Reconstruction of Mandibular Defects

ABSTRACT

Defects requiring reconstruction in the mandible are commonly encountered and may result from resection of benign or malignant lesions, trauma, or osteoradionecrosis. Mandibular defects can be classified according to location and extent, as well as involvement of mucosa, skin, and tongue. Vascularized bone flaps, in general, provide the best functional and aesthetic outcome, with the fibula flap remaining the gold standard for mandible reconstruction. In this review, we discuss classification and approach to reconstruction of mandibular defects. We also elaborate upon four commonly used free osteocutaneous flaps, inclusive of fibula, iliac crest, scapula, and radial forearm. Finally, we discuss indications and use of osseointegrated implants as well as recent advances in mandibular reconstruction.

KEYWORDS

Bone flap - condyle - fibular flap - mandible - osseointegrated implant - osteocutaneous flap

REFERENCES

• 1 Griffin C J, Hawthorn R, Harris R. Anatomy and histology of the human temporomandibular joint.  Monogr Oral Sci. 1975;  4 1-26
• 2 Miller M J, Schusterman M A. Secondary deformities following mandibular reconstruction.  Clin Plast Surg. 1997;  24 551-563
• 3 Jewer D D, Boyd J B, Manktelow R T et al.. Orofacial and mandibular reconstruction with the iliac crest free flap: a review of 60 cases and a new method of classification.  Plast Reconstr Surg. 1989;  84 391-403 discussion 404-405
• 4 Hidalgo D A, Pusic A L. Free-flap mandibular reconstruction: a 10-year follow-up study.  Plast Reconstr Surg. 2002;  110 438-449 discussion 450-451
• 5 Takushima A, Harii K, Asato H, Nakatsuka T, Kimata Y. Mandibular reconstruction using microvascular free flaps: a statistical analysis of 178 cases.  Plast Reconstr Surg. 2001;  108 1555-1563
• 6 Cordeiro P G, Disa J J, Hidalgo D A, Hu Q Y. Reconstruction of the mandible with osseous free flaps: a 10-year experience with 150 consecutive patients.  Plast Reconstr Surg. 1999;  104 1314-1320
• 7 Anthony J P, Foster R D, Kaplan M J, Singer M I, Pogrel M A. Fibular free flap reconstruction of the “true” lateral mandibular defect.  Ann Plast Surg. 1997;  38 137-146
• 8 Wei F C, Celik N, Yang W G, Chen I H, Chang Y M, Chen H C. Complications after reconstruction by plate and soft-tissue free flap in composite mandibular defects and secondary salvage reconstruction with osteocutaneous flap.  Plast Reconstr Surg. 2003;  112 37-42
• 9 Shpitzer T, Gullane P J, Neligan P C et al.. The free vascularized flap and the flap plate options: comparative results of reconstruction of lateral mandibular defects.  Laryngoscope. 2000;  110 2056-2060
• 10 Schusterman M A, Reece G P, Kroll S S, Weldon M E. Use of the AO plate for immediate mandibular reconstruction in cancer patients.  Plast Reconstr Surg. 1991;  88 588-593
• 11 Blackwell K E, Buchbinder D, Urken M L. Lateral mandibular reconstruction using soft-tissue free flaps and plates.  Arch Otolaryngol Head Neck Surg. 1996;  122 672-678
• 12 Cordeiro P G, Hidalgo D A. Soft tissue coverage of mandibular reconstruction plates.  Head Neck. 1994;  16 112-115
• 13 Mariani P B, Kowalski L P, Magrin J. Reconstruction of large defects postmandibulectomy for oral cancer using plates and myocutaneous flaps: a long-term follow-up.  Int J Oral Maxillofac Surg. 2006;  35 427-432
• 14 Maurer P, Eckert A W, Kriwalsky M S, Schubert J. Scope and limitations of methods of mandibular reconstruction: a long-term follow-up.  Br J Oral Maxillofac Surg. 2010;  48 100-104
• 15 van Gemert J T, van Es R J, Van Cann E M, Koole R. Nonvascularized bone grafts for segmental reconstruction of the mandible—a reappraisal.  J Oral Maxillofac Surg. 2009;  67 1446-1452
• 16 Foster R D, Anthony J P, Sharma A, Pogrel M A. Vascularized bone flaps versus nonvascularized bone grafts for mandibular reconstruction: an outcome analysis of primary bony union and endosseous implant success.  Head Neck. 1999;  21 66-71
• 17 Mosahebi A, Chaudhry A, McCarthy C M et al.. Reconstruction of extensive composite posterolateral mandibular defects using nonosseous free tissue transfer.  Plast Reconstr Surg. 2009;  124 1571-1577
• 18 Hanasono M M, Zevallos J P, Skoracki R J, Yu P. A prospective analysis of bony versus soft tissue reconstruction for posterior mandibular defects.  Plast Reconstr Surg. 2010;  125 1413-1421
