Department of Plastic Surgery, BIRDEM General Hospital, Dhaka, Bangladesh
Department of Plastic Surgery, Khidma General Hospital, Dhaka, Bangladesh
Department of Oral & Maxillofacial Surgery, BIRDEM General Hospital, Dhaka, Bangladesh
present a case of reconstruction of a bony defect due to the excision of recurrent mandibular odontogenic keratocyst
in a 45 years old diabetic male. Free vascularized fibular composite graft was
taken from the contra lateral lower leg to reconstruct the defect. A two team approach consisting of plastic and maxillofacial
(MF) surgeon was adopted. The functional and aesthetical outcome was
satisfactory and bone healing occurred without any major complication.
IMC J Med Sci 2017; 11(2): 00-00
Address for Correspondence:Dr. Farzana B Ibrahim,
Registrar, Department of Plastic Surgery, BIRDEM General Hospital, 122, Kazi
Nazrul Islam Avenue, Shahbag, Dhaka-1000, Bangladesh. Email: firstname.lastname@example.org
Cystic and cyst like lesions of the mandible are
primarily ellipsoid, radiolucent, and clearly demarcated. It may be odontogenic
or nonodontogenic. Odontogenic cysts and tumors develop
during or after the formation of teeth .
Most odontogenic mandibular lesions
are benign, but some particularly odontogenic keratocyst may be locally aggressive
and destructive . Odontogenic keratocysts are believed to arise from the
dental lamina and other sources of odontogenic epithelium and is highly recurrent and locally aggressive. They
represent 5%–15% of all jawcysts. Most odontogenic keratocysts
are found during the 2nd to 4th decades of life, although they can occur at any
age. The lumen of the cyst often contains “cheesy” material and has a
parakeratinized lining epithelium . Daughtercysts and nests of
cystic epithelia are found outside the primary lesion; as a result, odontogenic
keratocysts have the highest recurrence rate (50%) of any odontogenic cyst when
treated conservatively with curettage .
has traditionally been the mainstay of surgical therapy for oral squamous cell
carcinoma adjacent to or invading the mandible or for osteoradionecrosis. Combined
bone grafts are used for large mandible defects [4,5,6]. Since microanastomosed
bone grafts consist of living tissue, they are capable of independent survival
within a compromised recipient site. Furthermore, vascularized grafts are able
to improve the local wound regenerative situation. Most commonly used donor
sites are iliac crest and fibula. Vascularized fibular grafts present numerous advantages
for restoring mandible [3-6]. Their bony architecture is similar to that of the
mandible, unlike iliac crest and they are capable of restoring defects up to a
length of 25 cm. The grafts can be easily adjusted to the curvature of the
mandible using the osteotomy technique. They are associated with very low
postoperative donor site morbidity and facilitate the insertion of dental implants
[7-9]. Since vascularized grafts behave like an edentulous mandible,
osseointegration of dental implants can generally be achieved.
present a case of a 45 year old diabetic male in whom a free vascularized
fibular composite graft from the left leg was used to reconstruct a 6 cm bony
defect of the mandible following excision of odontogenic keratocysts. Informed
consent was obtained from the patient to perform this procedure and to publish
the case for academic purpose.
A 45 year
old, diabetic, male had cyst in the right side
of the mandible with a history of repeated infection with pain and discharge for
2 years. Histopathologically the cyst was diagnosed as osteogenic keratocysts. He
had history of extraction of lower right first premolar tooth and saucerization
for several times but the cyst kept recurring. On examination, his gum was swollen,
inflamed and there was absence of lower right 1st premolar tooth
[Fig1a]. Radiology showed a large perforation of the cortical plates [Fig 1b, 1c]. Operation was performed under general
anesthesia and two team approach was opted. Maxilllo facial
surgeons performed the mandibular tumor resection while the plastic surgery
team performed the flap and the receptor vessels dissection, and vascular anastomosis.
