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Evaluation of Mandibular Reconstruction With Particulate Cancellous Bone Marrow and Titanium Mesh After Mandibular Resection Due to Tumor Surgery Ikuya Miyamoto, DDS, PhD,* Yoshihiro Yamashita, DDS, PhD,† Noriaki Yamamoto, DDS, PhD,‡ Shinnosuke Nogami, DDS,§ Kensuke Yamauchi, DDS, PhD,k Daigo Yoshiga, DDS, PhD,§ Takeshi Kaneuji, DDS, PhD,§ and Tetsu Takahashi, DDS, PhD¶

dvanced mandibular tumors usually require extended resection, and large defects generally occur. Reconstruction is performed when there is a functional or aesthetic loss of structures in the oral cavity.1 The reconstruction of mandibular defects is still a challenging surgical procedure because both soft and hard tissues are required and the mandible is morphologically and functionally complex. There are several mandibular reconstruction techniques, including vascularized free flaps and autogenous bone grafting.2–4 It is usually difficult to reconstruct the mandible with only 1 procedure after tumor resection to the final dental prosthetic rehabilitation, particularly in cases with both soft tissue and hard tissue defects. The

A

*Lecturer, Division of Oral Medicine, Kyushu Dental University, Fukuoka, Japan. †Associate Professor, Department of Oral and Maxillofacial Surgery, Miyazaki University, Miyazaki, Japan. ‡Assistant Professor, Department of Oral and Maxillofacial Surgery, Oita University, Oita, Japan. §Assistant Professor, Division of Oral and Maxillofacial Surgery, Kyushu Dental University, Fukuoka, Japan. kLecturer, Division of Oral and Maxillofacial Surgery, Department of Oral Medicine and Surgery, Tohoku University Graduate School of Dentistry, Sendai, Japan. ¶Professor and Chairman, Division of Oral and Maxillofacial Surgery, Department of Oral Medicine and Surgery, Tohoku University Graduate School of Dentistry, Sendai, Japan.

Reprint requests and correspondence to: Ikuya Miyamoto, DDS, PhD, Division of Oral Medicine, Kyushu Dental University, 2-6-1, Manazuru, Kokura Kita-ku, Kitakyushu City, Fukuoka 803-8580, Japan, Phone: +81-93-582-1131, Fax: +81-93-592-3056, E-mail: [email protected] ISSN 1056-6163/14/02302-108 Implant Dentistry Volume 23  Number 2 Copyright © 2014 by Lippincott Williams & Wilkins DOI: 10.1097/ID.0000000000000041

There are numerous treatment modalities for mandibular defects after tumor surgery. Autogenous particulate cancellous bone marrow graft combined with titanium mesh (PCBM-MESH) is an alternative procedure. The purpose of this study was to evaluate PCBM-MESH for mandibular reconstruction. There were a total of 10 cases from 2000 to 2011. Mandibles were successfully reconstructed in 9 cases; however, reconstruction failed in 1 case. Overall, the recovery of facial contours was excellent; conversely, the evaluation of prosthetic treatment

varied widely. Thus, we suggest 3 steps for mandibular reconstruction: (1) recover the continuity of bone segments; (2) simulate optimum facial contours and dental occlusion; and (3) perform the occlusion with dental prostheses. PCBMMESH is a valuable method for mandibular defectsdparticularly for restoring facial contours and a favorable alveolar ridge. (Implant Dent 2014;23:108–115) Key Words: segmental defect, mandibular reconstruction, PCBM combined with titanium mesh, top-down approach

vascularized free flap is a successful modality to reconstruct mandibular defects.5–10 In contrast, few publications exist regarding free bone grafting.11–13 Another procedure similar to free bone grafting is particulate cancellous bone marrow (PCBM) combined with titanium mesh (PCBM-MESH), which was first described by Boyne.14 Several studies report successful results with this procedure.15–17 The ultimate goal of mandibular reconstruction is the improvement of facial contours and the occlusion of dental prostheses. The purpose of this study was to evaluate mandibular reconstruction after tumor surgery with PCBM-MESH.

