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Lower jaw reconstruction using a vascularized bone graft is the main stage of complex rehabilitation of a child with lower jaw osteoblastoclastoma
- Authors: Semyonov M.G.1,2, Golyana S.I.3, Michalov V.V.2, Afonichev K.A.1, Fillippova O.V.1, Stepanova Y.V.1
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Affiliations:
- H. Turner National Medical Research Center for Children’s Orthopedics and Trauma Surgery
- North-Western State Medical University named after I.I. Mechnikov
- H. Turner National Medical Research Centre for Children’s Orthopedics and Trauma Surgery
- Issue: Vol 9, No 4 (2021)
- Pages: 455-464
- Section: Clinical cases
- URL: https://journals.eco-vector.com/turner/article/view/73184
- DOI: https://doi.org/10.17816/PTORS73184
- ID: 73184
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Abstract
BACKGROUND: Jaw bone benign tumors and dysplasia in childhood often have an aggressive growth pattern, which requires early radical operations. Uneven growth and changing morphological characteristics of the child’s dentofacial apparatus imply stage-by-stage bone and plastic surgery in the maxillofacial region.
CLINICAL CASE: The paper presents a clinical observation of the medical rehabilitation of a patient from 5 to 24 years old with lower jaw osteoblastoclastoma following our proposed algorithm.
DISCUSSION: The presented clinical observation demonstrates all the main stages of medical rehabilitation of a child with a benign lower jaw neoplasm. Along with timely and fully operative neoplasm removal, rational dental prosthetics, and dispensary observation with X-ray diagnostics play an important role in the child’s growth period. All these measures were important to prevent a possible neoplasm recurrence, partially maintain the masticatory function for the growth period, and avoid secondary postoperative dental apparatus deformities. The age of repeated surgery to replace the titanium structure with autosteal tissue depends on the individual characteristics of patients. The operation can be performed, in some cases, starting from age 16–17 years.
CONCLUSIONS: Successful treatment of children with benign neoplasms of the lower jaw after post-resection defects is a complex multi-stage process of medical rehabilitation, of which the completion, most often, passes into the adult period.
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BACKGROUND
Treatment of pediatric patients with benign neoplasms of the jawbones is one of the most urgent and complex problems of modern reconstructive plastic surgery of the maxillofacial region [1–3].
A few studies have focused on the analysis of the treatment of children and adolescents with post-resection defect and lower jaw defects in both Russian and international literature [4–6]. According to Afanasov et al. (2017), most authors present generalized treatment results of adult patients [7].
The complexity of this problem is attributed to several important and often mutually aggravating factors that are typical for patients in this category. Several benign neoplasms of the jawbones in children are characterized by a very aggressive growth pattern that can lead quickly to the destruction of dentition structures. Once such neoplasms are confirmed, radical surgery is required [8, 9]. Moreover, uneven growth and changes in the morphological characteristics of the jawbones in a child can lead to the need for performing staged osteoplastic surgeries, and the final reconstruction of the jaw is performed only after the completion of bone formation, e.g., lower jaw [10, 11].
Further, several authors consider it possible, after removal of the jaw neoplasm and the formation of a defect during surgery, to replace it immediately with a vascularized graft, without exclusion of subsequent repeated corrective osteoplastic surgeries. The use of a blood-supplied bone graft helps restore the integrity of the jaw during one surgical stage, regardless of the defect size. Most often, fragments of the fibula and radius, lateral edge of the scapula, and part of the ilium are used as donor materials. A considerable number of studies on transplantation of vascularized bone grafts in adults and, to a lesser extent, in children reported good aesthetic and functional results of treatment [11–14].
Moreover, the use of vascularized grafts to restore the integrity of extended mandibular defects in younger children, by both maxillofacial surgeons and pediatric orthopedists, raises several concerns related to the duration and trauma rate of surgery and the possible consequences of har vesting a large graft from a limb, which limited the use of early functional chewing load on the jaw after transplantation.
One of the most controversial topics regarding the complete medical rehabilitation of these patients is the restoration of complete chewing function using dentures on dental implants [15, 16].
CLINICAL CASE
Since 2013, five pediatric patients with post-resection jaw defects after removal of benign neoplasms were under our follow-up. Their jaw defects were successively compensated with standard and individual reconstructive plates (endoprostheses) and a free vascularized bone graft. Herein, we present one of the cases.
