Tooth-Bearing Maxillomandibular Facial Transplantation: Insights and Lessons Learned

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Publication date: Available online 25 May 2019

Source: Journal of Oral and Maxillofacial Surgery

Author(s): Elie P. Ramly, Rami S. Kantar, J. Rodrigo Diaz-Siso, Allyson R. Alfonso, Pradip R. Shetye, Eduardo D. Rodriguez

Abstract

Purpose

To highlight challenges and lessons learned in tooth-bearing maxillomandibular facial allotransplantation.

Patients and Methods

Two patients with ballistic composite facial injury underwent tooth-bearing maxillomandibular facial transplantation (FT) after informed consent and institutional review board approval. Patient 1 underwent total face, double jaw, teeth, and tongue transplantation in March 2012. Patient 2 underwent partial face, double jaw, and teeth transplantation in January 2018. Le Fort III and bilateral sagittal split skeletal osteotomies were performed in both transplants. Computerized surgical planning was used in both cases, and the allografts were transferred in intermaxillary fixation (IMF) with prefabricated dental splints prior to rigid skeletal fixation.

Results

Normal class I occlusion was achieved at the conclusion of each surgery. Patient 1 had a 2x2mm palatal fistula in the early postoperative period and also gradually developed class III malocclusion. Orthodontic treatment was started at 5 months post-transplant but failed. A Le Fort III advancement was performed a month later with successful restoration of class I occlusion. The palatal fistula was successfully repaired at 9 postoperative months. Patient 2 developed postoperative palate and floor of mouth dehiscence, requiring palatal repair and hyoid and genioglossus advancement on POD 11. Orthodontic treatment was initiated for class II malocclusion. On POD 108, he was diagnosed with left mandibular nonunion. Left coronoidectomy, open reduction and internal fixation were performed. IMF was maintained for 2 weeks. Orthodontic treatment was then resumed, with normalization of the occlusion by 10 months post-FT.

Conclusion

Maxillomandibular transplantation is a viable reconstructive solution for composite midface defects not amenable to autologous reconstruction. Improvement of functional outcomes and prevention of major complications rely on close attention to occlusal relationships, temporomandibular joint dynamics, dental health, and the intraoral donor-recipient soft tissue interface.