Vascularized bone flaps in oromandibular reconstruction. A comparative anatomic study of bone stock from various donor sites to assess suitability for enosseous dental implants

Bone impacted fibular free flap: a novel technique to increase bone density for dental implantation in osseous reconstruction

BACKGROUND

Fibular free flap (FFF) bone has thick cortical bone surrounding a fatty marrow. The cortex has sufficient density for dental implantation, but the marrow limits bone stock. A novel technique was devised to increase bone density: the bone-impacted fibular free flap (BIFFF). The purpose of this study was to: (1) describe the BIFFF technique; (2) evaluate the bone density of BIFFF; and (3) evaluate the stability/success of implants placed in BIFFFs.

METHODS

Patients undergoing maxillary/mandibular reconstruction with FFFs were prospectively enrolled from 1998 to 2008. Two cohorts were compared: BIFFF and nonmodified FFF. The main outcome was bone density as seen on CT scans. Primary dental implant stability was determined via Periotest.

RESULTS

Thirty-eight patients were included in this study. BIFFFs achieved higher bone density versus unmodified FFFs (p < .05). Greater primary dental implant stability occurred in BIFFFs (p < .05). One hundred percent of BIFFF and 59% of nonmodified FFF implants were successful at 1 year.

CONCLUSION

BIFFF increases reconstructed bone density, initial dental implant stability, and 1-year implant success.

Introducing the tibial-dorsalis pedis osteocutaneous shin flap: a new option for oromandibular reconstruction

BACKGROUND

The authors investigated the possibility of incorporating a well-vascularized, partial corticotomy of the anterolateral aspect of the tibia "in-series" with a dorsalis pedis fasciocutaneous free flap for oromandibular reconstruction.

METHODS

A cadaveric injection study was performed to characterize the vascular territory of the anterior tibial artery with regard to the surrounding osseous and soft tissue. The two-point breaking strength of the tibia (twist) was examined with fracture strain gauge analysis to determine the threshold of tibia corticotomy that would lead to a pathologic fracture. Finally, the authors performed an in vivo prospective clinical examination of the tibial-dorsalis pedis osteocutaneous shin flap.

RESULTS

The perfusion study revealed that the anterior tibial artery provided a rich matrix of musculofascial periosteal blood supply to the anterolateral cortex of the tibia that could potentially support free osseous tibial transfer. Two-point osteotomy fracture strain gauge analysis demonstrated that the threshold of tibia corticotomy that would lead to pathologic fracture of the remaining tibia was greater than 30 percent. The osteocutaneous shin flap was performed in eight patients. The mean follow-up was 61 months. There were no cases of flap loss, salivary fistula, nonunion, or tibia pathologic fracture. All patients achieved ambulation.

CONCLUSIONS

The authors introduce the osteocutaneous tibial-dorsalis pedis free vascularized flap as a viable option for oromandibular reconstruction. Its most notable advantage is the independent mobility of the skin paddle, in combination with bone stock that replicates mandibular bone dimensions, facilitating primary osseointegration or denture rehabilitation.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Evolution of complex palatomaxillary reconstructions: the scapular angle osteomuscular free flap

PURPOSE OF REVIEW

This review summarizes the worldwide experience (105 patients) in primary and secondary reconstruction of palatomaxillary oncologic defects with the angular branch-based subscapular system of free flaps, comparing the advantages and disadvantages of the technique with those of other well known osseous donor sites such as the fibula and iliac crest.

RECENT FINDINGS

The most recognized indications for angular branch-based osteomuscular free flaps are class II (especially in association with zygomaticomaxillary buttress and/or floor of the orbit removal) and class III defects according to the Okay classification. Defects involving clearance of the orbital content have also been reconstructed in this manner. One of the most important drawbacks of this technique (i.e., need for intraoperative patient repositioning) is no longer considered an issue, and evidence has been provided that harvesting of angular branch-based scapular flaps may be routinely performed in a supine position. Three-dimensional morphologic similarity of the tip of the scapula with the native hard palate and other maxillary structures makes flap fabrication easy and practical, with at least two (horizontal and vertical) most commonly used flap orientations applied to reconstruct different defects.

SUMMARY

Angular branch-based osteomuscular scapular free flaps represent a major advance in palatomaxillary reconstruction: their versatility, long pedicle with large caliber donor vessels, morphologic similarity with maxillary bony structures, and limited donor-site morbidity compare favorably with those of other osteomuscular and osteomusculocutaneous free flaps described for such challenging reconstructive purposes.

Treatment of hemi-mandibulectomy defect with implant-supported telescopic removable prosthesis. A clinical report

Excision of head and neck tumors (benign or malignant) often leads to large segmental resections of the mandible. The following clinical report describes the oral rehabilitation of a 60-year-old Caucasian man after partial mandibulectomy due to primary oral leiomyosarcoma. Treatment consisted of a free fibula flap and an implant-supported telescopic removable prosthesis.

