The mandible is of critical value to the functional and aesthetic integrity from the face. As the strongest bone from the face, the mandible significantly contributes to the lower third from the face, the structural continuity from the temporomandibular joint (TMJ), functions in deglutition and houses the lower dentition. The goal of mandibular reconstruction is to restore form and function following tumor resection, trauma, or secondary to congenital abnormalities.
Reconstruction from the mandible is often both a soft tissue and bony problem. Though often technically demanding, precise mandibular reconstruction is essential to optimize oral competence, unimpeded mastication, proper dental occlusion, intelligible speech and intraoral sensation.
Mandibular reconstructive procedures could be grouped according to the principal anatomic regions of the mandible: the condyle and ascending ramus, the horizontal ramus and the symphyseal region.
The condyle with the coronoid process and the ramus constitute the vertical part of the mandible. Therefore this region is essential to revive the vertical height of the face. Connecting the vertical and horizontal regions is the angle of the mandible. The horizontal region (your body of the mandible) then continues on in a curvilinear fashion to incorporate the symphyseal regions.
Each part of the mandible poses unique reconstructive challanges. The condyle may be the foundation of the TMJ joint. It should permit rotation within the glenoid fossa to achieve adequate mouth opening and also at the same time frame possess the appropriate configuration to reestablish vertical facial height. Ankylosis in this region results in limited mouth opening and also pain in this region.
The angle region should be restored for reestablishment of continuity and also to help achieve an acceptable aesthetic result. The horizontal the main mandible and the symphyseal region are essential for dental rehabilitation (occlusion) and also for facial aesthetics.
The timing of reconstruction depends on the etiology from the underlying bony defect, the size of the defect and various patient factors. For most cases, we advocate early primary reconstruction, especially as a single stage procedure, to minimize the deleterious effects that follow lack of hard and soft tissue.
In the trauma patient, primary reconstruction of the mandible and occlusion are achieved by precise decrease in the bone then stabilization with osteosynthesis plates and screws. Delayed reconstruction is of particular importance in gunshot wounds. It is advisable to hold back until any sepsis or bacteremia has resolved, the soft tissue demonstrates that it's viable and tissue availability and quality is enough.
When mandibular reconstruction is required after tumor resection, the timing of the reconstruction should think about the tumor characteristics, the quantity of tissue to become resected and the possibility of achieving clear margins. When the resection margins are questionable, a two-stage procedure after many months would be more preferable.
Selections for reconstruction include composite free flaps, nonvascularized autologous bone grafts, or synthetic material. Immediate reconstruction with allograft materials or with autogenous bone might be associated with a 15-47% infection rate and lack of the transplant/implant.
Proper preoperative dental evaluation should identify any potential decaying teeth that might serve as a source of infection. Such teeth should be addressed either by restoration or extraction.
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Note: This article was sent to us by: Keith Hayes at 02142011
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