MATERIALS

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METHODS

This single-center retrospective study included consecutive patients at Division of Oral and Maxillofacial Reconstructive Surgery, Kyushu Dental University Hospital. All surgeries were performed from 2000 to 2011 by Kyushu Dental University staff. The subjects consisted of 2 men and 7 women at 10 sites (mean age, 54.4 years; range, 35–75 years). Patients were excluded from the study if they had a previous or present history of long-term corticosteroid or bisphosphonate medication or had a systemic bone disorder. The causes of mandibular defects were malignant tumors in

Table 1. Patient Details and Profiles Case

Age (y)

Gender

Defect Length, mm

Bone Gain by DO, mm (Elongation Days)

1

75

F

SCC

Body-chin

51 (PCBM + DOG)

41 (21)

Dumbach

2

61

F

SCC

Ramus-chin

65 (PCBM + DOG)

65 (60)

Titanium micromesh

3

35

M

Cemento-ossifying fibroma

Ramus-body

d

4

35

M

Recovery of case 3 failure

Ramus-body

68 (PCBM + DOG)

5

54

F

Ameloblastoma

Condyleramus-body

50

Dumbach

6

58

M

SCC

Body-chin

43

Dynamic mesh plate

7

52

F

SCC

Body-chin

114

Dumbach

8

64

F

SCC

Body-chin



Dynamic mesh plate

9

67

F

SCC

Body-chin



Dynamic mesh plate

10

43

F

Cemento-ossifying fibroma

Ramus-body

40

Reconstruction plate and dynamic mesh

Mean

54.4

Diagnosis

Type of Titanium Mesh

d

Dumbach

50 (25)

Dumbach

52

109

62.4

Schematic of Defect

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SCC indicates squamous cell carcinoma; DO, distraction osteogenesis.

Extent of Defect

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Table 2. Preoperative Conditions of the Mandible and Postoperative Course Case 1 2 3 4 5 6 7 8 9 10

Radiotherapy

Soft Tissue Reconstruction

Preoperative Mandibular Continuity

Complications

Final Result of Bone Graft

50 Gy d d d d d 20 Gy d 30 Gy d

Free forearm flap PMMC None None None Free abdominal flap Free flap Mandibular partial resection Mandibular partial resection None

Noneddistraction osteogenesis Noneddistraction osteogenesis None Noneddistraction osteogenesis None Vascularized iliac bone graft Vascularized scapular bone graft Mandibular partial resection Mandibular partial resection None

Implant failure None Infection None None None None None None None

Good Good Failure Good Good Good Good Good Good Good

6 cases, benign tumors in 3, and recovery from infectious failure in 1 (Table 1). All patients received written information about the surgery and provided written informed consent in accordance with the Declaration of Helsinki on human experimentation. All procedures were performed under general anaesthesia. At the point of the peripheral tissue, the soft tissue was reconstructed primarily by pectoralis major myocutaneous flap (PMMC) and forearm free flap in 1 case each for the reconstruction of intraoral soft tissue (cases 1 and 2). Mandibular continuity was not maintained in 8 cases (cases 1–7 and 10); among these, 3 cases were initially treated with distraction osteogenesis (DO) to shorten the defect before the placement of a titanium mesh and PCBM bone graft to reconstruct the defect (cases 1, 2, and 4). In these DO cases, a transport method was used to repair the defect.18 Briefly, the transport method composed 3 steps for the procedure. The first step of the process is known as the latency phase. This phase is the time allowed after osteotomy for the initiation of callus formation. The second step is the transport phase where the osteotomized bone edges are distracted twice a day with the aid of a distraction device. The last step is the consolidation phase, in which the regenerate undergoes remodeling and calcification.18 The internal mandibular distraction devices were adjusted and preplated before osteotomy. Subperiosteal corticotomy for the transport segment was subsequently performed as described previously.19 DO was performed at