• 19 King T W, Gallas M T, Robb G L, Lalani Z, Miller M J. Aesthetic and functional outcomes using osseous or soft-tissue free flaps.  J Reconstr Microsurg. 2002;  18 365-371
• 20 Wei F C, Demirkan F, Chen H C, Chen I H. Double free flaps in reconstruction of extensive composite mandibular defects in head and neck cancer.  Plast Reconstr Surg. 1999;  103 39-47
• 21 Wei F C, Celik N, Chen H C, Cheng M H, Huang W C. Combined anterolateral thigh flap and vascularized fibula osteoseptocutaneous flap in reconstruction of extensive composite mandibular defects.  Plast Reconstr Surg. 2002;  109 45-52
• 22 Chen H C, Demirkan F, Wei F C, Cheng S L, Cheng M H, Chen I H. Free fibula osteoseptocutaneous-pedicled pectoralis major myocutaneous flap combination in reconstruction of extensive composite mandibular defects.  Plast Reconstr Surg. 1999;  103 839-845
• 23 Deleyiannis F W, Rogers C, Lee E et al.. Reconstruction of the lateral mandibulectomy defect: management based on prognosis and location and volume of soft tissue resection.  Laryngoscope. 2006;  116 2071-2080
• 24 Deleyiannis F W, Lee E, Gastman B et al.. Prognosis as a determinant of free flap utilization for reconstruction of the lateral mandibular defect.  Head Neck. 2006;  28 1061-1068
• 25 Urken M L, Buchbinder D, Weinberg H et al.. Functional evaluation following microvascular oromandibular reconstruction of the oral cancer patient: a comparative study of reconstructed and nonreconstructed patients.  Laryngoscope. 1991;  101 935-950
• 26 Hidalgo D A. Condyle transplantation in free flap mandible reconstruction.  Plast Reconstr Surg. 1994;  93 770-781 discussion 782-783
• 27 Wax M K, Winslow C P, Hansen J et al.. A retrospective analysis of temporomandibular joint reconstruction with free fibula microvascular flap.  Laryngoscope. 2000;  110 977-981
• 28 Umeda H, Kaban L B, Pogrel M A, Stern M. Long-term viability of the temporalis muscle/fascia flap used for temporomandibular joint reconstruction.  J Oral Maxillofac Surg. 1993;  51 530-533 discussion 534
• 29 Güzel M Z, Arslan H, Saraç M. Mandibular condyle reconstruction with inlay application of autogenous costochondral graft after condylectomy: Cerrahpaşa's technique.  J Oral Maxillofac Surg. 2007;  65 615-620
• 30 El-Sayed K M. Temporomandibular joint reconstruction with costochondral graft using modified approach.  Int J Oral Maxillofac Surg. 2008;  37 897-902
• 31 Kroll S S, Robb G L, Miller M J, Reese G P, Evans G RD. Reconstruction of posterior mandibular defects with soft tissue using the rectus abdominis free flap.  Br J Plast Surg. 1998;  51 503-507
• 32 Butler C E, Lewin J S. Reconstruction of large composite oromandibulomaxillary defects with free vertical rectus abdominis myocutaneous flaps.  Plast Reconstr Surg. 2004;  113 499-507
• 33 Wei F C, Seah C S, Tsai Y C, Liu S J, Tsai M S. Fibula osteoseptocutaneous flap for reconstruction of composite mandibular defects.  Plast Reconstr Surg. 1994;  93 294-304 discussion 305-306
• 34 Hidalgo D A, Rekow A. A review of 60 consecutive fibula free flap mandible reconstructions.  Plast Reconstr Surg. 1995;  96 585-596 discussion 597-602
• 35 Wong C H, Ong Y S, Chew K Y, Tan B K, Song C. The fibula osteoseptocutaneous flap incorporating the hemisoleus muscle for complex head and neck defects: anatomical study and clinical applications.  Plast Reconstr Surg. 2009;  124 1956-1964
• 36 Wong C H, Tan B K, Wei F C, Song C. Use of the soleus musculocutaneous perforator for skin paddle salvage of the fibula osteoseptocutaneous flap: anatomical study and clinical confirmation.  Plast Reconstr Surg. 2007;  120 1576-1584
• 37 Mojallal A, Besse J L, Breton P. [Donor site morbidity after free fibula flap. Report of 42 consecutive cases].  Ann Chir Plast Esthet. 2004;  49 3-10
• 38 O'Leary M J, Martin P J, Hayden R E. The neurocutaneous free fibula flap in mandibular reconstruction.  Otolaryngol Clin North Am. 1994;  27 1081-1096
• 39 Woerdeman L A, Chaplin B J, Griffioen F M, Bos K E. Sensate osteocutaneous fibula flap: anatomic study of the innervation pattern of the skin flap.  Head Neck. 1998;  20 310-314
• 40 Anthony J P, Rawnsley J D, Benhaim P, Ritter E F, Sadowsky S H, Singer M I. Donor leg morbidity and function after fibula free flap mandible reconstruction.  Plast Reconstr Surg. 1995;  96 146-152
