35

Mandibular Body Reconstruction

Anna-Lisa Söderholm, Dorrit Hallikainen, and Christian Lindqvist

Mandibular continuity defects are the result of surgery for malignant tumors, large benign tumors of various origins (e.g., dental, mandibular bone, surrounding tissues), or different benign diseases (e.g., extensive fibrous dysplasia, cysts or osteomyelitis, and trauma).

A vast majority of these diseases, including cancer,1 involve mainly the mandibular body, the angular area, or both. Mandibular reconstruction surgery is, when appropriate equipment and surgical technique are chosen, usually to be considered as reconstruction of the mandibular body. If the hard tissue framework is successfully restored, good function is achieved; that is in contrast to bridging of even restricted continuity defects in the symphysis area. Lost anterior insertion of muscles of the floor of the mouth and tongue, lost soft tissue equilibrium between the floor of the mouth and lower lip, and lost lip support causes major functional problems for the patient, despite successful contouring of the hard tissue frame. Analogous problems may occur if the condyle is lost. Hence, evaluation of adequate extension of the resection to be performed, without unnecessarily large safety margins, is important for the success of the reconstruction.2

Rehabilitation of patients with mandibular continuity defects has always been a challenging problem. Without adequate primary reconstruction, loss of mandibular continuity, especially if combined with large soft tissue defects, lead to considerable difficulties with speech, mastication, swallowing, and oral continence,3–5 as well as psychosocial problems. Previously, free-bone grafting was the only available method for rebuilding the mandible.3 However, this operation, usually done as a secondary procedure, often led to complica- tions,6–8 and many patients were never offered such a reconstruction.

Today, immediate postoperative rehabilitation of patients with mandibular defects can be achieved through rigid-plate reconstruction. Bone can be transplanted either primarily or in a secondary procedure.9,10

Good early results have been achieved with various plates.11,12 Several problems, including plate exposure, plate

fracture, and infection, however, have occurred during fol- low-up with the various systems used.13,14 However, a majority of these problems can, if detected at an early stage, be solved with good results (Tables 35.1 and 35.2).10,15 Thorough knowledge of the principles and the limits of the system used are essential for good long-term results.15–18

In general, all plate systems work on the same basic principles. A conventional reconstruction plate, developed for osteosynthesis, is fixed to the bone by screws, the heads of which press the plate firmly against the bone surface. The screw holes are oval, and the cross-sectional area of the screw is less than that of the hole. Good buccal bone adaption is needed for adequate fixation. In our experimental studies on sheep, however, resorption of the buccal cortex has been observed to occur under the whole length of large reconstruction plates in almost every case, sometimes restricted to the area under individual screws (Figure 35.1). Adequate fixation was found in histological and microradiographic examination in only 26% of the screws (Table 35.3). A similar resorption was also recorded in our follow-up study on patients resulting in 30% screw failures observed on radiologic examination (Figure 35.2, Table 35.4).15 The plate interferes with blood circulation to the underlying bone, and areas of early osteoporosis are found under rigid plates, corresponding in size to the dimensions of the plate.9,19,20

The conventional plates need four to six screws per fragment if stable fixation is to be guaranteed. Owing to a lack of space, placing this number of screws can be difficult to accomplish in tumor surgery, especially in the ramus-condyle area. Accessory approaches may also be needed, increasing risks of nerve damage and/or scar problems. Loosening of screws and an inadequate number of screws often leads to instability, pain, infection, and a need for plate removal (Figures 35.3 and 35.4).10,14,15

Conventional reconstruction plates, which were originally developed for fracture ostheosynthesis, are in our opinion hazardous for use in permanent mandibular bridging. In reconstructive surgery, the situation is totally different from that in

