Hrychaniuk D.A., Ladutko D.Yu., Pekar A.V., Liashchynski A.N. Fibular reconstruction of mandible with fibrous dysplasia. Head and neck. Russian Journal. 2023;11(2):44–51 The authors are responsible for the originality of the data presented and the possibility of publishing illustrative material – tables, drawings, photographs of patients.
Fibrous dysplasia is a disease characterized by fibro-osseous osteopathy in which normal bone is replaced by fibrous tissue and non-functioning bony structures, e.g., trabeculae. In the head and neck area, monostotic or polyostotic lesions cause a progressive increase in destructive bone edema, which leads to cosmetic defects and functional disorders. The lower jaw is anatomically the most important structural and functional component of the lower zone of the facial skull. Pedicled fibula flap is the gold standard among the flaps in reconstructive surgery. Traditional planning methods, anatomical differences in the height, and contours of the fibula create certain difficulties for the timely restoration of a functioning dentition. For accurate reconstructive surgery planning, fundamental conditions should be present for CT-based diagnostics.
The purpose of this study is to present the possibilities of virtual planning and the method of surgical reconstruction of the lower jaw in fibrous dysplasia.
Material and methods. We present an analysis of the patient’s medical history, the description of the clinical case, the results of computed tomography and the X-ray features of fibrous dysplasia of the lower jaw, the results of computed tomography with angiography of the facial region and lower leg, the description of computer modeling and manufacturing of osteotomy templates for reconstructive surgery, stereolithographic model of the skull and fibula, individual miniplates and a reconstructive macroplate, the surgical intervention, and the clinical outcome. Results. This clinical case is presented by a monostotic form of fibrous dysplasia of the mandible. Clinical signs included a slight asymmetry of the lower facial area, a bilateral increase in the volume of the alveolar process and the corpus of the lower jaw, a malocclusion, a change in the position and deterioration in the stability of the teeth, pain with irradiation along the third branch of the trigeminal nerve, more pronounced on the left. The indications for surgery were a violation of aesthetic and functional parameters, pain. The virtual planning of the operation and the manufacturing of intraoperative templates were performed, as well as the production of individual reconstructive macroplates and microplates that stabilize fragments of the fibula. A subtotal resection of the lower jaw was performed with simultaneous reconstruction using a pedicled fibula flap. In this clinical case, a protocol for delayed dental implantation was used, considering multisegmented fibular reconstruction and the use of additional metal structures to stabilize the flaps.
We present an analysis of the medical history of a 25-year-old female patient with complaints of persistent aching pain and the absence of masticatory teeth on the left side of the lower jaw. Based on her complaints, clinical picture, CT angiography and punch biopsy data, she was diagnosed with monostotic FD of the LJ (relapse) with a subtotal spread. The indications for surgical intervention included aesthetic and functional disorders, pain. Virtual surgical planning was performed, intraoperative templates were made, individual reconstructive macroplate and microplate were constructed to stabilize the fibula fragments. Subtotal resection of the fibula with simultaneous reconstruction with a pedicled fibula flap was performed. In this clinical case, a delayed dental implantation protocol was used, given the multisegmented fibular reconstruction and the use of additional metal structures for flap stabilization.
Conclusion. The choice of the individual planning and surgical treatment method for fibrous dysplasia of the facial skull depends on the age of the patient, the growth rate of the facial skeleton, the anatomical localization of the pathological process, the degree of violation of the functional parameters and aesthetic proportions of the face.
Currently, surgery remains the treatment of choice for fibrous dysplasia. For the reconstruction of the lower jaw in fibrous dysplasia, a maximum preservation of the native oral mucosa with keratinized gingiva should be achieved.
Key words: fibrous dysplasia, computed tomography, angiography, reconstruction of the lower jaw, osteotomy, fibular graft, virtual planning, virtual surgery