Cementifying fibroma: resection of recurrent mandibular lesion with microsurgical preservation of inferior alveolar nerve and immediate reconstruction

Cementifying fibroma is a benign fibro-osseous lesion that may occur in either the mandible or the maxilla, with a predilection for the mandible. In the patient described, a recurrent mandibular cementifying fibroma was successfully resected, with microsurgical preservation of the inferior alveolar nerve and immediate reconstruction via an autogenous iliac bone graft.

Odontogenic myxoma of the mandible. Report of a case and review of the literature

The authors describe the case of an odontogenic myxoma occurring in a 30-year-old man and review the literature on the subject. They detail the radiological aspects of this neoplasms, the problems concerning its etiopathogenesis and the different microscopical patterns.

Assessment of trigeminal nerve function by means of short-latency somatosensory evoked potentials after microneurosurgical repair

In order to evaluate accurately trigeminal nerve damage and the response to microneurosurgical treatment, a reproducible, objective test of trigeminal nerve function is required. This study investigates the use of somatosensory evoked potentials as an objective monitor of trigeminal nerve function after microneurosurgical repair. We examined 10 patients, all but 1 treated for gnathic disorders, in whom a severe iatrogenic injury to the inferior alveolar nerve occurred unilaterally. One patient underwent partial mandibulectomy with sacrifice of the nerve because of a malignant tumour. A significant difference in trigeminal somatosensory evoked potential latencies after stimulation of the normal side of the lower jaw compared with the response after stimulation of the affected side was to be expected. Immediate microneurosurgical repair was carried out in 7 patients. The trigeminal somatosensory evoked potential latencies after right and left sided stimulation of the mandible did not differ significantly after subjective successful microneurosurgical repair. Somatosensory evoked potential testing appears to represent an objective method of evaluating trigeminal nerve function, in particular in relation to microneurosurgical procedures. The results of trigeminal testing should improve after technical refinement.

Clear cell variant of calcifying epithelial odontogenic tumor: case report and review of the literature

The calcifying epithelial odontogenic tumor (CEOT) is a rare benign odontogenic neoplasm which was first described by Pindborg in 1955 and accounts for less than 1% of all odontogenic lesions. Recently, a clear cell variant of CEOT has been identified with only eight well-documented cases in the literature. We present an additional case of clear cell CEOT of the mandible and review the salient clinical, radiologic, and histopathologic features of this entity and CEOTs in general. The differential diagnosis of clear cell tumors in the mandible includes: clear cell odontogenic tumor, clear cell ameloblastoma (odontogenic carcinoma), metastatic clear cell adenocarcinoma, primary intraosseous mucoepidermoid carcinoma, acinic cell carcinoma, epithelial-myoepithelial carcinoma, clear cell salivary gland tumors, and clear cell variant of squamous cell carcinoma. Because of the belief that clear cell odontogenic tumors are locally aggressive neoplasms, definitive resection of the entire mass with tumor-free surgical margins and long-term follow-up are recommended.

Advantages of mandibular reconstruction with the titanium hollow screw osseointegrating reconstruction plate (THORP)

Alloplastic reconstruction following segmental mandibulectomy is a simple way to maintain mandibular segmental relationships, partially preserving form and function for many patients. This study is a retrospective review of 40 patients who had mandibular reconstruction with metal plates over a 6-year period (April 1986 through August 1992). The results of reconstruction with titanium hollow-screw osseointegrating reconstruction plates (THORP [n = 12]) and solid screw (SS) steel and titanium plates (n = 28) are compared. One THORP has been removed as compared to 14 SS plates. While the improved results with THORP may be attributable in part to its advanced design, the success of soft-tissue reconstruction and tumor extirpation are important factors in the early outcome seen in this series. Longer follow-up is needed to determine if THORP can serve as a permanent implant. THORP is the authors' method of choice for alloplastic mandibular reconstruction.

