JSUR Journal

Surgical Technique: Segmental Mandibulectomy and Delayed Tibial Graft Reconstruction

Preoperative Preparation

The patient was placed under general anaesthesia with nasotracheal intubation to facilitate unobstructed access to the oral cavity and mandibular region. Standard aseptic protocols were observed, and the surgical field was draped to expose the left lower face and neck.

Mandibular Segmental Resection

A submandibular incision was made approximately 2 cm below the inferior border of the mandible, extending from the parasymphysis region (tooth 32) to the posterior border of the ramus. Dissection proceeded through the platysma and subcutaneous tissues, with careful preservation of the marginal mandibular branch of the facial nerve. The periosteum was elevated to expose the mandibular cortex. Segmental resection was performed using rotary instruments and osteotomes, excising the affected bone from 32 to the ramus. Haemostasis was achieved via bipolar cautery and ligation of facial artery branches. A pre-contoured titanium reconstruction plate was adapted and secured to maintain mandibular continuity and facial contour.

Histopathological Confirmation

The excised specimen was submitted for histopathological evaluation, which confirmed the diagnosis of ameloblastoma with tumour-free surgical margins.

Delayed Reconstruction with Tibial Cortico-cancellous Graft (Performed One Year Post-Resection)

Tibial Graft Harvesting

Under general anaesthesia, the patient was positioned supine. The ipsilateral leg was sterilized and draped. A longitudinal incision was made over the medial aspect of the proximal tibia, approximately 2–3 cm below the tibial tuberosity. Dissection proceeded to the periosteum, which was incised and elevated. A cortico-cancellous block graft was harvested using osteotomes and bone gouges, with care taken to preserve the tibial cortex and minimize donor site morbidity. Haemostasis was achieved, and the donor site was irrigated with saline and closed in layers using absorbable sutures for deep tissues and non-absorbable sutures for skin.

Mandibular Graft Placement and Fixation

The mandibular recipient site was re-accessed via the previous submandibular incision. Fibrous tissue was debrided, and the reconstruction plate was assessed for stability. The tibial graft was contoured using bone files and rotary instruments to match the defect dimensions. It was positioned and secured to the native mandible and reconstruction plate using titanium screws and Recon plates, ensuring rigid fixation and optimal host-graft contact.

Closure and Postoperative Care

Following confirmation of graft stability and haemostasis, the surgical site was irrigated with saline and closed in layers. Deep tissues were approximated using absorbable sutures, and skin closure was achieved with interrupted non-absorbable sutures. A suction drain was placed as needed and removed within 48–72 hours. Postoperative care included administration of antibiotics and analgesics, with close monitoring for signs of infection or graft rejection.

Follow-Up and Outcome

Radiographic evaluation at four months post-reconstruction demonstrated satisfactory graft integration, with evidence of bone remodelling and restoration of mandibular continuity. The patient exhibited improved mandibular contour and function, with no clinical or radiographic signs of recurrence or graft failure.

Implant Rehabilitation: Three endosseous (compressive) implants were placed in the grafted segment using a guided protocol. Compressive implants were chosen for this case as:

• Cortical Bone Engagement: Mechanically engages basal or cortical bone, providing primary stability even in compromised bone conditions. Reduces dependence on bone grafting procedures.
• Flapless, Minimally Invasive Protocol: Often placed without raising a flap, minimizing trauma, bleeding, and postoperative discomfort. Shorter surgical time and faster recovery. But in this case, a flap was raised to check the position of the recon plates and screws while placing the implants.
• Single-Piece Design: Eliminates micro gaps between implant and abutment, reducing the risk of peri-implantitis and bacterial colonization. Simplifies the prosthetic workflow.
• Versatility in Challenging Cases: Suitable for atrophic jaws, immediate post-extraction sites, and full-arch rehabilitations where conventional implants may fail.

Implant sites chosen were 34, 35, and 36 of sizes 5.5x10mm, 5.0x10mm, and 4.5x10mm, respectively. Three months postplacement, the implant at site 36 failed secondary to periimplantitis, presenting with progressive mobility. Given its proximity to the reconstruction plate and the associated risk of further complications, the implant was explanted. A replacement implant was deferred, and the patient was advised to wait six months to allow for adequate osseous healing and potential re-evaluation for future rehabilitation. After six months of osseointegration, a fixed implant-supported prosthesis was delivered that had teeth from 33 to 36 on the 2 implants in place of 34,35.

