This is a case of management of a mismanaged RTA case some 3 years back elsewhere. The 46 year old female patient reported 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 was managed with free fibular graft. 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 reconstruction plate.
The plan of reconstruction was 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.
To harvest the graft, inframammary incision was placed over the right side. Layer wise dissection was done. Periosteum was incised and the sixth and seventh rib harvested and closed layerwise. Care was taken to preserve the pleural tissues.
For better access and surgical maneuver, dental implants were placed first. 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. Due to multiple previous surgeries, the scar tissue needed to be carefully reflected so as to minimize the resulting scar. The reconstruction plate along with resorbed fibular graft was identified and removed. A pull wire was passed along inferior border of the existing ramus and the condyle was repositioned.
A new titanium reconstruction plate was contoured, adapted and fixed 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 layerwise. Double closure of the oral mucosa was done. Patient extubated, recovery spontaneous and uneventful.
The plan of reconstruction was 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.
To harvest the graft, inframammary incision was placed over the right side. Layer wise dissection was done. Periosteum was incised and the sixth and seventh rib harvested and closed layerwise. Care was taken to preserve the pleural tissues.
For better access and surgical maneuver, dental implants were placed first. 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. Due to multiple previous surgeries, the scar tissue needed to be carefully reflected so as to minimize the resulting scar. The reconstruction plate along with resorbed fibular graft was identified and removed. A pull wire was passed along inferior border of the existing ramus and the condyle was repositioned.
A new titanium reconstruction plate was contoured, adapted and fixed 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 layerwise. Double closure of the oral mucosa was done. Patient extubated, recovery spontaneous and uneventful.
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