A 9-year-old male patient presented at the Maxillofacial Surgery Service of San José Hospital (Chile) with painless swelling in relation to the left mandibular body and ramus of one month.
The patient had no relevant medical or surgical history.
1.
Examination of the head and neck showed a large increase in the volume of hard consistency that compromised the area of the body and left mandibular ramus.
There was no skin involvement in relation to the lesion, and there was an ipsilateral submandibular adenopathy with inflammatory characteristics.
There was no evidence of associated sensory impairment and the mandibular functional examination was normal.
Intraorally, the patient had a mixed dentition of first phase with an increase in volume at the bottom of the left mandibular vestibule of hard consistency.
The mucosa in relation to the lesion had normal characteristics.
A panoramic radiograph was requested, in which a multilocular radiolucent lesion of net limits was observed, extending from the distal root of the first left lower molar to the scottage sigmoid ramus.
No signs of rhizolysis were observed in teeth and third molar germ was displaced towards the sigmoid notch.
A CT scan was requested, showing areas of calcification and a large thinning of the cortical bones, especially the vestibular.
Intraoral incisional biopsy was performed under local anesthesia.
The histopathological diagnosis was DOTS.
1.
Based on the diagnosis, size and biological behavior of the lesion, a left hemimandibulectomy with immediate reconstruction was planned.
Through a submandibular, preauricular and intraoral surgical access on the affected side the lesion area was exposed.
It was observed that the mandibular nerve was rejected towards the basilar edge of the jaw, easily separating from the lesion, so it was decided to preserve it.
Reconstruction was performed using a costochondral graft to replace the condyle, mandibular ramus and iliac crest for body replacement.
Both were joined by a 2.4 mm reconstruction plate that was adapted and fixed intraoperatively to the remaining bone segment following the mandibular contour of the patient.
Subsequently, an elastic intermaxillary block was performed using glued arches, which was removed at 3 weeks.
1.
At the first month of evolution, the patient presented paresis of the facial nerve and hypoesthesia of the lower lip with limited mandibular dynamics, conditions that evolved favorably over time.
Radiographic follow-up 6 months after surgery showed a clear consolidation of the new condyle graft, coronoids, a branch and a mandibular body.
No signs of recurrence were observed.
In the clinical control of the 2 years after surgery, the mandibular dynamics was normal, there were no alterations in the pelvis, the aesthetic alterations especially in the surgical wound were practically imperceptible and the donor sites were not functional growth of the graft.
1.
Currently, after 7 years postoperatively, the patient is in good condition whose clinical controls show adequate facial symmetry with an almost imperceptible scar.
In the reconstruction 3 D of the CAT, a frank fixation of the injected bone tissue with formation of a coronoid process of normal characteristics can be observed, showing the clear effect of the function on the shape of the tissue.
It also presents adequate bone volume in the area of the mandibular body and is awaiting comprehensive rehabilitation with implants or implants.
