Mandibular Reconstruction: Expert Opinion and Outcome Studies Remain a Fragile Guide to Treatment

Straw Men 

(An oral history as told by a Greek professor at Columbia decades ago):

The elder commanders worked all night preparing the field. The young Greeks, asleep in their encampment, in fear of the advancing Persian army, awoke to the screams of their elders.

“The Persians are here. Awake and fight!”

Against the predawn light stood a seeming impenetrable wall of the enemy. The bravest of the young Greeks grabbed their swords and torches and attacked up the hill, hacking and slashing the foe. Soon the straw limbs began to fly and the “men” of the ersatz Persian army began to burn. The cries of “Victory” nonetheless bellowed up from the Greek army and it found its courage.

Straw men are imaginary foes set up to be slashed down, thus heartening their opponents and diverting observers from the real issues at hand. In mandibular reconstruction, the straw man can be “expense,” “length of surgery,” “inadequate bone for implant placement,” “donor site morbidity,” or “off-label use.”

Advancing Evidence-Based Debate 

Fortunately, this month's JOMS will advance the debate over technique in mandibular reconstruction toward a higher, more rational level with the contributions of Bell and Gregoire,1 evaluating the options in mandibular reconstruction and with the well-considered appraisal of rhBMP-2 by Herford.2 By these authors' assessments, the disease, the defect, the desired result, and the available technology serve as key guides to determine treatment. The ability to consider and utilize a broad range of techniques (from autogenous grafts to tissue transfer and tissue engineering) with an ecumenical mindset, will guide these surgeons to always be leaders in mandibular reconstruction. They are not bound by dogma, or susceptible to straw men. Thus they are capable of advancing their practice every day.

Science and clinical practice in mandibular reconstruction is advancing rapidly and changing yearly. Just 3 decades ago we would “let them swing.” Even in major centers, painfully few patients with continuity defects would obtain reconstruction.

Since then, the gap bridging bone plate, other alloplastic reconstruction, autogenous bone grafts, regional flaps with autogenous bone, microvascular osteomyocutaneous flaps, prefabricated flaps, microvascular tissue transfer, and most recently tissue-engineered reconstruction are in advanced clinical use and matched with equally important advances in implant/prosthetic reconstruction. For those willing to develop and select new ideas, information technology and molecular biology will offer even more astounding advances in the coming decades.

The Limited Importance of Technique 

In examining these advances in technique, recall that surgical method is but one of the determining factors in achieving successful outcomes of mandibular reconstruction. Trying to assess technique in case series is confounded by the very nature of the patients requiring reconstruction and the varying skills and technologies employed to correct these defects. Consider just some of the main factors affecting outcome in mandibular reconstruction, and how outcomes will be affected well beyond the technique employed for reconstruction.

If techniques are to be compared, the reader needs an understanding of the patients, the defects, and additional methods being used. Some of these variables are:

○ Hyperbaric oxygen

○ Bisphosphonates

○ Steroids

○ Vitamin D and calcium

Thus the application of technique by surgeon investigators and their expert opinions makes for a fragile guide to generalizeable treatment recommendations.

Reconstruction is not filling a hole. Our enemies are the functional and esthetic defects of our patients. All else is the straw army. Thus a functional and esthetic assessment of reconstruction needs to be done by patients, treating physicians and dentists, and independent observers. Assessment criteria needs to include a true understanding of the morbidity and mortality associated with various reconstruction techniques, even when the event is not directly related to the postoperative period. Objective assessments of speech, mastication, deglutition movement of bolus from oral cavity to pharynx, airway, PEG requirement, aspiration risk, and swallowing are needed to assess the true value of a method. Long-term results of reconstruction and patient-centered assessments, such as the oral health-related quality of life, University of Washington scale, are essential to understanding our success in treatment.

Truly the most exciting advances in our specialty of the last decades have been in the arena of oral and maxillofacial reconstruction. For equal success in the coming decades, we should keep the elders from building straw men and let the young Greeks attack the real enemy.