CLINICAL STUDY

Mandibular Reconstruction After Hemimandibulectomy

Huseyin Karagoz, MD, PhD,* Fikret Eren, MD,* Celalettin Sever, MD,* Ersin Ulkur, MD,*
Cengiz Acikel, MD,Þ Bahattin Celikoz, MD,* and Bilge Kagan Aysal, MD*

Abstract: Ameloblastoma is a benign tumor of the mandible, which

is not commonly diagnosed in the early stages. The extensive
mandible resection may be needed for treatment. In this report, we
present 6-year follow-up results of a patient who had undergone
hemimandibulectomy and mandible reconstruction with free vas-
cularized fibular flap, costochondral rib graft to restoration of the
temporomandibular joint, and iliac bone graft to enhance the vertical
height of the mandible. The long-term results are very satisfactory. FIGURE 1. Preoperative view of the patient.

Key Words: Mandible, ameloblastoma, fibular flap,

costochondral graft
(J Craniofac Surg 2012;23: 1373Y1374)
A meloblastoma is a benign tumor that develops from the epi-
thelial cellular elements and dental tissues, localized in the
mandible and the upper jaw.1,2 In many cases, ameloblastoma is not
diagnosed in the early stages because this benign tumor is often
asymptomatic and has a slow grow pattern without evidence of
swelling. Despite the benign nature of the tumor, ameloblastoma is
a locally aggressive tumor and malignant transformation is pos-
sible.3 To avoid recurrence and possible malignant transforma-
tion, the tumor should be resected totally with or without border
preservation.4
The mandible is a major component of the human facial ap-
pearance and makes a great contribution to the orofacial function.
For this reason, mandibular bone defects may result in oral function
deficits, aesthetic disturbances, and psychologic problems.5 Many
mandibular reconstruction options are available.
In this clinical report, we present 6-year outcomes of a pa-
tient who had undergone mandible and temporomandibular joint
(TMJ) reconstruction with combined free vascularized fibular flap,
costochondral rib, and iliac bone graft for reconstruction of the
hemimandibulectomy defect.
CLINICAL REPORT
A 21-year-old man was admitted to our clinic with a chief
complaint of swelling in the lower jaw (Fig. 1). He has noticed a mass
on the right side of his face, and the mass has grown slowly since
childhood without known etiology. On the basis of physical exam-
ination and radiography, the right ramus and the greater part of the
right mandibular body were involved, and we performed incisional
biopsy for a definite diagnosis and treatment (Fig. 2). The pathologic
diagnosis of the biopsy specimen was reported as ameloblastic fi-
broma, and the treatment was planned after careful analysis of each
factor. We performed right hemimandibulectomy and removed the
tumor and the right hemimandible (Fig. 3). For reconstruction,
15-cm-long free fibular flap with a 3  10-cm skin island was
planned and harvested. Osteotomies were performed to shape the
flap as a potential ramus and corpus of the neomandible. To restore
the TMJ, a 6-cm-long costochondral composite graft was harvested
from the sixth rib and the chondral segment was shaped like a
condyle of the mandible. In addition, the bony segment of the graft
was sharpened to a cone to be embedded in the proximal edge of the
flap that was planned as a connection with fibula flap (Figs. 4A, B).
Subsequently, the bony segment of the costochondral graft had been
implanted in a drilled hole at the proximal part of the fibula flap and
a new mandible with a condyle was established (Fig. 5). The flap
was placed to the defect, and rigid fixation was carried out. The
artery and the veins of the flap were anastomosed to the facial artery
and the jugular vein in an end-to-end and end-to-side fashion, re-
spectively. The operation was successful. There were no major or
moderate complications.
After 6 months, the patient was reoperated on to prepare the
neomandible for the dental osteoimplantation, and rigid internal
fixation materials were removed and the iliac bone graft was placed

From the *Department of Plastic and Reconstructive Surgery, Gulhane Mili-

tary Medical Academy, Haydarpasa Training Hospital; and †Department FIGURE 2. Preoperative panorex radiographic view of the patient.
of Plastic and Reconstructive Surgery, School of Medicine, Acibadem
University, Istanbul, Turkey.
Received November 1, 2011.
Accepted for publication March 12, 2012.
Address correspondence and reprint requests to Huseyin Karagoz, MD, PhD,
Plastik Cerrahi Servisi, GATA Haydarpasa Egitim Hastanesi, 34668
Uskudar, Istanbul, Turkey; E-mail: hkaragozmd@hotmail.com
The authors report no conflicts of interest.
Copyright * 2012 by Mutaz B. Habal, MD
ISSN: 1049-2275
DOI: 10.1097/SCS.0b013e31825653ad FIGURE 3. Right hemimandible with tumor that was resected en bloc.

