Hemangioma of the mandible in a 12-year-old boy

@#Intraosseous hemangioma is a benign, rare neoplasm that accounts to 0.5 - 1% of all benign tumors of bones.1, 2 While most hemangiomas arise from soft tissues, it is uncommon for it to arise from bones.2 The most common sites of growth are in the vertebral body and the calvarium with frontal bone making up approximately 45% of calvarial cases.2,3 However, they are also encountered in the head and neck with sites such as the skull (53%), mandible (10.7%), nasal bones (9%), and cervical spine (6%).4 In the mandible, the body is mostly affected and 65% are found in the molar and premolar region.1 They are more common in adult females with peaks at the second and fifth decades of life.1-3 Hemangioma of the mandible is difficult to diagnose due to its nonspecific clinical presentation and radiographic features. It mimics various mass lesions in the mandible such as giant cell granuloma, fibrous dysplasia, multiple myeloma, osteosarcoma, ameloblastoma and keratocysts. Therefore, a comprehensive history taking and physical examination plus examination of the imaging studies available and tissue biopsy all play important roles in arriving at the final diagnosis.5 We present the case of an aggressive mandibular hemangioma in a young boy and our management involving a failed fibular free flap reconstruction.

Thoracic limb salvage by fibular free flap

The treatment of most fractures of the ulna and radius is usually performed by anatomical reduction and internal fixation, when damage is extensive and local soft tissue cannot provide a complete wound coverage, locoregional flaps present a suitable reconstructive benefit. A 35-year-old male patient suffered an exposed diaphysio-metaphyseal fracture with multi-fragmented distal radius. The patient was evaluated during a 10-day period at the National Institute of Rehabilitation, where the osteosynthesis material and a severe infectious process with necrosis were identified. Necrosectomy of the posterior compartment and removal of the osteosynthesis material was performed, a skin defect of approximately 22x16 cm was observed with a bone gap of 6 cm of radius and ulna. a fibula-free flap is placed to correct the skin defect and an external fixative used for bone alignment. The fibular free flap presents an excellent therapeutic alternative in the resolution of bone gaps with extensive skin defect. Whenever a trained microsurgery team is available, current scales of limb injury should be considered but not utilized for therapeutic approach, always trying to shift amputation as the first option, to the very last one of them.

Condyle dislocation following mandibular reconstruction using a fibula free flap: complication cases / 대한악안면성형재건외과학회지

BACKGROUND: Condylar dislocation can arise as a complication in patients who required mandibular and/or condylar reconstruction and were operated on with fibula free flap (FFF) using surgical guides designed using simulation surgery. Surgeons should be aware of the complications in these present cases when planning and performing reconstructions as well as predicting prognoses. CASES PRESENTATION: Two cases showed condylar dislocation in mandibular reconstruction using a FFF fixed with a reconstruction plate. Three cases showed condylar dislocation in mandibular reconstruction using a fibula free flap fixed with a mini-plate. CONCLUSION: Despite the lack of clinical symptoms in these cases following mandibular reconstruction using an FFF, the mandibular condyle was severely displaced away from the glenoid fossa. A surgeon must have sufficient time to consider the use of a long flap with thickness similar to that of the mandible, ways to minimize span and bending, and methods of fixation. The patient, moreover, should be educated on condylar dislocation. Customized CAD/CAM-prototyped temporomandibular condyle-connected plates may be a good alternative even if virtual simulation surgery is to be performed before surgery. These considerations may help reduce the incidence of complications after mandibular reconstruction.

Reconstrução de mandíbula com retalho livre da fíbula em um caso de ameloblastoma / Mandibule reconstruction with free fibula flap in an ameloblastoma case

Objetivo: Relatar um caso de ameloblastoma na mandíbula, do tipo histológico plexiforme, com remoção completa da lesão e reconstrução com enxerto livre da fíbula. Materiais e métodos: Paciente do sexo feminino, 19 anos de idade, ASA I, atendida na Clínica Odontológica da Faculdade de Estudos Administrativos (FEAD), em Belo Horizonte, queixando-se de inchaço e incômodo na mandíbula do lado direito. O diagnóstico foi dado por exames clínicos e radiográficos e confirmado pelo exame anatomopatológico, que indicou ameloblastoma do tipo histológico plexiforme. O tratamento foi a hemimandibulectomia por meio do acesso submandibular do lado direito e reconstrução da área removida com enxerto livre da fíbula da paciente. Resultados: Remoção total da lesão com margem de segurança, reconstrução mandibular com placa óssea removida da fíbula. No pós-operatório foi realizada a laserterapia para melhor cicatrização e encaminhamento para tratamento fonoaudiólogico para ajudar na fonética e recuperação da função muscular, devido à excisão do nervo alveolar inferior, que teve como consequência uma parestesia definitiva comprometendo a fonética e a função. A paciente encontra-se há 2 anos sem sinais de reaparecimento do tumor e ausência de alterações funcionais. Conclusão: O tratamento adequado para este tipo de lesão neoplásica é controverso e sua indicação deve ser individualizada. A ressecção marginal é o tratamento mais seguro por remover completamente a lesão, determinar a cura por longo prazo e favorecer menor taxa de recorrência. A reconstrução mandibular com fíbula é considerada padrão-ouro por apresentar benefícios trans e pós-operatórios, levando-se em consideração riscos, benefícios e impacto na qualidade de vida do paciente.

