Waheed Murad Maxillofacial Surgery

1. Mandibular Defects and Algorithms for
Mandibular Reconstruction
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2. Waheed Murad
PGR, Maxillofacial
Surgery
Professor Noor Ul Wahab
Consultant Oral & Maxillofacial
Reconstructive Surgeon
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3. Mandibular Defects
• Cancer
• Trauma
• Osteonecrosis (medication related or after radiotherapy )
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4. Table of Contents
• Classification of Mandibular Defects
• Algorithms to Approach Reconstruction of Mandibular Defects
• Clinical cases
• Points to consider for treatment plan
• Possible reconstruction options
• Pros
• Cons
• Take home message
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5. Learning 0bjectives
• Describe the different mandibular defects
• Choose an appropriate reconstruction for each defect
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6. Classification of Mandibular Defects
• AOCMF Classification
• Jewer’s HCL classification
• Peter G. Cordeiro Classification
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7. AOCMF classification of mandibular defects
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8. Jewer’s HCL classification
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9. Peter G. Cordeiro Classification
• Consists of 13 primary types of defects
• Addresses both soft tissue and bony defects
• Roman numeral (I, II, III) describes the bony defects
• Letter (A, B, C, D) describes soft tissue defects
• Reconstruction of mandibular defects
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10. Type I defect: Anterior
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11. Type II defect: Hemimandible
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12. Type III defect: Lateral
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13. Peter G. Cordeiro Classification
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14. Algorithms to Approach Reconstruction of
Mandibular Defects
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15. Type I defect: Anterior
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16. Type IA defect: Defect due to a non-union after a
significant blunt trauma
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17. Type II defect: Hemimandible
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18. Type IIB2 defect : Adenoid cystic carcinoma
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19. Type III defect: Lateral
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20. Type IIID defect: Recurrent OSCC
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21. Points to consider
Regarding surgery
• No bony reconstruction temporary solution
difficult dental rehabilitation
• Free bone graft limitation regarding size
Depending up recipient site
• Micro vascular osseous flap technically demanding
more resources
Donor site morbidity
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22. Peter G. Cordeiro
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23. Possible Reconstruction Options
• Fibula
• DCIA
• Scapula
• Free soft tissue flaps (ALT, Rectus abdominus, Latissmus Dorsi)
• Combination flaps
• Regional flaps (pect major , DP)
• Customized titanium prosthesis
• Plate followed by secondary reconstruction with free iliac graft 23

24. Fibula Free Flap
Pros:
• Length up to 25 cm
• Two skin islands possible
• Long and large vascular pedicle
• Different shapes due to variety of osteotomies possible
• Low level donor site morbidity
• Two team approach possible
Cons:
• Small height
• Donor site skin graft
• Preoperative imaging of vessels of lower leg
• Compartment syndrom
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25. Addressing bone height discrepancy
Double barrel fibula
Vertical distraction of fibula
Custom plate with fibula placed superiorly
Fibula split + Iliac bone graft
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26. Problems that rule out fibula
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27. DCIA
• Inconstant cutaneous vessels
• Short vascular pedicle
• Good quality and quantity of bone
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28. Free scapular flap
• Combination with free latissmus dorsi flap possible
• Long or short vascular pedicle
• Intraoperative patient shifting needed
• No two team approach
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29. Conclusion
• Vascularized Free Fibula is gold standered for reconstruction of large mandibular defects
• DCIA is good alternative of fibula graft
• Free soft tissue flaps are good options for large lateral and hemi mandible defects
• Regional flaps can be used for mandibular reconstruction in patients not fit for extensive
reconstructive surgery
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30. Take home message
If You Fail To Plan, You Plan To Fail
Benjamin Franklin
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