Patient B (5.5 years old) presented to the Pediatric Maxillofacial Surgery Clinic of K.A. Raukhfus Children’s City Hospital No. 19 (St. Petersburg) in 2002 with complaints of impairment of facial contours, pain in the lower jaw, and eating difficulty. Clinical symptoms appeared a few months before the treatment. To clarify the diagnosis, the volume of the bone tissue damage was assessed, surgical treatment was planned, and orthopantomography and computed tomography (CT) of the skull were performed. The main diagnostic method was an extended surgical biopsy under anesthesia, for which the patient was hospitalized for a short time. The study confirmed the preliminary diagnosis of a lower jaw osteoblastoclastoma (Fig. 1).
Fig. 1. Patient B (5.5 years old). Osteoblastoclastoma of the jaw: a, appearance; b, orthopantomogram
During the primary surgery, the neoplasm was removed in the volume of the affected segment of the jaw and within 8–10 mm of the intact bone tissue. The jaw defect was replaced with a titanium reconstructive plate (endoprosthesis) manufactured by Konmet and fixed on each side with three screws (Fig. 2).
Fig. 2. Patient B (6 years old). Osteoblastoclastoma of the lower jaw: a, resection of the affected area; b, replacement of the jaw defect with a reconstructive plate
The postoperative period was uneventful. After 2 months, a removable denture for the lower jaw was manufactured. In subsequent years, the patient was followed up by an orthodontist, who, as she grew, replaced a removable denture to maintain chewing function (Fig. 3).
Fig. 3. Patient B (14 years old): a, stable remission 8 years after mandibular resection; b, partial restoration of chewing function with a removable denture
At age 10, the patient underwent local plastic correction of the auricles due to everted ears. At age 17, upon completion of the growth of the facial part of the skull, preparations were started for the final surgery, including the removal of the titanium endoprosthesis plate and its replacement with a vascularized bone graft. The surgical treatment was indicated, among other things, as the jaw growth was completed. A CT scan showed a pronounced discrepancy between the size of the base (titanium endoprosthesis) of the lower jaw and the size of the formed upper jaw and the skull as a whole. Further preservation of the endoprosthesis could lead to the dislocation of the jaw heads from the articular cavities (Fig. 4).
Fig. 4. Patient B (17 years old). Postoperative deformity of the lower jaw. Condition after the removal of the neoplasm and arthroplasty of the jaw with a titanium reconstructive plate: a, appearance and oral cavity; b, X-ray image
During preparation for the surgery, before hospitalization, a CT of the skull and lower leg was performed. The prototype models of the upper and lower jaws, as well as a template for modeling during the fibula graft surgery, were constructed (Fig. 5).
Fig. 5. Prototyping of the jawbones and model of the mandible template for the fibula graft (a); fragmented and modeled graft according to the jaw template (b)
The surgery was performed in the Department of Maxillofacial Surgery of the Turner Scientific and Research Institute for Children’s Orthopedics by two teams of surgeons. One team prepared the receptive bed on the jaw after the removal of the titanium endoprosthesis and then modeled and fixed the bone graft on the jaw. Within 10 years of using a titanium endoprosthesis, under the action of masticatory muscles, a partial remodeling of the stumps of the resected fragments of the jaw occurred, and a bone “bridge” was formed between them. Team 2 of surgeons harvested the vascularized graft from the fibula and made anastomoses on the vessels of the graft and the receptive bed of the jaw. Thus, the surgery consisted of several successive stages, namely, skeletonization of the jaw with an endoprosthesis (the last one was removed), removal through an S-shaped incision in the projection of the fibula of the diaphysis, and addition of feeding vessels, namely, two veins and an artery with a diameter of up to 2.5 mm. Vessels were ligated and dissected, and a fibula fragment of 23 cm long was resected. Then, a transosseous canal was formed through the incision in the ankle area with fixation of the lateral ankle with a bone pin. Thereafter, an osteotomy, fragmentation of the bone graft according to the jaw template, and fixation of its fragments with mini-plates were performed. The integrity of the compact plate and periosteum on one side of the graft and, accordingly, the feeding vessels (arteries and veins) were preserved. The autogenous bone graft was placed along the edges of the fragments and on the surface of the jaw branches and fixed with five mini-plates with screws. Then, vascular anastomoses (9-0 Prolene) were placed between the proximal peroneal artery and the superior thyroid artery and between two more vessels of the donor and recipient zones. The patency test of the anastomoses was positive. Layered sutures were placed on the wound, with passive drainage (Fig. 6).