395

396						A.-L. Söderholm, D. Hallikainen, and C. Lindqvist
TABLE 35.1 Summary of successfully treated late complications (7 of 34 reconstructions).10
							Interval
							from			Follow-up
		Diagnosis		Plate used			primary			from
	Age	(stage of	Resection	at primary	Radiation		surgery		Current	diagnosis
Patient	(years)	disease)	performed	surgery	(dose)	Complications	(month)	Treatment	state	(months)
1	77	SCC (IV)	Left hemi	AO-RPC	Postoperative	Plate fracture	24	AO-RPC free bone	FFD	67
					(66 Gy)			(iliac crest)
2	66	SCC (IV)	Right body and	AO-ARP	Postoperative	Screw loosening	12	ARP free bone (iliac	FFD	53
			ramus		(66 Gy)	proximally		crest) dental
								implants
3	77	SCC (IV)	Left body and	AO-ARP	Postoperative	Screw loosening	18	TH-ARP	AWD	44
			ramus		(66 Gy)	proximally
4	60	SCC (IV)	Symphysis right	AO-ARP	Postoperative	Tumor	12	AO-RPC salvage	FFD	41
			body		(66 Gy)	recurrence		operation
5	79	SCC (IV)	Symphysis	AO-SRP	Preoperative	Screw loosening	22	TH-SRP	FFD	30*
					(64 Gy)	proximally
6	26	Angiosarcoma	Symphysis right	W-RPC	Postoperative	Extraoral plate	3	Sternocleido	DFD	23†
		(grade II)	body and		(66 Gy)	exposure		musculocutaneous
			ramus					flap
7	45	SCC (IV)	Right hemi	AO-RPC	Postoperative	Intraoral plate	6	Antibiotics wound	FFD	17†
					(66 Gy)	exposure		care

Abbreviations: AO-ARP, classic angular AO plate; AO-RPC, classic AO plate with condylar head; AO-SRP, classic straight AO plate; AWD, alive with disease; D, dead from other reason; DFD, dead from disease; FFD, free from disease; SCC, squamous cell carcinoma; TH-ARP, AO-THORP angular plate; TH-SRP, AO-THORP straight plate; W-RPC, Würzburg plate with condylar head.

*From diagnosis of mandibular metastasis, 50-month follow-up from primary diagnosis of SCC of the tongue. †Primary plate in place after soft tissue closure.

Source: From ref. 10.

TABLE 35.2 Summary of patient records for late major complications (7 of 34 reconstructions) resulting in plate removal.10

										Follow-up
		Diagnosis						Interval to		from
	Age	(stage of	Resection		Radiation			removal	State of	diagnosis
Patient	(years)	disease)	performed	Plate	(dose)		Complication	(month)	patient	(months)
8	48	SCC (IV)	Symphysis	AO-SRP	Postoperative		Infection, fistulation	12	FFD	77
					(66	Gy)
9	60	SCC (IV)	Symphysis	AO-ARP		—	Infection, fistulation	10	FFD	66
10	57	SCC (II)	Symphysis	AO-SRP		—	Fistulation	17	FFD	34
							Plate exposure (partial
							flap necrosis)
11	69	SCC (III)	Right ramus	AO-ARP	Postoperative		Chronic infection,	6	D	25
			body		(66	Gy)	osteoradionecrosis?
12	77	SCC (IV)	Left hemi	AO-RCP	Postoperative		Chronic infection,	4	FFD	23
					(66	Gy)	fistulation
13	78	SCC (IV)	Right ramus	AO-ARP	Postoperative		Tumor recurrence, plate	7	DFD	16
			body		(66	Gy)	exposure
14	61	SCC (IV)	Right ramus	AO-ARP	Preoperative		Tumor recurrence,	2	DFD	6
			body		(40	Gy) and	infection
					postoperative
					(30	Gy)

Abbreviations: AO-ARP, classic angular AO plate; AO-RPC, classic AO plate with condylar head; AO-SRP, classic straight AO plate; AWD, alive with disease; D, dead from other reason; DFD, dead from disease; FFD, free from disease; SCC, squamous cell carcinoma; TH-ARP, AO-THORP angular plate; TH-SRP, AO-THORP straight plate.

Source: From ref. 10.

35. Mandibular Body Reconstruction	397
a	b

FIGURE 35.1 (a) Resorption under an AO-THORP plate fixed with solid screws for bridging of a continuity defect in a sheep mandible. Detailed image of the plate and the screw fixation in the ramus frag-

fracture treatment, where bone healing at the fracture site enhances stability after 4 to 6 weeks, before buccal resorption extensive enough to jeopardize plate fixation has developed.

