Department for Oral and Maxillo-Facial Surgery, University Dental School, University of Zurich, Szcitzerlond

Transcription

1 PRIMARY REPAIR OF THE MANDIBLE BY THE INTRAORAL ROUTE AFTER PARTIAL RESECTION IN CASES WITH AND WITHOUT PRE-OPERATIVE INFECTION 1 By HUGO L. OBWEGESER, M.D., D.M.D. Department for Oral and Maxillo-Facial Surgery, University Dental School, University of Zurich, Szcitzerlond PARTIAL resection of the mandible results in ~esthetic, functional and psychological disabilities to the patient. The remaining part of the mandible will deviate towards the resected side. The face is depressed and some masticatory function can be achieved only by the use of a splint with a training, flange. If the surgeon adopts the usual extraoral approach, disfiguring scars and paralysis of the mandibular branch of the facial nerve may cause additional trauma to the patient. Without immediate reconstruction, Such patients will be unable to pursue their normal way of life either for many months or sometimes for ever. The patient's psychological ability to adjust will depend on the standard of reconstruction. Possible Operative Procedures.win order to avoid the above-mentioned disadvantages as much as possible, their causes have to be eliminated. This can be done by immediate reconstruction of the resected part of the mandible and, by avoiding an external incision, using only the intraoral approach for both resection and immedate reconstruction. Some methods have already 16roved to be successful for the immediate replacement of the resected part of the mandible. Alloplastic material has often proved successful for temporary replacement of part or even the entire mandible. For permanent replacement, however, autogenous rib or iliac crest bone grafts are the best substitute. Whilst the use of long pieces of homologous vital bone grafts results in resorption of implanted bone (Kallenberger, I954; Ullik, x954), a recent report by Russian maxillo-facial surgeons (Plotnikov, x966) indicates successful lyophylised homologous mandibular grafts. Bone transplantation via the oral route was carried out successfully in the case of defects of the upper jaw (Clementschtitsch, I953 ; Schmid, x955) before the antibiotic era. Primary and secondary bone implantation into the defects of cleft lip and palate cases has become a routine procedure. The oral route proved successful also for removal and immediate reconstruction of a greater part of the mandible (Obwegeser, I963, I965a, b, I966 ; Heidsiek, I96t ; Nasteff, I965). In infected cases, successful results were obtained by transplanting cancellous chip grafts (Shira and Frank, I955 ; Gorsky, I959) and even in cases with pre-operative acute or subacute infection primary healing was obtained by removing through the oral route and replacing a great part of the mandible by a decorticated iliac block graft (Obwegeser, I96O). The following observations are based on the experience gained from 15 cases. i. Cases without Infection.wSo far we have had a total of z I such cases. Via the oral route, the involved mandibular segments were removed and replaced with autogenous bone transplants at the same operation. In one of these cases, the bone graft was rejected on account of a secondary infected hmmatoma. Each of the other to cases showed an uninterrupted post-operative history. Two cases will be described to 1 Paper read at the Winter Meeting of the British Association of Plastic Surgeons in London, z

