Self-regeneration of the mandible following hemimandibulectomy for ameloblastoma: a case report and review of literature

Review of the Literature on the Current State of Periosteum-Mediated Craniofacial Bone Regeneration

Study Design

This is an article review on the current state of periosteum-mediated bone regeneration (PMBR). It is a known mandibular reconstruction option in children, and though poorly understood and unpredictable, the concerns of developmental changes to donor and recipient tissues shared by other treatment options are nonexistent. The definitive role of periosteum during bone regeneration remains largely unknown.

Objective

The objective is to review the literature on the clinical and molecular mechanism evidence of this event.

Methods

Our search methodology was modeled after the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analysis) guidelines. Search strategies were categorized into search 1 for clinical evidence of mandibular regeneration and search 2 for gene expression review for craniofacial regeneration. The quality assessment of each publication was undertaken, and inclusion criteria comprise mandibular continuity defect for search 1 and use of gene expression assay propriety kit for search 2.

Results

33 studies were selected for search 1 while four studies with non-human subjects were selected for search 2. Monitoring of PMBR onset was advised at 2 weeks post-operative, and the gene expression results showed an upregulation of genes responsible for angiogenesis, cytokine activities, and immune-inflammatory response in week 1 and skeletal development and signaling pathways in week 2.

Conclusions

The results suggest that young periosteum has a higher probability of PMBR than adult periosteum, and skeletal morphogenesis regulated by skeletal developmental genes and pathways may characterize the gene expression patterns of PMBR.

Genetic determinants of periosteum-mediated craniofacial bone regeneration: a systematic review

BACKGROUND

Periosteum-mediated bone regeneration (PMBR) is a recognized method for mandibular reconstruction. Despite its unpredictable nature and the limited degree to which it is understood, it does not share the concerns of developmental changes to donor and recipient tissues that other treatment options do. The definitive role of the periosteum in bone regeneration in any mammal remains largely unexplored. The purpose of this study was to identify the genetic determinants of PMBR in mammals through a systematic review.

METHODS

Our search methodology was designed in accordance with the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analysis) guidelines. We conducted a quality assessment of each publication, and evaluated the differences in gene expression between days 7 and 15.

RESULTS

A total of four studies satisfied the inclusion criteria. The subjects and tissues examined in these studies were Wistar rat calvaria in two studies, mini-pigs in one study, and calves and mice in one study. Three out of the four studies achieved the necessary quality score of ≥ 3. Gene expression analysis showed increased activity of genes responsible for angiogenesis, cytokine activities, and immune-inflammatory responses on day 7. Additionally, genes related to skeletal development and signaling pathways were upregulated on day 15. Conclusions: The results suggest that skeletal morphogenesis is regulated by genes associated with skeletal development, and the gene expression patterns of PMBR may be characterized by specific pathways.

Continuous dynamic identification of key genes and molecular signaling pathways of periosteum in guided bone self-generation in swine model

BACKGROUND

Guided bone self-generation with periosteum-preserved has successfully regenerated mandibular, temporomandibular and interphalangeal joint. The aim of this study was to investigate the dynamic changes of gene expression of periosteum which was involved in the guided bone self-generation.

METHODS

Rib defects of critical size were created in mature swine with periosteum-preserved. The periosteum was sutured into a sealed sheath that closed the bone defect. The periosteum of trauma and control sites were harvested at postoperative 9 time points, and total RNA was extracted. Microarray analysis was conducted to identify the differences in the transcriptome of different time points between two groups.

RESULTS

The differentially expressed genes (DEGs) between control and trauma group were different at postoperative different time points. The dynamic changes of the number of DEGs fluctuated a lot. There were 3 volatility peaks, and we chose 3 time points of DEG number peak (1 week, 5 weeks and 6 months) to study the functions of DEGs. Oxidoreductase activity, oxidation-reduction process and mitochondrion are the most enriched terms of Go analysis. The major signaling pathways of DEGs enrichment include oxidative phosphorylation, PI3K-Akt signaling pathway, osteoclast differentiation pathway and Wnt signaling.

CONCLUSIONS

The oxidoreductase reaction was activated during this bone regeneration process. The oxidative phosphorylation, PI3K-Akt signaling pathway, osteoclast differentiation pathway and Wnt signaling may play important roles in the guided bone self-generation with periosteum-preserved. This study can provide a reference for how to improve the application of this concept of bone regeneration.

Recurrent osteomyelitis with proliferative periostitis after segmental resection and reconstruction of the mandible: a case report

A 50-year-old patient presented with a two-year history of chronic osteomyelitis of the left mandibular body. It was treated by wide segmental resection of the left hemimandible and reconstruction with a free vascularized fibular graft. Six months after surgery, the patient returned with pain, swelling, and moth-like lesions in the transplant in combination with appositional bone formation surrounding the ossified fibular bone. Radiographic and histological examination led to the diagnosis of a recurrent osteomyelitis with proliferative periostitis affecting the resected and reconstructed mandible. Application of ibandronate led to a significant symptom decrease.

