|DENTAL SCIENCE - ORIGINAL ARTICLE
|Year : 2014 | Volume
| Issue : 5 | Page : 39-43
Audit on titanium reconstruction of mandibular defects for jaw lesions
S Arun Paul1, A Kaneesh Karthik2, Rabin Chacko1, Whinny Karunya1
1 Department of Oral and Maxillofacial Surgery, JKK Nattrajah Dental College and Hospital, Komarapalayam, Tamil Nadu, India
2 Department of Dental and Oral Surgery, Unit I, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
|Date of Submission||30-Mar-2014|
|Date of Decision||30-Mar-2014|
|Date of Acceptance||09-Apr-2014|
|Date of Web Publication||25-Jul-2014|
Dr. A Kaneesh Karthik
Department of Dental and Oral Surgery, Unit I, Christian Medical College and Hospital, Vellore, Tamil Nadu
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Aims: The aim of the study is to audit the titanium reconstruction of jaw defects in benign conditions in Christian Medical College and Hospital , Vellore. Methods and Material: A retrospective study of titanium reconstruction of mandibular defects due to jaw lesions at Christian Medical College and Hospital, Vellore, India, between May 2008 and May 2011. Results: Mouth opening, facial symmetry, occlusion, chewing ability, plate exposure and patient satisfaction were used as outcome measures. Conclusions: The three-dimensional titanium plate is a reasonable material for immediate mandible reconstruction after surgical resection of benign jaw pathologies.
Keywords: Titanium, mandible reconstruction, jaw lesions
|How to cite this article:|
Paul S A, Karthik A K, Chacko R, Karunya W. Audit on titanium reconstruction of mandibular defects for jaw lesions. J Pharm Bioall Sci 2014;6, Suppl S1:39-43
|How to cite this URL:|
Paul S A, Karthik A K, Chacko R, Karunya W. Audit on titanium reconstruction of mandibular defects for jaw lesions. J Pharm Bioall Sci [serial online] 2014 [cited 2020 Jun 3];6, Suppl S1:39-43. Available from: http://www.jpbsonline.org/text.asp?2014/6/5/39/137385
Mandibular defects may result from trauma, inflammatory disease, and benign or malignant tumors. Segmental resection of the mandible results in collapse and instability of the remaining segments with the loss of normal facial contour and oral function.  Reconstruction is required for most of these situations failing which mastication, speech, and facial esthetics can be severely compromised. The goal of mandibular reconstruction is to restore facial esthetics form and function, implying repair of mandibular continuity and muscle attachments to enable the patient to achieve a reasonable quality-of-life with early oral functional rehabilitation. Mandibular reconstruction principles and techniques have evolved dramatically over the years. Refinements in techniques continue to improve patient quality-of-life. This audit reviews the outcome of mandibular reconstruction using titanium plates for mandibular defects caused by the resection of jaw lesions.
This audit was conducted to assess the outcome of patients who have undergone mandibular resection for jaw lesions and reconstruction using titanium plates in Department of Dental and Oral Surgery Unit-I, Christian Medical College and Hospital, Vellore, Tamil Nadu.
- To study and evaluate various jaw lesions requiring resection
- To study the reliability of the method of reconstruction in these cases
- To study the outcome of such treatments.
| Materials and Methods|| |
A retrospective study of titanium reconstruction of mandibular defects due to jaw lesions at Christian Medical College and Hospital, Vellore, India, between May 2008 and May 2011. Relevant data were collected and analyzed from the digital database and hospital records of the patients.
Cases requiring titanium reconstruction of the mandible.
Cases requiring microvascular reconstruction of the mandible and reconstruction of nonjaw lesions. Malignant lesions which underwent radiation post-operatively.
The surgical approach involved mandibular reconstruction with a preadapted titanium reconstruction plate.
| Results|| |
Mouth opening, facial symmetry, occlusion, chewing ability, plate exposure, and patient satisfaction were used as outcome measures [Table 1], [Table 2], [Table 3] and [Table 4].
| Discussion|| |
In the series of cases reviewed, post-operative information was available for 32 out of 36 (89%) cases operated. No information was available for four patients. Of the 34 cases operated upon, there were no significant intraoperative complications. In the first post-operative week, 1 case had significant oozing from the drain site and needed to be explored. The hematoma was evacuated and the patient had good post-operative recovery. From the available information, there was no recurrence of the primary lesion in any of the cases for the period followed-up.
From the follow-up information available, it is quite evident that the results of titanium plate mandibular reconstruction are good. The primary outcome measure of success is the survival of the plate maintaining mandibular continuity and without exposure of the plate through the skin or the mucosa.
In this study, none of the cases had plate separation from the bone (indicating good take up of the screw fixation of the plates) at 3 months. At 1 year post-operative review (15 cases) and 2 year review (five cases) again, there was no failure of the plates or of their fixation. This indicates therefore that titanium plates have excellent dimensional stability and strength, resisting breakage from masticatory stresses. It also indicates that titanium screw fixation is the best available method of fixation with no failure related to loosening of screws. It is believed that the excellent biocompatibility of titanium and the phenomenon of osseointegration discovered by Brεnemark et al. are contributory to the success of titanium plate fixation.
