Mandibular Reconstruction with Autogenous Fragment of ... · Intermaxillary immobilization with erich bar ... of the mandibular arch, often dispensing osteotomies and its structure

Journal of Pharmacy and Pharmacology 5 (2017) 688-696 doi: 10.17265/2328-2150/2017.09.011

Mandibular Reconstruction with Autogenous Fragment

of Previous Iliac Crest Associated to Hyperbaric Oxygen

Therapy: Case Report

João Fernando Veiga Pires1, Claudio Lessa2, Renata Pittella Cancado2, Filipe Barcellos Caldas2 and André

Alberto Camara Puppin2

1 Department of Oral and Maxillofacial Surgery, Hospital Naval Marcílio Dias, Rio de janeiro 20725-090, Brazil

2 Department of Oral and Maxillofacial Surgery, Universidade Federal do Espirito Santo, Vitória 29043-900, Brazil

Abstract: Early efforts at mandibular reconstruction are described from ancient China and the Etruscans to even Hippocrates, involving wooden, terracotta and metal prostheses attached to bone or teeth. Since then, modern surgery has developed more effective techniques, including no vascularized bone grafts, better alloplastic materials, vascularized loco regional grafts, soft and hard tissue compounds, bone fixation and stretching materials, and mechanisms for study models. These components have become indispensable in the surgeon’s arsenal with regard to reconstructive surgery. A gold standard for mandibular bone reconstruction is the use of autogenous grafts. The objective of this study was to describe a clinical case of mandibular reconstruction with autogenous graft associated with adjuvant hyperbaric oxygen therapy. The clinical case presented shows the treatment performed for after-effects correction due to the non-consolidation of sagittal mandibular osteotomy performed for correction of standard III dentofacial deformity, resulting in a pseudoarthrosis with bite deviation and facial asymmetry. As a treatment plan, mandibular reconstruction was instituted with autogenous graft of anterior iliac crest associated with the use prototyping biomodel and hyperbaric oxygen therapy. After a control of 1 year and 6 months, no signs of recurrence were identified and the radiographic image showed excellent positioning, good volume and maintenance of the mandibular contour. Key words: Mandibular reconstruction, hyperbaric oxygen therapy, auto-graft anterior iliac crest.

1. Introduction

The stability after orthognathic surgery, in addition

to the chosen fixation system, is influenced by

multifactorial problems such as: poor positioning of the

condyle in the fossa, experience of the surgeon, amount

of patient growth and bone remodeling [1].

The pseudoarthrosis, interposition of

fibrocartilaginous connective tissue, occurs due to

movements of the segments submitted to osteotomy

and is one of the main complications that the surgeon

wishes to avoid in the postoperative period of

orthognathic surgery. It usually results in mandibular

defects that require mandibular reconstruction with

Corresponding author: João Fernando Veiga Pires, Postdoc.,

research fields: oral and maxillofacial surgery.

bone grafts.

The rehabilitation of patients with mandible

continuity defects persists as a challenge. The gold

standard for mandibular bone reconstruction consists in

the use of autogenous grafts with predilection for the

iliac crest and fibula. However, the use of non-vascular

grafts for reconstruction of defects greater than 9 cm

represents a challenge due to the reduction of

revascularization and the osteogenic capacity of the

grafted bone tissue [2, 3].

The HBO (hyperbaric oxygen) therapy has been

used to reduce these difficulties. The HBO provides an

increase in oxygen tension, an increase in the immune

response and favors the neoangiogenesis of the area.

Hyperbaric oxygen therapy consists of administering

100% oxygen at a higher ambient pressure (usually

D DAVID PUBLISHING

Mandibular Reconstruction with Autogenous Fragment of Previous Iliac Crest Associated to Hyperbaric Oxygen Therapy: Case Report

689

close to 2.5 ATA) than that found at sea level. Reports

described the acceleration of bone graft incorporation,

greater gap filling capacity and a greater amount of

neoformed bone [4].

Therefore, we proposed in this study to report a

clinical case of a patient with pseudoarthrosis in the

mandible, where the defect was reconstructed with the

association of hyperbaric oxygen therapy and

non-vascularized graft of iliac crest.

2. Clinical Case Report

A 26-year-old female patient, leucoderma, attended

the Naval Marcilio Dias Hospital (HNMD) in May

2015. She was outpatient clinic for Oral and

Maxillofacial Surgery and Traumatology (HNMD).