Safe osteocutaneous radial forearm flap harvest with prophylactic internal fixation

We studied the efficacy of prophylactic plate fixation technique and a modified harvest of the osteocutaneous radial forearm free flap (OCRFFF) to minimize the incidence of postoperative donor radius pathological fracture. We retrospectively studied of the first 70 consecutive patients undergoing OCRFFF harvest by the University of Kansas Head and Neck Microvascular Reconstruction Team. Mean follow-up was 13 months. One of two patients undergoing OCRFFF harvest without prophylactic fixation developed a pathological radius fracture. The 68 subsequent OCRFFF patients underwent prophylactic fixation of the donor radius, and none developed a symptomatic radius fracture. Five of 68 patients did have a radiographically visible fracture requiring no intervention. The plate fixation technique was further modified to exclude monocortical screws in the radius bone donor defect (subsequent 39 patients), without any further fractures detected. One patient required forearm hardware removal for an attritional extensor tendon tear. The described modified OCRFFF harvest and prophylactic plate fixation technique may eliminate postoperative pathological fracture of the donor radius. Donor morbidity is similar to that of the fasciocutaneous radial forearm free flap , affording safe use of OCRFFF in head and neck reconstruction.

Implant mandibular rehabilitation postoncologic segmental resection: a clinical report

In cases of reconstruction of a discontinuity defect of the mandible, the surgeon has a major responsibility to maximize function as well as cosmetics and to preserve quality of life, restoring mastication, speech, and appearance. Treatment of mandibular discontinuity defects is a complex process and, among other methods, includes the use of free vascularized flaps. A variety of donor sites have been used for this purpose, including the iliac crest, radius, scapula, and fibula.At this time, the iliac crest free flap represents a versatile reconstruction method after mandibular ablation. This article reports a clinical case using the iliac crest free flap for comprehensive reconstruction of discontinuity defects in the mandible after resections of an aggressive odontogenic tumor. The immediate implant positioning reduced the number of surgical procedures and the rehabilitation time.

Functional long-term results after the harvest of vascularised iliac bone grafts bicortically with the anterior superior iliac spine included

The aim of this study was to evaluate the postoperative morbidity at the donor site and the long-term outcome after the harvest of bicortical iliac bone grafts, including the iliac crest and the anterior superior iliac spine (ASIS), by using a confirmed score. We retrospectively examined 54 consecutive patients who had had vascularised iliac bone grafts harvested to reconstruct different parts of the mandible. We used the Harris Hip Score to evaluate objectively the long-term postoperative morbidity at the donor site. Of 54 patients, 20 were female (37%) and 34 male (63%), with a mean age of 49 years (range 12-81). The causes of the bony defects were malignancy (n=37, 69%), benign tumours (n=7, 13%), osteomyelitis (n=9, 17%), and atrophy of the alveolar ridge (n=1, 2%). All transplants healed adequately. A total of 38/52 patients (73%) had a score of more than 80 points, which defines clinical success. Vascularised iliac bone grafts offer excellent bony dimensions with optimal shape to be used for reconstruction of different parts of the mandible. They can be harvested bicortically, including the iliac crest and the ASIS, with acceptable morbidity at the donor site. The Harris Hip Score is an appropriate tool for the evaluation of long-term impairment at the donor site after the harvest of vascularised iliac bone grafts, and it could be used to compare the results of different studies.

Five years follow-up of implant-prosthetic rehabilitation on a patient after mandibular ameloblastoma removal and ridge reconstruction by fibula graft and bone distraction

This case report presents a combination of surgical and prosthetic solutions applied to a case of oral implant rehabilitation in post-oncologic reconstructed mandible. Bone resection due to surgical treatment of large mandibular neoplasm can cause long-span defects. Currently, mandibular fibula free flap graft is widely considered as a reliable technique for restoring this kind of defect. It restores the continuity of removed segment and re-establishes the contour of the lower jaw. However, the limited height of grafted fibula does not allow the insertion of regular length implants, therefore favouring vertical distraction osteogenesis as an important treatment choice. This report presents a patient affected by extensive mandibular ameloblastoma who underwent surgical reconstruction by fibula free flap because of partial mandibular resection. Guided distraction osteoneogenesis technique was applied to grafted bone, in order to obtain adequate bone height and to realize a prosthetically guided placement of 8 fixtures. After osseointegration, the patient was rehabilitated with a full arch, screw-retained prosthetic restoration. At five-years follow up, excellent integration of grafted tissue, steady levels of bone around the fixtures and healthy peri-implant tissues were reported.

Dental implants after reconstruction with free tissue transfer

The transfer of composite tissue flaps by microvascular techniques has become the standard for reconstructing complex defects of the oral and maxillofacial regions. Despite advances in these techniques, sites reconstructed by free tissue transfer (free flaps) are often compromised by scarring, bulky tissue, and altered architecture. Dental rehabilitation is often impossible without endosseous implants to aid in stabilization and retention of prostheses. The most commonly used free flaps, however, have significant shortcomings with regard to implant placement, prosthetics, and maintenance. This article describes some site development and prosthetic techniques that can be applied to improve outcomes when dental implants are used in conjunction with free flap reconstruction.

Comparative study of the osseointegration of dental implants after different bone augmentation techniques: vascularized femur flap, non-vascularized femur graft and mandibular bone graft

OBJECTIVES

The purpose of this study was to evaluate the osseointegration of the dental implants placed into the mandible augmented with different techniques in pigs.

