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Successful mandible reconstruction with recombinant technology for failed fibular graft

31/10/2014

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A 46 year old female patient reported to our hospital for swelling and pus drainage from right side of mandible.  She had sustained a road traffic accident 3 years ago and had undergone multiple surgeries for the same. Her reports and x-rays showed that she had undergone free fibular graft treatment elsewhere. Currently, there was an associated swelling and pus drain from the region.  On examination,   there was graft dehiscence in the retromolar region with draining extraoral sinus.   The CT scan of the patient revealed a fibula graft and incorrectly contoured straight reconstruction plate.

Maxillofacial Surgeon Dr. S. M. Balaji successfully planned to surgically remove the infected graft and place a composite mandibular reconstruction with rib graft fixed with reconstruction plate and reinforced with rhBMP-2. As she also had a missing 21, 22, 23, dental implants were also planned as a part of this procedure.

Intraorally, crestal incision was placed from tooth 21 to 23 regions. Mucoperiosteal flap reflected, implants placed and flap repositioned and closed. Later after osseo-integration, super structures would be placed.

Right submandibular incision was placed through the existing scar. The scar and the sinus tract were carefully excised. The reconstruction plate along with resorbed fibular graft was identified and removed. A new titanium reconstruction plate was contoured, adapted and fixed to the jaw bone using screws. The rib graft was now placed along the medial aspect of the reconstruction plate and stabilized using screws. rhBMP-2 was placed over this reconstructed area and the closure was done layer wise.  rhBMP-2 will induce new bone formation that will ensure complete healing of the defect.

Preoperative orthopantamogram showing infected plate with failed fibular graft on right side of the lower jaw
3D CT scan of the lower jaw on the right side showing failed bone graft with defective bone formation
Upper missing teeth were replaced with dental implants with defective alveolar bone region enhanced with bone graft
Costal graft harvested for reconstruction of the right side of the mandible
Submandibular incision made to expose the infected plate with failed fibular graft
Infected bone graft with the bone plate along with bone screws were removed
Harvested costal graft stabilized with long titanium bone plate used to reconstruct the lower jaw
Miracle protein rhBMP-2 was wrapped over the costal graft to induce new bone formation
Submandibular incision was sutured by layer closure
Immediate postoperative orthopantomogram showing complete removal of infected bone and reconstruction of mandible with costal graft
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