Microsurgical mandibular reconstruction using a resin surgical guide combined with a metal reconstructive plate.

INTRODUCTION: In mandibular reconstruction, repositioning the mandibular position is still challenging and time consuming. We invented a new re-positioning technique using a resin plate combined with a reconstructive plate in reconstructing the mandible with an osteocutaneous free flap. The purpose of this report is to introduce this technique and evaluate the accuracy of mandibular reconstruction using free flaps. We hypothesized that this technique is precise and can reduce intraoperative plate bending at a low cost and short preparation period. METHODS: Mandibular reconstruction was successfully performed in a total of 10 cases without any complications. In this technique, a pre-bent reconstructive plate was prepared in accordance with a three-dimensional model, and then coated with resin. Intraoperatively, the mandibles were secured by fitting these plates snugly and fixing them using a reconstructive plate. Then the resin was removed and free osteocutaneous free flaps were transfer to the defect. Ten patients with a mean age of 68.2 who underwent mandibular resection for aggressive benign (n = 1) or malignant disease (n = 9) were reconstructed using this technique. Seven cases were reconstructed using fibular osteocutaneous free flaps, while scapular osteocutaneous free flaps were used in the remaining cases. The resections entailed: unilateral symphysis and lateral body in four cases, angle to ipsilateral angle in two, ramus to symphysis in two, and lateral body plus angle to symphysis in one case. The deviation of the mandible was evaluated by measuring the preoperative versus postoperative differences in the distances between six bilateral landmarks. RESULTS: There were no complications and flap failure in any of the 10 cases. No further intraoperative plate bending was required. One case underwent additional mucosal resection due to recurrence of cancer. Three cases were referred to postoperative chemoradiotherapy. Two patients expired during follow-up due to recurrence of cancer. Six cases were put back on a normal diet. The other cases who lacked opposing teeth had to remain on a soft diet. The mean follow-up period was 46.2 months. The average of the absolute deviation values was 1.45 mm. This value was 0.94 mm in six cases with mandibular body defects and 2.26 mm in four cases with mandibular defects involving the ramus. CONCLUSIONS: The present novel technique is simple, quick to prepare, and accurate. This technique can be a viable option for microsurgical mandibular reconstruction.

Reconstruction of the dynamic velopharyngeal function by combined radial forearm-palmaris longus tenocutaneous free flap, and superiorly based pharyngeal flap in postoncologic total palatal defect.

We attempted to reconstruct dynamic palatal function using a radial forearm-palmaris longus tenocutaneous free flap in conjunction with a pharyngeal flap for a postoncologic total-palate defect in a 67-year-old male patient. This reconstruction involved 3 important tasks, namely, separating the oral and nasal cavities, preserving the velopharyngeal space to avoid sleep apnea, and maintaining velopharyngeal closure to avoid nasal regurgitation during swallowing. In our technique, the radial forearm flap separates the oral and nasal cavities with an open rhinopharyngeal space, and a superiorly based pharyngeal flap, which is sutured to the posterior end of the forearm flap, limits the rhinopharyngeal space, and forms the bilateral velopharyngeal port. Furthermore, the palmaris longus tendon, which is attached to the forearm flap, is secured to the superior constrictor muscle to create a horizontal muscle sling. Contraction of the superior constrictor muscle leads to shrinkage of the sling, resulting in velopharyngeal closure. Swallowing therapy was started 4 weeks after the surgery. The patient could resume oral intake without any difficulties 6 months after the surgery. Speech intelligibility changed from severe to minimal hypernasality.

Soleus Muscle Necrosis Following Harvest of Fibula Free Flap: A Case Report and Retrospective Contrast CT Analysis.

Soleus muscle necrosis is a rare complication following fibula free flap harvest for mandibular reconstruction. This report presents a case of soleus necrosis without compartment syndrome or infection and reviews the blood supply of the soleus muscle in 24 patients. Variations in the vascular anatomy of the soleus muscle, particularly reliance on the peroneal artery, may predispose to this complication. Clinicians should consider soleus muscle necrosis in patients with atypical donor site pain after fibula harvest. Laryngoscope, 2024.

