Remodeling of costochondral graft after mandibular reconstruction

Accepted Manuscript Remodeling of costochondral graft after mandibular reconstruction Prof. Loreto Castellon., DDS, Mfs,OMS, Daniel Jerez, DDS, Oral and Maxillofacial Surgeon (OMS), Jaime Mayorga, DDS, Oral and Maxillofacial Surgeon (OMS), Carlos Fuenzalida, DDS, Oral and Maxillofacial Surgeon (OMS) PII: S0278-2391(16)30819-9 DOI: 10.1016/j.joms.2016.09.012 Reference: YJOMS 57447 To appear in: Journal of Oral and Maxillofacial Surgery Received Date: 21 October 2015 Revised Date: 8 September 2016 Accepted Date: 8 September 2016 Please cite this article as: Castellon. L, Jerez D, Mayorga J, Fuenzalida C, Remodeling of costochondral graft after mandibular reconstruction, Journal of Oral and Maxillofacial Surgery (2016), doi: 10.1016/ j.joms.2016.09.012. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. ACCEPTED MANUSCRIPT AC C EP TE D M AN US C RI PT Remodeling of costochondral graft after mandibular reconstruction. Prof. Loreto Castellon. DDS, Mfs, OMS* Head of Oral and Maxillofacial Surgery Unit Hospital Luis Calvo Mackenna, Santiago, Chile. Oral and Maxillofacial Surgery surgeon, Hospital Exequiel Gonzalez Cortes, Santiago, Chile. Program director of Oral and Maxillofacial Surgery, Universidad Mayor, Santiago Chile Professor oral surgery, School of Dentistry, Universidad Mayor, Santiago, Chile. Daniel Jerez, DDS, Oral and Maxillofacial Surgeon (OMS) Clinical Assistant of oral surgery, School of Dentistry, Universidad Mayor, Santiago, Chile Jaime Mayorga, DDS, Oral and Maxillofacial Surgeon (OMS) Clinical Assistant of oral surgery, School of Dentistry, Universidad Mayor, Santiago, Chile Hospital Militar, Santiago, Chile. Hospital Luis Calvo Mackenna Carlos Fuenzalida, DDS, Oral and Maxillofacial Surgeon (OMS) Clinical Assistant of oral surgery, School of Dentistry, Universidad Mayor, Santiago, Chile Hospital Exequiel Gonzalez Cortes, Santiago, Chile Hospital Luis Calvo Mackenna, Santiago, Chile *Corresponding author Kenedy 7120, dpto. 405, Vitacura, Santiago, Chile. 7650618 +562-23716232. castellonz@gmail.com ACCEPTED MANUSCRIPT Remodeling of costochondral graft after mandibular reconstruction RI PT Introduction Mandibular tumors are rare in children 1. The majority of the mandibular tumors in children are benign 2 , and locally aggressive and, some may require resection to M AN US C prevent recurrence 1. Staged reconstruction allows proper restoration of function and form. Mandibular reconstruction after tumor resection in children is less well documented in the literature than in adults There are some reconstruction protocols described in the literature with both free flaps and non-vascularized bone grafts.3 In adults, the length of the defect has been used a parameter for selection of reconstruction method. 3 Vascularized D grafts have been recommended in adults for reconstruction of defects greater than TE 6-7 cm3, However in children, age, growth potential of the mandible and the donor site are additional factors that must be considered. EP Troulis et al reported a staged protocol for mandibular reconstruction in pediatrics; the first stage involves a reconstruction with an osteosynthesis plate and the AC C second stage is comprised of bone reconstruction with non vascularized grafts. This staged protocol has shown good results, with low rates of complications and short recovery time.1 The objective of this case report is to demonstrate the potential for regeneration of the mandibular condyle in a young patient after mandibular tumor resection and reconstruction with a costochondral graft (CCG) Case Report 1 ACCEPTED MANUSCRIPT A two and half year old girl was seen at the OMS unit in Hospital Luis Calvo Mackenna for evaluation of a left mandibular swelling which evolved over a 7month period. A computed tomography (CT) scan revealed a left mandibular RI PT swelling with significant expansion and osteolysis involving the left condyle, ramus and body. ( Fig. 1 and 2 ). The incisional biopsy performed at an outside hospital indicated the mandibular swelling was a desmoplastic fibroma. M AN US C In order to plan the mandibular reconstruction after resection of the benign tumor, a stereolithographic model was requested. Different