Modified trans-oral approach for mandibular condylectomy 377

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E-mail: longxing_china@hotmail.com
Address:
Xing Long doi:10.1016/j.ijom.2009.01.020
Department of Oral & Maxillofacial Surgery
Key Lab for Oral Biomedical

Technical Note
Reconstructive Surgery

A novel modification of a bone K.

Y.
K.
Tominaga1, I. Yoshioka1,
Yamashita2, M. Habu1,
Iwanaga1, A. Khanal1,
Nishikawa1
repositioning device and a new T.
1
Department of Oral and Maxillofacial
Surgery, Division of Maxillofacial Diagnostic
and Surgical Science, Kyushu Dental College,

technique for reestablishing Kitakyushu, Japan; 2Department of Oral and

Maxillofacial Surgery, Division of Oral and
Maxillofacial Reconstructive Surgery, Kyushu

facial contours after mandibular Dental College, Kitakyushu, Japan

resection surgery
K. Tominaga, I. Yoshioka, Y. Yamashita, M. Habu, K. Iwanaga, A. Khanal, T.
Nishikawa: A novel modification of a bone repositioning device and a new technique
for reestablishing facial contours after mandibular resection surgery. Int. J. Oral
Maxillofac. Surg. 2009; 38: 377–381. # 2009 International Association of Oral and
Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Abstract. A novel modification of a bone repositioning device previously published

by the same authors is introduced. A flexible tube to define the intersegmental
bony relationship is filled with light-cured resin. It solidifies following exposure to
strong visible light for about 1 min. This technique can be used for bone
positioning after mandibular resection surgery and during positioning of the
proximal segment after sagittal split ramus osteotomy. The authors also propose a
Keywords: bone positioning; mandibular resec-
simple method for determining the contour of the reconstructed mandible to regain tion; sagittal split ramus osteotomy.
the original shape and form. The advantage of this technique is its simplicity and
flexibility compared with other methods of bone positioning during mandibular Accepted for publication 9 February 2009
segmental surgery. Available online 9 March 2009

For surgery in the mandible, precise posi- tional reconstruction of the mandible. Var- tions. The authors described a simple
tioning of the resected or split bone is often ious positioning devices1,2,8 have been method for bone segment positioning9 that
needed. 3-dimensional positioning of the developed to maintain bone position, but consists of a combination of bone plates and
mandibular stumps is mandatory for func- they are complex or have limited indica- a flexible tube filled with acrylic polymer,
378 Tominaga et al.

Fig. 1. Positioning steps for mandibular resection. (a) Fix bone plates outside resection margins. (b) Flexible tube filled with light-cured resin
covered in protective aluminum foil. (c) Stabbing the flexible tube into each plate. During this step, direct light should be avoided. (d)
Solidification of the flexible tube with strong visible light, which is cordless. (e) Completion of the positioning device. (f) After removing the
positioning device, mandibular resection is performed. (g) Re-application of the positioning device. Occlusal relationship is maintained with the
positioning device without any intermaxillary fixation. After this step, permanent fixation with bridging plate or bone grafting is performed.
which solidifies after injecting acrylic Surgical Technique Shibase Co. Ltd, Japan). The flexible tube is
monomer. The authors present a modifica- injected and filled with light-cured resin
Modified bone repositioning method
tion of this method and propose a simple (Clearfil Photo Core, Kuraray Medical
method for reestablishing the ideal facial The components of this device are bone Inc., Japan) instead of resin polymer. The
contours with grafted bone during recon- plates (Pape mini reconstruction plate, resin tube is then covered in aluminum foil
struction after extensive resection of the 1.27 mm thickness, Martin, Germany) to avoid light exposure before use and is
mandible. and a flexible tube (made of polypropylene, sterilized with ethylene oxide gas (Fig. 1b).
 Modified bone positioning method 379

Fig. 2. Positioning device during fixation of proximal segment in SSRO. (a) The bone plates on the right side are fixed to the maxilla and
ascending ramus as in single jaw surgery, and to the zygomatic buttress and ascending ramus on the left side as in two jaw surgery. (b) Proximal
segment positioning during SSRO with this technique.

Fig. 3. Contour reconstruction with contour indicator in subtotal mandibular resection. (a, b) Straight cobalt chromium nickel wire (1.0 mm
diameter) attached to small bone plate. (c) Wire attached to small plate between double flexible tubes indicates chin before resection. (d) After
subtotal mandibulectomy, the positioning device is reapplied. The shape of the grafted bone is determined by the chin indicator to recover the
original contour of the mandible.