Measurement of mandibular bone density after iliac crest grafting

Nonvascularized and microsurgically revascularized iliac bone grafts used for mandibular reconstruction behave differently during healing. Quantitative computer tomography (QCT) was used to investigate these differences with respect to mineralization and macrostructure of the grafts after a period of adequate functional loading. It was shown that in nonvascularized grafts, reactive sclerosis occurs, as a sign of an irregularly reparative metaplastic process and mineralization. In comparison with the intact iliac crest, the bone density of the graft was markedly increased. The microsurgically revascularized grafts, however, showed retention of structural differentiation into homogeneous cancellous bone, and a smoothly demarcated cortex with essentially unchanged bone density. Possible explanations of these differences are discussed.

Condyle transplantation in free flap mandible reconstruction

Fourteen patients requiring hemimandible resection were reconstructed with bone free flaps onto which the resected condyle was mounted as a nonvascularized graft. Postoperative mandible function, facial aesthetics, and patient symptoms were reviewed. The follow-up period ranged from 13 to 56 months (average 30.4 months). Interincisal opening ranged from 25 to 52 mm (average 37.10 mm). Opening ability inversely correlated with a need for intraoral soft tissue replacement and with the administration of postoperative radiation therapy. Eight patients were available for late study of the transplanted condyle with lateral tomograms and computed tomographic scans. Condyle volume diminished considerably in some, but this did not correlate with a decrease in function. Dual joint function and preoperative occlusion were maintained long term with this technique. Aesthetic results were enhanced by the contribution of the transplanted condyle to improved accuracy of free flap bone graft fabrication and insetting. There were neither postoperative morbidity nor abnormal symptoms due to the use of the condyle as a nonvascularized graft. This study demonstrates the effectiveness and safety of condyle transplantation in free flap mandible reconstruction.

Formation of double contour in the human mandibular condyle. A case report

This is the first report of double contour formation in the human mandibular condyle that includes both radiographic and histologic confirmation. Panoramic radiographs showed an additional cortical layer formation on the posterior of the condyle during follow-up after displacement of the condyle. Two cortical layers on the posterior portion of the condyle were demonstrated on the histologic specimen. The outer layer consisted of a few lamellated bone layers and included many osteocytes. However, minimal fibroconnective tissue was seen, and there was no cartilage layer. We concluded that the double contour formation was not caused by endochondral ossification but by periosteal bone formation.

Mandibular reconstruction with the Dacron urethane tray: a radiologic assessment of bone remodeling

A retrospective study was made of 22 consecutive patients who underwent mandibular reconstruction with a Dacron (Osteo-mesh, Xomed Inc, Jacksonville, FL) tray technique from September 1988 to April 1992. Free autogenous iliac bone, in the form of particulate cancellous chips and marrow, was densely packed into the Dacron tray, that was adapted to bridge the mandibular segmental defect. Sixteen cases underwent uneventful healing with the formation of a continuous bony bridge and union with the remaining mandible. The pattern of bone remodeling and rate of resorption in these cases were assessed by sequential panoramic radiographs taken up to 3 years postoperatively. The mean horizontal dimension of the mandibular defects was 75 mm and the mean vertical reconstructed height was 25 mm. When the grafted bone was radiographically of uniform density, it progressed into a mature trabecular pattern matching that of the normal mandible. However, when there were areas of radiolucency, most likely from inadequate condensation of the graft, such areas were not replaced by bone in the long term. The bony height at both ends and the middle of the reconstructed segment underwent reasonably even resorption and retained about 80% of the bony height over a 3-year period. The rate of resorption was highest in the first 6 months and stabilized at about 2 years. There were six failures, all showing significant irregular bony resorption prior to tray removal.