a rate of 1.0 mm/d (ie, 0.5 mm in the morning and evening). The bone gains and distraction period are presented in Table 1. Bifocal distraction was performed in cases 1 and 4. Two cases underwent secondary reconstruction after vascularized free flap transfer (cases 6 and 7); the flaps were taken from the iliac and scapular bone, respectively. The other 2 cases received partial resection of the mandible to improve the alveolar ridge morphology for prosthetic treatment (cases 8 and 9) (Table 2). PCBM-MESH reconstructions were performed immediately in 3 cases (cases 3, 5, and 10) and secondarily in 7 (cases 1, 2, 4, 6, 7, 8, and 9). Of the 6 malignant tumor cases, cases 1, 7, and 9 received 20, 30, and 50 Gy irradiation, respectively. One case with a benign tumor underwent unsuccessful mandibular reconstruction with a titanium mesh tray (from case 3 to 4). In this study, hyperbaric oxygen therapy was not performed. Additional graft materials were not used, with only titanium mesh plate and PCBM used for reconstruction. In all cases, the previously resected extraoral approach was performed using the same incision. In patients 2 and 8, the PCBM was taken from the anterior and posterior iliac crest, respectively, as described by the authors in a previous publication.20 With delayed reconstruction, the remaining mandible was exposed using an extraoral approach to avoid entering the oral cavity. Dumbach and dynamic mesh plates (Dumbach Titanium Mesh-System, Titanium Dynamic Mesh, Micro-Titanium Augmentation

Fig. 1. Intraoperative and radiographic appearance of case 1 immediately after the distraction period. Newly formed bone is seen in the segment (arrowhead). A, A 10-mm gap between right and left segments is seen. B, Intraoperative view after PCBM grafting. The PCBM was loaded into Dumbach mesh and condensed as much as possible. C, CT image 6 months after the bone graft. Favorable bone consolidation was observed.

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Fig. 2. Simulation of the implant surgery of case 8. A, Bone consolidation 6 months after the bone graft indicated sufficient alveolar ridge height and width for implant placement. B, Simplant image of the simulation. The image indicates good bone condition for the implant insertion.

to increase graft density. After adequate subcutaneous relaxation, incisions were made, the overlying skin was sutured with minimal tension (Fig. 1, A–C). Dumbach plates, titanium dynamic mesh plates, and titanium micromesh were used in cases 1, 3, and 6, respectively (Table 1). The selection of the titanium mesh depends on the length and shape of the defect. Relatively large segmental defects need Dumbach, dynamic mesh was used for small defect and large alveolar defect, and titanium micromesh was applied to alveolar defect. Intermaxillary fixation was maintained using an elastic for 7 to 10 days. A total of 16 dental implants were inserted into the reconstructed areas in 6 patients 6 to 24 months after the

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reconstructive procedure. After the healing period, computed tomographic (CT) image was taken, and the data were quantitatively and qualitatively analyzed using SimPlant Pro version 10 (Columbia Scientific, Inc., Columbia, MD). All dental implants were placed with the aid of a prefabricated surgical template that was prepared from a diagnostic wax-up before implant placement (Fig. 2, A and B). Prosthetic rehabilitation started 6 months after implant insertion. Due to the lack of attached gingiva around the alveolar crest, 2 patients underwent free mucosal grafts harvested from the palate (cases 6 and 8). Patient satisfaction was evaluated with regard to the aesthetic aspects of the facial contours after the reconstruction and the functional results of the prosthetic treatment. Patients were asked to fill out a questionnaire indicating their levels of satisfaction. On the completion of the reconstructive phase, patients were asked to subjectively evaluate their facial appearance using a 3-point rating scale: 0 ¼ unsatisfied; 1 ¼ partially satisfied; and 2 ¼ fully satisfied according to the report of Chiapasco et al.11

RESULTS In this study, all mandibles were successfully reconstructed. However, in case 3, intraoral mucous membrane perforation occurred, which required the removal of the mesh 1 month after the operation. After the mesh was

Fig. 3. Bone consolidation of the reconstructed mandible can be seen in the anterior part of the mandible (case 1). This condition suggests chronic osteomyelitis of this region. In this area, the implant failed twice during the functional period.

