Outcomes After Tooth-Bearing Maxillomandibular Facial Transplantation: Insights and Lessons Learned.

Abstract

PURPOSE\nTo highlight the challenges and lessons learned in tooth-bearing maxillomandibular facial allotransplantation.\n\n\nPATIENTS AND METHODS\nTwo patients with ballistic composite facial injury underwent tooth-bearing maxillomandibular facial transplantation (FT) after informed consent and institutional review board approval. Patient 1 had undergone total face, double jaw, teeth, and tongue transplantation in March 2012. Patient 2 had undergone 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 before rigid skeletal fixation.\n\n\nRESULTS\nNormal class I occlusion was achieved at the conclusion of each surgery. Patient 1 had developed a 2\xa0×\xa02-mm palatal fistula in the early postoperative period and had also gradually developed class III malocclusion. Orthodontic treatment was started at 5\xa0months after transplantation but failed. A Le Fort III advancement was performed 1\xa0month later with successful restoration of class I occlusion. The palatal fistula was successfully repaired at 9 postoperative months. Patient 2 developed a postoperative palate and floor of mouth dehiscence, requiring palatal repair and hyoid and genioglossus advancement on postoperative day (POD) 11. Orthodontic treatment was initiated for Class II malocclusion. On POD 108, left mandibular nonunion was diagnosed. Left coronoidectomy, open reduction, and internal fixation were performed. IMF was maintained for 2\xa0weeks. Orthodontic treatment was then resumed, with normalization of the occlusion by 10\xa0months after FT.\n\n\nCONCLUSIONS\nMaxillomandibular 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.