ORIGINAL ARTICLE
Oral Rehabilitation Outcomes After Free Fibula Reconstruction of the Mandible Without Condylar Restoration Jerry W. Chao, MD,* Christine H. Rohde, MD,† Michelle M. Chang, BS,† David I. Kutler, MD,‡ Joel Friedman, DDS,§ and Jason A. Spector, MD*‡
Purpose: Resection of the posterior mandible for tumor or osteonecrosis may include the mandibular condyle, an integral part of the temporomandibular joint (TMJ). Condylar reconstruction, including use of prostheses, the native condylar head, or part of the fibula, all have associated drawbacks including skull base erosion and the potential for ankylosis and TMJ dysfunction as well as the increased difficulty associated with trying to recapitulate the TMJ with high fidelity. We report our experience leaving a single side of the reconstructed mandible unsecured to the glenoid fossa, allowing the mandible to “hang.” We hypothesized that a good functional recovery may be achieved with this simple approach while avoiding the potential for ankylosis and TMJ dysfunction. Methods: A retrospective chart review of all patients undergoing free fibula reconstruction of the mandible with condylar removal was performed. Outcomes were determined by maximum interincisal opening, occlusion, and diet after full recovery. Results: Six patients were studied. Two had condylar reconstruction with a contoured fibular head secured to the glenoid fossa. One of them had progressive postoperative trismus and ankylosis. One patient was reconstructed with the native condyle rigidly fixed to the fibula flap, complicated by avascular necrosis requiring condylar resection, with good function afterward. Three patients were left to “hang.”
What Is This Box? A QR Code is a matrix barcode readable by QR scanners, mobile phones with cameras, and smartphones. The QR Code links to the online version of the article.
From the *Division of Plastic Surgery, New York Presbyterian Hospital/ Weill Cornell Medical Center, New York, New York; †Division of Plastic Surgery, New York Presbyterian Hospital/Columbia University Medical Center, New York, New York; and ‡Department of Otolaryngology/Head and Neck Surgery, and §Department of Oral and Maxillofacial Surgery, New York Presbyterian Hospital, New York, New York. Received December 5, 2013. Accepted for publication December 29, 2013. Address correspondence and reprint requests to Jason A. Spector, MD, Division of Plastic Surgery, New York Presbyterian Hospital/Weill Cornell Medical Center, 525 East 68th St, New York, NY 10065; E-mail: [email protected] The authors report no conflicts of interest. Copyright © 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000691
All 3 had either normal or improved function after surgery. Two had slight ipsilateral deviation on mouth opening. Conclusions: Function can reliably be reestablished after segmental mandibulectomy and condylectomy with a vascularized fibula flap whose distal end is not precisely contoured or actively seated in the glenoid fossa, as a valid alternative to condylar reconstruction. Key Words: Fibula, mandible, condyle, reconstruction, temporomandibular joint (J Craniofac Surg 2014;25: 415–417)
R
econstruction of the mandible is most often performed after tumor resection or, with increasing frequency, to treat osteonecrosis caused by radiation or bisphosphonates. Recent advances in computerassisted preoperative planning and additive manufacturing techniques have allowed for the recreation of the native mandibular anatomy with precision that was previously unachievable.1,2 When defects involve or extend to the upper mandibular ramus and condyle, the obvious question becomes with what degree of fidelity it is necessary to recapitulate the native condylar anatomy and relationships. Because the condyle articulates with the glenoid fossa of the temporal bone, thus playing an integral role in the proper function of the temporomandibular joint (TMJ), it is thought that loss of the condyle may lead to impaired jaw opening, mastication, deglutition, and speech. Normally, the native condyle is stabilized in the glenoid fossa via the temporomandibular ligamentous complex.3 Preservation of the fibrocartilaginous articular disk during extirpative surgery is ideal and is thought to lead to improved outcomes. Studies involving resection of the condyle have focused on methods of reconstruction with either prostheses or vascularized bone. However, using a prosthetic metal condyle may be considered suboptimal because it carries the risk for infection, exposure of the prosthesis, and erosion of the prosthesis into the skull base.4 Other materials that have been used for condylar prostheses, including silastic and Proplast-Teflon, can cause foreign body reaction, fibrosis, and poor long-term results.5 Leaving a single side of the mandible unsecured to the glenoid fossa, in essence allowing the mandible to “hang,” is a technique that has been used by head and neck surgeons after condylar resection, although outcomes when this is performed with a neomandible made from vascularized fibula have not been well documented in the literature. There have been data to suggest that patients may have good facial symmetry and TMJ function after condylectomy.6 We have translated this concept to patients undergoing reconstruction of the mandible with a free fibula flap who have had 1 condyle resected. Here, we review our experience with leaving the condyle unreconstructed, with the hypothesis that a good functional recovery may be achieved while minimizing effort spent recreating preoperative TMJ anatomy
