Mandible

Reconstruction

Dr. SHOUVIK CHOWDHURY

RAJA RAJESWARI DENTAL
COLLEGE, BANGALORE
 CONTENTS
► History
► Causes of mandibular defects
► Classification
► Goals/ principles and criteria
► Timing
► TMJ reconstruction
► Complications
► Recent advances
 History
► 1821- Vongraffe & Deadrick( partial
mandibulectomy)
► 1881-Free bone grafting was the first method of
reconstructing mandibular defects and was initially
reported by Bardenheuer
► 1889- Martin described immediate reconstruction
with prosthetic appliance
► 1897- Partsh use metal band to restore
mandibular continuity
► 1898- Berndt recommended use of celluloid
material
► 1909- White favoured silver wire
► 1912- Schudder, Ollier, Martin use hard rubber
► 1941- Vitallium, 1953-SS, 1954- Titanium
► 1945- use of matal trays with cancellous bone
chips
► 1971- Conley and Snyder introduced the
osteomyocutaneous flap
► 1978- McKee and Daniel were the first to report
out comes of free vascularized composite rib flaps
► In 1989, Urken introduced the sensate free flap
 Causes of mandibular defect
► Ablative surgery of oral cancer
► Removal of odontogenic tumors like
ameloblastoma
► Surgical treatment of cysts
► Trauma- RTA, assault
► Resection following chronic osteomyelitis
► Resection of osteoradionecrosis of mandible
► Gun shot wounds
 Classification of
mandibular defects
Classification of mandibular defect
according to BOYD et al
Classification by Cantor and
Curtis
GOALS OF RECONSTRUCTION
► Restoration of bone continuity:
restores much of the mechanical stability to
the functions of mastication, speech, and
deglutition
► Restoration of osseous bulk:
► a sufficient quantity of cellular cancellous
graft materials should be placed and firmly
fixed into a vascular and cellular tissue bed
that is free of contamination.
► Restoration of bone height
► Bone maintenance:
maintenance of the bone ossicle throughout the life
of the patient.
. Grafts that show initial bone formation but
later go on to resorb between 6 and 12
months. Grafts that maintain or increase their
radiographic mineral density for 18 months almost
always maintain their ossicle throughout the
patient’s lifetime.
► Elimination of soft tissue defect: unseating
forces that prevent the seal of a prosthesis.
► Restoration of facial contour:
► Vascularity of recipient bed: osteogenesis of
transplanted tissue depends on revascularization
 Timing of reconstruction
► Primary Vs Delayed Reconstruction:
Lawson et al in 1982, reported a success rate of
90% for delayed reconstruction versus 46% for
primary reconstruction. In addition, oral
contamination of primary reconstruction resulted
in unacceptably high complication rates from
infection.
no functional benefit obtained with immediate
restoration of mandibular continuity.
► In 1991, Shockley, Weissler, and Pillsbury
published a retrospective review of 19 patients
who underwent primary mandibular reconstruction
using reconstruction plates and noted a 79%
success rate.
► He concluded that immediate reconstruction of
mandibular defects using reconstruction plates
does not replace the use of free flaps but should
be remembered as an alternative that offers fast
and reliable reconstruction with no donor site
morbidity and excellent facial contour.
 Methods of mandibular
reconstruction
► 1. Prosthetic implants:
► A. Spacing devices:
► Kirschner wire
► Bone plate
► B. Formed appliances:
► Stainless steel
► Cr-co
► Tantalum
► Titanium
► Dimethyl siloxane(Silastic)
► Fluoroethylene(Teflon)
► PMMA(acrylic)
► Polyurethane & Dacron mesh
► 2. Bone grafts:
► A. fresh autografts- rib, iliac crest, tibia,
mandible
B. treated autografts- Freeze dried,
irradiated, autoclaved.
► 3. Combined Alloplast-autograft
► tray with cancellous bone
► plate with cortical bone
► 4. free & compound flaps:
► A. free flaps: rib. Iliac crest, scaplar spine,
metatarsal
► pedicled osteomyocutaneous flap with rib,
clavicle, scapula
► 5. homograft-autograft combination
 Prosthetic implant
► Used mainly as a spacing device in
immediate reconstruction to span the defect
& maintain the position of mandibular
segment for future definitive repair.
► 1992- Goode reported the use of
tobramycin impregnated methacrylate
 THORP
► (THORP) was an attempt to address the failures of
the older plating systems. This plate has a hollow
screw made of titanium with perforations along
the screw body which allow bone ingrowth and
result in increased plate stability at the bone-screw
interface. An expansion bolt within the screw head
allows the plate to be anchored to the
interosseous screw instead of being compressed to
the underlying mandible. This prevents pressure
necrosis of the underlying bone decreasing the
potential for plate failure at the screw-bone
interface.
► Pedicled and free flaps may be combined
with plate reconstruction for soft tissue
supplementation and to minimize the
possibility of postoperative complications.
The pectoralis myocutaneous flap is the
most commonly used pedicled flap for this
purpose. The plate is usually placed first,
and the muscular pedicle is then suspended
from the plate.
► Important considerations for using
reconstruction plates include
► (1) Preventing exposure of the plate and the
posterior need for removal using a full
thickness pectoralis major myocutaneous
flap, covering the full extent of the plate to
prevent dehiscence during radiotherapy;
► (2) To allow the healing process of the soft-
tissue cover to be completed for adequate
flap integration, radiotherapy should be
postponed for as long as possible without
compromising the cancer treatment;
► (3) Whenever available, titanium 2.7-mm plates or THORP
plates should be used instead of stainless steel 2.7-mm
reconstruction plates;
► (4) Stabilization of the reconstruction plate in the mandible
must be carried out with at least 3 screws in each
reminiscent side as far as a correct plate banding to
provide a good aesthetic result and not compress the
myocutaneous flap, causing ischemia and wound
dehiscence.
► Early plate failure in the first six weeks after surgery is
most often due to technical variations in plate application
such as over projection or unstable application of the plate
which can lead to soft tissue breakdown and infection.
► Exposure after 12 - 18 months can occur from resorption
of bone around the hardware with resultant plate
instability.
► Methylmethacrylate as a space
maintainer in mandibular
reconstruction:
•Methylmethacrylate is reported
to be well tolerated
by bone and soft tissues