alternatives were evaluated by a multidisciplinary team. The proposed treatment was to resect the tumor and an immediate reconstruction of the defect with a non-vascularized CCG fixed with a reconstruction osteosynthesis plate. The alternative option for reconstruction with a vascularized free fibula flap was ruled out because of the patient's age. D A transcervical approach was used to access and resect the tumor extending TE from left parasymphysis and including the ipsilateral condyle. The dissection for resection was subperiosteal and the periosteum was maintained intact. The defect EP was reconstructed immediately using a CCG fixed with a 2.0 reconstruction osteosynthesis plate. A 3mm cartilage cap was maintained on the CCG. There AC C were no complications during surgery and the resected specimen was submitted for histo-pathological examination. The results analyzed by our service and a second opinion from St. Jude Children’s Research Hospital confirmed the final diagnosis of aneurysmal bone cyst. (Figure 3). A postoperative CT scan obtained 10 days after the resection showed adequate reconstruction of the defect with the CCG (Figure 4). A follow up CT scan 8 months after the initial reconstruction, revealed formation of a neo condyle and coronoid 2 ACCEPTED MANUSCRIPT process (Figure 5, 6A and 6B). At 14 months post surgery, the patient was asymptomatic with good facial symmetry, stable occlusion and normal mandibular function (Figure 7 and 8) . At present, the patient is being periodically followed to RI PT monitor resected site for recurrence and to assess facial growth. M AN US C Discussion This case report on reconstruction of the mandible in a pediatric patient highlights the tremendous osteogenic potential and the importance of the soft tissue functional matrix in restoring form and function. Growth of the mandible exhibits both endochondral and intramembranous ossification. Mandibular condylar cartilage is ontogenetically designed as secondary cartilage and it differs from D primary cartilage in many ways- Condylar cartilage is heterogenous and it contains TE fibroblast, osteochondral progenitor cells and chondrocytes 4. The size of the mandible and its units, as well as the timing and amount of condylar growth, vary EP considerably between individuals5. Factors potentially contributing to this individual variation are the extent of masticatory action and genetic predisposition 5. AC C In order to reconstruct the mandible in pediatric patients, the use of CCG has been widely used.1,6,7 , especially for the ramus condyle unit 1,6,7,8, . Gillies in 1920 was the first to describe the use of this type of graft to perform a temporomandibular joint (TMJ) reconstruction7. Poswillo was the first surgeon to establish the physiologic compatibility of CCG for TMJ reconstruction9. Other non-vascularized grafts such as, metatarsal head, and sternoclavicular joint have been describes in the literature. The CCG has been proven to have higher clinical and functional 3 ACCEPTED MANUSCRIPT performance7,10. The CCG is adaptable to the TMJ not only because of its native size and dimensions but also because of its hyaline cartilaginous cap (as opposed to fibrocartilage). In addition, the biomechanical stresses of the TMJ can act as a RI PT new growth center 11. There are advantages to using the CCG for reconstruction of the condyle due to its biological and anatomic similarity to the TMJ and its regenerative and growth potential 11,12 . However, the amount of growth and the 11,12 . Medra reported 85 M AN US C potential for ankylosis can be an unpredictable factor cases of CCG, where excessive growth of the grafts was seen in three patients, 8 patients developed an ankylosis of the TMJ (9%) and resorption was noted in 21 grafts (25%) 13 . 