Free Fibula Flap Mandible Reconstruction in Benign Mandibular Lesions

Surgical Resection and Reconstruction of Ameloblastoma: A 13-Year Retrospective Review

BACKGROUND

Ameloblastoma is a locally aggressive, benign tumor presenting in the maxilla and mandible prone to recurrence. Resection greatly limits recurrence; however, reconstruction becomes critical to preserve patients' functionality and esthetics.

PURPOSE

The aim of this study was to describe surgical resection and reconstructive approaches in the treatment of ameloblastoma and compare clinical outcomes to conservative methods of treatment.

STUDY DESIGN, SETTING, SAMPLE

A retrospective case series was completed through analysis of patient records. The study population was composed of patients treated for ameloblastoma at the Royal Brisbane Hospital (Queensland, Australia) in the Oral and Maxillofacial Surgery Unit from January 1, 2008, to December 31, 2020. Patients without histological confirmation of intraosseous ameloblastoma were excluded from the study sample.

PREDICTOR VARIABLE

Not applicable.

MAIN OUTCOME VARIABLE(S)

The primary outcome variable was time to recurrence. Secondary outcome variables included any surgical complications incurred.

COVARIATES

The covariate variables collected included age at diagnosis/treatment, gender, ethnicity, location of lesion and site(s) of involvement, tumor extent, alveolar expansion, histopathological growth pattern, and soft tissue involvement.

ANALYSES

Descriptive statistics were computed for each study variable.

RESULTS

A total of 48 cases of histologically confirmed ameloblastoma were identified (41 mandibular, 7 maxillary) involving 50 excisional operations (44 resections, 6 enucleations). Of these cases, 44 were followed up > 12 months, with a mean length of follow-up time of 65.6 months. No recurrence was detected for resected lesions. One enucleated lesion recurred at 25 months. Thirty-seven reconstructive procedures were undertaken, including 32 immediate free flaps. All reconstructive flaps and grafts survived, and no major complications were recorded.

CONCLUSION AND RELEVANCE

Resection of ameloblastoma limits recurrence and should be considered curative. Immediate microvascular free flap reconstruction of maxillary and mandibular defects from resection of ameloblastoma is safe and predictable.

Fibular Free Flap and Iliac Crest Free Flap Mandibular Reconstruction In Patients With Mandibular Ameloblastomas

ABSTRACT

Ameloblastoma (AM) is the most common, locally aggressive odontogenic tumor. It comprises about 1% of all head and neck neoplasms. It occurs mainly in young adults in their 3rd and 4th decade of life. It localizes in the mandible in about 80% of the cases. According to the 2017 WHO classification, 4 types of ameloblastoma can be distinguished: ameloblastoma (previously referred to as solid/multicystic-SMA; the "conventional type" AM), unicystic (AM-UA), extraosseous/peripheral (AM-PA), and malignant/metastatic (AM-MA). Solid, multicystic is the most common type. It is characteristic for its aggressiveness and high risk of recurrence. Radical resection with consecutive reconstruction is the treatment of choice of mandibular ameloblastomas.In this study, the authors present their experience in the surgical treatment of mandibular ameloblastomas with vascularized free flap reconstructions. They discuss new technological possibilities that could improve the precision of the reconstructive procedure and therefore result in the better aesthetic outcome.The retrospective study of a group of 21 patients suffering from mandibular ameloblastoma who underwent segmental mandibulectomy with simultaneous microvascular free flap reconstruction was conducted. A thorough clinical analysis with various aspects was performed. Tumors resected before 2017 were double checked patomorphologically and assigned to the corrected subtype group.Seven patients were admitted to the department due to recurrent ameloblastoma. The most common localization of the tumor was the mandibular body (n = 6) and body with ramus of the mandible (n = 6). A total amount of 10 iliac crest free flaps and 12 fibular free flaps were performed. Complications were reported in 4 patients. A purulent oro-cutaneus fistula occurred in 3patients. There was a flap failure in each reconstructive group. The virtual surgical planning with intraoperative cone-beam computed tomography was used in 3 patients. Dentition implantation was conducted in 4 patients (3 simultaneously, 1 postponed). The mean follow-up was 5 years and 8 months.Radical resection that covers radical segmental mandibulectomy with immediate microvascular free flap reconstruction is a first-line and only effective treatment of mandibular ameloblastomas, that eliminates the risk of recurrence. The extent of surgical margins seems not to influence the recurrence rate, yet further investigation with statistical analysis should be performed. The choice of the adequate free flap must be adapted to dimensions and localization of the tumor and to each patient individually.New technologies such as virtual surgical planning with 3D models and intraoperativecone-beam computed tomography can make the reconstruction more accurate, improving patient's quality of life.