•The stabilized
methylmethacrylate
blocks allow the overlying oral
mucosa and skin
to heal without delay or wound
breakdown.
•Heat-cured methylmethacrylate
was originally used
in the early 1940s for facial
prosthetics and coldcured
methylmethacrylate was
reported to be initially
used in cranial reconstruction in
1941.
 Free Bone Grafting
► calvarium, rib, ilium, tibia, fibula, scapula,
humerus, radius, and metatarsus
► Cancellous bone grafts, consisting of medullary
bone and bone marrow, contain the highest
percentage of viable osteoblasts. These grafts
become revascularized rapidly due to their
particulate structure and large surface area. This
results in a higher percentage of surviving cells
after transplantation.
► Corticocancellous grafts contain both cortical bone and
underlying cancellous bone providing osteoblastic cells as
well as strength necessary for bridging discontinuous
defects.
► Allogenic bone graft:
► Allogenic mandible, rib, or iliac crest has been used
occasionally for mandibular reconstruction
► The allograft is usually hollowed and functions as a
biodegradable tray for particulate corticocancellous bone
grafts or as supplementation for autogenous bone grafting
when insufficient bone is available.
► The benefits of this method included low
immunogenicity of the graft, high concentration of
transplanted osteocytes, and complete
bioresorbability of the tray with transmission of
increasing stress to the autogenous graft which
can facilitate osteogenesis
 Advantages of Free Tissue
Transfer
► Wide variety of available tissue types
► Large amount of composite tissue
► Tailored to match defect
► Wide range of skin characteristics
► More efficient use of harvested tissue
► Immediate reconstruction
► Two team approach
► Improved vascularity and wound
healing
► Low rate of resorption
► Defect size little consequence
► Potential for sensory and motor
innervation
► Permits use of osseointegrated
implants
 Disadvantages of Free Tissue
Transfer
► Technically demanding
► Increased operating room time
► Increased flap failure rate
► Functional disability at donor site
 Vascularized Pedicled Bone
Transfers
► Non vascular bone grafting is a less reliable technique,
because high rates of infection secondary to salivary
contamination, vascularity to the graft was limited
► Vascularized bone maintains an intact blood supply
► Helps the graft to retain its original volume
► Bone remains viable no need of replacement.
► Healing time is shortened.
 Method of fixation
► Free Bone Grafting:
► Rib, ilium, tibia, fibula, scapula, radius, calvarium, metatarsus
► Myocutaneous flap: pectoralis major, sternocleidomastoid, radial
forearm flap, scapular, latissimus dorsi
► Free flap:, Illium based on deep circumflex iliac artery, Scapula based
on superficial circumflex artery, Rib based on internal mammary artery
Radius based on radial artery & cephalic veins, Fibula based on
peroneal artery, ulna based on ulnar artery
► Pedicle bone flaps:
► Clavicle/sternum based on sternocleidomastoid, Rib graft with
Pectoralis major, Rib via serratus branch of thoracodorsal artery,
Calvarial graft with temporalis muscle, Trapezius flap
Free bone grafting
 ilium
► Anterior iliac crest- 6
cm. posterior to AIS &
tubercle of ilium
► 50 cc of cancellous
bone can be harvested
► Posterior iliac crest-
100 cc of cancellous
bone
 incisions
► lateral approach stripping
tensor fascia lata & gluteus
medius
► Medial approach stripping
iliacus
► Crestal approach- spliting
or removing a portion of
iliac crest
