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G. Lauer
6. Gellrich N-C, Kwon TG, Lauer G, Fakler O, Gutwald R, Otten J-E, Schmelzeisen R. The lateral upper arm free ap for intraoral reconstruction. Int J Oral Maxillofac Surg. 2000;29:104–11.
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14. O’Connor NE, Mulliken JB, Banks-Schlegel S, Kehinde O, Green H.Grafting of burns with cultured epithelium prepared from autologous epidermal cells. Lancet. 1981;10:75–9.
15. DeLuca M, Albanese E, Megna M, Cancedda R, Mangiante PE, Cadoni A, Franzi AT. Evidence that human oral epithelium reconstituted in vitro and transplanted onto patients with defects in the oral mucosa retains properties of the original donor site. Transplantation. 1990;5:454–9.
16. Langdon JD, Leigh IM, Navsaria HA, Williams DM. Autologous oral keratinocyte grafts in the mouth. Lancet. 1990;335:1472–3.
17. Raghoebar GM, Tomson AM, Scholma J, Blaauw EH, Witjes MJ, Vissink A.Use of cultured mucosal grafts to cover defects caused by vestibuloplasty: an invivo study. J Oral Maxillofac Surg. 1995;53:872–6.
18. Arenholt-Bindslev D, Jepsen A, Mac Callum DK, Lillie JH. The growth and structure of human oral keratinocytes in culture. J Invest Dermatol. 1987;88:314–9.
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20. Southgate J, Williams HK, Trejdosiewicz LK, Hodges GM. Primary culture of human oral epithelial cells. Growth requirements and expression of differentiated characteristics. Lab Inv. 1987;56:211–23.
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for pre-prosthetic surgery. J Craniomaxillofac Surg. 1991;19:21–6.
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23. Johnson MC, Meyer AA, de Serres S, Herzog S, Peterson HD.Persistence of fetal bovine serum pro­teins in human keratinocytes. J Burn Care Rehabil. 1990;11:504–9.
24. Lauer G. Autogenous serum for culturing kerati­nocyte autografts. In: Phillips GO, von Versen R, Strong DM, Nather A, editors. Advances in tissue banking, vol. 1. Singapore: World Scientic; 1997. p.183–7.
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27. Pradel W, Blank A, Lauer G. Klinischer Einsatz von im Tissue Engineering hergestellten Gingivakeratinozyten-Gingivafibroblasten­Konstrukten als Weichgewebsersatz. Dtsch Zahnärztl Z. 2002;57:709–12.
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37. Mitchell DL, Synnott SA, Van Dercreek JA.Tissue reaction involving an intraoral skin graft and CP titanium abutments: a clinical report. Int J Oral Maxillofac Implants. 1990;5:79–84.
38. Schrott AR, Jimenez M, Hwang JW, Fiorellini J, Weber HP. Five-year evaluation of the inuence of keratinized mucosa on peri-implant soft-tissue health and stability around implants supporting full-arch mandibular xed prostheses. Clin Oral Implants Res. 2009;20:1170–7.
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Part XI
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Biological Procedures in Craniofacial
Reconstruction: Microsurgery
Microsurgical Jaw Reconstruction
https://t.me/medicina_free
MajeedRana andHenrietteMöllmann
23
Introduction: Mandibular Defects
The loss of continuity caused by trauma, defects following tumor disease, or inammation (i.e., osteonecrosis or osteomyelitis) signicantly impairs functions such as chewing, swallowing, speaking, and breathing. Microsurgery allows restoring mandibular continuity through free bone grafting, microvascular grafts, or recon­struction with allogeneic and alloplastic materi­als. Technological advancements in computer-assisted surgery (CAS) provide the foundation for sustainable procedures. Depending on the localization as well as the extent of man­dibular defects, there are considerable functional and aesthetic deteriorations.
Defects located in the lateral mandible or in the area of the ascending mandibular branch heavily impact the ability of chewing and swal­lowing. Due to a loss of continuity around the chin, the tongue loses its support. Along with issues of chewing and swallowing, patients are endangered due to possible obstruction of the upper respiratory tract. Furthermore, psychologi­cal as well as social consequences frequently occur, which might negatively inuence social
M. Rana (*) · H. Möllmann Department of Craniomaxillofacial Surgery, University Hospital Düsseldorf, Heinrich Heine University (HHU), Düsseldorf, Germany e-mail: rana@med.uni-duesseldorf.de;
henriettelouise.moellmann@med.uni-duesseldorf.de
life and interactions. Thus, a functional and aes­thetically appealing result using CAS represents an indispensable component for mandibular reconstruction.
