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blative surgery for neoplastic disease. The iliac crestemains the workhorse for autogenous bone graft har-esting when significant quantity of cortical and cancel-ous bone is required. In addition to this we should beeminded how useful the autogenous costochondralraft is for replacement of the mandibular component ofhe temporomandibular articulation.
Several cases will be used to illustrate these points andrinciples of reconstruction of the mandible. These will
nclude the severely atrophic but continuous edentulousandible and what needs to be done to maintain grafted
one volume. Autogenous rib grafting will be discussedo highlight its usefulness in joint replacement both postrauma or as a solution to isolated condylar degenera-ion, be it arthritic, idiopathic condylar resorption orost tumour excision. Finally a case of segmental resec-ion of the mandible for low grade osteosarcoma willemonstrate how a post ablative segmental defect cane restored to good function and esthetics with a mini-al amount of extensive surgery and relatively low mor-
idity.A review of postoperative morbidity and complica-
ions will allow the audience to compare this non vas-ularized technique with other techniques that may beiscussed.
References
Li Z, Zhao Y, Yao S, Zhao J, Yu S, Zhang W. Immediate reconstruc-ion of mandibular defects: a retrospective report of 242 cases. J Oralaxillofac Surg. 2007 May; 65(5): 883-90Marx RE, Kline SN. Principles and methods of osseous reconstruc-
ion. Int Adv Surg Oncol. 1983;6: 167-228Woodbury SC, Stanton DC, Quinn PD, Beanland DR, Foote JW.ptions for immediate reconstruction of the traumatized temporoman-ibular joint. J Craniomaxillofac Trauma. 1998 Summer; 4(2): 22-9
resent: Microvascular Free Flapsui P. Fernandes, DMD, MD, Jacksonville, FL
No abstract provided
uture: Tissue EngineeringRegenerative Medicine); Mandibleendrik K.W. Terheyden, MD, DMD, PhDassel, Hessen, Germany
In benign situations there is a choice of therapeuti-al options including free bone grafts and tissue engi-eering techiques. However, for malignancies and es-ecially for irradiated patients with large mandibularefects the clinical options are almost exclusively lim-
ted to microvascular bone flaps. However, recon-truction of the mandible with free bone flaps has twoimitations. 1) The shape of the bone does not matchxactly the requirements. 2) Limited availability/mor-
idity of donor sites. sAOMS • 2009
Tissue engineering can offer solutions. 1) The shapean be controlled by customised scaffolds on the basisf CAD/CAM and radiographic imaging data. 2) Bonean be grown in muscular environments and then bearvested with reduced morbidity. An ideal site foruch a bone flap prefabrication is the latissimus dorsiuscle.Three patients have been treated with custom shaped
ndividually prefabricated bone segments (2 for mandi-le and 1 for maxilla). Scaffolds (defect specific CAD/AM shaped titanium meshes filled with xenogenicone mineral) have been augmented with rhBMP-7 (Osi-raft) and bone marrow aspirate from the iliac crest. Thecaffolds were implanted into a pouch in the latissimusorsi muscle. After 6 weeks the muscular segments werearvested with the thoracodorsal vessels. The flaps wereransferred to the defects where the scaffolds were se-ured with bone screws and the blood vessels wereonnected to the facial vessels. Two reconstructionsmandible and maxilla) were clinically successful. Inne case (mandible) the bone disappeared within oneear.Limitations of the method and room for improvement
re discussed. Further research has to consider the pro-ection of bone against premature resorption and accel-ration of neovascularization of the scaffolds. The use ofisphosphonates and VEGF is demonstrated for theseurposes.
References
Terheyden H, Menzel C, Wang H, Acil Y, Springer ING, Rueger D.2004) Prefabrication of vascularized bone grafts using recombinantuman Osteogenic Protein-1 – Part. 3: dosage of rhOP-1, the use ofxternal and internal scaffolds. Int J Oral Maxillofac Surg 33: 164-72Warnke P, Springer I, Acil Y, Eufinger H, Wehmöller H, Wiltfang J,
erheyden H (2004) Growth and transplantation of a custom vascular-zed bone graft in a man. Lancet 364, 766-770
Warnke PH, Wiltfang J, Springer I, Acil Y, Bolte H, Kosmahl M, RussoA, Sherry E, Lutzen U, Wolfart S, Terheyden H (2006): Man as livingioreactor: Fate of an exogenously prepared customized tissue-engi-eered mandible. Biomaterials 27, 3163-3167
uture: Tissue EngineeringRegenerative Medicine); Condyle-Ramusonstructiller Smith, DDS, MD, Ann Arbor, MI
The temporomandibular joint proves to be one ofhe most difficult structures to reconstruct in theraniomaxillofacial skeleton. This owes to the com-lex 3-dimensional geometrical shape, intricate me-hanical function and load bearing, and the presencef both osseous and cartilaginous tissues in close prox-
mity to a fibrocartilagenous disc. Reconstruction isecommended for re-establishing function and occlu-
ion, correcting facial asymmetry, and reducing suffer-11