Fig. 6. Patient B (17 years old). Stages of bone grafting of the lower jaw with a vascularized fibula graft (a–d), and X-ray image of the immediate result of the surgery (e)
In subsequent years, the treatment was performed in an outpatient setting and in the Department of Maxillofacial Surgery of the Clinical Hospital “RZD-Medicina” in St. Petersburg.
At age 19 (2016), the patient underwent another surgery, when incisions were made on the scars in the submandibular region on both sides, the jaw was skeletonized, and two plates were removed from each side. A slight mobility of the edge of the formed jaw (former graft) on the right was revealed, and it was fixed with a mini-plate. A compact osteotomy of the jaw was performed, and cavities (“defects”) between the formed jaw and the remaining fragments of the previously resected jaw (bone “bridge”) were filled with xenogenic material “Osteomatrix” mixed with platelet-rich plasma (up to 4.0 cm3). The implanted material was covered with membranes of platelet-rich fibrin and collagen resorbable membrane Biomatrix (Connectbiopharm). The wound was sutured (Fig. 7).
Fig. 7. Patient B (19 years old): a, removal of the hardware, additional fixation of the formed jaw with a mini-plate; b, c, bone grafting of small jawbone defects with xenogenic material “Osteomatrix,” platelet-rich plasma, a biodegradable membrane is placed on top; d, X-ray image in the immediate postoperative period
Over the next 3 years, because of family reasons, the patient postponed further rehabilitation of the masticatory function on dental implants, the follow-up was continued, and the patient wore a removable denture (Fig. 8).
Fig. 8. Patient B (21 years old), before dental implantation: a, appearance of the patient; b, oral cavity; c, removable prosthesis
At age 21 (2018), the patient underwent the next stage of rehabilitation. Five screw implants (Hi-Tek LGI line) were installed in positions 43, 44, 45, 33, and 34 of the teeth for a bar structure and fixation of a conditionally removable denture on it. Gum tissues were grafted in positions 33 and 34 of the dental implants with a free connective tissue flap (graft) from the hard palate mucosa. The wounds were sutured with 6-0 Prolene (Fig. 9).
Fig. 9. Patient B (23 years old). After dental implantation
In September 2020, the mobility of implant 45 was revealed; it was removed, and the bed was filled with Parasorb osteogenic material. Figure 10 presents the appearance and condition of the oral cavity. The patient had no complaints about functional and esthetic disorders of the lower limb.
Fig. 10. Patient B (24 years old). Before the final stage of dental prosthetics: a, appearance; b, oral cavity state; c, X-ray image; d, lower limbs after fibular graft harvesting 7 years ago
In 2021, dental implantation in areas 45 and 35 with missing teeth was planned, followed by the manufacture of fixed dentures on six implants. The surgery was postponed because of the patient’s pregnancy.
DISCUSSION
The clinical case presented herein demonstrates all the main stages of medical rehabilitation of a pediatric patient with a benign neoplasm of the lower jaw. In this case, the post-resection defect of the jaw was compensated with a reconstructive titanium plate, which reduces significantly surgical trauma at age 5 [3, 10, 11] compared with the use of a vascularized graft [4, 12–14] and allows early masticatory loading using a removable denture. Rational dental prosthetics is significant in the growth period of the child. During the 10-year follow-up period before the next reconstructive surgery on the jaw, four removable dentures were made for the patient; she underwent regular dispensary examinations with X-ray diagnostics. All these measures were important for the prevention of secondary postoperative deformities of the dentoalveolar apparatus and recurrence of a benign tumor; the rather high risk of which is indicated by the authors who monitored several children with neoplasms of the jawbones [1, 4–6], including those after reconstructions using vascularized grafts.
Thus, in our opinion, replacement of an extended post-resection jaw defect in some cases, especially in younger children (up to 5–7 years), can be started with the use of various reconstructive endoprosthesis plates, replacing them by age 15–17 with a vascularized (or non-vascularized) autobone. This minimizes the risks of primary transplantation of the vascularized bone after jaw resection and reaches the final reconstruction of the jaw with a clear understanding of the size, shape, and position of the proposed graft and dental implants.
The age at which a repeated surgery will be performed to replace the titanium reconstructive plate with an autologous bone graft depends on the characteristics of the patient; in some cases, the surgery can be performed at age 15–17. Subsequent medical rehabilitation and full restoration of masticatory function with the use of dental implants and fixed dentures are often determined by the patient’s motivation, priorities during youth, and, of course, financial resources.