The AO-THORP system was developed by Raveh and coworkers.21–23 This reconstruction system allows stable fixation without compression of the plate against the bone surface due to the screw-plate locking principle (Figure 35.5). Good screw adaptation to cortical bone, lingually or buccally, guarantees stability with two or three screws per fragment, as observed in our experimental study on sheep (Figures 35.6 and 35.7)16,17 and radiologic follow-up study of patients (Figure 35.8).15 The fixation stability of this system has proved clearly superior to the conventional plate systems both primarily and in long-term follow-up (Tables 35.4 and 35.5; Figure 35.9). Although permanent reconstruction with bone, dental implants, and bridgework is desirable, plate reconstruction

ment. Slight resorption of the buccal cortex is seen after 8 weeks. Experimental study on sheep (unpublished data). (b) A diagrammatic representation of (a).

can, for several reasons (e.g., patient’s age), be regarded as permanent in many cases. Close monitoring of screw fixation, including adequate radiologic examination, is, however, in such cases required.15

Permanent reconstruction of the mandible requires bony continuity to allow rehabilitation of masticatory function with dental implants and/or dental prostheses. In the case of benign disease, tumor, or traumatic defect, immediate bone grafting is often indicated. For malignant tumors, the timing of the bone transplantation varies. Some surgeons reconstruct the defect with a vascularized bone graft at primary cancer surgery.24 Others prefer a secondary procedure using a strictly extraoral approach after primary wound healing.10,18,25,26 It has also been advocated to wait 1 to 2 years before carrying out the bony reconstruction to ensure early detection of re- currence.26–29 Whichever procedure is preferred, the rigid-

TABLE 35.3 Screw fixation to cortical bone with classic AO screws.

		Number	Good	Good
	Follow-up	of	buccal	lingual	Adequate
Sheep	(weeks)	screws	adaptation	adaptation	fixation
A	5	9	0	0	0
B	9	9	8	4	8
C	9	10	0	4	0
D	14	(10)	(7)	(8)	(7)*
E	14	10	2	7	2
Total		38	10	15	10

*Plate fracture between the screws excluded from the comparison of screw fixation. Source: From ref. 16.

398	A.-L. Söderholm, D. Hallikainen, and C. Lindqvist

a

b		c

d

FIGURE 35.2 Reconstruction of the mandibular symphysis area in a 66-year-old woman after cancer ablation surgery. (a) Panoramic view with the plate in place. (b,c) Cross-sectional tomography of the left mandibular body area 5 months postoperatively shows slight re-

sorption of the buccal cortex. (Compare buccal and lingual cortex. Normal cortical thickness is preserved lingually.) (d) A diagrammatic representation of (a), (b), and (c).

35. Mandibular Body Reconstruction

399

TABLE 35.4 Radiologic examination of screw fixation and plate stability in nine cases of mandibular reconstruction using classic AO plates.

							First signs
		Number of	Number of	State of	Resorption of	Resorption of	of screw
		screws	screws	screw	cortical bone	cortical bone	loosening	Follow-up
Case	Resection	proximally	distally	fixation	buccally	lingually	(months)	(months)
A		3	4	2 screws	—	—	9	55
				loose
B		*	8	good	xx	xx	—	28
C		*	7	1 screw	—	—	28	39
				loose
D		*	5	good	—	x	—	37
E		4	3	3 screws	xxx	xxx	2	4
				loose
F		3	4	3 screws	xx	—	4	18
				loose
G		5	4	4 screws	—	—	20	66
				loose
H		3	6	3 screws	xxx	xxx	5	10
				loose
I		4	3	4 screws	xxx	xxx	8	10
				loose
Total		22	44	20 screw	5 cases with	4 cases with
				failures	resorption	resorption

*Plate with condylar head; x probable resorption; xx slight resorption; xxx moderate resorption. Source: From ref. 14.

plate reconstruction can successfully bridge the defect during bony healing, and if needed, it can be used to fix the graft in place (Figure 35.9).

Vascularized free-bone grafts are being used increasingly to bridge mandibular defects, especially after large resections in cancer surgery. Vascularized grafts are represented by pedicled rib, scapular, or calvarial bone from the vicinity of the mandibular defect, or distant grafts applied using microvascular techniques. Several different donor sites have been used for free vascularized flaps.24,30–37 It seems that iliac crest, fibula, and in some cases the scapula are best suited for mandibular functional reconstruction.35,36,38 However, this technique has limitations with respect to the site and size of the defect, the patient’s general condition, the surgical team available, and the facilities of the clinic. The total failure rate reported for vascularized grafts (11%)35 also has to be taken into account.

Nonvascularized bone grafts are therefore still widely used for mandibular bony reconstruction. Numerous techniques for nonvascularized bone grafting have been presented including

frozen or irradiated autografts from the operation field, alloplastic or bony trays filled with cancellous bone, and compact grafts from the iliac crest.