Placement of a customised load-bearing titanium plate for prevention of iatrogenic mandibular fracture in surgical removal of odontogenic keratocyst recurrence

A 72-year-old woman with a history of removal of a right hemimandibular keratocyst 10 years ago was referred to our attention for a large swelling of the right cheek. The orthopantomography and the CT scan showed a huge osteolytic area of the right mandibular ramus and angle. The patient's refusal to resection and reconstruction with a free flap pushed us towards a conservative treatment. The high probability of a iatrogenic mandibular fracture during and after surgery required the design of a customised titanium plate to be preliminary placed through cervical incision along the posterior border of the mandible. The patient successfully underwent the surgical positioning of the customised plate and subsequent removal of the keratocyst. She was discharged fit and well 5 days after surgery. She did not experience any infections, pathological fractures or relapse in the 6-month follow-up.

Bone voyage: an expedition into the molecular and cellular parameters affecting bone graft fate

The demand for bone grafts in orthopaedic and craniofacial surgery is steadily increasing. Estimations suggest that about 500,000 are performed annually in the United States that include bone grafting as a component of the surgery, and the majority of these surgeries employ autografts. This perspective focuses on the biological events that occur during osseointegration of such bone grafts. Here, three key factors of graft osseointegration--the embryonic origin, the inclusion of skeletal progenitor cells, and the integrity of the recipient site--are discussed. Altogether, they form the foundation for survival of the bone graft and eventually for a positive clinical outcome of the procedure.

Extensive ameloblastoma of the jaws: surgical management and immediate reconstruction using microvascular flaps

OBJECTIVE

Ameloblastoma is a rare histological benign but locally aggressive tumor with a marked tendency for recurrence. Especially larger, aggressive lesions require a more radical surgical approach resulting in large jaw defects. The purpose of this study is to analyze the long-term functional and esthetic results after immediate reconstruction of large jaw defects using microvascular flaps.

STUDY DESIGN

A review of 7 cases of giant ameloblastoma (2 in the maxillary and 5 in the mandibular region) is presented. The lesions were between 4 and 8 cm in diameter. All patients were treated by a radical surgical protocol. All cases were immediately reconstructed using microvascular grafts from either the scapula or the iliac crest bone. Dental implants were inserted in all patients after removal of the osteosynthesis material.

RESULTS

All patients were prosthetically rehabilitated. All implants survived throughout the observation time. The esthetic and functional outcomes were satisfying in all patients. No case of recurrence of the tumor could be observed so far.

CONCLUSION

According to our opinion, immediate reconstruction is the treatment of choice after radical surgical excision of ameloblastoma. This 1-step procedure decreases the number of surgeries and allows earlier prosthetic rehabilitation.

Ewing Sarcoma of the Mandible in a Child: Interdisciplinary Treatment Concepts and Surgical Reconstruction

Ewing's sarcoma is the second most common primary bone malignancy in childhood and adolescence. We present a standardized interdisciplinary treatment protocol according to the EURO-E.W.I.N.G. 99 study, applied in the treatment of a 7-year-old patient with localized Ewing's sarcoma of the left mandible. After six blocks of VIDE (vincristine/ifosfamide/doxorubicin/etoposide) chemotherapy and stem cells rescue, intensity modulated external radiation with 48.6 Gy and subsequent high dose therapy with busulphan-melphalan were administered. Tumor resection and immediate bony reconstruction was performed using a microvascular fibula graft 10 weeks after radiation. Because of the effective neoadjuvant treatment, no extensive soft tissue resection was necessary. Healing of the osteosynthesis was uneventful. No local or systemic recurrence and no signs of significant facial deformity were found after 12 month follow-up. The presented case underlines the requirement for multidisciplinary protocols involving radiologists, pathologists, oncologists, radiation oncologists, and surgeons for accurate diagnosis and appropriate therapy. To preserve cosmetics and function within the craniofacial area after tumor resection in children, microvascular reconstructive procedures can be successfully performed with a vascularized fibular graft.