The "Phoenix Jaw" Phenomenon Revisited: Two Cases of Bisphosphonate-Related Mandible Osteonecrosis Surgically Treated with Complete Bone Regeneration

Bisphosphonate-related osteonecrosis of the jaws represents a well-recognized complication occurring in patients being administered drugs for the treatment of osteoporosis and/or malignant disease. Treatment of this condition, aiming to alleviate the symptoms and restore functional status, represents a challenge for the maxillofacial surgeon. Conservative management has been proposed for early stages of this condition, while surgical intervention is mandatory for advanced disease. Two cases of severe bisphosphonate-related osteonecrosis of the jaw that achieved complete osseous recontouring after partial mandibulectomy, are presented.

Complete Spontaneous Bone Regeneration following Surgical Enucleation of a Mandibular Cemento-Ossifying Fibroma

Background

Cemento-ossifying fibroma (COF) is a type of benign fibro-osseous tumor that mainly occurs in the maxillofacial region. Bone reconstruction after the surgery is often performed with bone transplantation. However, the present case report describes the accurate diagnosis and successful surgical resection of a COF with periosteum preservation, after which the defect was completely and spontaneously filled with the newly formed bone through a natural process. Case Presentation. A 32-year-old Iranian female patient presented with a history of gradual development of painful swelling, spontaneous pain, and lower lip and chin hypoesthesia in the lower third of the left side of her face. The dome-shaped swelling was tender. The patient was suffering from renal infection and urethral prolapse and was taking folic acid. She also mentioned a positive family history of similar swellings in her mother and uncle. Intraoral examination indicated a lesion in buccal and lingual vestibules extending from the first premolar to the third molar teeth. It had a firm consistency, and the covering mucosa was normal in terms of color and texture. The aspiration test was negative. The lesion had caused severe mobility of the second premolar and first and second molar teeth. Panoramic radiography revealed an extensive well-defined unilocular radiolucency. Significant knife-edge resorption of the first and second molar roots at the involved site and thinning of the alveolar crest and inferior border of the mandible were also clear. Cone-beam computed tomography showed severe expansion in the buccal and moderate expansion in the lingual aspect, causing thinning of both the buccal and lingual cortical plates. Histopathological analysis revealed neoplastic tissue mixed with fibrous connective tissue and several round and oval-shaped calcification foci. Immunohistochemical analysis confirmed the final diagnosis (COF) with the presence of SMA-8. The lesion was removed by enucleation and curettage, while the periosteum was carefully preserved. Fixation with screw and plate was also performed.

Conclusions

Correct diagnosis of COF and precise implementation of the periosteal osteogenesis technique, in this case, resulted in entirely and spontaneously bone regeneration, which was a rare and favorable outcome with minimum cost and complications for the patient.

Free Periosteal Flaps with Scaffold: An Overlooked Armamentarium for Maxillary and Mandibular Reconstruction

Simple Summary

Head and neck bone reconstruction with revascularized free periosteal flaps and scaffold is an overlooked option in the literature. Aim of the present paper was to systematically analyse the results of maxillary and mandibular reconstruction with this technique. We found a total of 7 studies with 55 patients fitting with our inclusion criteria. The overall rate of complications was 43.7%. The success rate intended as scaffold integration resulted to be 74.5%. Our paper therefore highlighted that maxillary and mandibular reconstruction with revascularized free periosteal flaps and scaffold is a possible alternative in patient unable to bone free flap complex reconstruction, with a success rate higher to that of other secondary options.

Abstract

Introduction: Head and neck bone reconstruction is a challenging surgical scenario. Although several strategies have been described in the literature, bone free flaps (BFFs) have become the preferred technique for large defects. Revascularized free periosteal flaps (FPFs) with support scaffold represents a possible alternative in compromised patient, BFF failure, or relapsing cancers as salvage treatment. However, only few clinical applications in head and neck are reported in literature. Purpose of the study was to systematically analyse the results of functional and oncologic maxillary and mandibular reconstruction with FPF with scaffold. Materials and Methods: A comprehensive review of the dedicated literature was performed according to the PRISMA guidelines searching on Scopus, PubMed/MEDLINE, Cochrane Library, Embase, Researchgate and Google Scholar databases using relevant keywords, phrases and medical subject headings (MeSH) terms. An excursus on the most valuable FPF’ harvesting sites was also carried out. Results: A total of 7 studies with 55 patients were included. Overall, the majority of the patients (n = 54, 98.1%) underwent an FPF reconstruction of the mandibular site. The most used technique was the radial forearm FPF with autologous frozen bone as scaffold (n = 40, 72.7%). The overall rate of complications was 43.7%. The success rate intended as scaffold integration resulted to be 74.5%. Conclusions: Maxillary and mandibular reconstruction with FPF and scaffold is a possible alternative in patient unfit for complex BFF reconstruction and it should be considered as a valid alternative in the sequential salvage surgery for locally advanced cancer. Moreover, it opens future scenarios in head and neck reconstructive surgery, as a promising tool that can be modelled to tailor complex 3D defects, with less morbidities to the donor site.