► AIC- 2-3 cm.(l) 1-2 cm.
posterior to tubercle 1 cm.
inf to AIS
► lateral scar lie parallel to crest, medial scar at 30-
45 degree to crest
► PIC- 6-8 cm curvillinear incision on pallable
insertion of gluteus
► Bone length available: 4-6 cm
► disadvantage
► Lateral approach: gait disturbance
► Crestal approach: irregularity
► Risk of damage to lateral cutaneous n.
 approach
► Clamshell: expands medial
& lateral cortices to gain
access
► Trap door: pedicles medial
& lateral cortex on muscle
► Tschopp: pedicles iliac
crest on external oblique
► Tessier: pedicles both
medial & lateral portions
by oblique osteotomy
► Pros:
► -Good bone stock
► Cons:
-shape of bone can make graft shaping
difficult
 complications
► Gaitdisturbance, infection, hematoma,
sacroiliac instability, intra abdominal
perforation, abdominal hernia
Costochondral Rib graft
 incision
►5 cm.long.
Inframammary crease
& carried from mid
axillary region to
sternum
► Use-TMJ
reconstruction
► 5-8 ribs are harvested
► Subperiosteal
dissection
 disadvantage
► Pleural tear, pneumothorax
 scapula
► Lateral border- 10×2
cm
► Flat blade: 7×5 cm
► Transversely located
spine- 7cm.
► Pedicle:transverse
cervical artery
 incisions
► Vertical incision from
standard radical neck
incision or serpiginous
incision from vertical
back incision-root of
neck & to lower border
of mandible
► Scapular blade:
transverse incision 2cm
below & parallel to
spine of scapula
► Trapezius m.-incised
vertically from level of
mastoid process
► Incision carried along
infraspinatous m. at
the junction of
scapular spine & blade
of scapula
 Scapular blade
► Transverse incision
2cm. Below & parallel
to spine of scapula
 Fibular free flap
► 1975
► Hidalgo – mandibular recon
1989
► Longest possible segment
of revasularized bone (25-
28 cm)
► Ideal for osseointegrated
implant placement
 Neurovascular pedicle
► Peroneal artery and vein
► Sensate restoration with lateral sural
cutaneous nerve
► Peroneal communicating branch
vascularized nerve graft for lower lip
sensation
► Skin perforators
 Posterior intermuscular septum
(septocutaneous or musculocutaneous
through flexor hallucis longus and
soleus)
 Should always include cuff of flexor
hallucis longus and soleus in flap harvest
 5-10% of cases blood supply to skin
paddle is inadequate
 Pedicle length-3cm
 Technical considerations
► Choose leg based on ease of
insetting
 Intraoral skin paddle
►Harvest flap from
contralateral side of
recipient vessels
► 8 cm segment preserved
proximally and distally to
protect common peroneal nerve
and ensure ankle stability
► Center flap over posterior
intermuscular septum
 Anterior to soleus and
posterior to peroneus
 Fibular free flap
► Morbidity
 Donor site complications
►Edema
►Weakness in dorsiflexion of great toe
 Skin loss in 5 – 10% of flaps
Myocutaneous flaps
 STERNOCLEIDOMASTOID FLAP
Introduced by Jinau in 1909.
1949-1955 – Owens.
Muscle, Myocutaneous or Myoosseous flap
ANATOMY :
Origin : Two heads – Manubrium sterni
Medial third of clavicle.
Insertion : Mastoid process
lateral third of superior Nuchal line.
Cutaneous innervations –Supraclavicular
Transverse colli
Greater auricular nerve
Motor – Spinal accessory nerve
Anterior rami of 2nd and 3rd
Skin – Subcutaneous tissue- platysma-
Sternocleidomastoid
Blood supply :
Superior- Occipatal artery (Dominant)
Middle- Superior thyroid artery.
Inferior- Thyrocervical trunk
Skin – Superior-Occipital/
Posterior auricular
artery
Inferior- Transverse
cervical/ Thyrocervical
For only muscle flap –
Vertical incision on muscle