In segmental resection of the mandible,
after adequate resection margins have been
determined, both bone plates of this fixation
device are fixed beyond the planned osteot-
omy margins without interfering with the
final plating (Fig. 1a). The flexible tube is
stabbed into each plate as shown in Fig. 1c.
Light-curing resin starts solidifying after
exposure to normal operating light, so
direct light over the tube should be avoided
during this stage. Strong visible light from a
special source (Pencure, J. Morita MFG
Corp., Japan) is then applied over the tube
for about 1 min to solidify it (Fig. 1d). After
polymerization of the resin, the tube hard- Contour reconstruction method
ens and the positioning device is completed
For esthetic and functional reasons, rees-
(Fig. 1e). The device is removed and the
tablishment of the original mandibular
planned mandibular resection performed
contour with reconstructed bone is impor-
(Fig. 1f). The positioning device is reap-
tant, especially in cases with wide resec-
plied by securing the bone plates to the
tion of the mandible, such as subtotal
residual bone stumps (Fig. 1 g). After final
mandibulectomy. Cobalt chromium nickel
reconstruction with bridging plates or
straight wire of diameter 1.0 mm (Sun-
microvascular bone grafts, the positioning
Platinum Orthodontic Wires, Dentsply-
device is removed.
Sankin, Japan) is tied through the holes
The operator can also use this device for
of a small bone plate (Fig. 3a and b). This
positioning the proximal segments during
bone plate bearing the wire is stabbed into
sagittal split ramus osteotomy (SSRO)
2 flexible tubes containing light-cured
(Fig. 2).
380 Tominaga et al.

Fig. 4. Clinical photographs showing contour indicator. (a) Preparation of positioning device with contour indicator. The right mental tubercle is
indicated with the indicator. Resection from the right ramus to the left mental tubercle is planned. (b) Reconstruction with free scapular flap. Single
osteotomy of the scapula is performed at the point of the contour indicator tip. (c) Postoperative panoramic view. (d) Postoperative CT. (e) Facial
contour after reconstruction.

resin arising from the positioning device
placed at the bilateral sides of the mand-
ible. Strong visible light (Pencure, J. Mor-
ita MFG Corp., Japan) is applied and the
positioning device is completed once the
resin has hardened. The straight wire is
bent using the hands and bending forceps
to indicate a certain point such as the
genial tubercle in the chin area (Fig. 3c
and d). This contour indicator is easy to
adapt and use (Fig. 4).
Discussion it can be used intraorally or extraorally for
extensive resection of the mandible.
The authors’ original description of the
In the original system, chemically cured
positioning device was published in
resin was used in the flexible tube, but the
20069. Since then, positioning devices
authors encountered problems during
using similar concepts have been
acrylic monomer injection, such as bubble
described. IWAI et al.5 reported a device
entrapment which could decrease its
for segmental resection. IIDA et al.4 intro-
strength. In the present modification, they
duced a modified method for proximal
have tried to address this problem and
segment positioning in SSRO. The advan-
made usage easier by replacing the che-
tage of the authors’ device is its versatility;
mically cured resin with light cured resin.

This modified technique also has the
advantage that there is no contamination
with acrylic monomer in the surgical field.
The light source used in this study is
usually applied during conventional dental
restorations. The light is supplied by a
light emitting diode so the device is com-
pact and the light polymerization reaction
occurs in a very short time.
Reestablishing a good contour for the
grafted bone after extensive resection of
the mandible is important esthetically and
for functional rehabilitation. Various
methods have been published for reestab-
lishing the ideal contour3,6,7,10. Templates
prepared intraoperatively after resection
are mainly used6. Recently, preoperatively
prepared stereolithographic models based
on CT data have been reported3,7,10. The
former method is less precise at reprodu-
cing the original configuration of the
mandible and the latter is expensive. In
cases of malignant tumors involving the
lateral cortex of the mandible, pre-bending
of the bridging plate that is commonly
used for fixing before resection and then
reinserted after surgery is not possible.
The present technique could address these
shortfalls as it is precise, easy to use,
simple, less time consuming, less expen-
sive and has greater flexibility in usage.
Modified bone positioning method 381
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