the 1970s completely changed the therapeutic concept. This technique allows different bone grafts, also possible in combination with soft tis­sue, which might be harvested from areas distant from the defect and transplanted into the head and neck region. Here, primary or secondary reconstruction is possible. Depending on the underlying diagnosis, primary osseous recon­struction is preferred in the case of fractures or chronic osteomyelitis as well as in the case of resections due to benign lesions. In the case of malignant underlying diseases, temporary xa­tion by means of a reconstruction plate and sec­ondary reconstruction is rarely performed. Through CAS, the size and extent of the tumor, the safety distances, the resection margins, as well as the reconstruction can be planned preop­eratively, visualized, and further implemented intraoperatively.
option of an obturator in the sense of a defect prosthesis [1] is not possible. The continuity of the mandible can be restored using microvascular grafts from different donor regions. Besides the quality, quantity, and shape of the bone, the vari­ability and volume of the required soft tissue, the length of the pellicle, and the morbidity of the
The introduction of microvascular surgery in
Unlike reconstruction in the maxilla, the
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donor region are of particular relevance when selecting the appropriate graft. For the recon­struction of the mandible, donor regions such as the bula, the scapula, as well as the iliac crest [2] are highly suitable for clinical and surgical demands. Along with the restoration of continu­ity, masticatory rehabilitation following recon­struction is also of great importance.
Virtual Planning
Three-dimensional virtual surgical planning (3D­VSP) uses three-dimensional imaging datasets from computed tomography (CT) and magnetic resonance imaging (MRI) of the defect site as well as CT angiography of the graft harvest site. Depending on the underlying disease, CT scans provide high resolution of both hard and soft tis­sues in the case of bony defects or bone erosion. In the case of soft tissue tumors and inamma­tory diseases such as osteomyelitis, MRI scans can further enhance soft tissue imaging. For improving the overall image quality, the strengths of the imaging modalities can be exploited by fusing and combining CT and MRI datasets using new software programs. After merging the desired datasets, the mandible and adjacent struc­tures are initially segmented. Intelligent software segments are semiautomatically based on algo­rithms, which simplies planning and shortens the overall duration [3]. In the context of virtual planning, the size and extent of the tumor, the resection margins, and the desired reconstruction can thus be planned preoperatively, visualized, and then implemented intraoperatively. For the planning of the intraoperative navigation, special dental splints are manufactured and placed or screws are inserted before the preoperative imag­ing. Intraoperatively, the digital planning and the clinical situation are merged via a navigation tri­pod temporarily attached to the skull. During the operation, navigation can be used to directly ver­ify the targeted resection and the correct position­ing of the patient-specic implants (PSI) and graft [4]. In addition to intraoperative navigation, preoperative planning can also serve as a basis for postoperative performance monitoring. By
merging the pre- and postoperative CT scans, the accuracy of t can be validated [5]. For a func­tional and aesthetically appealing reconstruction, the opposite side can be used as reference or tem­plate for achieving a symmetrical result. Besides the intersegmental cutting and visualization of the microsurgical reconstruction, the dental and prosthetic rehabilitation can also be considered, simulated, and planned [6]. If the prosthetic reha­bilitation is already addressed at an early stage, the procedure is referred to functional or pros­thetically oriented backward planning. Thereby, the condylar position and intermaxillary relation­ship are reproduced, visualized preoperatively, or planned. Thus, the entire functional and dental rehabilitation is achievable. Virtual planning fur­ther allows visualization of different reconstruc­tion possibilities enabling a completely individualized treatment concept for the patient without invasive procedures. However, not only surgeons should benet from the possibility of visualizing the surgical site in the future. The development of virtual reality devices will also provide access to the planned operation for patients. Regarding patient education, the opera­tion is presented in a more illustrative and tangi­ble way, increasing the transparency of the treatment concept [7].
Patient-Specic Implants (PSIs)
Advancements in CAS, particularly regarding computer-aided design/computer-aided manu­facturing (CAD/CAM) technology, are superior to more traditional methods of mandibular recon­struction with hand-bent plates [815]. CAD/ CAM or selective laser melting (SLM) plates achieve higher accuracy compared to manually bent reconstruction plates. These plates provide greater results in terms of strength and intraop­erative positioning [16]. Decisive factors for this procedure are anatomical and symmetrical bone shaping, restoration of a stable dental occlusion, and condylar repositioning into a centric relation [9, 1720].