MATERIAL AND METHODS

Four adult domestic pigs were used. Horizontal augmentation of the mandible was performed in animals by using vascularized femur flap (VFF), non-vascularized femur graft (NVFG) and monocortical mandibular block graft (MG). After 5 months of healing 10 dental implants were placed into each augmented site. The pigs were sacrificed after 3 months of healing. Undecalcified sections were prepared for histomorphometric analysis.

RESULTS

Mean bone-implant contact (BIC) values for implants placed into MG, NVFG and VFF were 57.38 ± 11.97%, 76.5 ± 7.88%, 76.53 ± 8.15%, respectively. The BIC values of NVFG and VFF group were significantly greater than MG group (P<0.001). On the other hand, there was not statistically significant difference between NVFG group and VFF group (P=0.999).

CONCLUSION

NVFG as well as VFF can be considered as a promising method for augmentation of alveolar defects and the placement of the implants. The selection of non-vascularized graft or vascularized flap depends on the condition of the recipient site.

Biomechanics of mandibular reconstruction: a review

Knowledge of the biomechanics of the mandible allows the surgeon to understand the forces acting on the mandible during function and the resulting deformation that can occur. This allows the appropriate selection and placement of osteosynthesis plates to neutralize these forces. Many methods have been proposed for mandibular reconstruction, each of which has strengths and weaknesses. Most papers evaluating these techniques have focused on survival rates and the quality of the grafted bones, and there have been few studies of the biomechanics (stress distribution and strength) of the various types of reconstructed mandibles. This paper reviews the biomechanics of the mandible and the various methods of reconstruction reported in past studies.

Microvascular Reconstruction of the Pediatric Mandible

BACKGROUND

Free tissue transfer for adult mandibular reconstruction is a well-established technique; however, there are few reports of pediatric microvascular lower jaw reconstruction.

METHODS

This retrospective study was undertaken to review the range of indications, choices, safety, and efficacy of pediatric free tissue transfer to the lower jaw. All patients underwent a parascapular, scapular, or fibula free tissue transfer. Flap choice was based on preoperative clinical examination, radiographic findings, need for linear or multiplanar mandibular reconstruction, need for dental restoration, severity of soft-tissue deficit, and peroneal artery anatomy.

RESULTS

Over a 10-year period (1989 to 1999), we performed eight free tissue transfers to reconstruct the mandibles of seven children, aged 6 to 17 years. Indications included radiation-induced hypoplasia (n = 1), postsurgical resection of fibrous dysplasia (n = 1), hemifacial microsomia (n = 3), Robin sequence with severe micrognathia (n = 1), and osteomyelitis (n = 1). The authors transferred four parascapular osseocutaneous, two scapular osseocutaneous, one fibular osseocutaneous, and one fibular osseous flap to reconstruct five ramus, four condyle, and two subtotal mandibular defects. All bony defects were successfully bridged and all osseous flaps successfully integrated. Postoperatively, mandibular symmetry and Angle class I occlusion were restored in all patients throughout the 10.5-year follow-up period (range, 9 to 14 years). Two patients received osseointegrated dental implants. Our only complication was the partial loss of a skin paddle.

CONCLUSION

Microvascular reconstruction of the pediatric mandible, in selected patients, is a safe, reliable procedure that provides the bone stock and soft tissue necessary to restore normal maxillomandibular growth and dental rehabilitation.

Scapular angle osteomyogenous flap in postmaxillectomy reconstruction: Defect, reconstruction, shoulder function, and harvest technique

BACKGROUND

Maxillary reconstruction continues to challenge in terms of optimal aesthetic and functional outcomes. The aim of this study was to describe the utility of the scapular angle osteomyogenous flap in a series of maxillectomy patients and to examine the donor site morbidity.

METHODS

This is a retrospective series of 14 patients undergoing maxillectomy and either primary or secondary reconstruction. The scapular angle can be oriented vertically and horizontally. Aesthetic, functional, and operative morbidity is described. The Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire was used to examine shoulder and upper limb morbidity.

RESULTS

Perioperative morbidity occurred in 4 patients. There were no free flap failures. Functional and aesthetic outcomes were acceptable with all patients having intelligible speech and none requiring nutritional supplementation. The DASH was completed by 12 of 14 patients. The mean and median DASH scores were 10.6 and 13, respectively. All patients gained full range of shoulder movement by 6 months after surgery.

CONCLUSIONS

The scapular angle flap is well suited for maxillary reconstruction and donor site morbidity is low.

Clinical Evaluation of Endosseous Implants in Nonvascularized Fibula Bone Grafts for Reconstruction of the Severely Atrophied Mandibular Bone

PURPOSE

The purpose of the present study was to assess changes in graft height after augmentation of the severely atrophied mandibula with the use of avascular fibula bone grafts, as well as evaluation of the clinical success of endosseous implants placed in the grafted mandibula.

PATIENTS AND METHODS

This retrospective study included 10 patients with a mean observation period of 31 months (range, 3 to 76 months). A total of 40 implants were placed. Clinical criteria included implant success, graft success, and crestal bone resorption.

RESULTS

The grafting procedure was successfully performed in all patients. All implants were integrated, 2 implants could not be used for prosthetic rehabilitation. One implant was lost 2 years after abutment connection. The maximum bone resorption of 7.21% (+/- 2.7%) was seen within the first year; no significant resorption was seen thereafter.

