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12 Microvascular Free Tissue Transfer in Osteoradionecrosis and Medication-Related…
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243
by Pautke etal. [51] described the occurrence of MRONJ not within the jaw bones,
but within the transplanted free iliac bone ap postoperatively. They reported that
intraoperatively the bone appeared vital; however postoperative serial imaging
lacked the evidence of bone remodeling at the margins, and biopsies were taken.
Histopathology of the biopsied iliac bone revealed the typical signs of MRONJ
including bone necrosis, bacterial colonization by actinomyces, and hypervascular
tissue surrounding the necrotic bone (Fig. 12.19). It is not possible, however, to
deduce whether the process occurred de novo within the iliac bone or was a direct
extension from the adjacent mandibular bone, and one single case report by no
means can provide a reliable data set upon which to make any viable conclusions.
There have also been further reports on the occurrence of MRONJ postoperatively
in the contralateral jaw bone and thus can complicate the postoperative course as
well [52, 53]. Similar to ORN, the extent of necessary resection in cases of MRONJ
can also be difcult to accurately assess, despite excellent clinical and radiographic
examination preoperatively. Most commonly surgeons will use one or a
Fig. 12.19 Histology of
MRONJ in iliac bone free
ap with typical hallmarks.
Necrotic bone with no
osteocytes (black arrows),
bacterial colonization with
actinomyces (white
arrows), and necrotic bone
surrounded by
hypervascular tissue (black
asterisks) and new
trabecular bone (white
asterisks). (Pautke C, Otto
S, Reu S, Kolk
A.Bisphosphonate related
osteonecrosis of the
jaw—Manifestation in a
microvascular iliac bone
ap. Oral Oncology.
2011:47;425–429 (with
permission))
a
b
244
ab
cd
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A. Kaleem et al.
combination of imaging modalities such as panoramic lms, cone beam computerized tomography (CBCT), medical-grade computerized tomography (CT), and
magnetic resonance imaging (MRI) to assess the extent of disease prior to surgery.
Moreover, intraoperative assessment of bone margin quality is also performed, with
resection to apparent healthy bleeding bone, in correlation with preoperative radiographic ndings to maximize the chances of obtaining a clear surgical margin.
Despite these efforts, occasionally resection margins appear inadequate on postoperative histopathological examination, imposing a risk of persistent and/or recurrent
disease, and possible treatment failure, sometimes within 3–6months [54, 55]. As
such, it is always prudent to err on the side of caution, and if an area adjacent to
obvious MRONJ-aficted bone is questionable, surgeons should consider extending
the resection to those regions, to decrease the risk of unresected disease. A linear
margin of at least 1cm beyond visible involved bone on imaging should be planned
to achieve good, negative margins [56]. As with ORN, the concept of tetracycline
bone labeling has also been investigated in patients with MRONJ, to help delineate
necrotic versus viable bone. Pautke etal. [57] reported their experience in a pilot
study using uorescence-guided resection, with administration of tetracycline for
about 10days prior to surgery. Intraoperatively, resection is performed until a clean,
uniform green uorescent margin is seen at the level of the residual bone margin
(Fig.12.20), and with this technique, they showed about an 85% success rate [58].
Fig. 12.20 Fluorescence-guided bone resection performed after 10-day doxycycline treatment.
Extent of necrosis evident clinically (a) and delineated by uorescence (b). After resection, healthy
bleeding bone seen (c), and a clean margin of viable uorescent bone seen (d). (Pautko C, Bauer
F, Otto S. Fluorescence-guided bone resection in bisphosphonate-related osteonecrosis of the
jaws: rst clinical results of a prospective pilot study. J Oral Maxillofac Surg. 2011;69:84–91
(with permission))
12 Microvascular Free Tissue Transfer in Osteoradionecrosis and Medication-Related…
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245
Studies have also shown that even one single intravenous dose of doxycycline about
1h prior to surgery can provide clinically evident uptake and uorescence that can
prove to be useful in determining resection margins [59]. The concept of autouorescence has also been investigated, namely, the use of a uorescence lamp without
tetracycline labeling, and has proven to potentially have some value; however no
studies currently exist comparing this to tetracycline-labeled uorescence [59].
Conclusion
Both ORN and MRONJ represent disease entities that can be difcult to manage,
with some controversies among surgeons. Segmental resection with free vascularized ap reconstruction has proven to be a very successful treatment option in cases
of advanced and refractory disease. Several considerations, however, must be taken
into account in this cohort of patients, which can affect overall treatment results and
will challenge the surgeon. Accurate diagnosis and disease delineation, intraoperative surgical considerations, and postoperative wound healing issues, disease progression, and compromise of the overall health of these patients can all lead to
potential complications that must be dealt with and overcome. Nevertheless,
advances in techniques, methodology, and technology have continued to provide the
tools to help mitigate some of these challenges.