2 PRIMARY REPAIR OF MANDIBLE BY INTRAORAL ROUTE 283 illustrate the above-mentioned course ; one of these especially arouses interest from the point of view of the possibility of growth of a bone graft. Case I (Fig. I, A to G).--A 38-year-old artisan was admitted into our clinic because of a moderate swelling of right mandible and symptoms of spontaneous fracture on that side. He admitted, in his past history, that the tooth 8- had been extracted some 12 years ago. Since then the right mandible had always shown a moderate swelling. In the past few weeks the swelling had increased, and a week before admission, pain during mastication suddetdy appeared. On admission, examination of the patient disclosed : extraorally as well as intraorally a moderate swelling of the ascending ramus and angle of the right mandible. The mandibular FIG. I, A Case i.--case of ameloblastoma in the vicinity of right angle of mandible with spontaneous fracture. In a one-stage operation, resection of turnout with disarticulation of ramus and removal of distal half, of horizontal ramus and simultaneous reconstruction of the defect with iliac block graft via the oral route only. A, Radiograph before and after operation. margin was slightly tender to pressure. Neither a fistula nor suppuration was evident. The oral mucosa was normak The mandibular segment posterior to the right row of teeth showed an abnormal mobility. Sensation of the lower lip was normal on both sides. In addition, all teeth of the right side of the mandible with the exception of the first bicuspid were vital. Radiographic findings revealed a relatively well-defined area of rarefaction of more than 2 cm. situated just in front of the angle of the right mandible. In this zone of radiolucency, there was seen a probable line of fracture. It was not possible to aspirate any fluid with a syringe. The histological section of an excisional biopsy showed an ameloblastoma. After fixing splints in position in both upper and lower jaws, under nasoendotracheal anaesthesia, the mandible was approached from the intraoral route and sectioned in the vicinity of the right second bicuspid. The bone segment, with periosteum, was completely removed along with the soft tissue surrounding the tumour and a sheath of mucous membrane. In order not to fracture during section the mandible at the weakened tumour site, the coronoid process and condyle were previously dissected separately. After removal of the diseased bone section, the condyle was disarticulated via the intraoral route. A bone graft was obtained from the right iliac crest and trimmed to the shape of the resected fragment. Its cortex was partially removed with a burr. IntermaxiUary fixation was used to maintain the remaining mandibular

3 284 BRITISH JOURNAL OF PLASTIC SURGERY fragment in central occlusion and then the shaped bone transplant was placed in the defect. This was done in such a way that a broad surface of contact was established between the bone transplant and the remaining mandibular segment. The upper end of the bone transplant FIG. I, B to E B, Patient's front view before the operation. C, Patient's front view after the operation. D, Profile from the operated side, after the operation. E, Profile from the non-operated side, after the operation. was pressed against the meniscus which was resting undisturbed in the glenoid fossa. A catheter drain was introduced. In order to adapt carefully the subcutaneous tissue to the transplanted bone, the stitches were led beyond the mandible, pulled through the skin and knotted over buttons. The mucosa readily yielded to closure. The patient received postoperatively mg. tetracycline daily for 7 days. Apart from occasional nausea until withdrawal of the tetracycline medication, progress was normal. The intermaxillary fixation

4 PRIMARY REPAIR OF MANDIBLE BY INTRAORAL ROUTE 285 was removed after six weeks. Intensive after-treatment with orthodontic applicances brought a rewarding result of perfect mouth opening. The occlusion was normal and opening of the mouth without lateral deviation. Perfect contour of the lower jaw was established without any difference between the right and left side. Case 2.--A I2-year-old boy. Because of the remarkable findings in this case, it is described again, although its history and photographs have already been published (Obwegeser, 1963, I965b). The boy was referred to me with the history of rapid tumour growth at the right angle and ramus region and with the histological diagnosis of" chondroblastoma ". The beginning of abnormal growth was noticed some six months before. There was nothing of significance in a general examination. Oral examination disclosed an elastic tumour swelling 2 cm. in diameter growing out from the mandible in the area of the right angle. Because of this swelling, normal occlusion was not possible. The overlying mucosa was firmly attached to the lesion. Roentgenograms suggested a tumour process in the right angle region extending through the alveolar process into the ramus up to the mandibular notch. In June 1962, after splints had been attached to both the upper and lower jaw, the right mandible was disarticulated and cut through at the right mental foramen via the oral approach. The overlying mucosa along with a part of the soft tissue surrounding the tumour, the periosteum and the bone were all removed at the same time. With a transplant from the iliac crest the defect was filled at the same operation. The bone graft was modelled to the resected piece. Before its introduction into the vacant bed, its cortex was, to a large extent, removed with a burr. The mandible having been fixed in the proper occlusion, special care was taken to ensure that the bone fitted snugly in the glenoid fossa. A catheter drain was inserted, and then the soft tissues were carefully sutured. Subcutaneous sutures placed around the transplanted bone and extending out to the skin were used to secure good circular apposition of soft tissues. Post-operatively, the patient received I g. of chloramphenicol daily for five days. The post-operative course was uneventful. After six weeks of intermaxillary fixation it was evident that the transplant had been tolerated and had grown into the rest of the mandible. An intensive after-treatment with orthodontic appliances brought about a normal opening of the mouth without lateral deviation. In the meantime, 4½ years have passed and the little boy has grown into a young man. Nothing has changed in the occlusion. Mandibular opening is normal and the forward and lateral excursion in both temporomandibular joints is good. Although ihitially the contour of the reconstructed side showed more prominently than that