Both teams participated at bone shaping and the final closure.
team excised about 6 cm of the mandible keeping the inner and lower cortex
intact. The alveolar socket was also excised [Fig 1d]. The
radical resection of the tumor was carried out. The plastic surgery team
started with harvesting the free fibular composite graft from left leg. The course of the fibula was noted and marked [Fig 1e]. The
majority of significant perforators emerge at 10 to 20 cm below the fibular head,
thus it is preferable to locate the skin paddle within this location. As the
anterior incision was made through the deep fascia, care was taken to avoid injury
to the superficial branch of the peroneal nerve. The dissection continued
posteriorly to the posterolateral intermuscular septum, exposing the peroneal
muscles. The anterior surface of the septum was then followed down the fibula,
and the peroneal muscles were elevated from the lateral and anterior surfaces
of the bone. The posterior skin incision was then made through the deep muscle
fascia, and the skin paddle was elevated to the edge of the soleus muscle. A
1-cm cuff of soleus muscle was taken from the lateral edge which was later
excised. The fibular cuts were made with an oscillating saw. The proximal cut
in the fibula was made first and positioned as superiorly as possible without
endangering the peroneal nerve. To ensure stability of the knee the proximal
10 cm of fibula was preserved. Once both cuts were made, the fibula was retracted
laterally. The peroneal vessels were located and followed distally where they
were ligated and divided.
The flap dissection continued in a medial to lateral direction to
avoid injury to the perforating vessels of the skin. About 8 cm of fibula was
harvested. Once the status of the neck vessels was assured and prepared, the
peroneal vessels were divided, and the flap was transferred to the oral defect.
A single closing wedge osteotomy was made to create a neoangle and the bone
fragments were then stabilized with the rest of the mandible with nail plate
and screw fixation. The graft was then revascularized using microvascular
techniques [Fig 1f]. We performed peroneal vessel anastomosis to facial artery. Vein anastomosis was performed to
the external jugular vein. End-to-end
vascular anastomosis was used and
microvascular anastomosis was performed as previously described under loupe
magnification with 7.0 and 8.0 sutures.
After checking for a watertight intraoral closure, the skin paddle
was removed, the neck flaps were replaced, and the skin was closed over drains
[Fig 1g]. The leg incision was closed primarily with suction drains in situ. The patient was hospitalized for
two weeks. For the first week feeding was allowed with soft diet through
naso-gastric tube. Lower limb was immobilized with a cast for the same period. His
post operative period was uneventful. Drains and stitches were removed on 5th
and 8th post operative day respectively. At three months follow up
since the surgical reconstruction, the result was found satisfactory both from
oncological and aesthetic point of view.
showing the mandibular bony defect and steps of reconstructive surgery. 1a: Absence
of lower right 1st premolar tooth; 1b & 1c: Large perforation in
the cortical plates as shown by CT scan
and X ray; 1d: Excised mandible; 1e: The marked course of the fibula for obtaining graft; 1f
& 1g: Reconstrctuted graft. Arrow indicates the lesions
The free fibular osteofasciocutaneous flap can become the standard
option for mandible reconstruction in our experience. The advantages were wide
and safe resection and the better functional outcome. The associated morbidity
at the donor site was minimal and the technique provided the opportunity of
two-team approach thereby reducing the operating time. Immediately after
integration dental implantation can be done.
1. Goaz PW, White SC. Oral Radiology: principles and interpretation 3rd ed. St
Lois, Mo: Mosby- Year Book, 1994; 398-676.
2. Weber AL. Imaging of cysts and odontogenic
tumors of jaw. Radiol Clin North Am. 1993;
3. Oikarinen VJ. Keratocyst recurrences at
intervals of more than 10 years: case reports. Br J Oral Maxillofac Surg. 1990; 28: 47-49.
4. Hidalgo DA, Pusic AL. Free-flap mandibular
reconstruction: a 10-year follow-up study. Plast
Reconstr Surg. 2002; 110: 438-451.
5. Hidalgo DA. Fibula free flap: A new method of
mandible reconstruction. Plast Reconstr
Surg. 1989; 84: 71-79.
6. Sultan MR. Mandible reconstruction with the
scapula osteocutaneous flap. Operative
techniques in Plastic and Reconstructive Surgery. 1996; 3(4); 248-256.
7. Kuprys R, Varinauskas V, Gervickas A,
Stanaityte R. A review of mandibular reconstruction with free microvascularized
fibular flap. Sveikatos mokslai/Health
Sciences. 2012; 22 3(82): 170-174.
8. Gbara A, Darwich K, Li L, Schmelzle R, Blake
F. Long-term results of jaw reconstruction with microsurgical fibula grafts and
dental implants. J Oral Maxillofac Surg.
2007; 65(5): 1005-1009.
9. Ferrari S, Bianchi B, Savi A, Poli T, Multinu
A, Balestreri A, Ferri A. Fibula free flap with endosseous implants for
reconstructing a resected mandible in Bisphosphonate Osteonecrosis. J Oral Maxillofac Surg. 2008; 66(5): 999-1003.