The Journal of Craniofacial Surgery • Volume 25, Number 2, March 2014
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
415
The Journal of Craniofacial Surgery • Volume 25, Number 2, March 2014
Chao et al
TABLE 1. Outcomes After Free Fibula Reconstruction of the Mandible and Condylar Resection, With and Without Reconstruction of the Condyle
Patient Age 1
56 28 61 51 46 48
2 3 4 5 6
Pathology
Condylar Resection Reconstruction Radiation
SCC Ameloblastoma Ameloblastoma Ameloblastoma Ameloblastoma ORN
Yes Yes Yes* No No No
Yes No No No No Yes
Complications
Condyle dislocation, facial nerve palsy
Take back for artery revision
MIO, mm 5 45 45 45 45 20†
Diet
Occlusion/Opening
Soft Centric/trismus Regular Centric Regular Centric/slight deviation Regular Centric Regular Centric/slight deviation Regular Centric/slight deviation
Follow-Up, mo 9 12 14 15 9 6
*Condyle was initially reconstructed; however, it was later resected secondary to avascular necrosis. †Preoperative opening, 7 mm. ORN, osteoradionecrosis; SCC squamous cell carcinoma.
as well as avoiding the potential for ankylosis and TMJ dysfunction associated with condylar reconstruction.
MATERIALS AND METHODS After obtaining institutional review board approval, a retrospective chart review of all patients undergoing free fibula flap reconstruction of the mandible at our institution between 2006 and 2013 was performed. Patients included in this study were those who had 1 condyle resected with the specimen, with or without reconstruction of the condyle. Charts were reviewed for patient comorbidities, pathology, resection amount, complications, postoperative maximum interincisal opening (MIO), occlusion, and diet after full recovery. Panorex and medical modeling images were reviewed for patients when available.
RESULTS Of a total of 44 patients who underwent free fibula reconstruction of the mandible, 7 were identified who had resection of the ipsilateral condyle as part of the specimen. One patient was discharged to hospice from her initial hospitalization after advanced disease was discovered; she died shortly after and was excluded from this study. Of the 6 patients included in this study, 3 had reconstruction of the condyle and 3 did not (Table 1). In all patients studied, computeraided medical modeling (Medical Modeling Inc, Golden, CO) was used to preform cutting guides and plates (Figs. 1, 2). The mean duration of follow-up was 10.8 months (range, 6–15 mo).
FIGURE 1. Patient 4. Eight months after segmental resection of the left mandible and condyle and free fibula flap without condyle reconstruction, the patient demonstrated normal opening with good esthetics and centric occlusion (above left and right). Preoperative computer-aided design images (below, left) and panorex 6 weeks postoperatively (below, right) are shown.
416
Of the 3 patients who had condylar reconstruction, 2 were reconstructed with vascularized fibula that was burred as precisely as possible to the shape of the native condyle and inset into the articular disk of the glenoid fossa with permanent sutures (patients 1 and 2). After ensuring proper centric occlusion, the patients were placed in intermaxillary fixation (IMF) at the conclusion of the case. Patient 1, who was treated for malignancy, had poor opening (MIO, 22 mm) and trismus preoperatively. Her tumor necessitated resection of nearly the entire hemimandible, portions of the inferior and posterior maxilla and zygoma, followed by mandibular reconstruction. Elastics were removed 11 days after surgery. She underwent radiation postoperatively with a total dose of 5400 cGy. She maintained centric occlusion, but during the course of the first 9 postoperative months, her interincisal opening diminished from 20 mm to 5 mm with persistent complaints of trismus, although she was ultimately able to tolerate a soft diet. Patient 2 progressed to a regular diet, with good opening (MIO, 45 mm) and centric occlusion. Patient 3 underwent reconstruction of the TMJ with his native condyle, which was removed with the specimen, osteosynthesized to the vascularized fibula as a condylar graft, and reinset to the glenoid fossa. On postoperative day 6, the patient’s condyle became laterally dislocated while in IMF elastics, with resultant transient facial nerve palsy necessitating open reduction. Ultimately, he required resection of the condyle graft 4 months postoperatively for avascular necrosis, leaving the distal fibula free, and was placed in IMF for 4 weeks. Condylar reconstruction was deferred at this point, and the patient did well functionally afterward, progressing to a regular diet, with centric
FIGURE 2. Patient 5. Three months after segmental resection of the right mandible and condyle and free fibula flap without condyle reconstruction, the patient demonstrated normal opening with slight ipsilateral deviation, good esthetics, and centric occlusion (above left and right). Residual postoperative swelling is seen. Preoperative computer-aided design images (below, left) and panorex 3 months postoperatively (below, right) are shown.