CONCLUSION

In this clinical and radiographic evaluation, it was found that nonvascular fibula graft is a reliable material for augmentation procedures. The resorption takes place within the first year after augmentation. The possibility of improving the clinical results in bone grafting situations with avascular fibula grafts will be further evaluated in a prospective follow-up study providing long-term assessment of this procedure.

Clinical outcome of dental implants placed in fibula-free flaps used for the reconstruction of maxillo-mandibular defects following ablation for tumors or osteoradionecrosis

OBJECTIVES

(a) To evaluate the clinical outcome of fibula revascularized flaps used for the reconstruction of maxillary and mandibular defects due to resection for tumors or osteoradionecrosis and (b) to evaluate the survival and success rates of implants placed in the reconstructed areas.

MATERIAL AND METHODS

In a 8-year period (1995-2002), 59 patients, 38 males and 21 females, aged from 13 years to 69 years (mean age: 48.7 years), presenting with maxillary and mandibular defects due to resection for tumors or osteoradionecrosis, were reconstructed with fibula-free flaps. Of the 59 patients, 16 received 71 implants for the prosthetic rehabilitation of the reconstructed edentulous areas.

RESULTS

Out of 59 fibula-free flaps, three failed and had to be removed, nine underwent partial necrosis involving the bone segment and/or the skin paddle but survived, while the remaining 47 healed uneventfully. The mean follow-up of patients after the reconstruction was 55 months (range: 24-120 months). The cumulative survival rate of fibula-free flaps was 94.9%. The mean follow-up of the 16 patients treated with dental implants and implant-supported prostheses was 50.2 months (range: 24-96 months). The cumulative implant success and survival rates of implants were 98.6% and 93.1% respectively.

CONCLUSION

The reconstruction of maxillo-mandibular defects following ablation for tumors or osteoradionecrosis with fibula-free flaps has been demonstrated to be a reliable technique with good long-term results. Implants placed in the reconstructed areas were demonstrated to integrate normally, with success and survival rates comparable to those obtained in case of implants placed in native bone.

Developments in reconstruction of midface and maxilla

Loss of the maxilla and midfacial structures after tumour removal has substantial functional and aesthetic consequences. The variable loss of soft tissue, bone, or both, leading to collapse of the lip, cheek, periorbital soft tissues, and palatal competence present a challenging dilemma for reconstructive surgeons. Efforts have been made to classify these midfacial defects and provide appropriate algorithms for optimum reconstruction. Not only does the cavity need to be obliterated and midfacial contours recreated, but swallowing function, phonation, and mastication need to be restored for an ideal result. Traditionally, these defects would have been repaired by a maxillofacial prosthesis but advances in tissue transfers, particularly of microvascular free flaps, have greatly increased reconstructive options. The wide variety of free flaps that contain both soft tissue and bone offer unique properties that could be applicable depending on the defect. Combinations of free tissue transfer, local flaps, and maxillofacial prostheses might achieve a more ideal result than one technique alone. Advances in osseointegration have also enhanced the ability to achieve the best function and form. No one flap or technique is sufficient to reconstruct midface defects in all patients. The choices should be tailored to the bony and soft-tissue needs of each specific defect, denture-bearing potential of the original tissues, and available prosthodontic support. Use of a multidisciplinary approach to reconstruct these defects can yield excellent results. The complexity of the techniques should match the desired goals and needs of each individual patient.

Choice of osseous and osteocutaneous flaps for mandibular reconstruction

Microvascular free flap transfer currently represents one of the most popular methods for mandibular reconstruction. With the various free flap options now available, there is a general consensus that no single kind of osseous or osteocutaneous flap can resolve the entire spectrum of mandibular defects. A suitable flap, therefore, should be selected according to the specific type of bone and soft tissue defect. We have developed an algorithm for mandibular reconstruction, in which the bony defect is termed as either "lateral" or "anterior" and the soft-tissue defect is classified as "none," "skin or mucosal," or "through-and-through." For proper flap selection, the bony defect condition should be considered first, followed by the soft-tissue defect condition. When the bony defect is "lateral" and the soft tissue is not defective, the ilium is the best choice. When the bony defect is "lateral" and a small "skin or mucosal" soft-tissue defect is present, the fibula represents the optimal choice. When the bony defect is "lateral" and an extensive "skin or mucosal" or "through-and-through" soft-tissue defect exists, the scapula should be selected. When the bony defect is "anterior," the fibula should always be selected. However, when an "anterior" bone defect also displays an "extensive" or "through-and-through" soft-tissue defect, the fibula should be used with other soft-tissue flaps. Flaps such as a forearm flap, anterior thigh flap, or rectus abdominis musculocutaneous flap are suitable, depending on the size of the soft-tissue defect.

Oral rehabilitation after treatment for head and neck malignancy

BACKGROUND

Advances in the management of oral malignancy have resulted in significant improvements in survival and functional outcome. Ablation of oral tissues and radiotherapy render many patients unable to wear conventional prostheses, and these patients are, thus, candidates for oral rehabilitation with osseointegrated implants. We aim to present outcomes and complications of such treatment over a 14-year period in a single unit.