Alternate two horizontal

incision
Myocutaneous – Superior /
Inferior based

Mc fee incision.
Superiorly based : Oral reconstruction / Soft
tissue coverage
► Muscle flap is developed by elevating skin,
platysma.
► Once the muscle is exposed sternal and
clavicular head is transacted.
► Dissected between superficial fascia and deep
surface of the muscle.
► Fascia is left in place over carotid sheath –for
protection.
► The vascular supply thyrocervical trunk is
ligated.
► proceeded to superior thyroid artery is ligated.
► Preserve the spinal accessory nerve.
► Then muscle is transposed.
MYOCUTANEOUS : Superiorly based
Skin outline is done

Inferiorly based flap

Pedicled flap
Advantage : Proximity of recipient site.
One stage procedure
Total flap loss is rare.
Good colour match.
Bulk.
Disadvantage :
Deformity at donor site
Muscle atrophy
 Pectoralis major myocutaneous
flap
► Workhorse for head and neck
reconstruction
► First described by Ariyan 1977
 PECTORALIS MAJOR
MYOCUTANEOUS FLAP
The Pectoralis major muscle is a broad, flat,
fan shaped muscle covers pec minor,
subclavius, serratus anterior and intercostal
muscles
Origin :
Medial- sternum
S- medial clavicle
Lateral- intertubercular
groove of humerus
Adjacent cartilage of 1st six
ribs
Bony portion of 4th 5th 6th
ribs

THREE MAJOR SEGMENTS

1. Clavicular segments
2. Sternocostal segment
3. Laterally placed external
segment
Clavicular segment :
Blood supply : Deltoid branch of thoraco
acromial artery
Nerve : Lateral pectoral nerve

Sternocostal segment :
Blood supply : Pectoral branch of
thoracoacromial artery
Nerve : Lateral/Medial pectoral nerve
External segment :
Blood supply :Lateral thoracic artery
Pectoral branch thoracoacromial
artery.
Nerve : Medial pectoral nerve
Other branch which supplies pectoralis
is
Internal mammary artery.
TECHNIQUE :
2 types of flaps
1. PMMC Island flap
2. PMMC Paddle flap
ISLAND FLAP:
► Measurement is from the clavicle to the inferior
margin of the skin island. The measuring tape is
rotated to the defect to arrive at the appropriate
length of the flap.
► Skin paddle should be medial and inferior to nipple.
► In women the inframammary
crease corresponds to the
inferior edge of the skin
paddle.

1. Midpectoral or inframammary
incision

► Incision is made through

skin/subcutaneous tissue.
► Dissected upto fascia of the
muscle.
► Dissection proceeds laterally towards the free margin
of pectoralis major muscle and insertion of the muscle
superiorly, medially toward the sternal origination.
Superiorly towards clavicular origination.
► Skin paddle margin is incised carefully.
► Elevation of flap is done.
► Entire muscle is elevated leaving 1cm thickness
attached to lateral sternum/ humerus. Superficial to
ribs/ intercoastal musculature, pectoralis minor
► Avoid trauma to pectoralis major pedicle.
► Complete elevation of the flap with skin island.
► Dissecttion of supraclavicular tissue to communicate
the neck and chest wall.
► Flap is taken through the tunnel.
PEDICLE FLAP:
Here skin for the paddle flap is not attached directly to
the muscle itself but rather get its blood supply from
an extension of the muscle fascia.
► Two separate island flap outlined.
► After flap is elevated and transposed. The muscle is folded so
that one island may be sutured into the oral defects and other
into skin.
ADVANTAGE :
► Arch of rotation is more than 20cm
► Bulk
► Functional/Cosmetic results
► Donor site is early close
► Hairless area.

DISADVANTAGE :
► Loss of muscle noticeable is male.
► Difficulty to identify vascular pedicle.
 TRAPEZIUS MYOCUTANEOUS
FLAP
Mutter described the flap in 1842.
Zovickian popularized in 1957.
ANATOMY: Flat, triangular muscle covers the
superior posterior part of the neck and shoulder.
Origin : Nuchal line of occipital bone
Spine process of C7 through T12.
Insertion : Lateral 1/3rd of
clavicle.
Acromion.
Spine of scapula.