The patient presented a sequel due to

non-consolidation of left sagittal mandibular

osteotomy of 45 mm thick, and the history of

performance of a surgical procedure for the correction

of standard dentofacial deformity III.

In the anamnesis, the patient denied pain, fever and

feeding difficulties. At the clinical examination, it was

observed that the patient had facial asymmetry,

laterodeviation, sensory and motor deficit in the lower

lip (Figs. 1 and 2).

On panoramic radiography pseudoarthrosis was

observed in the region. The size was of 45 mm wide

in the left mandibular osteotomy (Fig. 3).

The diagnosis of mandibular pseudoarthrosis was

reached after the clinical and radiographic data added

to the information obtained in the anamnesis. As a

treatment proposed was the confection of a prototype

model associated with hyperbaric oxygen therapy, the

protocol of HBO proposed was 20 preoperative

sessions and 20 postoperative sessions with 2.5

atmospheric pressure ATA for 90 minutes in a

Multi-place camera (Fig. 4).

The graft was removed of the iliac crest with a

width of 55 mm, a submandibular access for exposure

of the pseudoarthrosis region was performed. The

prior titanium plate was removed at the site. The

mandibular reconstruction with titanium 2.3 plate

system with 2 mm locking profile reabsorbable screen

(LKS Martin, Germany) and the iliac crest graft were

in place. Intermaxillary immobilization with erich bar

with steel wire number was sustained for 6 weeks.

The modeling of the titanium plate was performed

using a prototyping model, prior to surgery. In this

prototype, it was possible to visualize a space of 45

mm that will need grafting (Fig. 5).

Fig. 1 Patient presenting facial asymmetry.

Fig. 2 Patient presenting facial asymmetry.

Fig. 3 Panoramic radiography showing pseudoarthrosis.

690

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691

Fig. 8a Reconstruction with titanium plate.

Fig. 8b Mandibular reconstruction with graft of anterior iliac crest, titanium plate 2.3 and resorbable screen.

hours, Dexamethasone 8 mg EV of 8/8 h, Ranitidine

10 mg/mL EV 8/8 h, Metoclopramide 10 mg/mL EV,

Dipyrone Sodium 500 mg/mL EV 6/6 h.

The patient was discharged 2 days after the surgical

procedure, being submitted to the intermaxillary

immobilization for 6 weeks. She was followed weekly,

postoperatively. In one week, the suture was removed,

with no signs of infection or active bleeding.

After 1 month postoperative, maintenance of the

bone graft was observed in position (Fig. 9). At the

clinical examination, facial asymmetry improvement

could be observed with improvement in occlusion

and reduction of motor deficit of the lower lip

(Fig. 10 a-10b).

With 1 year and 6 months of postoperative control,

adequate bone contour was observed with graft

incorporation and improvement in the motor deficit of

the lower lip (Fig. 11a-11b).

Fig. 9 Postoperative panoramic radiography of 1 month.

Fig. 10a Patient with frontal view with 1 month postoperative.

Fig. 10b Stable occlusion, with 1 month postoperative..


692

Fig. 11a Post-operative panoramic radiography 1 year and 6 months.

Fig. 11b Patient with frontal view with 1 year and 6 months post-operative.

3. Discussion

The reconstruction of mandible continuity defects

using autogenous bone graft associated with a titanium

reconstruction plate is the method that has been used in

cases of mandibular bone loss resulting from trauma,

infectious processes or post-resection of tumors. This

form of treatment allows immediate function after

surgery and eliminates the need for maxillomandibular

immobilization [5]. The use of a reconstruction plate

allows the bone grafting procedure to be performed at a

later time [6], especially in those cases where local

conditions contraindicate the immediate graft.

When mandibular reconstruction is necessary, due to

pseudoarthrosis, we must choose between primary or

late reconstruction. Most of the authors presented in

this paper defend the primary reconstruction, which

was performed in the presented clinical case. For

Pogrel et al. [2], when soft tissue reconstruction is

required, primary reconstruction with vascularized

graft is the best treatment choice. For Shan et al. [7],

primary reconstruction promotes an early functional

outcome, often with placement of implants. For Chaine

et al. [8], late or secondary reconstruction would be

chosen when the patient had an unstable systemic

condition or lack of local conditions, such as absence of

vessels. Either way, prior surgery probably makes the

success of a secondary reconstruction decline

considerably. This is due to the scarring and fibrosis

caused by the first surgery.

