Pediatric Mandible Reconstruction: Controversies and Considerations

Does Free Fibular Flap Reconstruction Affect the Quality of Life in Pediatric Patients With Various Extend of Mandible Defects?

BACKGROUND

The long-term outcomes in pediatric patients with various extents of mandible defects have not been well-documented.

METHODS

A retrospective case series in which this study looked at pediatric patients under the age of 13 who had mandibular reconstruction with free fibular flap and had not received another operation in the previous 6 months. The eating, swallowing, speech function, and quality of life are evaluated with EORTC QLQ-H&N35 after the mandible growth spurt has occurred.

RESULTS

A total of 7 patients were included in this study with operation ages ranging from 6 years 1 month to 12 years 2 months. The etiology of malignant tumors was found in 2 patients and benign tumors in 5 patients. The mandibular defect distribution consists of 1 class Ic, 1 class II, 2 class IIc, 2 class III, and 1 class IVc. All patients reported no swallowing or speech difficulties. However, transient eating trouble was seen in 1 patient due to the extensive defect size that causes tooth loss. Only 1 patient received dental rehabilitation. The patients displayed an overall good quality of life with an average score of 2.857.

CONCLUSIONS

Free fibular flap for mandibular reconstruction in children who have not reached their mandibular growth peak have a satisfying outcome, both in their function and quality of life.

Aggressive presentation of ameloblastic fibro-odontoma: a clinical-pathological enigma

Ameloblastic fibro-odontoma (AFO) is a rare, gnathic, benign, mixed odontogenic tumor that commonly presents in the first or second decade of life as a unilocular and rarely multilocular radiolucency with variable amounts of calcified material. Tumor progression is typically indolent, and generally accepted treatment is surgical enucleation and curettage. This case report describes an atypical presentation in a 14-year-old male with a multilocular, aggressive AFO requiring hemimandibulectomy with immediate osseous and dental "Jaw-in-a-Day" reconstruction. This report highlights the debate regarding whether AFO is a true neoplasm or an early-stage hamartoma in the continuum of complex odontoma formation. Regardless of the pathogenesis, maxillofacial surgeons and pathologists should be cognizant of the potential for AFO to develop locally aggressive behavior with considerable morbidity.

Pediatric Craniofacial Tumor Reconstruction

Effective management of pediatric craniofacial tumors requires coordinated input from medical, oncologic, and surgical specialties. Reconstructive algorithms must consider limitations in pediatric donor tissue and account for future growth and development. Immediate reconstruction is often focused on filling dead space, protecting underlying structures, and ensuring skeletal symmetry. Staged reconstruction occurs after the patient has reached skeletal maturity and is focused on restoring permanent dentition. Reconstructive options vary depending on the location, size, and composition of resected tissue. Virtual surgical planning (VSP) reduces the complexity of pediatric craniofacial reconstruction and ensures more predictable outcomes.

Pediatric Mandible Fractures

The management of pediatric facial fractures requires several considerations by the treating surgeon. Pediatric facial fractures occur less commonly than in adults. Among fracture patterns in children, studies have repeatedly demonstrated that mandible fractures are the most common facial fracture particularly the condyle. Most fractures in children are amenable to nonsurgical or closed treatment; however, certain indications exist for open treatment. The literature describing epidemiology, treatment trends, and long-term outcomes are limited in comparison with adult populations. The purpose of the article is to review the etiology, workup, and management of mandible fractures in children.

Case report: Spontaneous mandibular body regeneration following unilateral subtotal mandibulectomy in a 3-month-old French bulldog

Objective

To document a case of spontaneous regeneration of the mandibular body following subtotal mandibulectomy in a juvenile dog.

Case summary

A 3-month-old male intact French bulldog was presented with papillary oral squamous cell carcinoma located at the dorsal aspect of the molar region of the left mandible. Initial biopsy of the mass was performed by the primary care veterinarian. Complete clinical staging revealed no signs of metastasis. Computed tomographic images of the head showed minimal contrast enhancement of the mass with no signs of periosteal or bone involvement. Subtotal mandibulectomy was performed. Histopathology indicated complete excision of the tumor. The patient returned 8-weeks later for follow up and cleft palate surgical repair, at which time bone was noted in the mandibulectomy area on palpation. Repeat computed tomography of the head revealed complete regeneration of the left mandibular body from the level of the ramus to the mandibular symphysis. No treatment for malocclusion was necessary due to the reformation of a functional mandible.

