The mandibular rehabilitation multidisciplinary after mandibulectomy

Current treatment of odontogenic tumors (OT) ranges from simple enucleation by curettage or segmental resection. But the treatment does not stop here, we need to think about the rehabilitation of the patients. The Mandibular reconstruction can begin immediately postoperatively, but the delayed reconstruction can be the best option for treatment, because of the high risk of recurrence in some OT, but it is always a challenge. The aim of this study is to describe the approach of a case of mandibular odontogenic myxoma and your total rehabilitations. The segmental hemi-mandibulectomia was performed with an intraoral. After 2 year the iliac crest grafting to intraoral approach was done and after 6 months osseointegrated implants were put and the immediate load with hybrid prostheses was done. After 2 years of complete rehabilitation we can consider that this sequence looks like to be a good form to become social, psychological, esthetic and function in the patients.


Introduction
Odontogenic myxoma (OM) is a benign mesenchymal tumor, characterized by stellate and spindle -shaped cells, which may contain odontogenic epithelium, (Chrcanovic e Gomez., 2018) the World Health Organization (WHO) classified as tumor of ectomesenchyma origin with or without odontogenic epithelium (Pindborg et al., 1971).
Segmental mandibular defect after tumor surgery can be reliably reconstructed using pedicled myocutaneous flaps, free grafts including particulate or cortical bone, alloplasts, pedicled osteomyocutaneous flaps, and free vascularized bone flaps. (Kumar et al. 2016;Shin et al., 2020) The aim of this study was to describe the long-term outcome of a case of mandibular odontogenic myxoma managed by segmental resection, with an intraoral approach followed by iliac crest grafting and rehabilitation with dental implants.

Methodology
This clinical case report is a descriptive observational study, which aims to discuss the treatment proposed by the authors in comparison to that found in the literature. (Adamo et al., 1980). The case was conducted in accordance with clinical and professional ethics. The patient reported in the study has a personal data sheet and anamnesis, where he authorized the use of images, clinical, radiographic and socioeconomic data for educational and research purposes, and with that he signed the Free and Informed Consent Term and the Free Consent Term and enlightened. Consent to Participation of the Person as a Subject, which have been duly read and explained.

Case Report
A 34-year-old female patient was referred to the Department of Oral-Maxillofacial Surgery, in the University of Sacred Heart, reported with a chief complaint of painless swelling over right cheek region. Clinical examination showed facial asymmetric in the right side. (Figure 1) On the intraoral examination the lesion extended from the mesial of the canine to distal the first molar. A panoramic radiograph revealed an extensive radiolucent and multilocular area with imprecise borders that extended from the mesial of the canine to distal the first mandibular molar and exhibited a "soap bubble" appearance (

Discussion
Odontogenic myxoma is a rare benign tumor derived from embryonic mesenchymal tissue associated with odontogenesis, (Jindwani et al., 2013) was first described in 1947 by Thoma and Goldman (Kawase-Koga et al., 2014). In most studies, the mandible appears to be more frequently affected than the maxilla (Kaffe et al., 1997;Jindwani et al., 2013) Female predilection is a common feature, reported in several studies, so in the present case, a 34-year-old female patient was reported, which is consistent with the other reported cases.
The radiological appearance is a "tennis racquet strings"logical " or of a "soap bubble" or show uni-or multi-locular "honey-panel" pattern, with cortical expansion and dental displacemen (Rotenberg et al., 2004;Peltola et al., 1994). Our patient reported no symptoms in the right mandibular area; however, panoramic radiography revealed an extensive radiolucent and multilocular area with imprecise borders that extended from the mesial of the mandibular canine to the distal first lower molar.
The first option for the treatment of odontogenic myxoma is surgery, but there is a consensus on the best approach option (Kawase-Koga et al. 2014). Conservative treatment was defined as marginal resection, enucleation, and curettage ( Cuestas e Carnero et al ., 1988) radical treatment was defined as segmental or block resection, and hemimandibulectomy with reconstruction. (Kawase-Koga et al., 2014) Research shows that conservative treatments for minor lesions and radical interventions for large lesions show better prognosis, with a lower risk of recidivism and greater preservation of vital structures (Adebayo et al., 2005;Fernandes et al., 2005;Li et al., 2006).
In agreement with the available literature, the tumor was removed by en marginal resection and no recurrence was reported even after four years of the surgery. Prognosis in the present case after excision was excellent in this four year followup period. The treatment performed with intraoral approach represented a less morbid intervention, the possibility of intraoral access, a shorter hospitalization time, and not interfering with facial nerve ( Higo et al., 2015) Reconstruction of mandibular defects can begin immediately postoperatively, but delayed reconstruction is the best option for treatment, because of the high risk of recurrence. The immediate mandibular reconstruction using a reconstruction plate and second surgery with delayed autogenous bone graft are advantageous to decrease the possibility of facial deformity and overcome the psychological effects. Full function and rapid dental rehabilitation are expected in this reconstruction (Sudhakar et al., 2017) After a clinical and radiographic follow-up of 2 years and without recurrence of the lesion, it was submitted to mandibular reconstruction with a block bone graft of the anterior iliac crest. The anterior iliac crest is the best option because provides an adequate harvest of corticocancellous, cancellous, or bicortical grafts for reconstruction of various osseous defects in the maxillofacial region with least morbidity and should be considered as a major reservoir of bone for bony reconstructive procedures (Sudhakar et al., 2017)

Conclusion
The success of the clinical management of this case after the 4-year follow-up is due to the correct treatment decision for odontogenic myxoma, to minimize the risk of recurrence and, at the same time, adopt a less invasive surgical approach, returning the patient a good masticatory function and aesthetics.