Regarding the choice of vascularized or

non-vascularized graft, some factors need to be

considered. Johannes et al. [9] reported that for large

reconstructions where it is necessary to reconstruct soft

tissues, the choice is for the vascularized graft.

Johannes et al. [9] and Shan et al. [7] report that the

vascularized graft is the best option for large

mandibular reconstructions. However, due to the lack

of a microvascular surgeon in our institution, we did

not choose to perform the vascularized graft.

Pogrel et al. [2] described that in defects less than 5

cm the nonvascularized graft is indicated. This

indication extends to non-irradiated tissues or in

patients with systemic abnormalities, who do not

tolerate a microvascular reconstruction of the head or

neck or when the defect includes bone only. However,

Chapisco et al. [10] said that the extension of the bone

defect does not represent limitation for the use of

nonvascularized graft.

Regarding the choice of iliac crest graft, it is justified

by the greater amount of bone provided in this region.

In addition, the iliac has a shape that Lateral curvature

of the mandibular arch, often dispensing osteotomies

and its structure facilitates the use of osseointegrated

implants. As disadvantages, there is a greater difficulty

in its removal, presence of excess adipose tissue in

obese patients and possibility of hernia occurrence

[11].


693

In our clinic, in cases of mandible continuity defects,

the iliac bone is the choice as the donor region,

reserving the use of the fibula for larger defects. The

iliac bone is the donor zone most commonly used in

this type of reconstruction [10].

The three-dimensional modeling systems use images

identical to those of the patient [12]. The 3D images

obtained from a CT are an aid in diagnosis and

treatment plan. The fidelity of the anatomical details

will only be achieved if there are a strict quality

standard at all stages of the manufacturing process,

since a series of artifacts can create distortions that will

be transmitted to the model. These artifacts can

generate inaccuracies in the surgical act. It is important

to apply an imaging protocol according to the routine

of the institutions or companies that provide these

biomodels [13].

Thus, the use of the biomodel in the preoperative

period was chosen due to its importance in the

measurement of structures, prediction of the necessary

volume of bone graft and modeling of the

reconstruction plaque. In addition, the biomodel allows

the simulation of osteotomies and resection techniques

in addition to a complete planning of the most diverse

types of surgery of the oral and maxillofacial region.

This tends to reduce surgical time and, consequently,

the period of anesthesia, as well as the risk of infection,

with an improvement in the result and a reduction in

the overall cost of the treatment [14, 15].

Arvier et al. [16] reported biomodels have

disadvantages when there is a need for an emergency,

due to the time required for its acquisition or the

detailed tomographic images, also because the

prototype depends on the initial tomographic image.

They also reported that the presence of artifacts, such

as metal restorations, prostheses and orthodontic

appliances, can produce distortions in CT scans and, as

a consequence, impair the quality of the prototyping

model [14, 15].

It is essential for the surgeons to know in detail the

local anatomy and the meticulous application of the

surgical technique, especially regarding the dissection

of the region for adequate exposure of the noble

structures belonging to the submandibular area,

without any damage to the branches of the facial nerve

[12]. In this context, the access of Risdon shows

excellent operative field and it is configured as a safe

access and widely diffused in the surgical environment.

In this respect, in facial reconstructions whose severity

leads to exposure of bone fragments and the area of

pseudoarthrosis, a direct view of the region to intervene

is fundamental. Without the adequate exposure of the

region, the resolution of the clinical case in question

would be compromised. This would happen if the

surgical approach was reduced or simply the access

was only intrabuccal [17].

Reconstruction plaques are usually shaped before

mandibular reconstruction and are subsequently

applied. By folding these plates and inserting holes into

the proximal and distal mandibular segments prior to

complete mandibular reconstruction, the surgeons can

more confidently maintain proper occlusion and

mandibular segment relationships. With the low profile

locking reconstruction plates currently available, the

contoured plate can approach the natural mandibular

projection without sacrificing durability and strength,

even when used in conjunction with bone grafts.

However, if there is involvement of the buccal cortex

of the mandible, the contour of the plaque directly to

the bone is not always possible. In these cases, the

removal of the vestibular part of the pseudoarthrosis to

allow the positioning of the plaque before complete

reconstruction is a possible option with satisfactory

results [12].

It is important to understand the appropriate

possibilities for bone graft fixation. In our experience

and according to MORAES et al. [12], adequate

internal fixation using reconstruction locking plates

and, subsequently, free autogenous bone grafts appear

to be more satisfactory.

