Off the hinge: Functional Restoration of subtotal hemimandibulectomy defects does not require condylar preservation
Adam S. Levy, MD, Karel-Bart Celie, BA, Alexandra Lin, BA, Christine H. Rohde, MD, David I. Kutler, MD, Gwendolyn S. Reeve, DMD, Jason A. Spector, MD.
New York-Presbyterian Hospital, New York, NY, USA.
Background: Mandibular tumors or osteonecrosis may often involve a “hemi-mandible”, though these pathologic processes usually spare the condyle, an integral component of the temporomandibular joint complex (TMJ). Subtotal resection of the hemi-mandible creates a complex reconstructive problem as the remaining condylar segment is small with questionable vascularity and insufficient surface area onto which hardware may be securely placed, increasing the risk of non-union and displacement. Alternatively, the uninvolved condylar segment may be resected with the specimen and a functional neo-condyle designed using pre-operative virtual planning and rounding of the distal end of the fibular construct intra-operatively to seat into the glenoid fossa. We reviewed our experience in those patients who underwent posterior mandibular reconstruction using vascularized fibula with or without condylar sacrifice and compared functional outcomes.Methods: A retrospective chart review was performed of all patients undergoing free fibula reconstruction after hemi-mandible resection without condylar preservation between 2006-2017. Neo-condyles were designed with virtual planning to be seated 2-3 mm below the temporomandibular disc and were contoured intraoperatively to have a round shape. Post-operatively patients who underwent neo-condylar reconstruction were kept in MMF for 3-4 weeks then placed in elastics. Outcomes measured included maximum interincisal opening (MIO), occlusion, and type of diet obtained.Results: Fifteen patients were identified that underwent condylar resection with neo-condyle creation. Mean age at time of reconstruction was 62±15.4 and BMI 24.9±5.6. All but 2 patients were able to tolerate regular diet at the time of follow up (mean 14 months). These two patients were unable to resume normal diet after 20 months and required long-term supplemental enteral feeding. Three patients developed trismus/ankylosis with reduced MIO (10/15/20), all of which received external beam radiation. The other 10 patients with neo-condyles retained normal occlusion and MIO distance.Conclusion: Fabrication of a neo-condyle using a vascularized fibula flap is a straightforward and reliable procedure that produces excellent outcomes. As the osteosynthesis of the condylar remnant to the fibula flap can be technically challenging, we propose routine discarding of the condylar remnant in order to make surgical reconstruction of subtotal mandibulectomy a technically simpler procedure.
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