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery • Volume 25, Number 2, March 2014
occlusion, normal opening (MIO, 45 mm), and resolution of his facial palsy, with only minimal deviation on opening after resection of the condyle graft. The 3 most recent patients had no condylar reconstruction. After mandibular resection, the distal end of the fibula flap was rounded and passively placed in the glenoid fossa, remaining nonsecured, after which osteosynthesis of the fibula to the native mandible was performed with a 2-mm plate. Intermaxillary fixation was released, and good mandibular excursion and occlusion were verified, and the patients were replaced in IMF before microanastomosis for a mean of 32 days (range, 20–42 d). Patient 4 healed with symmetric opening (MIO, 45 mm), tolerating a regular diet, and centric occlusion (Fig. 1). Patient 5 also had good opening (MIO, 45 mm), although with a slight ipsilateral deviation and centric occlusion (Fig. 2). Patient 6 had poor preoperative opening (MIO, 7 mm) and radiation-induced trismus. His postoperative function has exceeded his preoperative function (MIO, 20 mm; slight deviation), and he has progressed to a regular diet.
Reconstruction Without Neocondyle
hang subjacent to the glenoid fossa after minimal shaping. There are no obvious negative esthetic consequences, although there may be slight deviation on full mouth opening. Functionally, however, centric occlusion and normal interincisal opening can be achieved with tolerance of a normal diet. Furthermore, we believe that without a neo-TMJ, development of ankylosis is unlikely. Because the condyle may often be spared from extirpation, our sample size is small. Further follow-up will help us to identify long-term differences in outcome between those who have physiologic condylar reconstruction and those who do not. However, our early results are promising in demonstrating that allowing the neomandible to hang is a valid alternative to precise condylar reconstruction, which may confer unnecessary complexity and morbidity to an already challenging reconstruction. In conclusion, free fibula reconstruction after segmental mandibulectomy with condylectomy does not necessitate precise physiologic reconstruction of the mandibular condyle, and good function may be restored without potential for neo-TMJ dysfunction.
DISCUSSION Restoration of mandibular contour and function are the goals of reconstruction, and the free fibula flap is a versatile option for achieving this goal after segmental mandibulectomy. Because the TMJ constantly moves during speech and mastication, a unique and complex reconstructive challenge is presented when the segmental resection also includes the mandibular condyle. The free fibula flap has become the workhorse for mandibular reconstruction since its original description.7 In situations in which the condyle is taken from the glenoid fossa as part of the surgical specimen, Hidalgo8 reported good results using the resected condyle as a nonvascularized graft that is attached to the posterior end of the fibula, which can then be resecured to the glenoid fossa. Computed tomographic imaging showed condylar resorption over time; however, he noted that this did not impact function. This technique necessitates that the condyle is negative for carcinoma on frozen section and is not an option when there is gross invasion. Moreover, a recent study has suggested increased rates of locoregional recurrence when the condyle is preserved with posterior mandibular lesions.9 More recently, authors have advocated using the posterior part of the vascularized fibula flap, contouring it to fit the glenoid fossa, and using this as a neocondyle.10–14 These methods have largely involved actively seating the neocondyle in the glenoid fossa by either direct suture fixation to the articular disk or attachment of the masseter muscle to the reconstruction plate of the fibula. Although seemingly providing physiologic stabilization of the TMJ, this technique is limited by technical difficulty in contouring the bone to mimic the native condyle15 and potential for ankylosis and functional limitation of the joint.13 The various methods for condylar reconstruction that have been proposed in the literature carry their own potential risks, including ankylosis and TMJ dysfunction as well as potentially increasing the risk for tumor recurrence when the native condyle is replaced as a graft. One of our patients who underwent condylar reconstruction with a rounded end of the fibula actively seated in the glenoid fossa had progressively worsening trismus and opening ability postoperatively, likely as a result of radiation-induced fibrosis and ankylosis. Another patient required resection of the condylar graft after it became dislocated, demonstrating the potential consequences of avascular necrosis from a failed condylar reconstruction. Our results demonstrate that form and function can reliably be reestablished after segmental mandibulectomy and condylectomy with a vascularized fibula flap whose distal end is simply allowed to