Fibromatosis of the oral and paraoral region

The fibromatoses represent a group of infiltrating fibrous proliferations that exhibit a clinical behavior and biologic potential intermediate between benign fibrous lesions and fibrosarcoma. The head and neck region is a common site of involvement for these lesions especially in children and young adults. However, the oral structures per se are not often the site of origin. In this study of 31 cases of fibromatosis that involved the oral and paraoral region, patient ages ranged from birth to 51 years with 74% appearing in the first decade. The most common clinical presentation was a painless mass that involved the cheek, tongue, or submandibular region. Erosion of bone was a frequent finding in lesions arising in soft tissue contiguous with the jaws. After surgical excision, lesions recurred in five patients for a recurrence rate of 23.8%. One lesion recurred twice. The average interval from initial treatment to recurrence was 7.6 months. The recurrence rate observed in this series is significantly lower than that generally reported for fibromatosis of the head and neck (50% to 70%). This is most likely due to the exclusion in this investigation of lesions in the supraclavicular region.

Endosteal implants following tumor surgery and avulsive trauma

Endosteal implants are part of the reconstructive armamentarium used by head and neck surgical teams in cases of trauma or tumor ablation when inadequate residual anatomy prevents the fabrication of a traditional prosthesis. Three cases of implant supported prosthesis have been presented. Use of endosteal implants is an additional step toward functional reconstruction.

Microsurgical and prosthetic reconstruction of patient with recurrent ameloblastoma extending into the skull base

A patient with recurrent ameloblastoma extending into the skull base is presented. An interdisciplinary treatment strategy is described, which included proper diagnosis by computed tomography (CT) and magnetic resonance imaging (MRI) scans and radical resection of the tumor in cooperation with the neurosurgeon, followed by reconstruction with microsurgical methods, and prosthetic rehabilitation based on an implant-supported epithesis.

Cystic pleomorphic adenoma of the mandible

A cystic pleomorphic adenoma of the posterior mandibular alveolar ridge of a 73-year-old white man is reported. This tumor presented considerable diagnostic problems which may have consequences in treatment in similar cases.

Predictors of carcinomatous invasion of the mandible

The preoperative assessment of mandibular invasion by oral or oropharyngeal squamous cell carcinoma poses a challenge for the head and neck surgeon. A study of 64 composite resection patients was performed to determine which variables in the patient's history, physical exam, and diagnostic workup had a predictive association with carcinomatous mandibular invasion. Four postoperative variables were included in this analysis. Thirty-nine percent of the mandibular specimens demonstrated cancerous involvement. A multivariate recursive partitioning statistical analysis was performed to create a decision tree. Branching was based on the two statistically predictive variables: computed tomographic (CT) scan results and primary tumor location. The guide provides improved predictive accuracy with a 100% negative predictive value (NPV) and a 46% positive predictive value (PPV). This decision guide should help the surgeon provide accurate patient counseling, anticipate reconstructive needs, and maximize surgical oncologic effectiveness.

Desmoplastic fibroma. A rare oral tumor in children

A report on confirmed cases of desmoplastic fibroma in a 30-month-old male and a nine-year-old male, both of which responded well to surgical therapy and neither of which has shown signs of recurrence. A 10-year clinical and radiographic follow-up is included.

Achieving mandibular continuity with vascular bone flaps: a comparison of primary and secondary reconstruction

This retrospective study was performed to compare the functional and aesthetic results achieved in two distinct groups of patients undergoing composite reconstruction of complex head and neck defects using vascularized bone flaps. Fourteen consecutive patients undergoing reconstruction over a 30-month period (January 1988 through June 1991), nine primary and five secondary, were analyzed. The two groups were similar with respect to age, physical status, tumor type and stage, exposure to radiation, and previous history of cigarette smoking and alcohol consumption. The bone defect was similar between the two groups, but the soft tissue deficit was greater in the group of patients reconstructed secondarily. Surgery time and blood loss tended to be less in the patients reconstructed secondarily, but length of hospitalization was similar. Flap survival was 100%, although the complication rate approached 60%. Restoration of mandibular continuity and orofacial soft tissue defects with vascularized composite free flaps had a favorable impact on function and aesthetics in the group of patients reconstructed primarily. In those reconstructed secondarily the benefit was primarily cosmetic. Continued emphasis on primary reconstruction of the composite defect with composite free tissue transfers is advised.