5 286 BRITISH JOURNAL OF PLASTIC SURGERY of the healthy side, it has with time, undergone mild changes and is today rather somewhat flattened; however, it is not conspicuous in comparison with the other side. Only in the area innervated by the mental nerve is hypomsthesia existent. The graft at the time of insertion had a small amount of cortical plate on the lateral area in the condylar region. The graft was shaped in the form of a condyle even to the extent of reproducing the neck in contour. Rcentgenographically this area of the graft has now formed a normal appearing condylar shape as well as a complete cortication. A noticeable coronoidlike process has forme d also. Its upper end primarily shaped like a condyle has not altered its form and appears covered with a cortical layer and has also re-assumed the form. The condyle, which clearly lies in the glenoid fossa during mandibular closure, glides forward when the mouth is opened. In my opinion these facts can only be interpreted as evidence that the transplant has grown just as well as have the other parts of the facial skeleton. II. Cases with Pre-operative Infection.--We have, in four cases, carried out simultaneous resection and reconstruction~ performed through an intraoral approach, although the diseased mandibular segment and its surrounding soft tissues showed evidence of acute or subacute suppurative inflammation prior to the resection. In one of these cases, we had to remove the bone graft because ofosteomyelitis of the transplant. While two of the cases, despite the existent massive pre-operative infection, were completely successful, the third case is specially instructive, and I would therefore like to go into more details about the pre- and post-operative course, although this, like Case 2, has already been described elsewhere (Obwegeser, I965b). Case 3 (Fig. 2, A to D).--The patient was a housewife aged 3 o. For the previous IO years her mandibular opening had been practically nil. Several attempts had been made to remove an ameloblastoma of the right ramus. A year before the patient was referred she received radiation therapy because of a fresh recurrence. On admission we found almost no opening of the mouth, but slight abnormal mobility in the area of the right ramus. The skin above the right ramus was pale and rather atrophic, and there were a few small subcutaneous abscesses. Intraorally there was a wide opening leading into the depth of the ramus. Pressure produced a flow of purulent material. 'Radiographic examinations confirmed the clinical diagnosis of radio-osteomyelitis of right mandibular ramus with fracture. Naso-endotracheal anaesthesia. The large fistula in the mouth cavity was cut around and the mandible divided in the vicinity of the molars and disarticulated along with the surrounding soft tissues. Because of the existing fracture, it became necessary to make an additional marginal incision at the tragus in order to cut through the capsule. After intermaxillary immobilisation of the rest of the mandible, a piece of bone, taken from the iliac crest, was inserted in the vacant space as a substitute. Before insertion, the transplant was largely shelled of its cortex. A large contacting surface to the mandible was provided. At the site of apposition, spongiosa pulp was inserted. Transosseous wiring kept the transplant in position. After swabbing of the site of operation with a solution of tetracycline, a catheter drain was inserted and the incision carefully sutured. Because of an extensive loss of mucosa, it became necessary to mobilise a flap from the remaining mucosa. Circumferential sutures which led out to the face adapted the soft tissues to the transplant. The patient received daily 2 x 275 mg. of tetracycline intravenously. Seven days later, the following report came from the bacteriological culture of the pus taken during the operation : " Tetracycline-resistant staphylococci ". This implied that the antibiotic therapy probably had no influence on the germs present at the time of grafting. None the less, the clinical course was uneventful. We deemed it wise, for the next five days only, to give I½ g. ofchloramphenicol daily and then to cease completely all antibiotic therapy. Two weeks after operation, a fistula was discovered near the mucosa of the vestibulum at the side of the former incision line. Because of special circumstances, surgical revision was only possible one week later. In the meantime, two small subcutaneous abscesses had made their appearance on the cheek. These spontaneously discharged pus containing a small bone sequestrum. At the revision, the bone