Action : Rotation of scapula

Elevation, flexion,
abduction of the upper
arm.
Blood supply :
► Branch of thyrocervical trunk-
transverse cervical artery
► Occipital artery
► Paraspinal perforators
Venous drainage :
► Sub dermal plexus.
► Deeper venae commitants.
► Transverse cervical vein.
► Suprascapular vein.

Nerve :
► Motor – Spinal accessory nerve
► Sensory – Cervical/Intercoastal nerve.
TECHNIQUE:
Transverse cervical trapezius
myocutaneous flap.

► The vessel must be identified in the

neck and traced to the anterior
border of the muscle.
► Anterior incision for the skin island
extend along the anterior border of
trapezius.
► Muscle and its blood supply is
elevated.
► Appropriate skin island is cut and
underlying muscle is incised.
Transverse cervical trapezius
myocutaneous flap
► It is rotated into defect and sutured.

Lower trapezius myocutaneous flap

1. Island flap
2. Solid flap
► Vessels are identified and trace the muscle.
► Muscle is divided lateral to vessel artery.
► Appropriate skin island is cut.
► Muscle is completely divided along lateral line.
► Muscle is elevated below upwards.
► Then it is rotated/ and sutured.
► Cephalic end flap – 7-8cm proximal to tip of
scapula
► McCraw –Anterior margin follows the border
of trapezius. Posterior margin runs parallel
and extends upto midline of the posterior
neck.
Width – 10cm
Length – 30cm
Advantage :
1. Hairless
2. Scar is not obvious
3. Skin of uniform thickness available.
Disadvantage :
1. Short pedicle
2. Limited arch of rotation
3. Vessels may be injured
4. Painful shoulder
 Lower trapezius
myocutaneous flap
 Radial Forearm Flap
► 1978 (China) by Yang etal, 1985 (pharyngeal
recon)
► Thin, pliable skin
 Reconstitution of contours, sulci, vestibules
► Fasciocutaneous flaps are highly tolerant of
radiation therapy
► Composite flap with bone, tendon, brachioradialis
muscle and vascularized nerve.
 Neurovascular pedicle
► Up to 20 cm long
► Vessel caliber 2 – 2.5 mm
► Radial artery
► cephalic vein
► Lateral antebrachial
cutaneous nerve (sensory)
 Technical considerations
► Tourniquet

► Flap designed with skin paddle

centered over the radial artery
► Dissection in subfascial level as
the pedicle is approached.
► Pedicle identified b/w medial
head of the brachioradialis, and
the flexor carpi radialis
► Radial artery is dissected to its
origin
 Radial Forearm Flap
► Morbidity
 Hand ischemia
 Fistula rates - 42% to 67% in early series
 Radial nerve injury
 Variable anesthesia over dorsum of hand.

Advantage:
Thin pliable skin, often hairless,long pedicle(12-15cm),
Disadvantage:
Donor site defect visible
Pedicle bone flaps
 Rib graft with Pectoralis major
► In 1980, Ariyan and
Cuono reported the use of
a pectoralis major pedicled
myocutaneous flap
transferred with a segment
of the underlying fifth rib.
► Latissimus dorsi with
attached rib has also been
used. Richards et.al
reported use of Serratus
anterior/rib composite flap
in mandibular
reconstruction
 Rib flap
► First vascularized bone to be used
in mandibular reconstruction.
(osteocutaneous)
► Blood supply to the rib
 Internal mammary artery
 Posteriorly or posterolaterally
on the posterior intercostal
vessels
 Transferred with the pectoralis
major, serratus anterior, or
latissimus dorsi muscle
► Poor bone stock except for
condylar reconstruction
► Not commonly used
 Combined lattissimus dorsi serratus anterior/rib