The Journal of Craniofacial Surgery & Volume 23, Number 5, September 2012 1373

Copyright © 2012 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Karagoz et al The Journal of Craniofacial Surgery
FIGURE 4. Costochondral graft (A) and shaped graft (B) to replace the
mandibular condyle.
FIGURE 5. Final view of the fibular flap and the costochondral graft.
to enhance the vertical height of the fibular flap. The osteointegrated
dental implantation was performed 1 year after the first operation.
The patient has been followed up for 6 years, and no recur-
rence has been observed. No resorption has detected at the neo-
condyle (Fig. 6). The appearance of the patient and the function of
TMJ are good (Fig. 7).
DISCUSSION
Ameloblastoma is a relatively uncommon benign tumor of
the odontogenic type situated in the upper and lower jaws, which
develops from the epithelial cellular elements and the dental tissues.1
Most cases are localized in the third molarYramus area. Ameloblas-
tomas are locally agressive tumors. In many cases, ameloblastomas
are not diagnosed in the early stages because these benign tumors
are often asymptomatic and has a slow grow pattern without evi-
dence of swelling and any other symptoms.3 Becelli et al1 has
60 patients who were followed-up for 21 years and revealed that only
39 patients had real symptoms such as paresthesia of the hemi-
mandible, anesthesia of the innervated region of the mandibular
nerve, and alteration in the dental occlusion. The patients other than
those who had been diagnosed incidentally using plain radiographs
were taken because of irrelevant indications.
Among the subtypes of ameloblastoma, cystic ameloblas-
tomas are well-known to become large and destructive with significant
recurrence potential. The recurrence rate is clearly influenced by the
initial method of treatment. Enucleation and curettage has very high
recurrence potential compared with en bloc resection and reconstruc-
tion.4 En bloc resection should be carried out to avoid recurrence and
malignant transformation.
The mandible makes a great contribution to the facial ap-
pearance and the orofacial function. Many mandibular reconstruction
options are available. Vascularized free bone flaps, nonvascularized
bone grafts, and prosthetic rehabilitation may be chosen to reconstruct
the mandibular bone defects after tumor resections.5 Free vascularized
fibular flap may restore the mandibular bone defect and the soft tissue
defect simultaneously and remain as a strong cortical bone for the
osteointegrated dental implantation. In addition to those superiorities
FIGURE 6. Patient panorex radiographic view at the end of the sixth year.
1374
Copyright © 2012 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
& Volume 23, Number 5, September 2012
FIGURE 7. Facial appearance of the patient at the end of the sixth year.
of the fibular flap, it may also be combined with the anterolateral thigh
flap when the skin is not reconstructed using the free fibular os-
teocutaneous flap alone. Free vascularized fibular flap represents the
first choice for the head and neck reconstructions.6
The anatomic and functional features of the TMJ are complex,
and reconstruction of the TMJ is one of the most challenging is-
sues faced by the head and neck surgeons.7 Temporomandibular joint
may be reconstructed using alloplastic prosthesis or autogenous
bony, cartilaginous, and condylar grafts.5 The costochondral grafts
are used commonly in the immediate mandibular reconstructions.8
Biologic compatibility, minimal donor-site morbidity, and potential
for growth are important advantages of the costochondral grafts.
However, some certain problems such as resorption, fracture, an-
kylosis, and unpredictable growth pattern are defined after costo-
chondral grafting.7
In this case, we used the free fibula flap for the mandible
reconstruction, the costochondral graft for the TMJ reconstruction,
and the iliac bone graft for increasing the vertical height of the
mandible for the osteointegrated dental implantation. The patient has
satisfactory range of motion of TMJ that provides a functional
mandible and a normal facial aesthetic appearance. We have been
able to obtain a functional mandible using a combination of several
methods despite all their own disadvantages. Even more importantly,
these good results are not temporary.
Tumors that have a high recurrence potential such as ame-
loblastomas should be excised wide enough, without hesitation, to
prevent recurrence because it is possible to create a functional man-
dible using a combination of different methods.
REFERENCES
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analysis of surgical treatment carried out in 60 patients between 1977 and
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2. Gerzenshtein J, Zhang F, Caplan J, et al. Immediate mandibular
reconstruction with microsurgical fibula flap transfer following
wide resection for ameloblastoma. J Craniofac Surg 2006;17:
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experience and literature review. ANZ J Surg 2009;79:739Y744
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of surgical treatment carried out in 60 patients between 1977 and 1998.
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255Y260
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* 2012 Mutaz B. Habal, MD