The analysis of our experience in treating such patients allows identifying several important tasks of the surgeons:
- Early and accurate verification of a neoplasm, including those with atypical hyperplastic inflammatory processes of the jaws.
- The use of informative and minimally invasive techniques for surgical biopsy.
- Computer modeling to determine the scope of surgical intervention and planning a reconstructive surgery to replace a jaw defect using stereolithographic models.
- The use of modern systems of reconstructive plates, individual endoprostheses to correct a defect, and jaw defect during primary surgery, especially in younger children (up to 5–7 years old).
- Development and improvement of techniques to correct an abnormality and/or defect of the jaw in older children with the use of vascularized grafts.
- Organization of a system of unified case follow-up with rational orthopedic and orthodontic treatment.
- Completion of medical rehabilitation with the restoration of the functional dentition in patients of this category, if possible up to age 18 years, which is of great medical and social importance.
CONCLUSION
Successful treatment of children with benign neoplasms and post-resection defect and lower jaw defects is a complex multi-stage process of complex medical rehabilitation, and its final stage is the complete restoration of the patient’s masticatory function after placing dental prosthetics on dental implants.
ADDITIONAL INFORMATION
Funding. The work was performed within the state order No. 121031700123-3.
Conflict of interest. The authors declare no conflict of interest.
Ethical considerations. The patient provided consent for the publication of the clinical case description and photographs in the journal.
Author contributions. M.G. Semyonov performed surgical interventions as an operator, conducted postoperative patient management, tracked long-term results, collected and analyzed the data, and wrote the article. S.I. Golyana performed a part of the surgical interventions as an operator and wrote a part of the article. V.V. Mikhailov performed a part of the surgical interventions as an operator, tracked long-term results, and corrected the article. O.V. Filippova took part in the preparation of an analytical review. K.A. Afonichev analyzed the data, edited and corrected the text, and prepared the article for publication. Yu.V. Stepanova performed postoperative management of the patient and corrected the text.
All authors made a significant contribution to the study and preparation of the article, read and approved the final version before its publication.
About the authors
Mikhail G. Semyonov
H. Turner National Medical Research Center for Children’s Orthopedics and Trauma Surgery; North-Western State Medical University named after I.I. Mechnikov
Email: sem_mikhail@mail.ru
ORCID iD: 0000-0002-0803-1923
SPIN-code: 2603-1085
MD, PhD, рrofessor, Head of the Department of Maxillofacial Surgery and Surgical Dentistry, Leading Researcher
Russian Federation, 64-68 Parkovaya str., Pushkin, Saint Petersburg, 196603; 41, Kirochnaya street, Saint-Petersburg, 191015Sergey I. Golyana
H. Turner National Medical Research Centre for Children’s Orthopedics and Trauma Surgery
Email: ser.golyana@yandex.ru
ORCID iD: 0000-0003-1319-8979
SPIN-code: 8360-8078
MD, PhD, Scientific Supervisor Department of Reconstructive Microsurgery and Hand Surgery
Russian Federation, 64-68 Parkovaya str., Pushkin, Saint Petersburg, 196603Vasily V. Michalov
North-Western State Medical University named after I.I. Mechnikov
Email: vm911@mail.ru
ORCID iD: 0000-0002-8593-2039
MD, PhD, Associate Professor of the Department of Maxillofacial Surgery and Surgical Dentistry
Russian Federation, 41, Kirochnaya street, Saint-Petersburg, 191015Konstantin A. Afonichev
H. Turner National Medical Research Center for Children’s Orthopedics and Trauma Surgery
Email: afonichev@list.ru
ORCID iD: 0000-0002-6460-2567
SPIN-code: 5965-6506
MD, PhD, D.Sc., Head of the Department of Trauma Sequelae and Rheumatoid Arthritis
Russian Federation, 64-68, Parkovaya str., Saint-Petersburg, Pushkin, 196603Olga V. Fillippova
H. Turner National Medical Research Center for Children’s Orthopedics and Trauma Surgery
Email: olgail@mail.ru
ORCID iD: 0000-0002-1002-0959
SPIN-code: 8055-4840
MD, PhD, D.Sc.
Russian Federation, 64-68 Parkovaya str., Pushkin, Saint Petersburg, 196603Yulia V. Stepanova
H. Turner National Medical Research Center for Children’s Orthopedics and Trauma Surgery
Author for correspondence.