composite free flap

► First described by Tansini
in 1895
► Not as versatile as pmmc
but certain qualities such
as the hair free skin and
donor site scar make it an
invaluable alternative
► Indicated when large
amount of tissue is
required
 Neurovascular pedicle
► Thoracodorsal artery
► Arise from subscapular vessels off
of third portion of axillary artery
and vein
► Pedicle length 9.3 cm (6 to 16.5)
 Can be lengthened by sacrificing
branch to serratus anterior
► Numerous variations
 Most common: independent origin of
thoracodorsal vein/artery
 Technical considerations
► Lateral decubitis position
 If at 15 degrees, flap may be
harvested simultaneously with
primary lesion resection
 Anterior muscle border along
line b/w midpoint of axilla and
point midway b/w ASIS and
PSIS
► Vessels enter undersurface of
muscle 8 to 10 cm below midpoint
of axilla
► Serratus vessels ligated during
harvest
► Can design two paddle flap based
on medial and lateral branches of
thoracodorsal vessels
 Latissimus dorsi
► Morbidity
 Marginal flap necrosis
 Pedicled flaps pass b/w pec major and minor
►Changes in arm position may occlude pedicle
►Should immobilize arm in flexed position
 Serratus anterior
► based upon a pedicle derived from a branch
of the thoracodorsal artery which supplies
the lower third of the muscle
► The latissimus dorsi muscle may be
transferred with serratus anterior on a
common pedicle of thoracodorsal vessels
 Deep  circumflex iliac artery bone
flap
► Blood supply: Deep
circumflex iliac artery from
the external iliac artery.
► Artery: Large caliber of 1.5
to 4 mm.
► Pedicle length: From 4 to 7
centimeters. Length
depends on size and
position of the bone flap
and skin paddle.
► The incision is marked a
finger breadth above and
parallel to the inguinal
ligament.
► SCIA and DCIA vessels are
identified at or near their
origin.  Once identified,
the DCIA vessels are
traced distally toward the
anterior superior iliac
spine, in the substance of
the transversalis fascia.  
► The external and internal
oblique muscular fascia is
divided superficial to and
along the course of the
artery and vein
► As the dissection proceeds
lateraly and the iliac crest is
encountered,
► the muscles superficial to the
pedicle are divided from the iliac
crest insertion, exposing the
iliacus muscle and iliac crest. 
► The vessels lie on the surface of
the iliacus muscle, guiding the
dissection as it proceeds
posteriorly. The vessels diverge
later into branches that
penetrate the iliacus and the
overlying transversalis fascia.
► On the anterior surface of the
iliac crest, the cautery is used to
score the iliacus muscle and
“square off” the area need for
osteotomy
 Trapezius osteomyocutaneous flap

► Demergasso and Piazza (1977)