Clinical relevance

The present case demonstrates that spontaneous regeneration of the mandibular body is possible following subtotal mandibulectomy in immature dogs. Subtotal mandibulectomy is a radical procedure that can lead to long term complications including mandibular drift, malocclusion, and oral pain. This case report provides evidence that these sequelae may be mitigated or eliminated in young patients undergoing this procedure.

Pediatric Mandibular Reconstruction With Free Serratus Anterior-Rib Composite Flap: A Case Report

ABSTRACT

Reconstruction of children's mandibles after mandibular resection for benign or malignant tumors is challenging. Microvascular flap reconstruction is a common treatment option for restoring mandibular continuity after the resection of oral cavity neoplasms.We presented 2 cases of childhood mandibular reconstruction after tumor wide excision and segmental mandibulectomy, one for malignant cancer and one for benign ossifying fibroma, with serratus-rib composite free flap. All 2 patients had a favorable facial profile, functional outcome, and dental occlusion at the last follow-up. The development of children's mandible and donor site needs to be considered compared with adult's mandibular reconstruction. Given its reliability and utility, this flap can be an alternative for pediatric mandibular reconstruction compared with the free fibular flap and other candidates.

Reconstruction of Dentomaxillofacial Deformity Secondary to Mandibular Defect Using Concomitant Orthognathic Surgery and Fibula Free Flap

SUMMARY

The reconstruction of mandibular defects may be delayed or compromised for many reasons, especially in pediatric patients. With the growth of the remaining mandible and the maxilla in the malocclusion status, secondary dentomaxillofacial deformity is plausible. To treat the concomitant mandibular defect and secondary dentomaxillofacial deformity, a hierarchical algorithm using orthodontics, orthognathic surgery, and fibula free flap was developed. This retrospective case series included six patients with long-term mandibular defects caused by tumor resection without repair or with compromised costochondral reconstruction. All patients were treated using the same staged protocol, but with minor changes: (1) presurgical orthodontics, (2) virtual surgical planning, (3) fabrication of the guides and splints, (4) sequenced operations, and (5) postoperative care. The sequence of surgery included the Le Fort I osteotomy, mandibular sagittal split ramus osteotomy of the remaining ramus, final occlusion registration, repositioning of the distal segment of the mandible, segmented fibula reconstruction, and finally, the fixation of mandibular sagittal split ramus osteotomy. The operations and wound healing were uneventful in all patients, and no flap failure or severe complications were detected. Also, the patients exhibited no signs of temporomandibular joint ankylosis during the follow-up. The subspinale-nasion-supramental angle was significantly reduced after surgery. A significant improvement was detected in the facial contour symmetry measurements postoperatively. This proposed workflow of concomitant orthognathic surgery and the fibula free flap is effective and reliable for the reconstruction of dentomaxillofacial deformity secondary to the long-term mandibular defect.

Long-Term Update: Free Fibula Flap Growth After Pediatric Mandibular Reconstruction

A free fibular flap is commonly used in adult mandibular reconstruction; however, its use in the pediatric population is not strongly supported. The authors are reporting the long-term update of a case of a pediatric patient who underwent a mandibular reconstruction using a free fibular flap after a resection of mandibular desmoid fibromatosis. Greatest growth was objectively measured and demonstrated at the condyle using a 3-dimensional model generated from Materialise software. This is 1 case and subsequent studies should be observed to further elucidate the full growth potential of the mandible in pediatric patients undergoing mandibular reconstruction.

Long-term Growth, Functional, and Aesthetic Outcomes after Fibula Free Flap Reconstruction for Mandibulectomy Performed in Children

Background:

The long-term outcome of mandible reconstruction when performed in children has not been well documented.

Methods:

This is a retrospective case series of patients who underwent immediate oncologic mandible reconstruction with a fibula free flap at younger than 18 years of age over a 20-year period, by a single surgeon, who had long-term follow-up.

Results:

A total of 10 patients met inclusion criteria. Patient age ranged from 3 years and 8 months to 17 years and 9 months (mean 11 years). The etiology was malignant tumors in seven patients and benign locally aggressive tumors in three patients. All fibula flaps survived. All donor sites were closed primarily. The mean follow-up duration was 10 years and 5 months (range 3–20 years). The mean patient age at follow-up was 21 years and 10 months (range 8 years and 9 months to 30 years and 9 months). All patients achieved a regular diet and normal speech. Final occlusion was normal in seven of 10 patients. The aesthetic outcome, as evaluated by clinical examination, was a symmetric mandible in eight patients (in the other two the aesthetic asymmetry and malocclusion was minor and did not require operative intervention). Dental implants were ultimately placed in three patients. Leg function was normal in eight patients. Achilles lengthening and tendon transfer was required in one patient, and one patient developed ankle pain associated with running.