Fibula osteoseptocutaneous flap for reconstruction of composite mandibular defects

The fibula osteoseptocutaneous flap is a versatile method for reconstruction of composite-tissue defects of the mandible. The vascularized fibula can be osteotomized to permit contouring of any mandibular defect. The skin flap is reliable and can be used to resurface intraoral, extraoral, or both intraoral and extraoral defects. Twenty-seven fibula osteoseptocutaneous flaps were used for composite mandibular reconstructions in 25 patients. All the defects were reconstructed primarily following resection of oral cancers (23), excision of radiation-induced osteonecrotic lesions (2), excision of a chronic osteomyelitic lesion (1), or postinfective mandibular hypoplasia (1). The mandibular defects were between 6 and 14 cm in length. The number of fibular osteotomy sites ranged from one to three. All patients had associated soft-tissue losses. Six of the reconstructions had only oral lining defects, and 1 had only an external facial defect, while 18 had both lining and skin defects. Five patients used the skin portion of the fibula osteoseptocutaneous flaps for both oral lining and external facial reconstruction, while 13 patients required a second simultaneous free skin or musculocutaneous flap because of the size of the defects. Four of these flaps used the distal runoff of the peroneal pedicles as the recipient vessels. There was one total flap failure (96.3 percent success). There were no instances of isolated partial or complete skin necrosis. All osteotomy sites healed primarily. The contour of the mandibles was good to excellent.

Osteomyocutaneous flap reconstruction for major mandibular defects

Mandibular defects after composite resections for carcinoma of the buccal mucosa require immediate restitution of both form and function with an acceptable cosmetic result. The pectoralis major osteomyocutaneous flap (PM-OMC) provides restoration of bone, soft tissue and skin with minimum morbidity. The procedure is technically simple, and in our series reconstruction using this flap has been performed by consultants, fellows and residents in training. We present a series of 116 PM-OMC flaps with good postoperative mastication in more than 70% of cases, and satisfactory swallowing and intelligible speech in 85% patients.

The place of the iliac crest in vascularized oromandibular reconstruction

The iliac crest is reevaluated with respect to the rapid evolution of vascularized mandibular reconstruction. With more flaps to choose from, indications for the crest have become more specific-playing to the strengths of this particular transfer. Ideally, defects should exclude soft tissue and occupy lateral segments of the mandibular arch-up to and including a complete hemimandible. The composite flap is capable of reconstructing external skin with ease, but the color match leaves something to be desired. Mucosal defects are less well handled. The flap can replace soft tissue bulk as well as mandibular height following through-and-through excisions in the region of the chin. Where donor site cosmesis is of paramount importance, the iliac crest is simply the best flap available.

[Periosteal osteosarcoma of the jaw. Apropos of 2 cases]

The authors report two cases of periosteal osteosarcoma of the jaws, a tumour which is one of the two variants of juxtacortical osteosarcoma. Periosteal osteosarcoma involving the jaw bones is extremely rare. Because of its chondroblastic differentiation, sometimes predominant, this tumour may pose some problems of differential diagnosis with chondrosarcoma or pleomorphic adenoma: immunochemistry may be necessary. This localization does not change the clinical, radiologic, histologic and prognostic features of periosteal osteosarcoma.

Fibula osteoseptocutaneous flap for mandible reconstruction

The fibula free flap has become an established flap for mandible reconstruction when vascularized bone is desirable. Recreating mandibular contour, providing soft tissue coverage, and restoring masticatory function are equally important in mandible reconstruction, and these can be provided by the fibula osteoseptocutaneous flap. This article is a summary of the anatomy, indications, and operative technique of the fibula osteoseptocutaneous flap accumulated from 49 consecutive mandible reconstructions.