There was however, plate exposure through the skin in two cases seen at first follow up (3 months). There was no plate exposure seen in the other patients even at 1 year and 2 year follow up visits. All the patients had good mucosal cover over the plate. One of the cases which developed failure was a case of subacute mandibular osteomyelitis with multiple sinus tracts, which were excised during the surgery. In this case, failure was due to the inadequacy of skin over the plate. Such cases should not be taken up for plate reconstruction. Both the cases with plate exposure had removal of the plates. If restoration of mandibular continuity without plate exposure is the primary criterion of success - there is a 94% rate of success in this series of titanium plate reconstruction [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6] and [Figure 7].
Reconstruction of mandibular defects after trauma or tumor resection is one of the most challenging problems facing reconstructive surgeons. The mandible plays a major role in airway protection and support of the tongue, lower dentition, and the muscles of the floor of the mouth permitting mastication, articulation, deglutition, and respiration. It also defines the contour of the lower third of the face. Interruption of mandibular continuity, therefore, produces both a cosmetic and functional deformity. The resulting dysfunction after the loss of part of the mandible varies from minimal to major. Loss of mandibular continuity results in deviation of the mandible toward the resected side due to the unopposed pull of the remaining muscles of mastication and soft tissue contracture and scar formation. There is limited range of motion when attempting lateral and protrusive movements of the jaw with a return to midline on opening or closing secondary to the remaining contralateral muscles of mastication. In addition, malocclusion and problems with proprioception occur.
In a series of 27 patients  with Titanium plate reconstruction and pectoralis flap cover of the plates undergoing resection and reconstruction following oral carcinoma and also undergoing radiation Salvatori and others reported a success of rate of 78% in terms of mandibular continuity and soft tissue cover with no dehiscence over the plates. The authors believed that their success rate was acceptable and concluded from their study that bridging plate reconstruction is successful, provided the plates are well-covered with viable muscular tissue.
However, when undertaking mandibular reconstruction, the restoration of bony continuity and absence of dehiscence should not be considered the only measure of success. There are three important factors that play a role on the overall success of the reconstruction. First, rigid fixation of the graft is essential. Second, adequate soft tissue ought to be available both in terms of vascularization as well as volume. Third, the volume and contour of the reconstructed bone should mimic the original or desired volume and contour of the resected or missing part as close as possible. 
The functions of chewing, swallowing, speech articulation and oral competence must also be addressed. The ultimate goal of mandibular reconstruction is to return the patient to their previous state of function. In order to achieve this goal, the reconstructive surgeon must attempt to restore bony continuity and facial contour, maintain tongue mobility, and attempt to restore sensation to the denervated areas. Oral rehabilitation post-operatively is important to improve the patient's ability to manipulate the food bolus, swallow, and articulate speech. Dental rehabilitation must also be addressed.
In 1994, Cheung et al.  have reported results of 12 fibula flaps used to reconstruct anterior mandibular defects. The authors noted that the anterior arch of the mandible is a critical area in mandibular function and facial appearance, providing support for the tongue and maintaining support of the lateral portions for effective mastication. The success rate in this series was 100%. In addition, the functional and cosmetic results were rated as excellent or good in 75% of the patients. They recommended use of the fibula osteocutaneous free flap for reconstruction of angle to angle mandibular defects. The opportunity to rehabilitate the dentition with prosthesis also makes this method useful for mandibular reconstruction especially for defects crossing the midline.
| Conclusion|| |
• The three-dimensional, bendable, titanium plate or tray is a reasonable material for immediate mandible reconstruction after surgical resection of jaw pathologies
• Oromandibular reconstruction is a complex procedure with many available options. The reconstructive surgeon must address several concerns before undertaking any reconstructive attempts. The residual soft tissue must provide sufficient bulk and ensure adequate tongue mobility. In addition, the reconstruction must provide sufficient durability and strength to allow resumption of daily activities.
A water-tight closure must be achieved to avoid problems with infection or fistula formation. The training and availability of the reconstructive team must be considered, as well as the time required for reconstruction, the patients long-term prognosis, and the type of defect. Lastly, the overall health status and the desires of the patient must be taken into consideration. Keeping these concerns in mind, it is important for the surgeon to be familiar with a wide range of reconstructive alternatives so that the best procedure for each patient can be chosen.
| References|| |
|1.||Tideman H, Samman N, Cheung LK. Functional reconstruction of the mandible: A modified titanium mesh system. Int J Oral Maxillofac Surg 1998;27:339-45. |
|2.||Brånemark PI, Adell R, Breine U, Hansson BO, Lindström J, Ohlsson A. Intra-osseous anchorage of dental prostheses. I. Experimental studies. Scand J Plast Reconstr Surg 1969;3:81-100. |
|3.||Salvatori P, Motto E, Paradisi S, Zani A, Podrecca S, Molinari R. Oromandibular reconstruction using titanium plate and pectoralis major myocutaneous flap. Acta Otorhinolaryngol Ital 2007;27:227-32. |
|4.||Merkx MA, Fennis JP, Verhagen CM, Stoelinga PJ. Reconstruction of the mandible using preshaped 2.3 mm titanium plates, autogenous particulate cortico-cancellous bone grafts and platelet rich plasma: A report on eight patients. Int J Oral Maxillofac Surg 2004;33:733-9. |
|5.||Cheung SW, Anthony JP, Singer MI. Restoration of anterior mandible with the free fibula osseocutaneous flap. Laryngoscope 1994;104:105-13. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
[Table 1], [Table 2], [Table 3], [Table 4]