The introduction of different metal prostheses for primary functional reconstruction has markedly improved the prospects for secondarily performed free-bone grafting.25,28,39 Nevertheless, failure rates of up to 30% have been reported.15,25,29 These failures are, however, often due to the use of an inadequate technique. When nonvascularized bone is used in combination with rigid-plate bridging, the plate has to be fixed in the remaining mandible at both ends. If fixed with one end only in the graft, the plate will loosen during rebuilding of the transplanted bone. The requirement of stability when using this technique cannot be neglected without a high complication risk.

The intraoral approach and intraoral contamination of the operation field have been cited as two reasons for the high failure rates of nonvascularized grafts.25,29,40 Others, however, routinely use the oral approach.27,41 In our own study we found that one third of the cases where an additional

400	A.-L. Söderholm, D. Hallikainen, and C. Lindqvist
a	b

c

d

e

f

FIGURE 35.3 Recurrent carcinoma of the tongue in the left mandibular area, with resection of the mandibular body and reconstruction of the body defect with a classic AO plate. Fixation was performed with three screws proximally. (a) Immediate postoperative panoramic

view. (b) A diagrammatic representation of (a). (c,d) Panoramic detailed images 21 months later shows massive resorption of the angular area. (e,f) A diagrammatic representation of (c) and (d).

35. Mandibular Body Reconstruction	401
a	b

c

FIGURE 35.4 (a) Postoperative Townes’ view of proximal (angular) screw fixation of a plate reconstruction in the body region performed at primary cancer surgery. The straight classic plate was fixed at the angle with only three screws. (b) At check-up, 4 years later loosen-

ing of the screws was seen in the x-rays. (c) Histologic view of loose classic AO screw. Buccal cortex resorption under the plate. This screw no longer participates in plate fixation.

402	A.-L. Söderholm, D. Hallikainen, and C. Lindqvist

FIGURE 35.5The screw-plate locking principle ensures adequate plate fixation even with bone apposition only lingually. Histologic view of a section through the head of an AO-THORP hollow screw in position. The expansion bolt presses the head of the screw firmly against the surface of the round plate hole (basic Fuchsin stain, magnification 16).

FIGURE 35.6 Microradiograph of adequately fixed AO-THORP hollow screw (ramus part). No buccal bone apposition left. Good bone apposition to outer screw surface lingually. This is sufficient for adequate screw fixation with this system because of the screw-plate locking principle.

a

b

FIGURE 35.7 (a) Microradiograph of adequately fixed AO-THORP hollow screw (ramus part). Good bone apposition both buccally and lingually (magnification 4.4). (b) Histologic view of AO-THORP screw fixed in bone (basic Fuchsin stain; magnification 12.6).

FIGURE 35.8 Comparison of screw fixation failures with classic AO plates and AO-THORP reconstruction in long-term follow-up.15

35. Mandibular Body Reconstruction								403
TABLE 35.5 Radiological examination of screw fixation and plate stability in 13 cases of mandibular reconstructions using the
AO-THORP system.15
							First signs
		Number of	Number of	State of	Resorption of	Resorption of	of screw
		screws	screws	screw	cortical bone	cortical bone	loosening	Follow-up
Case	Resection	(ramus)	(body)	fixation	buccally	lingually	(months)	(months)
K		3	3	good	—	—	—	6
L		2	2	2 screw	x*	—	1	4
				fractures
H		3	5	good	xx	—	—	16
M		3	3	good	xx	xx	—	33
N		3	3	good	xx	—	—	5
O		4	4	good	xx	—	—	13
P		2	4	good	xx	—	—	12
Q		2	3	good	—	—	—	9
R		3	3	good	x	x	—	31
S	†	3	3	1 screw	xx†	—	3	9
				loosened
T		2	3	good	xx	—	—	9
F		3	3	good	—	—	—	35
V		2	2	good	x	—	—	12
Total		35	41	3 screw	10 cases with	2 cases with
				failures	resorption	resorption

*Tumor recurrence at fixation area.

† secondary reconstruction after radiotherapy. x probable resorption; xx slight resorption.

404	A.-L. Söderholm, D. Hallikainen, and C. Lindqvist
a	b

c

d

e

f

FIGURE 35.9 A segmental resection of the right angle and body was performed due to mandibular cancer in a 55-year-old woman. After postoperative radiotherapy the patient was referred 1 year later to our department for rehabilitation. (a) Panoramic view at referral. (b) A diagrammatic representation of (a). (c) Reconstruction of the

mandibular continuity was performed with an angular AO-THORP plate. (d) A diagrammatic representation of (c). (e) Cross-sectional tomography of the condylar neck area 36 months later. The screws are in good position, and no bone resorption has occurred. (f) A diagrammatic representation of (e).