Email: turner8ord@gmail.com
ORCID iD: 0000-0001-7064-3069
SPIN-code: 8606-0381
MD, PhD, Chief of the Department of Maxillofacial Surgery
Russian Federation, 64-68 Parkovaya str., Pushkin, Saint Petersburg, 196603References
- Kolesov AA, Vorob’ev JuI, Kasparova NN. Novoobrazovanie mjagkih tkanej i kostej lica u detej i podrostkov. Moscow: Medicina; 1989. (In Russ.)
- Matjakin EG, Roginskij VV, Matjakin EE. Opuholi i opuholepodobnye obrazovanija cheljustno-licevoj oblasti. Rukovodstvo po hirurgicheskoj stomatologii i cheljustno-licevoj oblasti. Ed. by V.M. Bezrukova, T.G. Robustovoj. Vol. 1. Moscow: Medicina; 2000. (In Russ.)
- Ovchinnikov IA, Roginskij VV, Sedyh AA, Ivanov AL. Hirurgicheskaja reabilitacija detej s defektami i deformacijami nizhnej cheljusti. In: Sbornik materialov Nauchno-prakticheskoj konferencii “Perspektivy razvitija poslediplomnogo obrazovanija specialistov stomatologicheskogo profilja. Aktual’nye problemy stomatologii: Tezisy dokladov. Moscow; 2003. P. 449–451. (In Russ.)
- Genden EM, Buchbinder D, Chaplin JM, et al. Reconstruction of the pediatric maxilla and mandible. Arch Otolaryngol Head Neck Surg. 2000;126(3):293–300. doi: 10.1001/archotol.126.3.293
- Perry KS, Tkaczuk AT, Caccamese Jr JF, et al. Tumors of the pediatric maxillofacial skeleton: a 20-year clinical study. Otolaryngology Head Neck Surg. 2015;141(1):40−44. doi: 10.1001/jamaoto.2014.2895
- Benoit MMcK, Vargas SO, Bhattacharyya N, et al. The presentation and management of mandibular tumors in the pediatric population. Laryngoscope. 2013:123:2035–2042. doi: 10.1002/lary.24020
- Afanasov MV, Lopatin AV, Jasonov SA, Kosyreva TF. Metody ustranenija postrezekcionyh defektov u detej. Russian Journal of Dentistry. 2017;21(1):49−56. (In Russ.). doi: 10.18821/1728-28022017;21(1):49-56
- Paches AI. Opuholi golovy i shei. Moscow: Osobaja kniga; 2013. (In Russ.)
- Abramowitz Sh, Goldwasser BR, Troulis MJ, et al. Primary jaw tumors in children. J Oral Maxillofacial Surg. 2013;71(1):47−52. doi: 10.1016/j.joms.2012.04.045
- Semenov MG, Filippova AV, Stecenko AG. Sposob modelirovanija kostno-rekonstruktivnyh operacij pri lechenii novoobrazovanij cheljustnyh kostej v detskom vozraste. Patent No. 2607651 RF. Zajavka No. 2015136960. 31 Oct 2015: opubl. 10 Jan 2017. (In Russ.)
- Topol’nickij OZ. Kostnaja plastika nizhnej cheljusti u detej i podrostkov kompozitnymi m materialami na osnove akrilatov. [dissertation] Moscow; 2002.
- Warren SM, Borud LJ., Brecht LE, et al. Microvascular reconstruction of the pediatric mandible. Plast Reconstr Surg. 2007;119(2):649–661. doi: 10.1097/01.prs.0000246482.36624.bd
- Bolotin MV, Lopatin AV. Microvascular reconstruction of defects of the mandible in children. Opukholigolovyishei. 2013;(2):16–19. doi: 10.17650/2222-1468-2013-0-3-16-19
- Guo L, Ferraro NF, Padwa BL, et al. Vascularized fibular graft for pediatric mandibular reconstruction. Plast Reconstr Surg. 2008;121(6):2095–105. doi: 10.1097/PRS.0b013e3181712399
- Nikitin DA, Mirgazizov MZ, Nikitin AA. Lechenie i reabilitacija bol’nyh posle kostno-rekonstruktivnyh i vosstanovitel’nyh operacij na nizhnej cheljusti s ispol’zovaniem jendoprotezirovanija i dental’nyh implantatov. Al’manah klinicheskoĭ mediciny. 2011(24):15−21. (In Russ.)
- Markov NM, Grachev NS, Babaskina NV, et al. Dental rehabilitation in the complex treatment of children and adolescents with maxillofacial neoplasms. Stomatologiia (Mosk). 2020;99(6. Pt. 2):44−62. doi: 10.17116/stomat20209906244
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