► provide 12 x 2.5 cm of
scapular bone
► The medial scapular spine
is used in combination
with either a superiorly
based trapezius flap,
based on the paraspinous
perforators and the
occipital artery, or an
island trapezius flap based
on the transverse cervical
vessels.
► Cephalic end flap – 7-8cm proximal to tip of
scapula
► McCraw –Anterior margin follows the border
of trapezius. Posterior margin runs parallel
and extends upto midline of the posterior
neck.
Width – 10cm
Length – 30cm
Advantage :
1. Hairless
2. Scar is not obvious
3. Skin of uniform thickness available.
Disadvantage :
1. Short pedicle
2. Limited arch of rotation
3. Vessels may be injured
4. Painful shoulder
 Lower trapezius
myocutaneous flap
 Calvarial graft with temporalis
muscle
► Gratz et al
► Advantages:
► thick enough to take an
endosseous implant,
► early revascularization which is
related to numerous vascular
systems
► morbidity is low,
► there is virtually no
postoperative pain,
► the scar is invisible,
► and there is only one donor
area for both hard and soft
tissue.
 Scapular osseocutaneous free
flaps
► In1993, Sevin et al described a
hemimandibular reconstruction with
scapular crest vascularized by two pedicles
(circumflex scapular artery and angular
branch) associated with a parascapular skin
flap
 Sternocleidomastoid
Osteomyocutaneous Flap
► Conley and Gullane
► After tumor resection, the
clavicle is measured to obtain
the desired segment to fill the
mandibular defect. The clavicle
that is harvested must include
its medial portion and at least
two thirds of the lateral
clavicular body. Clavicle is
released from all its
attachments except for the
SCM; it is rotated on the
muscular pedicle across the
midline into the defect and
fixated with conventional bone
fixation systems.
 Scapular flaps
► Fasciocutaneous, osteofasciocutaneous,
cutaneous flap, parascapular cutaneous flap,
latissimus dorsi myocutaneous flap, and
serratus anterior flap
► Thin, hairless skin
► Two cutaneous flaps may be harvested
 Horizontally oriented flap – transverse
cutaneous branch
 Vertically oriented flap parascapular flap –
descending cutaneous branch
► Long pedicle length
► Large surface area
► Complex composite midfacial or
oromandibular defects
► Up to 10 cm bone
► Osseointegrated implants possible
► Single team approach
 Neurovascular pedicle
► Subscapular artery and vein
 Circumflex scapular artery and vein emerge from
triangular space (teres major, teres minor and long
head of triceps)
 Paired venae comitantes
 Artery caliber – 4 mm at takeoff from subscapular
► Subscapular caliber – 6 mm at takeoff from axillary
artery
 Pedicle length – 7 to 10 cm, 11 to 14 cm (from
axillary artery)
► Largest amount of tissue available for transfer
 Technical considerations
► Decubitis positioning
 15 degree angle
 Separate axillary incision helpful
in dissecting pedicle to axillary
artery and vein
 Bone harvest
► Teres major, subscapularis
and latissimus dorsi need to
be reattached to scapula
► Flap harvest opposite side of
modified or radical neck dissection
 Scapular flaps
► Morbidity
 Brachial plexus injury 2/2 lateral decubitis
positioning
►Use axillary roll
 Stay 1 cm inferior to glenoid fossa
 Detach teres major and minor to harvest bone
►Can cause shoulder weakness and limit range of
motion.
 Scapular flaps
► Preoperative ► Postoperative
Considerations management
 Prior axillary node  Immobilize for 3 to 4
dissection – days
contraindication  Early ambulation
 5 days for bone harvest
 PT
► Pros:
-more soft tissue than other flaps
-can get skin island up to 30cm long
-can also include latissimus
-bone and soft tissue independent
-14 cm of bone
► Cons
-bone does not have a segmental blood supply
-skin is thick
-can’t harvest flap during tumor resection
-can have compromised shoulder fxn
 TMJ RECONSTRUCTION
► The first arthroplasty was made by Percy
and Barton in 1826.
► GOALS:
► To reduce patient suffering and improve TMJ
function.
► To reduce disability.
► To contain excessive treatment and cost.
► To prevent morbidity
 Autogenous Temporomandibular Joint
Replacement
► defined as construction or reconstruction of
the mandibular ramus condyle unit (RCU),
glenoid fossa, and TMJ meniscus with the
patient's tissue.
 Goals
► Restorationof mandibular ramus length and
morphology,
► Normal range of motion and jaw relations
► occlusion.
 Costochondral Graft
► Goals:
► To reestablish vertical height of lower face
► Reestablish premorbid occlusion
► Dynamic grow of new condylar head
► Popularized by Poswillo, Mcintosh, Henny
► Adv: biologically acceptable with possessing
growth & remodelling potential
► Disadv: fracture, resorption, donor site
morbidity, recurrence of ankylosis
 Metatarsal Head Graft
► Harvested from 2nd
metatarsal phalangeal joint
► Pedicle: dorsal metatarsal
artery
► The MTPJ is capable of
providing only rotational
movement to the jaw
without the ability to
translate,
► interincisal opening- 25
mm to 30 mm.
 Disadvantage
► Charcotjoint is insensate and is unable to
provide sensory feedback regarding any
potentially damaging functional overload.
 Other flaps used
► Sternoclavicular Joint Graft
► Calvarial Bone Graft
► Fibular Free Flap
► Iliac Crest
► Coronoid Process
 Alloplastic temporomandibular
joint reconstruction
► 1840- John Murray Camochan attempt to mobilize
a patient's ankylosed TMJ by placing a small block
of wood between the raw bony surfaces of the
residual mandible after creating a gap at the neck
of the condyle.
► 1890- a German surgeon named Gluck reported
total joint arthroplasties with ivory prosthetic TMJs
and hip joints that he stabilized with cement made
of colophony, pumice, and gypsum.
► Goodsell (1947)- use of Tantalum foil.
► 1951, Castigliano and Kleitsch resurfaced the bone
in TMJ ankylosis cases with Vitallium.
► In 1952 Smith reported the use of stainless steel