Useful Genioplasty for Repeated Recurrent Sleep Apnea of Congenital Anomalies and Its Evaluation.

Congenital facial anomalies with hypoplasia of the midface or lower face are associated with obstructive apnea syndrome. Although such patients underwent bone advancement surgery and their sleep apnea improved in the short term, it often recurred several years after surgery. It is difficult to perform another major osteotomy because of impairment of the facial contour or prior orthodontic treatment. Genioplasty was performed for genioglossus muscle advancement in patients with congenital anomalies and repeated sleep apnea. In this study, we evaluated the usefulness of this procedure and the mechanism for the improvement of sleep apnea. Methods: Six patients were included: three with syndromic craniosynostosis, two with Treacher-Collins syndrome, and one with micrognathia by Goldenhar syndrome. Patients who had recurrence of sleep apnea after previous maxillomandibular osteotomies, or advancement and orthodontic treatment, received genioplasty for genioglossus muscle advancement. The patients were evaluated by body mass index, simple polysomnography, hyoid bone position on cephalogram, and the airway area on computed tomography images pre- and postoperatively. Results: Polysomnography showed a significant improvement in the apnea-hypopnea index. Cephalometric measurement showed significant results of the hyoid bone position from point B and the ramus plane. However, no significant results were obtained in the airway area assessment. Conclusions: Genioplasty for genioglossus muscle advancement can improve apnea-hypopnea index by moving the hyoid bone forward. Genioplasty was useful in patients with congenital anomalies who had a recurrence of sleep apnea after several procedures.

Clinical Applications of Meshed Multilayered Anatomical Models by Low-Cost Three-Dimensional Printer.

SUMMARY: In recent years, even low-cost fused deposition modeling-type three-dimensional printers can be used to create a three-dimensional model with few errors. The authors devised a method to create a three-dimensional multilayered anatomical model at a lower cost and more easily than with established methods, by using a meshlike structure as the surface layer. Fused deposition modeling-type three-dimensional printers were used, with opaque polylactide filament for material. Using the three-dimensional data-editing software Blender (Blender Foundation, www.blender.org) and Instant Meshes (Jakob et al., https://igl.ethz.ch/projects/instant-meshes/) together, the body surface data were converted into a meshlike structure while retaining its overall shape. The meshed data were printed together with other data (nonmeshed) or printed separately. In each case, the multilayer model in which the layer of the body surface was meshed could be output without any trouble. It was possible to grasp the positional relationship between the body surface and the deep target, and it was clinically useful. The total work time for preparation and processing of three-dimensional data ranged from 1 hour to several hours, depending on the case, but the work time required for converting into a meshlike shape was about 10 minutes in all cases. The filament cost was $2 to $8. In conclusion, the authors devised a method to create a three-dimensional multilayered anatomical model to easily visualize positional relationships within the structure by converting the surface layer into a meshlike structure. This method is easy to adopt, regardless of the available facilities and economic environment, and has broad applications.

EEC-LM-ADULT syndrome caused by R319H mutation in TP63 with ectrodactyly, syndactyly, and teeth anomaly: A case report.

RATIONALE: Ectrodactyly ectodermal dysplasia-cleft lip/palate (EEC) syndrome, limb-mammary syndrome (LMS), and acro-dermato-ungual-lacrimal-tooth (ADULT) syndrome are caused by a TP63 gene disorder and have similar features. In the present article, a R319H mutation in TP63 is reported, and the correlation between genotype and phenotype is discussed based on the current case and previous literature. PATIENT CONCERNS: A 13-year-old Japanese boy had ectrodactyly in the right hand and left foot and syndactyly in the left and right foot, and tooth shape abnormalities. DIAGNOSES: Peripheral blood samples were obtained, and mutation analysis was performed. A heterozygous G>A transition at cDNA position 956 of the TP63 gene was found. The patient was diagnosed with ELA (EEC/LM/ADULT) syndrome based on his clinical features and mutation analysis results. INTERVENTIONS: The patient underwent surgery to correct the left foot malformation at 1 year of age and the right foot syndactyly at 11 years of age. OUTCOMES: No complications were observed after the first and second operations. He can walk comfortably after them, and no additional interventions will be planned in him. We continued to follow up with him up to the present. LESSONS: The concept of ELA syndrome, which is the original concept of combining 3 syndromes (EEC syndrome/LMS/ADULT syndrome) into a unique clinical entity, can help clinicians to better understand TP63-related syndromes and improve the differential diagnosis of these syndromes.