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Chapter 13
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Advancements inFacial Trauma
DinaAmin andNagiDemian
Introduction
Facial trauma reconstruction is challenging due to proximity of adjacent vital structures [1–3]. Several factors have been identied for poor outcome [4, 5], such as
surgical planning on two-dimensional (2D) imaging for a three-dimensional (3D)
problem, difculty in assessing intraoperative position, projection, and symmetry of
repositioned skeletal anatomy and poor visualization of deep skeletal contours
involving orbit and skull base [5]. This chapter will focus on the application of
recent advancements in facial trauma.
Computer-Assisted Surgical Simulation
Computer-assisted surgical simulation (CASS) offers an individualized, 3D manipulation of patient’s computed tomography (CT) data [5–7]. CASS technology has
been combined with patient-specic implant designing and/or surgical navigation
[5–7]. Atrophic and complex mandibular fractures [8, 9], orbital fractures [7], and
panfacial fractures are the most common applications of CASS [9]. CASS workow
can be divided into four phases: (1) data acquisition phase, (2) planning phase, (3)
surgical phase, and (4) assessment phase (Fig.13.1) [10].
D. Amin (*)
Oral and Maxillofacial Surgery, University of Rochester, Rochester, NY, USA
N. Demian
Oral and Maxillofacial Surgery, University of Texas Health Science Center at Huston,
Houston, TX, USA
e-mail: nagi.demian@uth.tmc.edu
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
J. C. Melville et al. (eds.), Advancements and Innovations in OMFS, ENT, and
Facial Plastic Surgery, https://doi.org/10.1007/978-3-031-32099-6_13
249
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D. Amin and N. Demian
Fig. 13.1 CASS workow is divided into four phases
Surgical Navigation
Surgical navigation(SN) was primarily developed for neurosurgical procedures
[11]. However, it has been implemented for head and neck surgery and facial
fractures [12]. SN function is comparable to global positioning system (GPS)
used in cars [5]. Orbital fractures, foreign body removal, and skull-base surgery
are the most common applications of SN in facial trauma [13]. SN has three components: (1) localizer, an equivalent to the satellite in space; (2) surgical probe,
represents the track waves emitted by GPS; and (3) CT scan dataset, an equivalent
ab
de
13 Advancements inFacial Trauma
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to a road map [5, 13]. NS allow precise location of an anatomic landmark with a
margin of error of less than 1–2 mm. There are several types of SN systems.
However, electromagnetic and optic based are the most widely used (Fig.13.2)
[5, 13].
c
251
Fig. 13.2 A 25-year-old male patient sustained rearm injury (FI). FI caused comminuted symphysis
and bilateral parasymphysis fractures, and four retained bullets in his neck. Lateral view (a) of 3D
reconstruction of pre-op CT scan demonstrating mandibular fracture, track of bullet fragments
extended from hyoid bone to lingual surface of mandible, and three bullets (red circles). Axial view
of CT scan (b) showing the fourth bullet retained in the oor of the mouth. Axial view of CT scan (c)
showing the fth bullet retained at the level of his right maxillary sinus. Using surgical navigation,
the surgeon was able to retrieve four bullets (three bullets in the neck, one in the oor of the mouth)
through the transcervical approach (d) (yellow arrow pointing at a retrieved bullet). A screenshot of
the navigation monitor showing how to locate a bullet during the procedure (e)
252
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D. Amin and N. Demian
Intraoperative Computed Tomography
The use of rst application of intraoperative computed tomography (ICT) was
15years ago in management of orbitozygomatic injuries in 1999 [14]. ZMC, zygomatic arch, and orbital fractures are the most common applications. Several companies offer ICT; however the main differences between are the ability to provide an
immediate 3D reconstruction of craniofacial structures and image resolution
(Fig.13.3). Several studies have shown that the use of ICT leads to accurate fracture
reduction and reduces the possibility of a postoperative corrective surgery [15]. ICT
can be integrated with the SN system. The main advantage is reduced take back to
OR (Fig. 13.4). However, the application of ICT increases exposure to ionizing
radiation, operative time, and treatment cost [16].
Fig. 13.3 Several
companies offer
intraoperative imaging
systems; the main
differences are radiation
dose, availability of 3D
reconstruction of
craniofacial skeleton, and
image resolution. The most
used companies by authors
and in the United States
are the O-ARM™
(Medtronic©, Minneapolis,
Minnesota) (a) and Ziehm
Vision RFD 3D (Ziehm
Imaging, Orlando,
Florida) (b)
b
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