METHODS

Data were collected for 81 consecutive patients, most of whom had received microvascular free flap reconstruction after surgical ablation of oral squamous cell carcinoma. Three hundred eighty-six implants were placed after a delay of 12 months after surgery. Sixty-five percent of implants were placed in the anterior mandible. Radiotherapy was used in 47% of the patients, and hyperbaric oxygen treatment was routinely used in irradiated subjects during the latter half of the series. Retrospective analysis of implants and prostheses was made by use of case notes, radiographs, and a computerized database.

RESULTS

Data are presented for 364 of the 386 implants in 77 of the 81 patients after a median follow-up of 4 years. Two hundred sixty-five (73%) of the implants were in function supporting prostheses, 56 (15%) had been lost, and 43 (12%) were present but not loaded (ie, "sleepers"). Implant loss seemed patient specific and was also correlated with host bone type. Thirteen percent of patients in whom implants were placed in the mandible lost at least one implant, and the equivalent values for the maxilla was 40%. Thirty-six percent of patients in whom implants were placed in bone graft or flap lost at least one implant. The effects of implant manufacture, dimensions, radiotherapy, and hyperbaric oxygen did not reach statistical significance in this series. Cases of a second primary malignancy were noteworthy; however, the impact of recurrence was minimized by the delay between resection and rehabilitation. Of the 42 fixed and 29 removable prostheses fitted, 12 (17%) failed.

CONCLUSIONS

Implants placed in mandible were reliable, but failure rates in vascularized bone graft and maxilla were higher. Radiotherapy did not seem to prejudice implant survival, and hyperbaric oxygen had no demonstrable benefit in this series. Despite some persistent soft tissue problems and implant loss, most patients reached a successful prosthetic and functional outcome.

Use of Fibula-Free Tissue Transfer With Preoperative 2-Vessel Runoff to the Lower Extremity

OBJECTIVE

To present our experience with fibula-free tissue transfer in patients with documented 2-vessel runoff to the lower extremity on preoperative angiography.

METHODS

A case series of 16 patients with segmental mandibular defects reconstructed with a fibula-free flap by the senior author with 100% stenosis of the anterior or posterior tibial arteries were retrospectively reviewed for radiographic data and complications.

RESULTS

All flaps performed were successful, and there were no donor site complications. Angiography documented flow of contrast to the foot by a patent anterior or posterior tibial artery in all patients. Occlusive arteriosclerotic disease was identified in the anterior tibial artery in 10 patients and in the posterior tibial artery in 6 patients.

CONCLUSIONS

Using our specific criteria, we experienced no complications with the use of a fibula-free flap in extremities with 100% obstructive vascular disease in the anterior or posterior tibial artery. Preoperative angiography is indicated to select appropriate candidates for fibula-free tissue transfer with 2-vessel lower extremity runoff to avoid potential donor site ischemic complications.

The use of implant retained mandibular prostheses in the oral rehabilitation of head and neck cancer patients. A review and rationale for treatment planning

Surgical treatment of malignancies in the oral cavity (tongue, floor of the mouth, alveolus, buccal sulcus, oropharynx) often results in an unfavourable anatomic situation for prosthodontic rehabilitation. The outcome is a severe disturbance of oral functioning despite the improved surgical techniques for reconstruction that are currently available. Radiotherapy, which often is applied postsurgically, worsens oral functioning in many cases. Main problems that may hamper proper prosthodontic rehabilitation of these patients include a severe reduction of the neutral zone, an impaired function of the tongue, and a very poor load-bearing capacity of the remaining soft tissues and mandibular bone. Many of these problems can, at least in part, be diminished by the use of endosseous oral implants. These implants can contribute to the stabilisation of the prostheses and intercept the main part of the occlusal loading. Surgical interventions after radiotherapy are preferably avoided because of compromised healing, which may lead to development of radionecrosis of soft tissues and bone as well as to increased implant loss. If surgical treatment after radiotherapy is indicated, measures to prevent implant loss and development of radionecrosis have to be considered e.g. antibiotic prophylaxis and/or pre-treatment with hyperbaric oxygen (HBO). To avoid this problem, implant insertion during ablative surgery has to be taken into consideration if postoperative radiotherapy is scheduled or possibly will be applied. This approach is in need of a thorough pre-surgical examination and multidisciplinary consultation for a well-established treatment planning. The primary curative intent of the oncological treatment and the prognosis for later prosthodontic rehabilitation have to be taken into account too.

The use of free fibular flap for functional mandibular reconstruction

PURPOSE

The purpose of this investigation is to document our experience using the free vascularized fibular flap for comprehensive reconstruction of discontinuity defects in the mandible, after combined resections of malignant and aggressive odontogenic tumors, with special emphasis on functional aspect of the reconstruction process.

MATERIALS AND METHODS

The study group consisted of consecutive patients treated for reconstruction of discontinuity defects of the mandible, using the fibular vascularized free flap, between 1997-2002. All procedures were performed in the same hospital and by the same surgical team.

RESULTS

A total of 13 patients (9 males, 4 females) were treated in our department in a period of 6 years for reconstruction of discontinuity mandibular defects using the free fibula vascularized flap. Wound healing disturbances at the donor site occurred in 4 cases. Two flaps were lost, 1 because of total failure in a patient who was heavily irradiated because of osteosarcoma, the other because of resorption of the bone tissue transfer in a case of total avulsion of the mandible caused by a fall from height.

