the table. And this is the basis of the flap.

Then the inside was done, and then the vessels were connected with the neck vessels. And skin island is covering the mucosa, which is going to be [INAUDIBLE] in [INAUDIBLE].

Another case-- left lateral ameloblastoma. Single segment fibula reconstruction was done with the reconstruction put in place. Occlusion is good. The patient has normal functions after that.

So in recent years, over almost the last decade, we have new tools. We have technology [INAUDIBLE] this type of reconstructions-- virtual surgical planning through a CAD-CAM, which is computer assisted design and manufacturing. So, using this technology, we can able to do more complex reconstructions. So it provides the important advantages to the oncologic surgery when you can get the cutting guides and using these cutting guides.

This is a demonstration from a cadaver workshop. As you know, for the surgeons, new technology means you need to train or teach yourself [INAUDIBLE] to doing some training. You can get also 3D mandible models in there now, which exactly mimic depression in [INAUDIBLE] plates using this model. And this is quite significant in the decreasing of the surgical time.

And also you can get the cutting guides for the fibula-- this is the fibula from a cadaver. You can plan operating, and then use these cutting guides during the surgery. And you see, you can get the precisely cut fibula, and the alignment piece almost perfect. When the flap is inset, it's quite easy to inset the flap off again.

A clinical example today is a patient, 65 years old, T4 squamous cell carcinoma of the mandible, lead to the oral mucosa and floor of mouth. This is the broad plan. Do you see that the image was taken from a CAT scan. And the tumor is involving the mandible here. So the pre-operative cutting guides were planned. And also the fibula cutting guides were planned. Pre-operatively, we see the three segment fibula. We need to reconstruct the [INAUDIBLE].

Now this is the post-operative. You see this is the also [INAUDIBLE] plate, which was in the plan before the surgery. And then we were able to do the surgery, saving the time. This is the post-op, one year after the surgery. Patient received radiation. That's why he didn't like dental implants. But now he's ready for the dental implants. Cosmetically, the good outcome-- he can able to open the mouth nice. And occlusion is normal.

One of the other options is scapular flaps. Scapular flap provides the large amount of tissue to cover the composite defects, such as through-and-through defects of the mucosa, bone, skin. The major disadvantage is you need to wait an oncologic surgeon to finish his or her job. And then you can raise this flap. You can [INAUDIBLE] work together. And decreased range of motion at shoulder sometimes can be seen after the surgery.

This is a clinical example of the flap. As you see, this is the flap here-- the bone flap-- the plate is in place. This is the muscle. And these are the skin islands that can be raised with the flap together and then can be used to reconstruct other defects, which is a good flap. With a single flap, you can construct different parts.

So the key points is immediate reconstruction is the rule, because muscle contracture is minimal with immediate reconstruction. And also you can get the best occlusion during this. Reconstruction with the bone is the mainstay except poor surgical candidates, or the patients with short life expectancy.

When you do surgery, there's always risks and complications associated with the surgery. If the patient has prior operations to the neck, atherosclerosis, or previous radiation, then there's a slightly increased risk for the new operation and the flap loss. But, generally, flap success rate is about 95% to 97%, which is pretty good. Infection and wound healing problems and fistula or donor site morbidities can be seen, but can be easily treated with the conventional technologies.

The long term functional outcome can be assessed by speech evaluation, transition of soft diet to regular diet, and cosmetic appearance, and also the occlusion. But, essentially, when you reconstruct [INAUDIBLE] the anterior defects or central defects, these outcomes are worse than the [INAUDIBLE] defects.

The bone retention is important, especially if you use the non-vascularized bone graft. We don't know how much of this tissue is going to remain after a couple of years. And the ultimate goal, the quality of life of these patients of dental rehabilitation, you should do that, especially for the younger patients.

So, in summary, the careful pre-operative planning is essential, as all surgeries. And the anterior defects are the most important defects to reconstruct primarily. Vascularized bone flaps provide the best functional and cosmetic outcome of mandible reconstruction. CAD-CAM or new technology can potentially decrease operative time. However, we need more studies to move forward long term outcomes. And dental restoration is the ultimate goal, specifically for the younger patients.

[MUSIC PLAYING]

Video

Mandible and Maxilla Reconstruction

Can Ozturk, MD, discusses common indications for mandibular reconstruction as well as reconstruction goals. 

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Can Ozturk, MD.

Can Ozturk, MD

Department of Head & Neck/Plastic and Reconstructive Surgery, Roswell Park Comprehensive Cancer Center

Dr. Ozturk received his medical training at Istanbul University Cerrahpasa Medical School and went on to complete a residency in Plastic, Reconstructive and Aesthetic Surgery. He worked as a microsurgery course instructor and completed ...

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