Mesh [M-TAM]; Stryker-Leibinger, GmbH & Corp., KG, Freiburg, Germany) were then adapted to the remaining bone by cutting and bending them into the desired shape. The mesh was fixated to each side of the host bone using 5 to 8 monocortical titanium screws (2 mm diameter and 5, 6, 8 mm length). The surrounding soft tissues, including muscle, fatty tissue, and fibrous tissue, were then tightly sutured to the lateral, medial, and inferior surfaces of the tray to eliminate any dead space. The PCBM was loaded into the mesh and condensed

Fig. 4. A, Facial appearance of case 5; ameloblastoma affecting the left mandible body to the coronoid process. The facial deformity is apparent. B, Facial contours 3 years after the reconstruction demonstrating good appearance.

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Table 3. Patient Evaluation Scores of Facial Contour and Dental Prosthesis of the Implant Survival Case

Facial contour

1

2

2

2

3 4

d 2

5 6

2 2

7

2

8

2

9

2

10

2

Prosthesis Implant over denture Conventional denture d Fixed implant bridge None Fixed implant bridge Implant over denture Fixed implant bridge Conventional denture Fixed implant bridge

Prosthesis Function

No. of Implants

Follow-up (mo)

2

2/1

108

1

None

120

d 2

d 4

d 84

0 2

d 3

110 86

1

4/0

82

2

2

55

1

d

86

2

1

18

Facial contour: 0 ¼ unsatisfied, 1 ¼ partially satisfied, 2 ¼ fully satisfied; dental prosthetic satisfaction: 0 ¼ unsatisfied, 1 ¼ partially satisfied, 2 ¼ fully satisfied.

One implant in case 1 was lost due to infection after 3 years of function; although another implant was inserted, the same site was lost again 2 years later due to chronic osteomyelitis (Fig. 3). The mean follow-up period was 83.2 months (range, 18–120 months). In 1 case, the reconstructed mandible was resected due to the recurrence of the tumor (case 7). The implant survival rates were 69% overall and 92% excluding tumor recurrence. All patients were fully satisfied regarding the aesthetics of their facial contours (Fig. 4, A and B). Five of 9 patients were fully satisfied regarding the functional aspects of their prosthetic restoration; 3 patients were only partially satisfied; and 1 was not satisfied: 1 patient refused prosthetic treatment. Satisfaction scores are shown in Table 3. The partially satisfied patients complain about the difficulty with deglutition due to the immobility of the tongue or soft tissue. This is the result of soft tissue resection by operation. Furthermore, immobility of tongue makes food impaction between soft tissue and it makes difficult to clean up intraoral environment.

DISCUSSION Fig. 5. A, The intraoral membrane tissue defect was treated with skin tissue by forearm free flap. B, Intraoral appearance shows that enough oral membrane was reconstructed by DO.

removed, DO was performed to shorten the length of the defect; PCBM-MESH was subsequently performed again. The mean length of the defects was 62.4 mm (range, 40–114 mm). The cases treated with DO received 41, 65, and 50 mm of newly formed bone, respectively (cases 1, 2, and 4). PCBM-MESH reconstruction was performed in these cases because not enough bone was obtained in the gap between the bone segments or in the bone height of the alveolar ridge. To date, at the point of prosthetic rehabilitation, 4 patients received a fixed implant supported bridges (cases from 3 to 4, 6, 8, and 10), 2 cases received an implant-supported overdenture (cases 1 and 7), and 2 cases received a set conventional removal partial dentures (cases 2 and 9).

Implant–supported bridges had a good condition of the residual ridge relatively, the deficit and small benign tumor after surgery. Patient 5 refused prosthetic treatment due to the good stability of residual teeth and occlusion. Therefore, the satisfaction of the prosthesis is 0 points. A total of 16 dental implants in 6 patients were inserted. Implant-supported overdenture patients were relatively older; oral cancer patients and their antagonistic arches were almost totally edentulous. Moreover, the follow-up of implants and of possible oncologic relapse is likewise poorer. However, fixed implant bridge patients were relatively young and antagonistic arch were almost normal. The follow-up of tumor relapse is better.

