“FREE FIBULA OSTEOCUTANEOUS FLAP FOR RECONSTRUCTION OF MANDIBLE IN A RARE CASE OF AMELOBLASTIC CARCINOMA”.
PRESENTED BY: DR. PRAMOD SUBASH MAXILLOFACIAL SURGERY UNIT DEPT OF HEAD & NECK SURGEY
AIMS KOCHI
CASE HISTORY54 yr old man
chief complaint – Swelling on lower jawmobility of lower front tooth x 1 year
HOPI - since 2 yearsgradually increasing in sizeno h/o of pain, bleeding,
anesthesia/paresthesia of lipno h/o of trauma to the mandible no h/o tooth ache in relation to the lower
teeth. No deleterious habits
PAST MEDICAL HISTORYKnown case of CAD – Inferior wall MI in 1998
Developed APD Stopped cardiac medications Started APD treatment Now not on any drugs
RTA 1 year back – Fractured both bones - left leg Closed reduction done.
EXAMINATION
• Symmetrical face
• Good mouth opening - 3 finger’s breadth
• Poor oral hygiene – few missing teeth.
• Single swelling in the lingual aspect of mandible on the left side(continuous with the bony contour of mandible),
extending from left lower incisor to second premolar
• Measuring 2 ½ x 2 cms, the swelling was firm, non-fluctuant and non-tender
• A small ulcerated area was seen on the swelling which measured around 0.5 cms in diameter
• Expansion of buccal cortex of mandible was palpable though clinically not visible
• There were no palpable neck nodes
• Tooth vitality test - the involved teeth & contra lateral incisors and canines were also non-vital
INVESTIGATIONS
•Orthopantomogram ( OPG)
•CT Scan
•DIFFERENTIAL DIAGNOSIS
• Ameloblastoma
• Odontogenic keratocyst
• Solitary (traumatic) bone cyst
BIOPSY
•Incisional biopsy
HISTOPATHOLOGY REPORT
Diagnosis: Ameloblastic carcinoma
[As long standing history of ameloblastoma is absent, ameloblastic carcinoma could
have arisen de novo from epithelial cell rests of mandible]
AMELOBLASTOMA
PATHOGENESIS
Dental embryonic remnants i. Epithelial lining of odontogenic cyst ii. Dental lamina or enamel organ iii. Stratified squamous epithelium of oral cavity iv. Displaced epithelial remnants
• Odontogenic tumor• Locally invasive• Tends to recur
• Rarely behaves aggressively or shows metastatic dissemination
MALIGNANCY IN AMELOBLASTOMA ?
• Malignant Ameloblastoma
Ameloblastomas that metastasize despite benign histological features in both primary and
metastatic lesions
• Ameloblastic carcinoma
- Show histologic features of both ameloblastoma and carcinoma
- Both primary and secondaries show histologic signs of malignancy
AMELOBLASTIC CARCINOMA
• No definite sex / age/ race predilection
• Mandible most commonly involved area.
• Usually asymptomatic
• perforates bone
• extends into soft tissue
• tends to recur
• Metastasis to regional lymph nodes
• Most common distant metastasis to lungs
TREATMENT PLAN
• Wide excision (segmental mandibulectomy)
• ? Neck dissection (Clinically N0 neck)
• RECONSTRUCTION
WHY RECONSTRUCTION?
• Functional impairment- difficulty in chewing- difficulty in speech- TMJ problems
• Disfigurement
“Two piece mandible”
OPTIONS FOR RECONSTRUCTION
Common
• Mandibular Reconstruction Plate
• Reconstruction plate and bone graft
e.g. Ileac crest
• Contoured titanium trays with bone chips
Other
• Micro-vascular free Flaps
A.Scapula
B. Ilium
C. Radius
D. Fibula
OPTIONS – FREE FLAPS
ADVANTAGES OF FREE FIBULAR FLAP
• Long thin non weight bearing bone
• Initially used to reconstruct long bones
• Distant from head and neck region
• 22 to 25 cms of bone can be harvested
• Segmental multiple nutrient arteries to the bone ( bone can be osteotomised into smaller
fragments by keeping the periosteum intact)
• Relative ease of harvest
FREE FIBULA OSTEO-CUTANEOUS FLAP
•Based on Peroneal artery and vein
• Skin flap receives supply from septo-cutaneous or musculo-cutaneous perforators from the Peroneal artery
Anterior view – Lt. leg Posterior view – Lt. leg