6 PRIMARY REPAIR OF MANDIBLE BY INTRAORAL ROUTE 287 FIG. 2 Case 2.--Radio-osteonecrosis of right ramus with spontaneous fracture and wide communication into the mouth in a case of ameloblastoma with history of I0 years' therapy. A, Condition of ramus after surgery and radiotherapy of ameloblastoma. B, Shape of reconstructed ramus and its relationship to condylar fossa after one-stage operation for resection and reconstruction via the oral route. C, Condition before operation. Note swelling of right ramus area. D, Condition one year after operation. Slight depression of right ramus area is due to atrophy of soft tissues after radiotherapy.

7 288 BRITISH JOURNAL OF PLASTIC SURGERY transplant was found with normal blood supply. The bone wiring was removed at the same time. It is probable that the fistula arose from a small bone sequestrum which may have broken off from the end of the resected mandibular ramus. The wound was no longer sutured. The exposed bone was packed with chlortetracycline gauze coated with Vaseline petroleum jelly. Granulation tissue grew from the transplanted bone and finally, six weeks after the operation, uneventful healing occurred with bony consolidation. Post-operative treatment to obtain a normal mouth opening was relatively difficult. At present, two years after the operation, the mouth opening and the occlusion are normal and the mandibular contour is good. Failures.--As already mentioned, out of a total number of 15 cases, there were two failures. In one case, it was a question of chronic osteomyelitis of the mandible with spontaneous fracture. Consequent upon the long continuance of inflammation, the bone in the mouth was exposed, the surrounding soft tissue cicatrised and evidence of inflammatory infiltration was present. In spite of the generous mobilisation of the soft tissue to cover the bone graft, within a week of the suturing a dehiscence ensued which could no longer be closed. Daily irrigation of the bone transplant with a solution of tetracycline and oral application of I½ g. of chloramphenicol could not save the bone graft which had to be removed six weeks after its insertion. The second failure was a case of synovioma laterally situated in the vicinity of the chin and warranting a mandibular resection from the right canine to just in front of the left angle of the jaw. This defect was then repaired with a bone transplant from the iliac crest. At the close of the operation, it appeared as if conditions were favourable for uncomplicated healing. A catheter drain was therefore deemed unnecessary. The patient received I½ g. of chloramphenicol daily. For seven days the post-operative course was very satisfactory. But the eighth day brought with it an acute hmmatoma which peeled off a considerable portion of the soft tissue surrounding the bone. The hmmatoma was evacuated and thereafter a catheter drain was introduced for two weeks. In spite of intensive antibiotic therapy, guided by cultures of bacteria repeatedly carried out to determine their resistance, the bone graft finally had to be removed because of osteomyelitic destruction. CONCLUSION AND SUMMARY It is my opinion that the same degree of success can be obtained with an intraoral simultaneous resection and grafting of part of the mandible as with an extraoral approach. Infection is not a factor which warrants delayed grafting. Success cannot be exclusively attributed to antibiotic therapy. Further, where treatment with antibiotics is insufficient, the bone transplant can still be incorporated. Even when the bone and soft tissues are infected and radiation damage is present, successful grafting has been accomplished. On the other hand, it appears as if massive antibiotic therapy cannot bring under control an already existent infection of the bone graft. Backed by the history of Case 2, we believe all the more that we can assume that in this case the transplanted bone showed normal growth with the rest of the facial skeleton. I wish to express my best thanks to Dr A. L. Nwoku for his great help in translating this paper into English.

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