In the present study, mandibular reconstructions were successfully achieved, providing from the recovery of bone continuity and allowing dental prosthetic rehabilitation. The main difference between autogenous cortico-cancellous bone grafts and PCBM-MESH is the healing mechanism of the graft. Cortical bone is densely packed, whereas cancellous bone is porous with marrow tissue in between the bone trabeculae. Due to this structural difference, vascular ingrowth occurs 30% more rapidly in cancellous grafts than in cortical bone grafts.21 The revascularization of cancellous bone can be completed after a few weeks (at least in part) due to end-to-end anastomoses of the host vessels and those of the graft itself.21 During the healing of the bone defect, there is competition between soft and bone tissue to fill voids and cavities. This is probably also the case during the incorporation of a bone graft. In this respect, cancellous bone grafts may be more prone to soft tissue ingrowth than

IMPLANT DENTISTRY / VOLUME 23, NUMBER 2 2014 cortical bone grafts. Albrektsson22 concludes that both the blood supply from the recipient bed and the ability of newly formed vessels to penetrate the graft are crucial for successful grafting. A clinical study of grafts in cleft palate patients shows that the PCBM becomes mature bone about 5 to 6 months after surgery.20 In this study, PCBM failed in 1 case due to infection; this occurred because the intraoral membrane was perforated from the oral cavity and infection subsequently occurred during a relatively stable period. The risk factors for infection are reconstruction length, radiation therapy, and the existence of vascularity in the peripheral soft tissue.11,13 In particular, irradiated mandibles are a risk factor for failure due to scarred soft tissue and hypovascularity. In this study, most patients received relatively low doses (ie, 20 and 30 Gy), whereas 1 patient received 50 Gy irradiation (case 1). Radiation reduces osteogenic cell numbers, alters cytokine capacity, and delays and damages bone remodeling. However, interindividual variations and how such changes become irreversible lesions are still unclear.23 In case 1, the right-side implant inserted into the reconstructed area failed twice, whereas the soft tissue underwent reconstruction with a free forearm flap. The CT image of case 1 showed osteo-consolidation similar to chronic osteomyelitis (Fig. 3); this might suggest hypovascularity around the mandibular lesion due to irradiation even though the soft tissue vascularity with the forearm flap recovered. In this case, because this implant was removed, the symptoms of osteomyelitis were not specifically noted. The 3 cases treated with DO before reconstruction with mesh exhibited additional positive results. As described above, the distance of the defect not only influences graft failure but also infection and minor complications. The first benefit is that DO shortens the defect, although the segment has a limited ability to restore the continuity of the defect, considering its size. DO could extend the bone, and the almost of continuity of segments could be recovered. However, there are morphological unbalances between newly formed bone by DO and residual bone. Therefore, additional surgery is often

needed for reconstruction of optimum alveolar ridge. The second benefit is that DO can regenerate not only bone but also oral membrane. This can reduce the flap volume in cases of free flap transplants. With free flap transfer reconstruction, some cases can begin prosthetic treatment directly without any preprosthetic treatment due to the existence of adequate soft tissue membrane (Fig. 5, A and B). The reconstructed mandible usually presents problems for prosthetic treatments, such as insufficient height (fibula), insufficient horizontal width (scapula), and too much soft tissue (iliac).1 The soft tissue over reconstructed bone is often composed of irradiated damaged oral mucosa or the cutaneous portion of the regional or microsurgical flap. It is easy to find gingival areas with a lack of attached keratinized epithelium; this condition without adequate oral hygiene leads to repeated inflammatory reactions. Dental implants allow us to design stable prostheses without soft tissue support. This circumstance needs to reduce the thickness of the fat or soft tissue of the flaps and perform vestibuloplasties or gingival-free graft with large amount of tissue around implants. Therefore, the decision to construct a removable implant–supported prosthesis or a fixed prosthesis is sometimes difficult at the point of soft tissue.24 It should be based on a series of considerations: the available occlusal space, the thickness of the gum or flap skin, the presence or absence of an antagonistic arch, the number and position of available implants, the presence of lingual or labial hypoesthesia, and the corporation that may be expected from the patient for ensuring correct prosthesis hygiene.24 Moreover, the difficulties of correct implant placement when guidance stents cannot normally be used and where anatomical landmarks have been lost.25 In this study, all patients reported good facial contours. PCBM-MESH has advantages for the reconstruction of facial contours in relatively difficult areas (eg, the anterior part of the mandible) and the preparation of the bony bed for the application of dental implants. After or concurrently with the