Conclusion:

Mandible reconstruction in children with the fibula free flap provides excellent aesthetic and functional outcomes that are durable over time.

Post-operative Complication at the Donor Site of Fibular Free Flap in a Pediatric Patient

The fibular free flap is most frequently used for reconstructing the mandible owing to the adequate length of the bone with a reliable blood supply. It has a long vascular pedicle with adequate vessel diameter for anastomosis and also a good amount of skin paddle for coverage. However, the reports of post-operative complications at the donor site among pediatric patients are scarce in the literature. We present a pediatric case of ankle valgus deformity following vascularized fibular harvest.

Periosteal reaction as a crucial radiographic finding for desmoplastic fibroma of the jaw bone in children: A case report

This report presents the case of a 5-year-old boy with a hard swelling on the right side of the mandible body. An important point of this case is that the primary imaging finding was fine spicules in the inferior border of the mandible on panoramic radiography without significant changes in bone density. Cone-beam computed tomography views revealed a lytic lesion on the lingual side of the right mandibular body with the destruction of the lingual cortex and periosteal reaction from the midline to the first molar area. Careful attention to this radiographic finding in the primary stage in the absence of other significant imaging findings, particularly in children, could result in the early diagnosis of desmoplastic fibroma. Therefore, a better prognosis can be expected following early surgical treatment.

Rigid versus resorbable plate fixation in fronto-orbital advancement in unicoronal stenosis - A retrospective study

Introduction:

Rigid plating fixation (RPF) and resorbable plating systems (RPS) advanced the field of reconstruction in craniomaxillofacial region. However, their performance in patients, particularly the effect on bone remodeling at site of hardware placement is not much documented. This manuscript aims to compare the performance of RPF and RPS in a cohort using a retrospective audit of case records.

Methods:

Archival records were searched for patients who had undergone cranial metal-RPF or RPS or combination for the correction of craniofacial deformities following inclusion-exclusion criteria. From records, data of the quality and quantity of bone formed along the site of plate fixation as compared with the adjacent site, accommodating or facilitating brain growth, and persistence of bone deformity at the site of hardware placement were collected at the end of the follow-up period. A total of 128 sites from 18 individuals (6 with exclusive metal-RPF and 12 with RPS) mean age of 7.45 ± 7.28 (Median 4; IQR of 8.88;2.6–11.5) who underwent cranial bone remodeling surgery formed the study group.

Results:

There was a statistically significant difference between the RPF and PRS system at the fronto-orbital suture (P = 0.002) and coronal suture (P = 0.036) with bone quality and quantity.

Discussion:

The RPF system was rigid but had a set of issues, while RPS has advantages and limitations. The qualitative difference in between the two systems is different. Due to inherent dissimilarity, the two systems cannot be interchanged and due diligence has to be exercised while deciding on the system. More prospective studies are needed to validate the findings.

Protocol and Evaluation of 3D-Planned Microsurgical and Dental Implant Reconstruction of Maxillary Cleft Critical Size Defects in Adolescents and Young Adults

Functional and esthetic final reconstruction of the cleft maxilla is still challenging. Current reconstructive and augmentation techniques do not provide sufficient bone and soft tissue support for the predictable rehabilitation with dental implants due to presence of maxillary bone critical size defects and soft tissue deficiency, scaring and poor vascularity. In this article the protocol for the use of 3D virtual surgical planning and microvascular tissue transfers for the reconstruction and rehabilitation of cleft maxilla is presented. Twenty-five patients (8 male/17 female) aged 14–41 years old with cleft-associated critical size defects were treated by 3D-virtual planned microvascular tissue transfers taken either from fibula, iliac crest, radial forearm, or medial femoral condyle. Follow-up lasted 1–5 years. No significant bone resorption (p > 0.005) nor volume loss of the graft was observed (p = 0.645). Patients received final permanent prosthetic reconstruction of the anterior maxilla based on 2–5 dental implants, depending on the defect severity. This is the first study presenting the use of virtual planning in the final restoration of the cleft maxilla with microvascular tissue transfers and dental implants. Presented protocol provide highly functional and aesthetic results.