Actinomycotic osteomyelitis with proliferative periostitis arising in the mandibular ramus: an unusual case with spontaneous bone regeneration after coronoidectomy

Actinomycotic osteomyelitis is an aggressive and persistent disease capable of invading and destroying bone, and chronic osteomyelitis with proliferative periostitis represents new bone formation with periosteal reaction. We report a rare case of actinomycotic osteomyelitis with proliferative periostitis arising in the mandibular ramus and spontaneous bone regeneration after coronoidectomy. A 14-year-old girl was referred for swelling in the right parotid-masseteric region and severe trismus. Contrast-enhanced CT revealed that heterogenous enhancement of the right masseter muscle, and a reactive bone formation over the lateral cortex of the right mandibular ramus and osteolysis of the condyle were seen in plain CT. MRI showed that the mandibular ramus was a low-signal intensity and the reactive bone on the ramus was signal intensity similar to muscle on T1-weighted images. The lesion was clinically and radiologically diagnosed as chronic osteomyelitis of the mandibular ramus. However, a biopsy was performed intraorally under general anesthesia to rule out a malignant bone tumor, and pathological examination showed fibrous bone and Actinomyces druses. Finally, the lesion was diagnosed as actinomycotic osteomyelitis with proliferative periostitis. She underwent image-guided intraoral removal of impacted right third molar and reactive proliferative bone on the right mandibular ramus under general anesthesia. To improve trismus, coronoidectomy also was performed. After the discharge, AMPC was administrated intraorally for 7.5 months. Postoperative panoramic radiograph and CT showed the right mandibular angle resorption and coronoid process regeneration. There was no recurrence of mandibular osteomyelitis 7 years after surgery.

Spontaneous Regeneration of Bone in Segmental Mandibular Defect

Aim

To highlight the spontaneous regeneration of mandibular segmental defects in young and pediatric cases and to review the literature of this unusual and rare phenomenon.

Methodology

Two case reports of a 17-year old male and a 8-month-old infant has been presented who underwent resection of mandible for benign tumors. These two cases have been compared with the existing literature of 61 cases published till date.

Inference

Spontaneous regeneration of mandible as a viable reconstructive option is not practically feasible. The consistency and predictability of the phenomenon is questionable. Bone grafting should probably be done immediately in all cases, even in young patients if a delay would interfere with quality of life. In infants and small children though, we propose that immediate reconstruction may be avoided to allow some regeneration at the defect site. If it does not occur, secondary reconstruction may then be considered.

Microarray gene expression of periosteum in spontaneous bone regeneration of mandibular segmental defects

Spontaneous bone regeneration could occur to reestablish mandibular bony continuity in patients who underwent partial or total mandibulectomy for tumors with periosteum-preserving. However, scarce data is available related to the precise role of periosteum in this bone regeneration. Therefore we aimed to investigate the gene expression of periosteum that were involved in the mandibular bone regeneration. Mandibular segmental defects were created in six mini-pigs with periosteum preserved. The periosteum of defects and control site were harvested at 1 and 2 weeks. Gene ontology (GO) analysis showed that the mechanisms concerning immature wound healing were clearly up-regulated at week 1. In contrast, by week-2, the GO categories of skeletal development, ossification and bone mineralization were significantly over-represented at week-2 with several genes encoding cell differentiation, extracellular matrix formation, and anatomical structure development. Furthermore, Tgfβ/Bmp, Wnt and Notch signaling were all related to the osteogenic process in this study. Besides osteogenesis, genes related to angiogenesis and neurogenesis were also prominent at week-2. These findings revealed that the gene expression profile of the periosteum’s cells participating in bone regeneration varied in different time points, and numbers of candidate genes that differentially expressed during early healing stages of intramembranous bone regeneration were suggested.

Management of a Dentigerous Cyst in a Child with Robin Sequence

This is a brief clinical report describing an 18-month-old female with Robin sequence found to have an incidental mandibular cystic lesion on a head computed tomography scan in the preoperative workup before performing mandibular distraction. She underwent enucleation of the tumor, which was found to be a dentigerous cyst. One year following cyst enucleation, mandibular distraction was performed in order to alleviate her tongue-based obstruction. This case demonstrates the ability of the mandibular bone to successfully regenerate after undergoing cyst enucleation.

Spontaneous regeneration of bone after removal of a vascularised fibular bone graft from a mandibular segmental defect: a case report

Spontaneous bony regeneration of a segmental mandibular defect is rarely, if ever, reported and its mechanism is not clearly understood. However, several predisposing factors, including the presence of the periosteum, the age of the patient, the presence of local infection or stumps or fragments of bone, postoperative immobilisation, and functional or mechanical stress on the mandibular stumps, have all been suggested. We present a rare case of unexpected spontaneous regeneration of bone after removal of a vascularised fibular bone graft with osteomyelitis in a 48-year-old patient. In particular, the periosteum of the bone graft rather than the mandibular site was preserved. We know of no such previous report.