17-year Follow-up after Mandibular Distraction Performed in an Infant with Robin Sequence.

Robin sequence is a congenital anomaly, first described by Pierre Robin as a triad of micrognathia, upper airway obstruction and glossoptosis. The most significant airway management technique is the use of distraction osteogenesis to advance the mandible. On the other hand, late complications such as permanent dentition loss and malformation of the damaged teeth have been reported. Therefore, long-term follow-up after mandibular distraction is important. In our case report, we describe 17 years of follow-up after mandibular distraction performed in a 4-month-old male infant with Robin sequence. The patient was a male with a cleft palate. The tracheotomy and tongue-lip adhesion was performed 1 month after birth, because the percutaneous oxygen saturation decreased to 70% during feeding and crying. However, postoperative X-ray examination revealed that he could not obtain sufficient airway after the operation. For the purpose of closing the tracheotomy early, we performed bilateral mandibular distraction at the age of 4 months. The bilateral corticotomy was performed on the mandibular body and an internal traction device was placed. The mandible was bilaterally lengthened by 17.5 mm, and expansion of the airway was confirmed by X-ray. A cleft palate operation was performed at the age of 17 months. At the age of 3 years, the tracheostomy orifice closed and speech/language training and orthodontics were begun. Dental panoramic radiographs showed favorable mandibular growth. No additional operation has been performed. Finally, his orthodontic treatment was completed without any complications at age 17.

Rejection of intradermally injected syngeneic tumor cells from mice by specific elimination of tumor-associated macrophages with liposome-encapsulated dichloromethylene diphosphonate, followed by induction of CD11b(+)/CCR3(-)/Gr-1(-) cells cytotoxic against the tumor cells.

Tumor cell expansion relies on nutrient supply, and oxygen limitation is central in controlling neovascularization and tumor spread. Monocytes infiltrate into tumors from the circulation along defined chemotactic gradients, differentiate into tumor-associated macrophages (TAMs), and then accumulate in the hypoxic areas. Elevated TAM density in some regions or overall TAM numbers are correlated with increased tumor angiogenesis and a reduced host survival in the case of various types of tumors. To evaluate the role of TAMs in tumor growth, we here specifically eliminated TAMs by in vivo application of dichloromethylene diphosphonate (DMDP)-containing liposomes to mice bearing various types of tumors (e.g., B16 melanoma, KLN205 squamous cell carcinoma, and 3LL Lewis lung cancer), all of which grew in the dermis of syngeneic mouse skin. When DMDP-liposomes were injected into four spots to surround the tumor on day 0 or 5 after tumor injection and every third day thereafter, both the induction of TAMs and the tumor growth were suppressed in a dose-dependent and injection number-dependent manner; and unexpectedly, the tumor cells were rejected by 12 injections of three times-diluted DMDP-liposomes. The absence of TAMs in turn induced the invasion of inflammatory cells into or around the tumors; and the major population of effector cells cytotoxic against the target tumor cells were CD11b(+) monocytic macrophages, but not CCR3(+) eosinophils or Gr-1(+) neutrophils. These results indicate that both the absence of TAMs and invasion of CD11b(+) monocytic macrophages resulted in the tumor rejection.

Application of cultured dermal substitute for amelioration of maxillary bone growth suppression after cleft palate operation in rats.

