PMC3578664_01
Imaging of the patient's mandibular defect pre-surgically. (a) Radiolocal image of patient's jaw. (b) CT scan of head
rjs02801.jpg
PMC3578664_01_rjs02801.jpg
RJS028F1
Scans show that the superior margin of the resection is well corticated under the inferior dental nerve (Fig. 1a and b).
Image of patient's oral cavity during insertion of Osmed pellets. (a) Incisions made in the submucosa. (b) Guides used to size the tunnel for the Osmed pellets. (c) Osmed pellets before insertion into the submucosa
rjs02802.jpg
PMC3578664_01_rjs02802.jpg
RJS028F2
The first step was achieving significant tissue expansion (>2 cm) using Osmed pellets, guided into the submucosa and kept over the alveolar ridge for several months (Fig. 2a-c). 
Submucosa after adequate tissue expansion. (a) Opening of submucosa to reveal Osmed pellets. (b) Size of Osmed pellets
rjs02803.jpg
PMC3578664_01_rjs02803.jpg
RJS028F3
The Osmed pellets were removed from the subperiosteum (Fig. 3a and b) and the iliac bone graft was taken, made up of cortical and cancellous bone and placed to one side (Fig. 4a-c).
Titanium construct packed with iliac bone graft and screwed into position on the lower mandible
rjs02805.jpg
PMC3578664_01_rjs02805.jpg
RJS028F5
Once fitted to the patients jaw, it was packed with the bone graft and screwed down into position (Fig. 5).
Image of patient's surgical site. (a) Tissue expanded submucosa is sutured close. (b) Buccal mucosa is sutured close. (c) Image of post-surgical site
rjs02806.jpg
PMC3578664_01_rjs02806.jpg
RJS028F6
To complete the surgery, the periosteum was sutured over the construct and then the buccal muscosa was sutured over again to form a double-layered closure (Fig. 6a-c).The purpose of this was to prevent infection and rejection, by ensuring that there was an increased distance between the foreign object (titanium construct) and the outside environment.