The Mandible

Abstract

Following a brief recapitulation of the embryology and anatomy of the mandible and its profound significance together with a brief discussion on patterns of spread, an approach is presented for the possible designs of mandibular resection, based on imaging.

The importance of the Free Fibular Graft, which is the current workhorse for mandibular reconstruction all over the world, is enunciated, along with a discussion on the pre-operative evaluation of patients needing mandibular reconstruction.

Although details of flap elevation are mentioned in the chapter on Skin Flaps, a detailed approach to mandibular reconstruction is presented, along with nuances for different types of defects. Wherever possible and appropriate, we prefer to employ pre-plating of the mandible prior to segmental mandibulectomy in order to achieve very precise defect measurements and to assist in planning of osteotomies.

In other cases with obvious deformation of mandibular contour / pathological fracture, where pre-plating is not an option, we routinely request 3-D printing of the mandible using CT images. This model is sterilized and used at the time of surgery for appropriate plate bending.

The important contra-indications for the Fibular graft are mentioned and include vascular anomalies like the Peronea Magna and peripheral vascular disease with advanced atherosclerosis of the lower limb vessels, often found in elderly individuals.

The clinical case scenarios presented vary from the regular medium-sized defects to very extensive composite defects, which might sometimes need an additional free flap.