10 cases showed partial resorption and complete reabsorption was observed in 11 patients 13 . Peltomaki et al in experimental studies showed that “growth” of the CCG is related to the size of the cartilage cap on the graft 14,15. In a D case series of 26 patients treated with 33 CCG, Perrot et al reported no excessive 16 . Using clinical parameters evaluated one TE growth in any of the patients treated year post surgery they concluded that CCG can be used to reconstruct in a safe EP and successful way to reconstruct TMJ defects, and recommended leaving no more than 3 mm of cartilage on the CCG 16. Troulis et al reported 15 consecutive AC C patients treated with CCG after condylectomy used to treat idiopathic condylar resorption 8. Their recommendation is to leave no more than 2 mm of cartilage on the head of the graft 8. No over growth was seen in their patients 8 We report a complete restoration of the normal shape of the condyle and the coronoid process after a complete resection and reconstruction using a CCG. In evaluating the regeneration of the mandible condyle we must take into account the surgical technique, method of reconstruction and the post surgical function of the 4 ACCEPTED MANUSCRIPT mandible after reconstruction. The regeneration of the mandibular condyle and coronoid process is likely due to the intact periosteum and presence of residual mesenchymal stem cells and the influence of the functional soft tissue matrix as RI PT described by Moss. The functional matrix theory was proposed by Moss in 1962 17. This theory states that bone and cartilage, grow as a compensatory response to the normal growth of soft tissue. Moss entitled them as functional matrices, where M AN US C each matrix has an specific task. According to Moss, bones do not have the genetic information to determine direction and rhythm of growth; therefore, growth pattern is defined by surrounding soft tissue17. The re-attachment of muscles and periosteum regenerative capacity, that is higher in pediatric patients, could explain this particular remodeling of the CCG in our patient. Also, one must consider the diagnosis of this patient. Aneurysmal bone cyst is a benign locally aggressive D bone tumor that occurs in the jaw bones. Biological behavior allows clean TE resections and the possibility of preserving adjacent soft tissue intact, including the periosteum. EP The fibula free flap is the gold standard graft for mandibular reconstruction in defects over 6 cm in adults AC C patients over 10 months 3 18 . In children, it has been reported safe to use in , and success rates are comparable to adults 19 . However, the experience of the surgeons and medical team, the age of the patient, the diagnosis, the size of the defect, the mandibular unit affected are important factors to be consider. This case report exhibits the advantages of the CCG and the high success rates of non-vascularized grafts in pediatric patients as previously reported in literature. It shows the importance of maintaining the integrity of the periosteum whenever 5 ACCEPTED MANUSCRIPT feasible and the reposition of soft tissues, as long as the biological behavior of the tumor allows it. It highlights the importance of the regenerative and remodeling potential of the skeletal tissues in pediatric patients. Also this case demonstrates RI PT as previously documented in the literature, good consolidation and integration of the CCG with the native mandible. In addition, by using this type of graft there is the possibility of using a fibula graft as a second reconstructive procedure, if it is M AN US C necessary. Acknowledge To Dr. Hugo Herrera and Dr. Carlos Bahamondes, residents in OMS, for their help in collecting data for this case report and to the pathologist service of Hospital Luis D Calvo Mackenna for providing us the histologic images of this case. TE REFERENCE (1) Troulis MJ, Williams WB, Kaban LB: Staged protocol for resection, skeletal EP reconstruction and oral rehabilitation of children with jaw tumors. J Oral Maxillofac Surg 62:335, 2004 AC C (2) Sato M, Tanaka N, Sato T, Amagasa T. Oral and maxillofacial tumours in children: a review. Br J Oral Maxillofac Surg. 35:92, 1997 (3) Guo L, Ferraro NF, Padwa BL, Kaban LB, Upton J: Vascularized fibular graft for mandibular reconstruction in pediatric patients. Plast reconstr Surg 121:205, 2008 (4) Mizoguchi I, Toriya N, Nakao Y: Growth of the mandible and biological 6 ACCEPTED MANUSCRIPT characteristics of the mandibular condylar cartilage. Japap Dental Science review. 