CONCLUSION

Fibula free vascularized flap is a safe and reliable method for comprehensive functional and esthetic mandibular defect reconstruction. Our protocol has a significant impact on preserving the patients quality of life.

Reconstruction mandibulaire : les lambeaux microchirurgicaux de crête iliaque et péroné

Reconstruction of the mandible osseous defects following radical ablation is usually carried out by means of vascularized f. Plapsossible donor sites often include fibula, radius, scapula and iliac crest. In the present report, we raise our experience of 45 cases of osseous reconstruction of the mandible utilizing the iliac crest (35 patients) and the fibula (10 patients). Patients were selected to this study based on the presence of purely osseous defects and evaluated functionally after the inclusion the osseous integrated implants.

Oral rehabilitation after mandibular reconstruction using an osteocutaneous fibula free flap with endosseous implants

BACKGROUND

The development of endosseous implants and free vascularized bone grafting has permitted increased possibilities of oromandibular reconstruction in patients with oral cancer. In this study, a concept combining surgical and prosthodontic treatments for mandibular fibula free flap reconstruction after tumor surgery was made based on a classification of bone defects. A follow-up study was performed to evaluate the treatment concept for oral rehabilitation in order to identify possible factors which may influence the functional result.

MATERIAL AND METHODS

A follow-up examination included 28 patients who underwent the ablative tumor surgery and mandibular reconstruction during a 4-year period. The follow-up protocol included clinical examination, radiological evaluation, and an interview using a standardized questionnaire. The timing of the study was set to allow for a minimum 2-year follow-up (mean 45 months).

RESULTS AND CONCLUSION

At the time of examination, prosthesis-based oral rehabilitation was completed in six patients (21%), and the prosthodontic work was still unfinished in four other patients. The other 18 had no dental prosthetic rehabilitation. Thirteen patients received a total of 37 oral implants, and 23 implants were functionally loaded. No implant loss was recorded. Oral functions such as speech, diet tolerance and oral competence were not directly affected by the presence of dentures. A decisive factor affecting the oral function was the extent of soft-tissue loss. According to the classification described here, the extent of the mandibular defect did not correlate with oral functions. The application of oral implants seemed to be advantageous for the oral rehabilitation of patients who had undergone intraoral resections.

Longitudinal health-related quality of life after mandibular resection for oral cancer: a comparison between rim and segment

BACKGROUND

Mandibular resection for oral cancer is often necessary to achieve an adequate margin of tumor clearance. Segmental mandibulectomy has been associated with a poor health-related quality of life (HRQOL), particularly before composite free tissue transfer to reconstruct the defect. Little is published in the literature contrasting the subjective deficit of segmental compared with rim resection. The aim of this study was to use a validated head and neck HRQOL questionnaire to compare rim and segmental mandibular resection in patients having primary surgery for oral cancer.

METHOD

There were 224 consecutive patients between 1995 and 1999 who were treated by primary surgery for oral squamous cell carcinoma. One hundred twenty-tree had no mandibular resection, 44 had a rim resection, and 57 had a segmental resection. The University of Washington Quality of life questionnaire (UW-QOL) was administered before treatment, at 6 months, 12 months and after 18 months.

RESULTS

Preoperatively, patients undergoing segmental resection reported significantly more pain, chewing problems, and a lower composite UW-QOL score. Postoperatively, the segment group tended to score worse at all time points, particularly in appearance, swallowing, recreation, and chewing; however, the difference between rim and segment was only seen in smaller resections without adjuvant radiotherapy. Little difference was seen between rim or segment for tumors < 4 cm with radiotherapy and between rim and segments for tumors > 4 cm.

CONCLUSION

After segmental mandibulectomy and reconstruction using composite free tissue transfer, the UW-QOL scores were relatively good. The only 2 difference between rim and segments was noted in the small resections without radiotherapy, and some of this was reflected in differences at baseline.

Oromandibular reconstruction with vascularized free flaps: A review of 50 cases

Fifty cases of oromandibular reconstruction using vascularized free flaps to evaluate functional parameters of results were evaluated. There were 23 iliac crest flaps, 17 fibula flaps, 30 ulnar forearm flaps, and 3 radial forearm flaps with bone. Thirteen female and 37 male patients comprised the study, with a mean age of 57.66 years. Squamous-cell carcinoma (SCC) constituted 86% of cases, of which 60% were T4 lesions and 13.9% were recurrent. Anterolateral mandibular defects constituted 48.7%, and the mean bone gap was 8.13 cm. Functional evaluation was based on the University of Washington Questionnaire (UWQ) through phone calls and personal communication. The mean hospital stay was 12.42 days. The external carotid (75%) and facial (18.3%) were the main recipient arteries. The internal jugular (47.05%) was the main recipient vein. Overall flap survival was 95.9%. Three flaps were lost due to unsalvageable venous thrombosis. Major local complications such as partial flap loss, hematoma, and orocervical fistula constituted 10% of cases. Speech was classified as "excellent" and "good" in 43.3% of cases. Swallowing was identified as "excellent" and "good" in 53.3% of cases. Cosmetic acceptance was rated "good" in 63.3% of cases. Vascularized free flap reconstruction of oromandibular defects provides excellent functional and aesthetic results. The majority of patients are able to tolerate a regular diet. Intelligible speech and acceptable appearance are restored, providing patient satisfaction.

