Massive trauma to mandible: treatment plan?

I have a 21 year old female patient. She suffered massive trauma to her mandible about a year ago. She had a fibula graft to reconstruct her mandible. Now that she is healed and stable, she wants a full mouth reconstruction with implants and fixed partial dentures. However, her financial situation is limited. Could you make some recommendations on how I should proceed? What are your recommendations for how I should reconstruct her dentition?

8 Comments on Massive trauma to mandible: treatment plan?

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OMS resident

4/24/2014

Wow, this is a tricky one! Where was the patient treated, and by what kind of surgeon? Has the right side been reconstructed with an iliac free flap? Despite the massive trauma, this seems like bad repositioning, fixation and reconstruction. At this stage I guess the patient would benefit from being treated in a hospital by surgeons trained in maxillofacial trauma, post-ablative reconstruction, orthognatic surgery and dental implants, eg. OMFS. The right hemimandible has auto-rotated and has been fixed too much cranially (probably the left side as well). It can be adressed (or at least improved) by a modified unilateralt SSO in conjunction with bone grafting to reposition the right hemimandible and correct (improve) the asymmetry. The key is to get a proper max/mand relationship first, then assess the available bone and soft tissue! A vestibuloplasty may be indicated at a later stage. Besides, the maxillary teeth needs som conservative treatment as well. From my point of view this is not a quick-fix and not only one valid answer. A CT/CBCT scan and casts are advised. Regarding treatment/reconstruction, at least team up with a board certified OMFS and a hospital based, board certified, prosthodontist. Financially, well - maybe try to "sell it" as a pro bono case to a teaching hospital?! Would love som comments from Baker Vinci, CRS and Sboms on this one...

CRS

4/24/2014

First off you are not going to do anything but refer her to a teaching hospital which will have the resources to fix this. Clean the upper teeth and refer. When they were saving the patient's life it does not look like any consideration was given to inter occlusal space perhaps impossible to do at the time. When the graft was placed the condylar segment was rotated forward , this has to be fixed with orthognathic surgery. We would fix this with well made gunning splint, I'm showing my age, re- establish the inter occlusal dimension so that the dentition can be restored. The original treating hospital may have a LCSW to get the patient some resources. But a large teaching hospital is the way to go on these challenging cases. The good news is that the graft healed and the patient lived.Probably a unilateral sagittal split to correct and avoid the grafted side blood supply issues. Don't try to plunk in some implants even in the maxilla the jaws aren't aligned. Gunshot wound? Great advice OMS resident!

OMS resident

4/27/2014

CRS - Thanks! I like the "old school" idea of a gunning splint. It's time to put the old awl back in action:-) It may be a more cost effective treatment compared to putting in a lot of hardware, but where I work these techniques are a lost art. Some more thoughts from a novice: To me it seems like the right side is grafted as well (vascular clips and bone opasity). I think we would consider using an extra-oral approach (probably some old scars that can be used/revised), then make an osteotomy in the right parasymphyseal region and put a short locking-plate with bicortical screws on the lower border (load-bearing), combined with a more cranially placed miniplate. This osteotomy is more similar to a mandibulotomy as for access to tumors of the floor of the mouth or the tounge base, than a true SSO. Making the osteotomy as sagittal as possible one should be able to derotate the hemimandible, fix it in anatomical position and still have good interproximal bone contact. I think we would pack the defect/diastasis created with cancellous bone from the iliac crest. Performing a unilateral SSO (Obwegeser, Dal Pont) would probably call for a concomitant distal osteotomy , or osteoplasty, to adress the bone "tenting" the oral mucosa. I would avoid excessive stripping of the intraoral mucoperiosteum in a case like this. I still think it would be necessary to strip the pterygomasseteric sling to free up the proximal segment of the mandible and facilitate repositioning. Regarding later implant treatment, the plate on the lower border can often be left in situ. But all these thoughts need to be rethinked after proper examination, scans, casts, discussion with the patient etc. As you said, the vertical relationship (inter occlusal dimension) between the jaws needs to be corrected, and this calls for some type of splint/"denture" in the mandible. It can be used at a later stage for the vestibuloplasty as well. I think your idea of a well made gunning splint should be considered.

CRS

4/27/2014

Good call, I like the idea of staying away from the blood supply in the grafted areas. Now I think the best way to establish the vertical dimension is a splint, gunning or orthognathic , to hold the vertical while all this heals.Also the services of a maxillofacial prosthodontist are valuable to plan and make this. And you're gonna love this, some mini implants or bone screws to stabilize the splint. Another option is Biphasic pins to stabilize the graft. That's what we did in the olden days. But the key to all of this is the most humble and common to all our dental backgrounds, a dental splint establishing the vertical reference for the dental restorations, fixed or removable. A good splint will always save the case as you see in this end result of the grafting however this may not have been possible at the get go. This I feel makes us unique as oral surgeons to link the dental background with the surgical procedures the ENTs and plastic guys don't have this perspective. So somebody is gonna have to take an impression, mount the case and work backwards establishing an occlusal relationship now that the patient has continuity, perfect teaching case. I like your treatment ideas.

CRS

4/27/2014

One further comment, I think that sometimes the general dentists, perio guys and other dental practitioners, oral surgeons included forget that we all have the same humble background and training in dental school. I find that sometimes my referring dentists forget that even though I don't do this on a daily basis I can understand where they are coming from and the challenges they face. I feel it is the perfect background to work together and am always thrilled when it comes together in treatment of our mutual patients. I also love to hear on the new surgical techniques in the OMS world! Thanks for posting wise and youthful one!

OMS resident

4/30/2014

CRS, thanks again. And thank you for a lot of valuable input on this case and a lot of others! And yes, I like using monocortical screws to stabilize splints and dentures. Guess you've got some insight in the world of an OMS resident of 2014:-) I'm soon getting ready for my boards, and I actually find a lot of interesting stuff on these pages when it comes to dental implants. Funny enough though, the regular "big posters" have not commented on this case.. Would love some input from a GP, perioguy or 'implantologist'. Like you said, we all share a dental background. As a resident in a surgical environment it can be easy to forget that, but sometimes we need to go back to the roots (yeah, to the place of my birth..) - get it?

CRS

4/30/2014

First off thanks for the complement. It is exciting how much Oral Surgery has changed since I took the boards, dental implants were not even a subject. It is interesting that enough time has passed that many if the same suspect techniques for example,TMJ therapies have resurfaced for a new generation of dentists, weekend courses, " residencies " in other fields and advertising with the emergence of the super general dentists. The longer I practice the more I realize the need for working together, there is so much out there I just don't know and with advertising, self proclaimed gurus, experts and "evidenced based" studies one I feel has to be very careful in treatment decisions. That said I personally have benefitted from my restorative colleagues in AAID from their experience and imput. I have always found that very valuable. So I think the key is use the training and experience learned in your residency to evaluate each clinical situation. I have found that going back to the core competences has kept me out if trouble, doing things for the good of the patient vs financial gain and ego. Being honest, open, accepting that nothing is perfect and not listening to the self promotors but the real deal practitioners has helped my practice. With time it becomes easier to discern this. I truly enjoy working with my colleagues and hope the benefit is a two way street even when they don't agree or take it personally. As OMS we share a medical and surgical background which is unique with our dental credentials, I find that the dental community may not realize that we sit on both sides of the fence.I just hope they don't ask you the clotting sequence or to read a chest film on the ABOMS! Those were the first things I forgot! Pp

Raul Mena

5/6/2014

Is the graft a Vasclarized fibula graft or is it a allograft figula graft? Ia there paresthesia present?