Written by Gordon Snow
Major deformities after cancer surgery in the head and neck impose a severe psychological impact on the patient, and often interfere with such vital functions as speech, deglutition, mastication, and facial expression. This applies in particular to the situation after mandibulectomy, especially when the continuity of the anterior arch is lost. Usually, the dreadful picture is further complicated by major soft tissue loss.
In the Netherlands Cancer Institute experience has been gained with a planned staged method of reconstruction after mandibulectomy for cancer that aims at both cosmetic and functional rehabilitation and that is based on a close cooperation between surgeon and prosthodontist. Stage I, stabilization of the remaining mandibular fragments by means of intermaxillary fixation at the time the tumour is resected to maintain preoperative occlusal relationship, Stage II, delayed bone grafting (about three months after the first procedure with an autogenous iliac bone graft), and Stage III, preprosthetic surgery (formation of lower buccal and lingual sulcus by skin inlay grafts) after the intermaxillary fixation appliance has been removed – usually six months after the first procedure) to allow the use of a functional denture are the high points of the method.
From 1963 until 1975, 117 partial mandibulectomies were performed in the Netherlands Cancer Institute, nearly always as part of a commandoprocedure. In the great majority of cases, the tumour was a squamous cell carcinoma, measuring more than 4 cm in its greatest dimension, on or adjacent to the inferior alveolar ridge. Only four sarcomas were included in this series. Reconstruction is planned before resection and patients are therefore seen by the surgeon and prosthodontist at their initial visit. Any anticipated anterior arch defect of the mandible is considered a condition for reconstruction: the so-called Andy Gump appearance is not socially acceptable. When a lateral defect in the mandible is anticipated, the decision whether to reconstruct depends on age, general condition, and motivation of the patient. In this series of 117 mandibulectomies, staged reconstruction was planned in 58 patients.
This staged method of reconstruction after mandibulectomy is not easily sustained by the patients. This is especially true for the intermaxillary fixation of about six months duration. Still, only very few patients gave up. Recurrence of tumor was the main reason that attempts at reconstruction had to be abandoned. In the great majority of patients in whom the reconstruction program could be completed (N=37), it was considered a success, both from the cosmetic and the functional point of view. Technical failures were few. Therefore, the long-term survivors benefit considerably from this method of reconstruction.
In trying to shorten the period of intermaxillary fixation, we have attempted immediate bone grafting at the time of resection. Like others we were faced with a high incidence of loss of the grafts. Therefore, immediate bone grafting is only to be considered in the rare cases where the mandibulectomy is associated with only a minor soft-tissue loss (eg, in sarcomas of the lower jaw).