Comparison of miniplates and reconstruction plates in mandibular reconstruction

BACKGROUND

The aim of this study is to compare complication rates of miniplates versus reconstruction plates in the fixation of vascularized grafts into segmental mandibular defects.

METHODS

Retrospective analysis of 143 consecutive successful microvascular composite flaps performed between 1993 and 2001 was performed. Data were gathered from a computerized database, case notes and pathology reports. Complications were classified as dehiscence, infection, plate or bone removal.

RESULTS

In the series, 49% of patients received miniplates, and 51% received plates. No significant differences in complication rates were found between those grafts fixed with miniplates (27%) and those with reconstruction plates (30%). Plate choice was primarily determined by consultant preference. No significant differences were found in patient, defect, treatment, or follow-up characteristics between the plate groups. Twenty-nine percent of patients had at least one late complication at the reconstructed site, and this was higher (39%) in those who had postoperative radiotherapy.

CONCLUSIONS

No evidence was found in this study that the increased rigidity offered by reconstruction plates influences the rate of plate or bone removal, infection, or plate exposure. Thus, the decision to use reconstruction or miniplates is not dependent on the rate of plate complications.

Functional Rehabilitation of the Atrophic Mandible and Maxilla with Fibula Flaps and Implant-Supported Prosthesis

Historically, nonvascularized bone grafts have been the standard treatment for severe mandibular and maxillary atrophy, followed by immediate or delayed implant placement. Extreme atrophy is an unfavorable biological and mechanical location for nonvascularized autologous bone transplants. The authors present the results of a multidisciplinary treatment protocol for rehabilitation of extreme mandibular and maxillary atrophy by use of the vascularized fibular flap. This protocol includes bone augmentation, implant surgery, soft-tissue management, and prosthetic restoration. Since 1993, 18 patients with a mean age of 47.5 years presented with extreme mandibular and/or maxillary atrophy and underwent alveolar crest augmentation with vascularized fibular flaps. Bone healing was achieved in 17 of the 18 patients. Seventy-three osteointegrated implants were inserted in 12 of 17 fibular flaps. Altogether, 62 implants were loaded and 11 dental prostheses were made. Average follow-up of the loaded implants was 41 months. The success rate of loaded implants was 100 percent. The authors strongly recommend the use of the fibular bone flap when dealing with extreme atrophy of the mandible and maxilla and suggest the protocol outlined in this review.

[Oromandibular reconstruction with free peroneal flap and osseointegrated implants]

Free fibula flaps have proved to be one of the most versatile for oromandibular reconstruction due to the available length of bone and the possibility of incorporating a long skin paddle to cover intraoral soft tissues. The use of a osseointegrated dental implants is an important technique for the oral rehabilitation of these patients. Osseointegrated implants provide the most rigid prosthetic stabilization available to withstand masticatory forces. These implants can be placed immediately or in second time procedure. In our case, implantation in the fibula free flap is done after 6-9 months because of the large amount of osteosynthesis material required for the fixation of the flap. Four or six months later, when osseointegration has taken place, the implants are loaded with a dental rehabilitation. We analize 10 cases of mandibular reconstruction with fibula free flap and their aesthetic and functional rehabilitation with osseointegrated implants with a 2 year follow up. Forty-six dental implants were placed developing all of them but one a correct osseointegration. All these patients recovered masticatory function and underwent a considerable improvement in labial competence, salivary continence, speech articulation and facial harmony.

An anatomical study of vascularized iliac bone grafts for dental implantation

PURPOSE

The purpose of this study was to clarify the anatomical features of vascularized iliac bone grafts used for mandibular reconstruction and dental implantation.

MATERIAL AND METHOD

Twenty-six cadavers were dissected to examine vessels and areas of iliac bone that could be used as pedicles and grafts. The length and diameter of vessels of the vascular pedicle were determined, and the length and depths of the iliac bone were measured with respect to points determined by the relative dimensions of the bone.

RESULTS

The deep circumflex iliac arteries were classified as double nutrient type (75%), iliac-crest type (19%), or iliacus-muscle type (6%). The mean arterial length was 64+/-15 mm in the double nutrient type. The mean internal diameters at the origin of the deep circumflex iliac artery and vein that could be used for anastomosis were 1.7+/-0.4 mm and 2.1+/-0.7 mm respectively. The greatest mean cross-sectional width and height were 18+/-3 and 42+/-5 mm respectively. The greatest mean cross-sectional cortical thickness at the intermediate line of the iliac crest was 3.4+/-0.8 mm.

CONCLUSION

These results should be useful in designing bone grafts for mandibular reconstruction followed by dental implantation.