Outcome

At three years post-rehabilitation:

• No recurrence was observed.
• CBCT confirmed graft stability and implant success of the 2 implants in positions 34 and 35.
• The patient reported high satisfaction with function and aesthetics.

Discussion

Multi-cystic ameloblastoma is a benign but locally aggressive odontogenic tumour that arises from the epithelial remnants of the tooth-forming apparatus. It is known for its infiltrative growth pattern and high recurrence rates, particularly when treated conservatively [4,5,18]. The multi-cystic variant, in contrast to the uni-cystic form, often invades surrounding bone and soft tissue, making complete excision challenging. As a result, radical surgical approaches such as segmental mandibulectomy are frequently warranted to ensure oncologic clearance and minimize the risk of recurrence [4,5]. The removal of a substantial portion of the mandible, while necessary for tumour control, leads to significant functional and aesthetic deficits. These include impaired mastication, speech difficulties, and facial asymmetry. Therefore, reconstructive surgery becomes an essential component of the treatment plan. The timing of reconstruction—whether immediate or delayed—remains a subject of clinical debate. Immediate reconstruction offers the advantage of restoring form and function in a single stage, but it may carry a higher risk of complications if residual tumour cells are present. Delayed reconstruction, on the other hand, allows for a period of surveillance to confirm the absence of recurrence and provides a more stable environment for graft integration [19-21]. Autogenous bone grafting remains the gold standard for mandibular reconstruction due to its superior osteogenic, osteoinductive, and osteoconductive properties. While donor sites such as the fibula and iliac crest are commonly used, the tibia presents a viable alternative in select cases. Tibial cortico-cancellous grafts offer a balanced composition of dense cortical bone for structural support and cancellous bone for rapid vascularization and integration. These grafts are particularly suitable for moderate-sized defects and have the added benefit of reduced donor site morbidity, shorter operative time, and easier harvesting technique [13,14,22,23].Once the graft has successfully integrated with the native bone, the next phase involves prosthetic rehabilitation using dental implants. Implant placement in grafted bone requires careful planning and timing to ensure optimal outcomes. Studies have consistently demonstrated that when implants are placed in a staged manner-after confirming graft stability and bone remodelling—the success rates exceed 95% [15,16,24,25]. This high predictability is attributed to the improved biomechanical environment and reduced risk of implant failure, infection, or graft resorption. In summary, the management of multi-cystic ameloblastoma necessitates a multidisciplinary approach that balances oncologic safety with functional restoration. Segmental resection followed by delayed tibial graft reconstruction and staged implant rehabilitation offers a reliable pathway to achieving long-term tumour control, structural integrity, and patient satisfaction. The tibial donor site, though less commonly utilized, provides a practical and effective solution for moderate mandibular defects, especially when minimizing donor site morbidity is a priority [23-25].

Conclusion

This case underscores the clinical value of a staged approach in the management of multi-cystic mandibular ameloblastoma. The initial segmental resection ensured oncologic clearance, while delayed reconstruction with a tibial graft provided a structurally sound and biologically favourable foundation for subsequent implant-supported rehabilitation. The tibial graft’s corticalcancellous composition facilitated predictable osseointegration, and its minimal donor site morbidity made it a practical alternative to more commonly harvested sites such as the fibula or iliac crest. The decision to delay grafting allowed for vigilant postoperative surveillance, reducing the risk of graft compromise in the event of tumour recurrence. Implant placement in the grafted site was successful, restoring both function and aesthetics, and contributing to the patient’s overall quality of life. This case highlights that tibial grafts, when selected appropriately, can offer reliable outcomes in moderate mandibular defects. Moreover, it reinforces the importance of individualized treatment planning, interdisciplinary coordination, and long-term follow-up in achieving durable disease control and optimal prosthetic rehabilitation.

Acknowledgments: The author acknowledges the surgical team and the OMFS department for their contributions to patient care and rehabilitation.

Ethical Statement: Informed consent was obtained from the patient for publication of this case report and accompanying images. The study was conducted in accordance with institutional ethical guidelines.

Conflict of Interest: The author declares no conflict of interest.

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