Objective: to present a case of mandible ameloblastoma, plexiform histologic type, with complete removal of the lesion and reconstruction with free fibula graft. Materials and Methods: A 19-year-old female patient, ASA I, attended at the Dental Clinic of FEAD, in Belo Horizonte, complaining of swelling and discomfort in the right side of the jaw. The diagnosis was given by clinical and radiographic exams and confirmed by anatomopathological examination, which indicated ameloblastoma of plexiform histologic type. The treatment was hemimandibulectomy through right submandibular access and reconstruction of the area removed with free graft of the patient's fibula. Results: Total removal of the lesion with safety margin, mandibular reconstruction with bone plate removed from the fibula. No postoperative was performed to laser therapy for better healing and referral for speech therapy, to aid in the recovery of muscle function due to excision of the inferior alveolar nerve, which resulted in a definite paraesthesia compromising a phonetics and a function. The patient has been found for 1 year and 7 months with no signs of tumor recurrence and no employee. Conclusion: The adequate treatment for this type of neoplastic lesion is controversial and its indication must be individualized. Marginal resection is the safest treatment by completely removing the lesion, determining the long-term cure, and preferring lower recurrence rates. The mandibular reconstruction with fibula is standard gold-gold for presenting trans and postoperative benefits, leading to risks, impacts and impact on the quality of life of the patient.

Anatomical Review of Fibular Composite Free Flap for Oral and Maxillofacial Reconstruction

Treatment of Chronic Osteomyelitis of Femur and Reconstruction with Fibular Osteocutaneous Free Flap

PURPOSE: Incidence of chronic osteomyelitis in femur is lower than that of tibia due to abundantsurrounding soft tissue like muscles and subcutaneous fat. However, if the femur is infected, surgical approach would be very difficult because of surrounding soft tissue and bony defects would be getting larger due to the late detection. Chronic osteomyelitis of femur is an intractable disease with frequent recurrence and remained bone instability in spite of multiple classical operations . METHODS: From August 1998 to October 2005, we had 7 cases of fibular osteocutaneous free flap to reconstruct the femur. Those were followed-up for 23 months. All 7 cases were male. 4 cases were in midshaft and the others are distal part of femur. RESULTS: The 7 cases that had not been healed in spite of average 9.1 times previous operations were reconstructed successfully without the recurrence of chronic osteomyelitis. Continuous rehabilitation therapy and brace were very helpful for the ambulation. It took 5.6 months for complete union of bone, and 9.8 months for the ambulation. CONCLUSION: After wide resection, reconstruction of the femur using fibular osteocutaneous free flap guaranteed bone stability and prevented recurrence of osteomyelitis through rich blood supplying fibula and muscle. Double barrel graft of fibula would be needed in case of the sufficient strength and thickness of femur. We report the successful results of reconstruction of femur with fibular osteocutaneous free flap for chronic osteomyelitis of femur.

Condylar autograft with fibular free flap for mandibular reconstruction

DESIGN: Surgical Innovation SETTING: Academic Tertiary Hospital OBJECTIVE: The objective of the study was to describe an alternative technique using a condylar autograft in conjunction with a fibular free flap in mandibular reconstruction and to prospectively assess the functional outcome in terms of inter-incisal distance, lateral excursion, maximum protrusion, occlusion, type of diet, speech and mandibular contour. METHODOLOGY: All patients who underwent segmental mandibulectomy with fibular free flap reconstruction done by one microvascular team from 1997 to 2004 were reviewed. From a total of 38 patients who underwent fibular free flap reconstruction, 7 patients who had condylar disarticulation, rigid fixation using miniplates to the fibula then replacement into the glenoid fossa were identified but 2 patients were excluded due to poor follow-up. Functional outcomes in terms of inter-incisal distance, lateral excursion, maximum protrusion, occlusion, type of diet, speech and mandibular contour were assessed post-operatively. Presence of tumor recurrence was also noted. RESULTS: Five patients were included in the study. The inter-incisal distance was noted to be 31 mm (+/- 12.5) with maximum protrusion of 1.4 mm (+/- 0.9). For those with right hemimandibulectomy (n=2), the right lateral excursion was 2.34mm (+/- 3.3) and left lateral excursion was 1.66mm (+/- 2.35). For those with left hemimandibulectomy (n=3), the right lateral excursion was 8.17m (+/- 2.25) and left lateral excursion was 3 mm (+/- 2.65). Four out of 5 patients had normal diet with excellent intelligible speech. The same 4 patients had good mandibular contour with a Class I occlusion as assessed by a dentist. The only patient with fair outcome had a mucoepidermoid carcinoma of the floor of the mouth with extensive soft tissue reconstruction aside from the bony reconstruction. No patient had tumor recurrence. CONCLUSION: The use of condylar autograft in conjunction with fibular free flaps holds promise as a way to restore temporomandibular function in mandibular reconstruction. (Author)

The treatment of reconstructing long bone defects as a result of longterm postoperative infections following fractures in the childhood / 解放军医学杂志

Objective To probe the pathogenesis of long bone defects and damage to epiphysis as the result of postoperative infections following fractures in the childhood of patients, and to look for ideal ways to prevent and repair the defects and damages. Methods The treatment of the infected bone defect of a tibia had been continued for one year following fracture in one four-year old patient, and the treatment of the infected bone defect of a humerus had been continued for ten years following fracture in another seven-year old patient, but all the treatments had failed. The injured limbs developed bone infection, bone defect, bone exposure, shortening, and pseudoarthrosis deformities at last. Then the lesions were completely cleaned, and the deformities of the infected bones were corrected in one stage, with reconstruction of the bone and the repair of the wounds by transplantations of fibular free flaps. Results Both fibular free flaps survived in one stage transplantation. The bones of the injured limbs healed half a year after the operations, and weight-bearing and walking functions of the injured limbs recovered as well. Conclusion Transplantation of fibular free flap was an ideal way to treat a long bone defect as a result of postoperative infection following fracture in the childhood. The early appropriate treatment of postoperative infection following fracture is very important to avoid bone and epiphysis damages.