Sunday, October 10, 2004

Segmental Resection And Free Fibula Flap Reconstruction For The Definitive Treatment Of Mandibular Fibrous Dysplasia

Serhan Tuncer, MD, Suhan Ayhan, MD, Kemal Fındıkcıoglu, MD, and Yakup Sarıguney, MD.

Fibrous dysplasia is a benign, proliferative disease of the bone, frequently affecting the craniofacial skeleton, especially maxilla and calvarium. Mandible is an uncommon site of involvement. Although aggressive treatment modalities are recommended in orbitozygomatic region, most of the authors have an agreement on conservative approach for the monostotic fibrous dysplasia of the mandible. Lacking of the detailed data in the literature about mandibular fibrous dysplasia causes controversy on the treatment preference. The aim of this paper is to support the idea that radical excision and free fibula reconstruction is a definitive one stage procedure, not an aggressive approach. Here we report a 26-year-old woman who is a dentist, presented with a painless unilateral swelling on her right mandibular region which caused significant asymmetry. Mandibular bony mass was detected on the right corpus with the help of computerized tomography and panorex (figure 1). Finally definitive diagnosis was obtained by tissue sampling and histopathological examination.  

Segmental excision of the corpus which was 6 cm long and immediate microvascular reconstruction with free fibula flap was performed (figure 2, left). Facial artery and accompanying vein were used as recipient vessels. Fibular bone segment was fixed to the mandible with a reconstruction plate (figure 2, central, right). Patient was hospitalized for 5 days and no postoperative complications such as infection and hematoma were seen. Vascularization of the reconstructed segment was confirmed with the sintigraphic examination on the postoperative seventh day (figure 3, right). The occlusion and symmetry were quite well at the post-operative second month (figure 3, left). She was satisfied with the result.

Conservative surgeries such as curettage and shaving have limited success rates because of the proliferative nature of the disease. Besides, occlusal defect is a frequently seen problem which necessitates secondary procedures. Reshaping and autoclavising the dysplastic bone is another alternative that has been preferred especially for the cranial region. But this unviable bone has some disadvantages such as high infection rates, partial bone resorption, contour defects and long healing period. On the other hand, weak bony architecture of the autoclavised segment may not provide an appropriate site for the future dental implantation. Radical excision and immediate free fibula flap reconstruction which seems to be the definitive approach, avoids complications and repetitive surgeries by transporting a vascularized tissue to the recipient site. Developments in microsurgery and dental prostheses make the technique superior to the conventional methods for the treatment of monostotic mandibular fibrous dysplasia.



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