The growth and development of maxillary bone and dentition is often impaired in patients who have undergone the cleft palate operation (push back method). Wound contraction exerts adverse effects on maxillary bone growth. The present study investigates the ability of cultured dermal substitute (CDS) to ameliorate maxillary bone growth suppression in experimental animals. We prepared CDS by incorporating rat fibroblasts into a matrix comprising a spongy hyaluronic acid (HA) sheet combined with collagen gel. The number of fibroblasts in the CDS was adjusted to 1.0 x 10(5) cells/cm(2). Wistar rats were randomly assigned to one of the following groups: I, control (no operation); II, surgically exposed bone without matrix or CDS; III, surgery with matrix; IV, surgery with CDS. Under pentobarbital anesthesia, about 2 x 4 mm of the mucosa and periosteum was surgically removed from the left half of the palate. A silicone sheet was placed on the matrix or CDS and affixed with superglue. The palatal width was measured 9 weeks later in skull preparations as the distance between the cheek side cusps of the second molar. The palates in group IV were significantly wider than those in groups II and III, and did not significantly differ from that in the control group. These findings indicated that CDS has the ability to promote wound healing and reduce scar formation through the synergic effects of fibroblasts and the matrix, and thereby to ameliorate indirectly the growth of maxillary bone.

Functional Temporomandibular Joint Reconstruction in Costochondral Grafting of Micrognathia.

Rib bone and costochondral complex grafting has been used to treat micrognathia classified as Pruzansky type III. To acquire more physiological joint movement, we reconstructed a temporomandibular joint with the glenoid fossa in addition to the mandibular ramus. The patient underwent a tracheostomy to correct her airway obstruction at 2 months of age. After that, no further surgical treatments were performed on the micrognathia. When she was 6 years of age and during consultation at our department, micrognathia caused by Goldenhar syndrome was confirmed. A head and neck computed tomography scan showed hypoplasia and deficit of the mandible, severe glossoptosis and airway constriction. Initially, a bilateral mandibular body distraction was performed at 6 years of age, and 15 mm of elongation was obtained. Subsequently, reconstruction of the right ramus and right temporomandibular joint fossa was performed at 8 years of age to achieve extubation. Part of her sixth rib and costochondral complex graft was used for the ramus, and costochondral graft was used for the joint fossa. Some new ideas for temporomandibular joint reconstruction were added. Postoperatively, the open mouth range was increased and improvement of the airway space narrowing was observed in a computed tomography scan. The main points of this new method are prevention of ankylosis, skull cortex thinning, and reconstructed ramus' dislocation. This method may become an effective new treatment for cases of micrognathia with a ramus classified as Pruzansky type III.

Three-Dimensional Computer-Assisted Two-Layer Elastic Models of the Face.

To make three-dimensional computer-assisted elastic models for the face, we decided on five requirements: (1) an elastic texture like skin and subcutaneous tissue; (2) the ability to take pen marking for incisions; (3) the ability to be cut with a surgical knife; (4) the ability to keep stitches in place for a long time; and (5) a layered structure. After testing many elastic solvents, we have made realistic three-dimensional computer-assisted two-layer elastic models of the face and cleft lip from the computed tomographic and magnetic resonance imaging stereolithographic data. The surface layer is made of polyurethane and the inner layer is silicone. Using this elastic model, we taught residents and young doctors how to make several typical local flaps and to perform cheiloplasty. They could experience realistic simulated surgery and understand three-dimensional movement of the flaps.

Intermediate Phenotype between ADULT Syndrome and EEC Syndrome Caused by R243Q Mutation in TP63.

A patient who had ectrodactyly, dry skin, exfoliative dermatitis, and hypodontia with peg-shaped teeth, but not cleft lip and palate, is described. Ectrodactyly with a tooth anomaly is recognized in both acro-dermato-ungual-lacrimal-tooth (ADULT) syndrome and ectrodactyly-ectodermal dysplasia-cleft (EEC) syndrome. These 2 syndromes are caused by heterozygous mutations in the transcriptional factor gene p63. Mutation analysis of p63 gene showed a heterozygous mutation c.728G>A, p.Arg243Gln (previously referred to as R204Q) in the patient, but not in his parents. Therefore, this was a sporadic case of the p63 mutation-associated disorder. Although the mutation has been mostly reported in EEC syndrome patients, the present case did not have cleft lip and palate. Furthermore, the present case did not exhibit freckling or some of the other ectodermal dysplasia phenotypes typical of ADULT syndrome. The concept of ELA syndrome proposed by Prontera in 2011 resolves the problem confronted in diagnosing the present case. ELA syndrome is an acronym of EEC/limb-mammary syndrome/ADULT syndromes, and these 3 syndromes are united into a unique entity. This system can classify p63 mutation-associated disorders simply without interfering with treatment.