in hemiarthroplasty for ankylosis.
► Ueno et al reported experimental and clinical
results with zirconium in TMJ ankylosis in 1955.
► In 1960 Henry described replacement of an
ankylosed TMJ with prosthesis; that same year
Robinson reported correction of a TMJ ankylosis by
means of an artificial stainless-steel fossa.
 Indications for alloplastic joint
reconstruction
► Ankylosis or re-ankylosis with severe anatomic
abnormalities.
► Failure of autogenous grafts in patients who have
undergone multiple operations.
► Destruction of autogenous graft tissue by pathosis.
► Failure of Proplast-Teflon resulting in severe anatomic
joint mutilation.
► Severe inflammatory joint disease, such as rheumatoid
arthritis, that results in anatomic mutilation of the joint
components and functional disability.
 contraindications
► Insufficient patient age.
► Lack of understanding on the part of the
patient
► Uncontrolled systemic disease, such as
diabetes mellitus.
► Allergy to the materials that are used in
the devices to be implanted.
► Active infection at the implantation site.
 Advantages
► Physical therapy can begin immediately.
► no need for a secondary donor site, and
surgery time is decreased.
► can be constructed in such a way as to
mimic the normal anatomic contours of the
structures they are to replace
 Disadvantages
► Cost of the prostheses.
► Material wear and failure.
► Long-term stability. Screws may loosen with
time and function and may thus require
replacement.
► Inability to follow a patient's growth.
 The Christensen Temporomandibular
Joint Prosthesis System
► used as a partial joint for treatment of
severe internal derangement, adhesions,
disc perforation, and ankylosis.
► The condylar prosthesis is always used in
conjunction with a Fossa Eminence
Prosthesis and constitutes a total joint
replacement (TJR)..
 Fabrication
► This device is
fabricated entirely of
Co-Cr alloy and is
approximately 20 mm
to 35 mm across and
0.5 mm thick
 Indications
► Ankylosis or reankylosis with severe anatomic
abnormalities.
► Failed autogenous grafts in patients who have undergone
multiple operations.
► Destruction of autogenous graft tissue by pathology
► Failed Proplast-Teflon that results in severe anatomic joint
mutilation.
► Failed stock or custom total or partial joints.
► Severe inflammatory joint disease, such as rheumatoid
arthritis, that results in anatomic mutilation of the joint
components and functional disability.
 Contraindications
► Age of the patient
► Mental status of the patient
► Disease, such as diabetes mellitus
► Active infection at the implantation site.
 Lorenz Prosthesis
► The basic goal for this
prosthesis was to
maximize the mating of
articular surfaces, which
was accomplished with a
spherical condylar head.
This design feature allows
positional freedom of the
mandibular component,
following fixation of the
fossa component, in all
planes
 COMPLICATIONS
► Plate complications
► Consists of extraoral exposure , intraoral
exposure , screw loosening, plate fracture, and
osteomyelitis
► musculoskeletal or soft tissue, with varying
degrees of defects in shape, position, stability, and
function.
► Secondary deformities may arise from structural
instability that occurs from infection,
osteoradionecrosis, nonunion, or fracture of the
reconstruction plate for cases in which hardware
was used alone without bone replacement
► Carlson and Monteleone have given Protocol for
managing intraoperative perforations of
mucosa and skin:
► 1. Irrigation of perforation
► 2. Two-layer closure
► 3. Consider the use of growth factors to seal
submucosal/dermal tissue closure
► 4. Eliminate dead space in neck closure
► 5. Passive drainage of neck closure
► 6. Consider maxillomandibular fixation
► 7. Administer intravenous antibiotics
throughout hospital course
► 8. Provide enteral tube feeds for at least 3
days postoperatively
► 9. Perform twice-daily mucosal/skin suture
line care
► 10. Prescription for oral antibiotics for 1
week following discharge from hospital
 RECENT ADVANCES
► Tissue Engineering:
► Tissue engineering is an interdisciplinary field that
combines and applies the principles of engineering
and the life sciences for the development of
biological substitutes to restore, maintain, or
improve tissue function.
► Biodegradable polymers such as polyglycolic acid
(PGA) have been combined with bovine
periosteum to form new bone. Poly DL-lactic–co-
glycolic acid (PLGA) has also been used to tissue
engineer bone.
 Transport disc distraction
osteogenesis
►A segment of bone is cut adjacent to the
defect and moved gradually across the
defect by a mechanical device. New bone
fills in between the two bone segments. The
piece of bone being moved or transported is
referred to as the transport disc.
 Modular endoprosthesis
► . An endoprosthesis is a metallic device that replaces
diseased bone in long bones and is fixed internally with
bone cement within the medullary space of the remaining
healthy bone. There is no need for screw fixation. The
variable length of the bone gap can be bridged by using
modules that allow for accurate three-dimensional
reconstructions. The modules are connected by a locking
system. In principle, the mandible would qualify for such
an endoprosthesis because of the existing medullary
space. Occlusal rehabilitation could be achieved on
implants that are screwed into existing holes of the
endoprosthesis.
 Gunshot injury
► Reconstruction with a free
fibular osteocutaneous flap
► 23 cm fibular
osteocutaneous flap was
harvested
► Two osteotomies were
performed at the proximal
part of the flap for the
symphyseal and
parasymphyseal defect
reconstruction.
► Osteotomies were
stabilised with
miniplates
► osteomuscular dorsal
scapular (OMDS) flap
is used as an
alternative technique
 Other flaps
► PMMC
► Latissimus dorsi
► DP flap
► Reconstruction plates
Reconstruction in ORN