REFERENCES 1. Antony AK, Chen WF, Kolokythas A, et al. Use of virtual surgery and stereolithography-guided osteotomy for mandibular reconstruction with the free fibula. Plast Reconstr Surg 2011;128:1080–1084 2. Roser SM, Ramachandra S, Blair H, et al. The accuracy of virtual surgical planning in free fibula mandibular reconstruction: comparison of planned and final results. J Oral Maxillofac Surg 2010;68:2824–2832 3. Alomar X, Medrano J, Cabratosa J, et al. Anatomy of the temporomandibular joint. Semin Ultrasound CT MR 2007;28:170–183 4. Patel A, Maisel R. Condylar prostheses in head and neck cancer reconstruction. Arch Otolaryngol Head Neck Surg 2001;127:842–846 5. Wolford LM. Temporomandibular joint devices: treatment factors and outcomes. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997;83:143–149 6. Lippold C, Kruse-Losler B, Danesh G, et al. Treatment of hemimandibular hyperplasia: the biological basis of condylectomy. Br J Oral Maxillofac Surg 2007;45:353–360 7. Hidalgo DA. Fibula free flap: a new method of mandible reconstruction. Plast Reconstr Surg 1989;84:71–79 8. Hidalgo DA. Condyle transplantation in free flap mandible reconstruction. Plast Reconstr Surg 1994;93:770–781 9. Petruzelli GJ, Cunningham K, Vandevender D. Impact of mandibular condyle preservation on patterns of failure in head and neck cancer. Otolaryngol Head Neck Surg 2007;137:717–721 10. Wax MK, Winslow CP, Hansen J, et al. A retrospective analysis of temporomandibular joint reconstruction with free fibula microvascular flap. Laryngoscope 2000;110:977–981 11. Guyot L, Richard O, Layoun W, et al. Long-term radiological findings following reconstruction of the condyle with fibular free flaps. J Craniomaxillofac Surg 2004;32:98–102 12. Engroff SL. Fibula flap reconstruction of the condyle in disarticulation resections of the mandible: a case report and review of the technique. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005;100:661–665 13. Gonzalez-Garcia R, Naval-Gias L, Rodriguez-Campo FJ, et al. Vascularized fibular flap for reconstruction of the condyle after mandibular ablation. J Oral Maxillofac Surg 2008;66:1133–1137 14. Moore EJ, Hamilton SS. Mandibular condyle reconstruction with fibula free-tissue transfer. Ear Nose Throat J 2012;91:e18–e24 15. Nahabedian MY, Tufaro A, Manson PN. Improved mandible function after hemimandibulectomy, condylar head preservation, and vascularized fibular reconstruction. Ann Plast Surg 2001;46:506–510
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
417
Oral Rehabilitation Outcomes After Free Fibula Reconstruction of the Mandible Without Condylar Restoration Jerry W. Chao, MD,* Christine H. Rohde, MD,† Michelle M. Chang, BS,† David I. Kutler, MD,‡ Joel Friedman, DDS,§ and Jason A. Spector, MD*‡
Purpose: Resection of the posterior mandible for tumor or osteonecrosis may include the mandibular condyle, an integral part of the temporomandibular joint (TMJ). Condylar reconstruction, including use of prostheses, the native condylar head, or part of the fibula, all have associated drawbacks including skull base erosion and the potential for ankylosis and TMJ dysfunction as well as the increased difficulty associated with trying to recapitulate the TMJ with high fidelity. We report our experience leaving a single side of the reconstructed mandible unsecured to the glenoid fossa, allowing the mandible to “hang.” We hypothesized that a good functional recovery may be achieved with this simple approach while avoiding the potential for ankylosis and TMJ dysfunction. Methods: A retrospective chart review of all patients undergoing free fibula reconstruction of the mandible with condylar removal was performed. Outcomes were determined by maximum interincisal opening, occlusion, and diet after full recovery. Results: Six patients were studied. Two had condylar reconstruction with a contoured fibular head secured to the glenoid fossa. One of them had progressive postoperative trismus and ankylosis. One patient was reconstructed with the native condyle rigidly fixed to the fibula flap, complicated by avascular necrosis requiring condylar resection, with good function afterward. Three patients were left to “hang.”