35. Mandibular Body Reconstruction	405
g	h

i

j

k

l

FIGURE 35.9 Continued. (g) In a second operation, nonvascular bone from the iliac crest was transplanted to the defect area. Soft tissue shortage was reconstructed by a pectoralis major flap. (h) A diagrammatic representation of (g). (i) Dental implants were thereafter installed in the symphysis area, both in the bone transplant to the right and in the patient’s own mandibular bone to the left. The plate

was removed from the body area. (j) Intraoral view 4 years later with the dental implants and the connecting bar. (k) The patient’s implant based over dentures in good occlusion and (l) mouth opening of the patient. Both speech and masticatory function have improved markedly in consequence of the reconstruction performed.

406	A.-L. Söderholm, D. Hallikainen, and C. Lindqvist
a	b

c

d

e

f

FIGURE 35.10 Because of an ameloblastoma in the right angular area, a segmental resection of the mandible was necessary. Primary reconstruction with an AO-THORP plate and nonvascular bone from the iliac crest was performed. (a) Immediate preoperative panoramic view. (b) A diagrammatic representation of (a). (c) Postoperative de-

tailed image of the plate and the one-piece bone reconstruction.

(d) A diagrammatic representation of (c). (e) Due to intraoral wound dehiscence, infection of the resection area and severe resorption of the bone transplant followed. Finally, the transplant was lost. (f) A diagrammatic representation of (e).

35. Mandibular Body Reconstruction	407
g	h

i

j

FIGURE 35.10 Continued. (g) After revision, antibiotics, and secondary healing, a new similar nonvascular transplant was inserted several months later from a strictly extraoral approach. (h) A diagrammatic representation of (g). (i) The height of the bone trans-

intraoral approach was needed resulted in postoperative infection and graft failure.15 In our opinion, these complications stress the importance of extremely good intraoral wound care and the use of an extraoral approach only whenever possible (Figure 35.10).

High plate rigidity has been claimed to enhance graft resorption. Plate removal within 6 months after bone grafting has been recommended.25,42 This was not confirmed in our own study. The mean interval between bone grafting and plate removal was 26 months for the patients with good bone healing and a resorption of less than 15%.15

Nonvascularized bone grafts in combination with rigidplate reconstruction still play an important role in permanent mandibular reconstruction (Figure 35.11).15,43 The technique does not require much time or resources and is particularly valuable in trauma and benign tumor cases.

Regular radiologic examination is essential in graft fol- low-up. Radiologic examination contributes to the evaluation of the possible resorption and resorption rate. Complications can be detected early and rescue therapy initiated wtih adequate time. Special attention must be paid to the imaging technique and image quality (Figure 35.2b,c). Good spatial resolution and good contrast are necessary, and the

plant was unchanged 3 years later. The plate has been removed. Three of the hollow screws were integrated into the bone tissue and could not be removed by a screwdriver and hence were left. (j) A diagrammatic representation of (i).

imaging procedure must be selected according to the specified diagnostic task. Radiologic literature on bone graft evaluation is sparse; especially, experience with computed tomography (CT) and magnetic resonance imaging (MRI) is limited.44,45 Artifacts originating from metal reconstruction devices may complicate interpretation of CT images. MRI is even more sensitive to minute magnetic metal pieces, such as those originating from drills or other metal tools. We have used panoramic radiography in combination with detailed panoramic images and cross-sectional tomography.14,18 Close collaboration between clinician and radiologist is beneficial.

Editors Note

Concerning two-screw fixation of segments: Following J. Raveh’s initial preference for the fixation of segments with only 2 hollow screws (owing to the possibilities for bone ingrowth), international clinical experience presently indicates the necessity for a minimum of 3 to 4 screws (hollow or otherwise). The exception remains that 2-screw fixation of only the subcondylar segment is acceptable. For further discussion see Chapter 27.

a

b

c

d

e

f

g

FIGURE 35.11 A large ameloblastoma of the right mandibular angle in a 37-year-old woman was treated by a segmental resection and reconstruction with an AO classic angular plate and multiple nonvascular bone transplants from the iliac crest. (a) A panoramic view of the reconstruction. (b) A diagrammatic representation of

(a). (c) The patient’s mandible after removal of the plate. (d) A diagrammatic representation of (c). (e,f) Rehabilitation of the dentition was performed by dentures. (g) Excellent occlusion, mouth opening, swallowing, mastication, and speech were achieved.

35. Mandibular Body Reconstruction

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