49:149, 2013 the condylar cartilage. Europ J of Orthodontics 31:1, 2009 RI PT (5) Pirttiniemi P, Peltomaki T, Muller L, Luder H: Abnormal mandibular growth and (6) Tasanen A, Leikomma H: Ankylosis of the TMJ of a child. Int J Oral Surg. 6:95, 1977 M AN US C (7) Kumar, Ratta, Rai: Do costochondral grafts have any growth potential in temporomandibular joint surgery? A Systematic Review. Journal of oral biology and craniofacial research. 5:198, 2015 (8) Troulis M, Tayebaty F, Papadaki M, Bradford W, Kaban L: Condylectomy and costochondral graft reconstruction for treatment of active idiopathic condylar resorption. J Oral Maxillofac Surg 66:65, 2008 D (9) Poswillo D: Experimental reconstruction of the mandibular joint. Int J Oral Surg. TE 3:400, 1974 (10) Robert Bruce Macintosh. The use of autogenous tissues for EP Temporomandibular Joint reconstruction. J Oral Maxillofac Surg 58:63~9, 2000 (11) Fernandes R, Fattahi T, Steinberg B: Costochondral rib grafts in mandibular AC C reconstruction. Atlas Oral Maxillofac Surg. 14:179, 2006 (12) Ko EW, Huans CS, Chen YR: Temporomandibular joint reconstruction in children using costochondral grafts. J Oral Maxillofac Surg. 57:789, 1999 (13) Medra AM: Follow up of mandibular costochondral grafts after release of ankylosis of the temporomandibular joints. Br J Oral Maxillofac Surg. 43:118, 2005 (14) Peltomaki T, Ronning O: Interrelationship between size and tissue-separating 7 ACCEPTED MANUSCRIPT potential of costochondral transplants. Eur J Orthod 13:459, 1991 (15) Peltomaki T: Growth of a costochondral graft in the rat temporomandibular joint. J Oral Maxillofac Surg 50:851, 1992. RI PT (16) Perrott DH, Umeda H, Kaban LB: Costochondral graft reconstruction of the ramus/condyle unit: long-term follow-up. Int. J. Oral Maxillofac. Surg. 23:321, 1994 M AN US C (17) Moss, ML: The primary role of functional matrices in facial growth. Am J. Orthod. 55:566, 1989 (18) Zhang, C.; Sun, J.; Zhu, H.; Xu, L.; Ji, T.; He, Y.; Yang, W.; Hu, Y.; Yang, X.; Zhang, Z: Microsurgical free flap reconstructions of the head and neck region: Sahngai experience of 34 years and 4640 flaps. Int J Oral Maxillofac Surg. 44: 675, 2015 D (19) Upton, J.; Guo, L: Pediatric Free Tissue Transfer: A 29-Year Experience with EP TE 433 Transfers. Plast Reconstr Surg. 121: 1725, 2008. AC C Figure 1: Axial view of computed tomography showing the osteolytic lesion of condyle, ramus and left body of the mandible. Figure 2: 3D reconstruction of computed tomography showing the osteolytic lesion of the condyle, ramus and left body of the mandible. Figure 3: a: Partially fasciculated fibrous tissue with multinucleated giant cells, foci 8 ACCEPTED MANUSCRIPT of osteoid in relation to uncoated cavity with blood content. b: Multiple cystic cavities with hemorrhagic content with edematous connective tissue walls. c: Unlined cystic cavity with blood content and reactive bone tissue with bone cell stroma with multinucleated giant cells. RI PT trabeculae. d: Coated cystic cavities, serous and hemorrhagic content with spindle M AN US C Figure 4: 3D reconstruction of the 10 days computed tomography control. It shows the position of the graft. Figure 5: 3D reconstruction of the CT scan 8 months after the initial reconstruction, revealed formation of a neo condyle and coronoid process. D Figure 6A: Coronal view computed tomography control. It revealed formation of a TE neo condyle, which resembles the anatomy of the mandibular units. EP Figure 6B: Sagittal view computed tomography control. It revealed formation of a neo condyle and coronoid process, which resembles the anatomy of the AC C mandibular units Figure 7: Frontal clinical photo of the patient 14 month post surgery. It shows the simetry that was able to keep with this type of treatment. Figure 8: Oral views 14 month post surgery showing the oclussal relationtship 9 AC C EP TE D M AN US C RI PT ACCEPTED MANUSCRIPT AC C EP TE D M AN US C RI PT ACCEPTED MANUSCRIPT AC C EP TE D M AN US C RI PT ACCEPTED MANUSCRIPT AC C EP TE D M AN US C RI PT ACCEPTED MANUSCRIPT AC C EP TE D M AN US C RI PT ACCEPTED MANUSCRIPT AC C EP TE D M AN US C RI PT ACCEPTED MANUSCRIPT AC C EP TE D M AN US C RI PT ACCEPTED MANUSCRIPT AC C EP TE D M AN US C RI PT ACCEPTED MANUSCRIPT AC C EP TE D M AN US C RI PT ACCEPTED MANUSCRIPT AC C EP TE D M AN US C RI PT ACCEPTED MANUSCRIPT AC C EP TE D M AN US C RI PT ACCEPTED MANUSCRIPT AC C EP TE D M AN US C RI PT ACCEPTED MANUSCRIPT