What Is This Box? A QR Code is a matrix barcode readable by QR scanners, mobile phones with cameras, and smartphones. The QR Code links to the online version of the article.
From the *Division of Plastic Surgery, New York Presbyterian Hospital/ Weill Cornell Medical Center, New York, New York; †Division of Plastic Surgery, New York Presbyterian Hospital/Columbia University Medical Center, New York, New York; and ‡Department of Otolaryngology/Head and Neck Surgery, and §Department of Oral and Maxillofacial Surgery, New York Presbyterian Hospital, New York, New York. Received December 5, 2013. Accepted for publication December 29, 2013. Address correspondence and reprint requests to Jason A. Spector, MD, Division of Plastic Surgery, New York Presbyterian Hospital/Weill Cornell Medical Center, 525 East 68th St, New York, NY 10065; E-mail: [email protected] The authors report no conflicts of interest. Copyright © 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000691
All 3 had either normal or improved function after surgery. Two had slight ipsilateral deviation on mouth opening. Conclusions: Function can reliably be reestablished after segmental mandibulectomy and condylectomy with a vascularized fibula flap whose distal end is not precisely contoured or actively seated in the glenoid fossa, as a valid alternative to condylar reconstruction. Key Words: Fibula, mandible, condyle, reconstruction, temporomandibular joint (J Craniofac Surg 2014;25: 415–417)
R
econstruction of the mandible is most often performed after tumor resection or, with increasing frequency, to treat osteonecrosis caused by radiation or bisphosphonates. Recent advances in computerassisted preoperative planning and additive manufacturing techniques have allowed for the recreation of the native mandibular anatomy with precision that was previously unachievable.1,2 When defects involve or extend to the upper mandibular ramus and condyle, the obvious question becomes with what degree of fidelity it is necessary to recapitulate the native condylar anatomy and relationships. Because the condyle articulates with the glenoid fossa of the temporal bone, thus playing an integral role in the proper function of the temporomandibular joint (TMJ), it is thought that loss of the condyle may lead to impaired jaw opening, mastication, deglutition, and speech. Normally, the native condyle is stabilized in the glenoid fossa via the temporomandibular ligamentous complex.3 Preservation of the fibrocartilaginous articular disk during extirpative surgery is ideal and is thought to lead to improved outcomes. Studies involving resection of the condyle have focused on methods of reconstruction with either prostheses or vascularized bone. However, using a prosthetic metal condyle may be considered suboptimal because it carries the risk for infection, exposure of the prosthesis, and erosion of the prosthesis into the skull base.4 Other materials that have been used for condylar prostheses, including silastic and Proplast-Teflon, can cause foreign body reaction, fibrosis, and poor long-term results.5 Leaving a single side of the mandible unsecured to the glenoid fossa, in essence allowing the mandible to “hang,” is a technique that has been used by head and neck surgeons after condylar resection, although outcomes when this is performed with a neomandible made from vascularized fibula have not been well documented in the literature. There have been data to suggest that patients may have good facial symmetry and TMJ function after condylectomy.6 We have translated this concept to patients undergoing reconstruction of the mandible with a free fibula flap who have had 1 condyle resected. Here, we review our experience with leaving the condyle unreconstructed, with the hypothesis that a good functional recovery may be achieved while minimizing effort spent recreating preoperative TMJ anatomy
The Journal of Craniofacial Surgery • Volume 25, Number 2, March 2014
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
415
The Journal of Craniofacial Surgery • Volume 25, Number 2, March 2014
Chao et al
TABLE 1. Outcomes After Free Fibula Reconstruction of the Mandible and Condylar Resection, With and Without Reconstruction of the Condyle
Patient Age 1
56 28 61 51 46 48
2 3 4 5 6
Pathology
Condylar Resection Reconstruction Radiation
SCC Ameloblastoma Ameloblastoma Ameloblastoma Ameloblastoma ORN
Yes Yes Yes* No No No
Yes No No No No Yes
Complications
Condyle dislocation, facial nerve palsy
Take back for artery revision
MIO, mm 5 45 45 45 45 20†
Diet
Occlusion/Opening
Soft Centric/trismus Regular Centric Regular Centric/slight deviation Regular Centric Regular Centric/slight deviation Regular Centric/slight deviation
Follow-Up, mo 9 12 14 15 9 6
*Condyle was initially reconstructed; however, it was later resected secondary to avascular necrosis. †Preoperative opening, 7 mm. ORN, osteoradionecrosis; SCC squamous cell carcinoma.