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reconstruction of mandibular bone continuity, it is important to simulate dental occlusion for improvement of quality of reconstruction, because the morphology of the alveolar ridge is sometimes very complicated owing to defects of soft and hard tissue and the methods of reconstruction. Recently, 3-dimensional simulations are helpful for overcoming the technical difficulties in the reconstruction of the chin and ramus and can consequently shorten the operating time and improve facial appearance.17,24 Lots of efforts are made to computer-aided surgery to assist the challenging mandibular reconstruction.26–33 Digital imaging technology is a useful tool to help surgeons visualize the defect of the patients and perform operative maneuvers on the computer before implementation in the operating room. Moreover, computer simulation and stereomodel technology allow surgeon to complete accurate ablation and reconstruction and to decrease the operating time. With computer simulation, the entire simulation of ablation and reconstruction can be preoperatively made and compared to select the best design and show the postoperative result. Although these technologies have many advantages, there would be limitations to their clinical use that include financial, technical, and practical challenges. Although this simulation surgery is a promising methodology to reconstruct mandible, using DO or free flap transfer, ideal alveolar ridge for the prosthetic rehabilitation would have morphological unbalance between reconstructed tissue and residual alveolar ridge. If facial contour is focused, the alveolar reconstruction would be difficult due to the morphological difference between mandible and reconstructed bone. In these cases, PCBM-MESH is a useful technique to reconstruct large defect of alveolar ridge for the optimum prosthetic treatment in these morphological unbalance condition. Prosthetic treatment evaluation varied widely: 5 patients were fully satisfied with their implant-retaining prostheses while 3 patients were partially satisfied due to the limitations of their conventional or implant-retaining dentures.

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Because these partially satisfied patients were malignant cases, the lack of soft tissue with extensive resection as a result of tumor surgery induced morbidity of the peripheral soft tissue. Iizuka et al34 suggest that oral functioning is strongly affected by the extent of soft tissue defects caused by the tumor surgery and not by the bony defect alone. Implant retained over dentures facilitate occlusal fitting, require fewer implants, facilitate soft tissue hygiene, distribute the occlusal forces, and are less expensive. Fixed prostheses afford improved patients satisfaction, although we believe that this solution is less indicated in mostly oncologic patients because the treatment involved more complex and costly. Moreover, occlusal fitting is difficult, hygiene is poorer, and the follow-up of implant and of possible oncologic disease relapse is likewise poorer.26

CONCLUSION Taken together, we propose the following treatment process for the reconstruction of mandibular defects: 1. The continuity of the mandible should be restored according to the tissue condition. In severe cases, free flap transfer should be performed. Relatively short segments or benign tumors with sufficient vascularity could possibly be treated with PCBMMESH. 2. Facial contours and the final dental occlusion are simulated to determine the optimum base of the dental implant or conventional dentures. CT is quite useful for 3-dimensional simulation. 3. The final prosthetic treatment requires intraoral environment for the prosthesis, particularly enough alveolar ridge with good oral membrane. For this purpose, PCBMMESH is a useful technique to link between optimum facial contour and alveolar ridge.

DISCLOSURE The authors claim to have no financial interest, either directly or indirectly, in the products or information listed in the paper.



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Evaluation of mandibular reconstruction with particulate cancellous bone marrow and titanium mesh after mandibular resection due to tumor surgery.

There are numerous treatment modalities for mandibular defects after tumor surgery. Autogenous particulate cancellous bone marrow graft combined with ...
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