In the conventional technique, in contrast to
CAS, the plates are bent intraoperatively or pre-
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operatively manually before their adaptation. Depending on the complexity of the case and the skills as well as experience of the surgeon, this procedure might be very time consuming. The standard plates offered by manufacturers do not always possess the required size and number of holes for the intraoperative situation. PSIs do not need to be bent to t the patient’s mandible and do not require predened bending points as with conventional reconstruction [21, 22]. With improvements of CAD/CAM, it is possible to accurately plan the reconstruction of craniofacial defects preoperatively, manufacture precise PSI, and place them in less complex surgeries with shorter operating times [12, 2325]. The implant can be designed and shaped by the surgeon according to the defect size, shape, and morphol­ogy [26, 27]. By selecting the appropriate design method, manufacturing process, and implant material, it is possible to perform a precise surgi­cal procedure and reduce complications [2835]. The integration of this technology in the pre- and intraoperative workow has simplied the pro­duction of cutting guides and has been shown to shorten the operation time and the length of stay and to improve osseous consolidation, symmetry, and morphology [34, 36, 37]. Recent research demonstrated additional advantages, for instance, minimized interoperator variability caused by the surgeon’s experience and improved teaching pos­sibilities for younger colleagues involved in the planning procedures/sessions with a senior con­sultant and/or biomedical engineer [38].
Computer-Assisted Reconstruction oftheMandible Using Microvascular Grafts
After continuity resections of the lower jaw in case of carcinoma, osteonecrosis, osteomyelitis, or trauma, a mandibular reconstruction is essen­tial to restore function and aesthetics [6, 39]. The size of the defect is determined by the preopera­tive extent, the entity of the pathology, and the resulting radicality of the resection.
Defects of the mandible are reconstructible using either a reconstruction plate without bony reconstruction or immediately with a combina-
tion of reconstruction plate and primary bone ap. Despite the considerable progress in micro­vascular surgery, complications such as tissue necrosis, failure of the graft, infections (donor site or recipient), prolonged hospital stay, and long recovery process occur [4042].
Fibula, scapula, or iliac crest grafts are suit­able for the clinical requirements for reconstruc­tion of the mandible, in the sense of a free tissue transfer.
Fibula-Tx
The microvascular bula graft ingests a major role in computer-assisted reconstruction of the mandible and in dental rehabilitation. It provides a similar cross section as an atrophied mandible, shows good corticoid bone quality and special vascularization, and can be harvested up to a length of 20–25cm [43].
Nevertheless, not every patient can undergo bular grafting as in 6% of cases a nonunion of the anterior or posterior tibial artery is present [22]. In more than 1% of cases, the peroneal or bular artery is the only vessel supplying the entire lower leg making microsurgical bular transfer impossible. Angiography of the donor region is used to check whether transplantation is advisable, where the perforators are located, and how the graft can be obtained in an individual­ized manner. During virtual planning, the har­vesting templates including drill holes are individually designed so that the number and position of the perforators are considered along with the planned osteotomy lines. This also facil­itates the removal of a suitable skin transplant. Due to the digital and visualized planning as well as the facilitated handling, ischemia and opera­tion time can be shortened, and an optimal aes­thetic and functional result is achievable.
Scapula-Tx
The microvascular scapula graft is highly appro­priate for reconstruction of the mandible [44], especially if a bula graft is not possible due to peripheral vascular arteriopathy [45]. The lateral
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scapula edge with the maximal length of 14cm can be used for bony reconstruction [46]. The cir­cumex scapular artery supplies the lateral scap­ula as the terminal branch of the subscapular artery and equips the soft tissue above the scapula via two other vascular branches. This special vas­cular anatomy allows two independent fasciocutaneous aps, the scapular and the para­scapular aps, to be harvested simultaneously for soft tissue reconstruction with one pellicle [45]. Therefore, this transplant can be primarily used for the reconstruction of combined defects where intraoral and extraoral soft tissue reconstruction is necessary as well as bony reconstruction. Compared to the removal of the bula graft, a change of position must be performed intraopera­tively. When harvesting the scapula graft, it is not possible to operate in two teams and save operat­ing time.
Iliac Crest-Tx
The iliac crest transplant is further suitable for microsurgical reconstruction of the mandible. Supplied via the circumex ilium profunda artery, the iliac crest graft is a valid graft because of the good bone quality, the slightly curved con­tour, and the bone volume. The special bone structure can facilitate the desired dental rehabili­tation [47]. Nevertheless, the special vascular supply (short pellicle) makes microsurgical anas­tomosis difcult. Thus, strict indication and con­crete preoperative planning are advisable.
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Part XII
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Planning of Craniofacial Malformation
Surgery: Surgical Planning Principles