Surgical repair of a mandibular bony defect following the removal of an amelobalstoma
A 35-year-old lady presented to the craniofacial surgeons looking for a permanent fixture to the bony defect in her lower-right mandible. In 1991 she had her first operation to remove the ameloblastoma and then had it further excised 6 years later due to a reoccurrence. This resulted in an absence of teeth from the canines back and removal of bone down to the inferior alveolar nerve. The patient has since been clear of any further reoccurrences and wears lower dentures for aesthetic reasons.\nShe has no significant past medical history nor family history, nor does she have any known drug allergies. She does not smoke or drink alcohol.\nOn clinical examination, the patient experiences mild parasthesia in the distribution of her right inferior dental nerve, particularly the lateral aspect of the lower lip.\nOn examination, there is clear absence of teeth on the lower-right side from the canines back (to include the premolar, molar and wisdom teeth) and presence of healthy oral mucosa with laxity to move the submucosa medially. There is a loss of the vertical height of the posterior body of the mandible of about 50% and the vestigial remnants of the lingual plate are just palpable and visible on plain radiograph and CT. Scans show that the superior margin of the resection is well corticated under the inferior dental nerve (Fig. a and b). No functional problems exist. As a long-term solution to her defect, the patient wishes to get dental implants. The surgical approach taken, prior to the implants, shall be discussed.\nThe patient was initially given the option between a bone graft or vascularized tissue (free fibular flap) and informed of the complications—a bone graft carries a risk of rejection and vascularized tissue needs an increased amount of post-operative care to ensure that the tissue remains vascularized. The patient was not keen on a free flap and given the fact that the bony deformity was <5 cm, non-vascularized iliac bone graft was deemed to be sufficient to carry out this operation [].\nThe surgery occurred in several steps. The first step was achieving significant tissue expansion (>2 cm) using Osmed pellets, guided into the submucosa and kept over the alveolar ridge for several months (Fig. a–c).\nTwo months later, the patient underwent the main bulk of her operation. The Osmed pellets were removed from the subperiosteum (Fig. a and b) and the iliac bone graft was taken, made up of cortical and cancellous bone and placed to one side (Fig. a–c). An epidural catheter was placed inside the soft tissue of the graft site and left overnight. It had a continuous fusion of a local anaesthetic to improve post-operative pain and encourage early mobilization.\nPreviously, using CT scans, a titanium construct was made to guide the outline of the bone graft and complete the missing height and width of the mandible []. Once fitted to the patients jaw, it was packed with the bone graft and screwed down into position (Fig. ). A slight groove was made on the mandible to allow space for the inferior dental nerve to lay, so that the construct did not compact the nerve and cause functional problems.\nTo complete the surgery, the periosteum was sutured over the construct and then the buccal muscosa was sutured over again to form a double-layered closure (Fig. a–c).The purpose of this was to prevent infection and rejection, by ensuring that there was an increased distance between the foreign object (titanium construct) and the outside environment. The dental implants are scheduled to be inserted several months after this operation.