as well as avoiding the potential for ankylosis and TMJ dysfunction associated with condylar reconstruction.
MATERIALS AND METHODS After obtaining institutional review board approval, a retrospective chart review of all patients undergoing free fibula flap reconstruction of the mandible at our institution between 2006 and 2013 was performed. Patients included in this study were those who had 1 condyle resected with the specimen, with or without reconstruction of the condyle. Charts were reviewed for patient comorbidities, pathology, resection amount, complications, postoperative maximum interincisal opening (MIO), occlusion, and diet after full recovery. Panorex and medical modeling images were reviewed for patients when available.
RESULTS Of a total of 44 patients who underwent free fibula reconstruction of the mandible, 7 were identified who had resection of the ipsilateral condyle as part of the specimen. One patient was discharged to hospice from her initial hospitalization after advanced disease was discovered; she died shortly after and was excluded from this study. Of the 6 patients included in this study, 3 had reconstruction of the condyle and 3 did not (Table 1). In all patients studied, computeraided medical modeling (Medical Modeling Inc, Golden, CO) was used to preform cutting guides and plates (Figs. 1, 2). The mean duration of follow-up was 10.8 months (range, 6–15 mo).
FIGURE 1. Patient 4. Eight months after segmental resection of the left mandible and condyle and free fibula flap without condyle reconstruction, the patient demonstrated normal opening with good esthetics and centric occlusion (above left and right). Preoperative computer-aided design images (below, left) and panorex 6 weeks postoperatively (below, right) are shown.
416
Of the 3 patients who had condylar reconstruction, 2 were reconstructed with vascularized fibula that was burred as precisely as possible to the shape of the native condyle and inset into the articular disk of the glenoid fossa with permanent sutures (patients 1 and 2). After ensuring proper centric occlusion, the patients were placed in intermaxillary fixation (IMF) at the conclusion of the case. Patient 1, who was treated for malignancy, had poor opening (MIO, 22 mm) and trismus preoperatively. Her tumor necessitated resection of nearly the entire hemimandible, portions of the inferior and posterior maxilla and zygoma, followed by mandibular reconstruction. Elastics were removed 11 days after surgery. She underwent radiation postoperatively with a total dose of 5400 cGy. She maintained centric occlusion, but during the course of the first 9 postoperative months, her interincisal opening diminished from 20 mm to 5 mm with persistent complaints of trismus, although she was ultimately able to tolerate a soft diet. Patient 2 progressed to a regular diet, with good opening (MIO, 45 mm) and centric occlusion. Patient 3 underwent reconstruction of the TMJ with his native condyle, which was removed with the specimen, osteosynthesized to the vascularized fibula as a condylar graft, and reinset to the glenoid fossa. On postoperative day 6, the patient’s condyle became laterally dislocated while in IMF elastics, with resultant transient facial nerve palsy necessitating open reduction. Ultimately, he required resection of the condyle graft 4 months postoperatively for avascular necrosis, leaving the distal fibula free, and was placed in IMF for 4 weeks. Condylar reconstruction was deferred at this point, and the patient did well functionally afterward, progressing to a regular diet, with centric
FIGURE 2. Patient 5. Three months after segmental resection of the right mandible and condyle and free fibula flap without condyle reconstruction, the patient demonstrated normal opening with slight ipsilateral deviation, good esthetics, and centric occlusion (above left and right). Residual postoperative swelling is seen. Preoperative computer-aided design images (below, left) and panorex 3 months postoperatively (below, right) are shown.