Choosing the most suitable titanium plate system is

critical to the success of the procedure. Mandibular


694

defects with loss of continuity require more robust

systems (load bearing) that support the mandibular

function. Thus, plates and screws of mandibular

reconstruction (System 2.4 mm) have been the most

used devices, being indicated in the presented case. It

also should be taken into account the rigid fixation of

the graft, since it is important for healing, and its

movement can cause infection or formation of fibrosis

[9].

Intermaxillary immobilization is necessary in the

trans-operative and postoperative moments. This is

important in order to avoid rotation of the condyles and

the movement of the bone fragments. In case of

instability in fixation it may result in a new

pseudoarthrosis and, consequently, a new surgical

intervention [12].

For Johannes et al. [9] reconstruction plaques

represent high rates of complications, such as plate

fracture, loosening of screws, and impossibility of

using dentures, difficulty of treatment when exposures

of titanium plates occur. The most common

complication is intraoral dehiscence of the wound,

which leads to failure of the graft. This complication is

related to intra-oral access and wound contamination

with microorganisms.

For Johannes et al. [9], wound contamination can

occur during surgery, or in the postoperative period,

when spillage of saliva occurs to the graft area, a fact

that is facilitated by the use of intense suctioning of the

wound in the postoperative period. The presence of

dead space and a delayed surgery are important factors

in increasing the chance of wound infection, and may

lead to dehiscence of the wound. Nonvascularized bone

grafts present considerable remodeling, especially in

patients who were previously irradiated. In these,

post-graft complication rates are particularly high.

After the trauma of the mandibular reconstruction,

there is a vascular rupture that leads to the formation of

a hypoxic zone. Although hypoxia is required to

stimulate angiogenesis and revascularization,

prolonged hypoxia will break the healing process.

HBO can be used to aid in the healing of these

compromised wounds by increasing the diffusion of

oxygen from the capillaries to the tissues [18]. The

available oxygen stimulates bacteriostatic and

bactericidal activities, increases the phagocytic

capacity of white blood cells and promotes fibroblast

differentiation by interfering with collagen synthesis.

Important biological events such as angiogenesis and

osteogenesis are also stimulated by HBO, improving

tissue repair and increasing the overall success of

reconstruction procedures [19, 20].

From the reported studies, hyperbaric oxygen

therapy was chosen as the adjunctive treatment in the

preoperative and postoperative period, aiming to

improve the prognosis of the mandibular

reconstruction performed.

There are also divergences regarding the timing of

rehabilitation with implants. While for Pogrel et al. [2]

nonvascularized grafts undergo considerable

remodeling, which means that implants can only be

inserted with confidence when remodeling has ceased,

for Johannes et al. [9]. Prosthetic rehabilitation with

implants in reconstructed portions of mandibles seems

to inhibit bone resorption because of functional

biomechanics in the graft region.

Thus, in the presented clinical case, we opted for the

rehabilitation in a second time, waiting for the

complete bone remodeling. For this, it is of great

importance the outpatient follow-up in the first 5 years

after the initial treatment, to diagnose early bone

resorptions suggested in a panoramic radiography [8,

11].

Based on the literature studied and on the clinical

case presented, it was concluded that the use of the

anterior iliac crest autogenous bone graft as well as the

2.4 mm titanium plate together with the HBOT for

mandibular reconstruction was an excellent alternative

for better prognosis and increased predictability of the

bone graft. It is important to emphasize that the aim of

mandibular reconstruction is to restore oral

rehabilitation, aiming at restoring masticatory capacity


695

and facial esthetics.

4. Conclusions

The iliac crest is one of the most commonly used

autogenous grafts because of the facility of removal

and manipulation.

The use of the prototyping model facilitates the

planning and gain of trans-operative time, besides

allowing an accurate choice of the reconstructive

material. In addition, adequate bone healing requires

vascularization and immobility.

Thus, the use of maxillomandibular immobilization

and hyperbaric oxygen therapy has a very important

supporting role in the reconstructions. Based on the

case report, it was concluded that the use of a strong

fixation system, such as the 2.4 mm system, returned

the facial contour and kept the bone graft in position.

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Mandibular Reconstruction with Autogenous Fragment of ... · Intermaxillary immobilization with erich bar ... of the mandibular arch, often dispensing osteotomies and its structure