Stability of dental implants in microvascular osseous transplants

Microvascular iliac crest and scapula transplants have been used in reconstruction of the lower jaw following tumor surgery. It has only been with the insertion of dental implants that a satisfactory prosthetic rehabilitation of the patient has been achieved. For this study, a follow-up of 38 patients with lower jaw tumors was carried out. The patients had been treated with partial resection of the lower jaw and neck dissection with microvascular iliac crest transplants (n = 20) or microvascular scapula transplants (n = 18); this was followed with dental implants (n = 143) in the region of the transplants or the local lower jaw. One hundred thirty-nine of the 143 dental implants were loaded by prosthetic superstructures. In all patients, the implant situation was evaluated on average 2 years 5 months after implantation. Periotest values, periimplant probing depths, and contact bleeding were registered, and the extent of periimplant bone loss was defined radiographically. The clinical situation in the region of the implant was compared for both types of implants and also with the nonresected lower jaw. The average Periotest values were within the normal range for all groups. In one scapula implant, however, a better average of Periotesting, -3.3, was found compared with implants of the iliac crest with Periotest values of -0.7. A measurement of -2.1 was found for the local lower jaw, similar to that of scapula implants. Pathologic probing depths were found for all three compared groups. The radiographically determined vertical loss of bone was the same for all three groups, on average 1 mm at 27 months postoperatively. The highest incidence of sulcus bleeding was found in the scapula implant group. Thus, it can be stated that the scapula transplants provide a similar transplant site to local lower jaw bone, whereas implants in iliac crest transplants show lesser bony stability. Periimplant soft-tissue conditions are worse for both types of transplants compared with local tissue of the lower jaw.

Mandibular reconstruction using microvascular free flaps: a statistical analysis of 178 cases

For this article, 178 consecutive cases of mandibular reconstruction using microvascular free flaps and performed from 1979 to 1997 were studied. The purpose of this report is to compare flap success rates, complications, and aesthetic and functional results. The ages of the 131 men and 47 women ranged from 13 to 85 years, with an average of 55 years. Donor sites included the rib (11 cases), radius (one case), ilium (36 cases), scapula (51 cases), fibula (34 cases), and soft-tissue flaps with implant (45 cases). Complications included total flap necrosis, partial flap necrosis, major fistula formation, and minor fistula formation. The rate of total flap necrosis involving the ilium and fibula was significantly higher than that of all other materials combined (p < 0.05). The overall rate of implant plate removal, which resulted from the exposure or fracture of the plate, was 35.6 percent (16 of 45 cases). Each mandibular defect was classified by the extent of the bony defect and by the extent of the soft-tissue defect. The extent of the mandibular bony defect was classified according to the HCL method of Jewer et al. The extent of the soft-tissue defect was classified into four groups: none, skin, mucosal, and through-and-through. According to these classifications, functional and aesthetic assessments of deglutition and contour were performed on 115 subjects, and speech was evaluated in 110. To evaluate the postoperative results, points were assigned to each assessment of deglutition, speech, and mandibular contour. Statistical analysis between pairs of bone-defect groups revealed that there was no significant difference in each category. Regarding deglutition, statistical analysis between pairs of soft-tissue-defect groups revealed there were significant differences (p < 0.05) between the none and the mucosal groups and also between the none and the through-and-through groups. Regarding speech, there was a significant difference (p < 0.05) between the none and the through-and-through groups. Regarding contour, there were significant differences (p < 0.01) between the none and the through-and-through groups and between the mucosal and the through-and-through groups. The points given for each function, depending on the reconstruction material, revealed that there was no significant difference between pairs of material groups. From this prospective study, the authors have developed an algorithm for oromandibular reconstruction. When the bony defect is lateral, the ilium, fibula, or scapula should be chosen as the donor site, depending on the extent of the soft-tissue defect. When the bony defect is anterior, the fibula is always the best choice. When the soft-tissue defect is extensive or through-and-through with an anterior bony defect, the fibula should be used with other soft-tissue flaps.

Retrospective case series of primary and secondary microvascular free tissue transfer reconstruction of midfacial defects

STATEMENT OF PROBLEM

Midfacial defects arising from tumor extirpation or trauma may involve any portion of the central area of the face, including the palate, maxilla, orbit, lip, and/or nose. Speech, mastication, swallowing, and cosmesis are significantly impaired and present a unique challenge to the reconstructive surgeon.

PURPOSE

This study evaluated the functional and cosmetic success of both soft tissue and osteocutaneous free flap reconstruction of the midface.

MATERIAL AND METHODS

A retrospective chart review of 34 patients who underwent primary and secondary free flap reconstruction of the midface was conducted. The main outcome measures were perioperative complications, diet, speech intelligibility, type of dental restoration, and cosmetic result.

RESULTS

Fifteen patients underwent soft tissue free flap reconstruction of the midface. Six of these patients also had additional nonvascularized free cranial bone grafts to improve restoration of the orbitozygomatic region. Nineteen patients who might have required osseointegrated implants to anchor a dental prosthesis underwent osteocutaneous free flap reconstruction. Thirty-three of 34 free flaps survived, and wound complications were minimal. After surgery, 20 patients were able to eat a regular diet and 14 a soft diet. All patients had intelligible speech over the telephone. Ten patients used a dental prosthesis (5 conventional and 5 implant-borne). Cosmesis was judged to be excellent in 12 patients, good in 15 patients, fair in 5 patients, and poor in 2 patients.

CONCLUSION

In the patients reviewed, free flap reconstruction of the midface was completed in a single stage and created a reproducible, permanent separation of the oral and sinonasal cavities with adequate speech and swallowing.