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery • Volume 25, Number 2, March 2014
occlusion, normal opening (MIO, 45 mm), and resolution of his facial palsy, with only minimal deviation on opening after resection of the condyle graft. The 3 most recent patients had no condylar reconstruction. After mandibular resection, the distal end of the fibula flap was rounded and passively placed in the glenoid fossa, remaining nonsecured, after which osteosynthesis of the fibula to the native mandible was performed with a 2-mm plate. Intermaxillary fixation was released, and good mandibular excursion and occlusion were verified, and the patients were replaced in IMF before microanastomosis for a mean of 32 days (range, 20–42 d). Patient 4 healed with symmetric opening (MIO, 45 mm), tolerating a regular diet, and centric occlusion (Fig. 1). Patient 5 also had good opening (MIO, 45 mm), although with a slight ipsilateral deviation and centric occlusion (Fig. 2). Patient 6 had poor preoperative opening (MIO, 7 mm) and radiation-induced trismus. His postoperative function has exceeded his preoperative function (MIO, 20 mm; slight deviation), and he has progressed to a regular diet.
Reconstruction Without Neocondyle
hang subjacent to the glenoid fossa after minimal shaping. There are no obvious negative esthetic consequences, although there may be slight deviation on full mouth opening. Functionally, however, centric occlusion and normal interincisal opening can be achieved with tolerance of a normal diet. Furthermore, we believe that without a neo-TMJ, development of ankylosis is unlikely. Because the condyle may often be spared from extirpation, our sample size is small. Further follow-up will help us to identify long-term differences in outcome between those who have physiologic condylar reconstruction and those who do not. However, our early results are promising in demonstrating that allowing the neomandible to hang is a valid alternative to precise condylar reconstruction, which may confer unnecessary complexity and morbidity to an already challenging reconstruction. In conclusion, free fibula reconstruction after segmental mandibulectomy with condylectomy does not necessitate precise physiologic reconstruction of the mandibular condyle, and good function may be restored without potential for neo-TMJ dysfunction.
DISCUSSION Restoration of mandibular contour and function are the goals of reconstruction, and the free fibula flap is a versatile option for achieving this goal after segmental mandibulectomy. Because the TMJ constantly moves during speech and mastication, a unique and complex reconstructive challenge is presented when the segmental resection also includes the mandibular condyle. The free fibula flap has become the workhorse for mandibular reconstruction since its original description.7 In situations in which the condyle is taken from the glenoid fossa as part of the surgical specimen, Hidalgo8 reported good results using the resected condyle as a nonvascularized graft that is attached to the posterior end of the fibula, which can then be resecured to the glenoid fossa. Computed tomographic imaging showed condylar resorption over time; however, he noted that this did not impact function. This technique necessitates that the condyle is negative for carcinoma on frozen section and is not an option when there is gross invasion. Moreover, a recent study has suggested increased rates of locoregional recurrence when the condyle is preserved with posterior mandibular lesions.9 More recently, authors have advocated using the posterior part of the vascularized fibula flap, contouring it to fit the glenoid fossa, and using this as a neocondyle.10–14 These methods have largely involved actively seating the neocondyle in the glenoid fossa by either direct suture fixation to the articular disk or attachment of the masseter muscle to the reconstruction plate of the fibula. Although seemingly providing physiologic stabilization of the TMJ, this technique is limited by technical difficulty in contouring the bone to mimic the native condyle15 and potential for ankylosis and functional limitation of the joint.13 The various methods for condylar reconstruction that have been proposed in the literature carry their own potential risks, including ankylosis and TMJ dysfunction as well as potentially increasing the risk for tumor recurrence when the native condyle is replaced as a graft. One of our patients who underwent condylar reconstruction with a rounded end of the fibula actively seated in the glenoid fossa had progressively worsening trismus and opening ability postoperatively, likely as a result of radiation-induced fibrosis and ankylosis. Another patient required resection of the condylar graft after it became dislocated, demonstrating the potential consequences of avascular necrosis from a failed condylar reconstruction. Our results demonstrate that form and function can reliably be reestablished after segmental mandibulectomy and condylectomy with a vascularized fibula flap whose distal end is simply allowed to
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© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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