• 41 Bodde E W, de Visser E, Duysens J E, Hartman E H. Donor-site morbidity after free vascularized autogenous fibular transfer: subjective and quantitative analyses.  Plast Reconstr Surg. 2003;  111 2237-2242
• 42 Sassu P, Acland R D, Salgado C J, Mardini S, Ozyurekoglu T. Anatomy and vascularization of the flexor hallucis longus muscle and its implication in free fibula flap transfer: an anatomical study.  Ann Plast Surg. 2010;  64 233-237
• 43 Jones N F, Swartz W M, Mears D C, Jupiter J B, Grossman A. The “double barrel” free vascularized fibular bone graft.  Plast Reconstr Surg. 1988;  81 378-385
• 44 Horiuchi K, Hattori A, Inada I et al.. Mandibular reconstruction using the double barrel fibular graft.  Microsurgery. 1995;  16 450-454
• 45 Wallace C G, Chang Y M, Tsai C Y, Wei F C. Harnessing the potential of the free fibula osteoseptocutaneous flap in mandible reconstruction.  Plast Reconstr Surg. 2010;  125 305-314
• 46 Iizuka T, Hallermann W, Seto I, Smolka W, Smolka K, Bosshardt D D. Bi-directional distraction osteogenesis of the alveolar bone using an extraosseous device.  Clin Oral Implants Res. 2005;  16 700-707
• 47 Schleier P, Hyckel P, Fried W et al.. Vertical distraction of fibula transplant in a case of mandibular defect caused by shotgun injury.  Int J Oral Maxillofac Surg. 2006;  35 861-864
• 48 Blackwell K E. Donor site evaluation for fibula free flap transfer.  Am J Otolaryngol. 1998;  19 89-95
• 49 Fukaya E, Grossman R F, Saloner D, Leon P, Nozaki M, Mathes S J. Magnetic resonance angiography for free fibula flap transfer.  J Reconstr Microsurg. 2007;  23 205-211
• 50 Ribuffo D, Atzeni M, Saba L et al.. Clinical study of peroneal artery perforators with computed tomographic angiography: implications for fibular flap harvest.  Surg Radiol Anat. 2010;  32 329-334
• 51 Ahmad N, Kordestani R, Panchal J, Lyles J. The role of donor site angiography before mandibular reconstruction utilizing free flap.  J Reconstr Microsurg. 2007;  23 199-204
• 52 Kelly A M, Cronin P, Hussain H K, Londy F J, Chepeha D B, Carlos R C. Preoperative MR angiography in free fibula flap transfer for head and neck cancer: clinical application and influence on surgical decision making.  AJR Am J Roentgenol. 2007;  188 268-274
• 53 Urken M L, Weinberg H, Buchbinder D et al.. Microvascular free flaps in head and neck reconstruction. Report of 200 cases and review of complications.  Arch Otolaryngol Head Neck Surg. 1994;  120 633-640
• 54 Boyd J B. The place of the iliac crest in vascularized oromandibular reconstruction.  Microsurgery. 1994;  15 250-256
• 55 Taylor G I. Reconstruction of the mandible with free composite iliac bone grafts.  Ann Plast Surg. 1982;  9 361-376
• 56 Aviv J E, Urken M L, Vickery C, Weinberg H, Buchbinder D, Biller H F. The combined latissimus dorsi-scapular free flap in head and neck reconstruction.  Arch Otolaryngol Head Neck Surg. 1991;  117 1242-1250
• 57 Swartz W M, Banis J C, Newton E D, Ramasastry S S, Jones N F, Acland R. The osteocutaneous scapular flap for mandibular and maxillary reconstruction.  Plast Reconstr Surg. 1986;  77 530-545
• 58 Coleman III J J, Sultan M R. The bipedicled osteocutaneous scapula flap: a new subscapular system free flap.  Plast Reconstr Surg. 1991;  87 682-692
• 59 Frodel Jr J L, Funk G F, Capper D T et al.. Osseointegrated implants: a comparative study of bone thickness in four vascularized bone flaps.  Plast Reconstr Surg. 1993;  92 449-455 discussion 456-458
• 60 Sullivan M J, Carroll W R, Baker S R. The cutaneous scapular free flap in head and neck reconstruction.  Arch Otolaryngol Head Neck Surg. 1990;  116 600-603
• 61 Coleman S C, Burkey B B, Day T A et al.. Increasing use of the scapula osteocutaneous free flap.  Laryngoscope. 2000;  110 1419-1424
• 62 Weinzweig N, Jones N F, Shestak K C, Moon H K, Davies B W. Oromandibular reconstruction using a keel-shaped modification of the radial forearm osteocutaneous flap.  Ann Plast Surg. 1994;  33 359-369 discussion 369-370
• 63 Thoma A, Allen M, Tadeson B H, Archibald S, Jackson S, Young J E. The fate of the osteotomized free radial forearm osteocutaneous flap in mandible reconstruction.  J Reconstr Microsurg. 1995;  11 215-219
• 64 Mounsey R A, Boyd J B. Mandibular reconstruction with osseointegrated implants into the free vascularized radius.  Plast Reconstr Surg. 1994;  94 457-464
• 65 Thoma A, Khadaroo R, Grigenas O et al.. Oromandibular reconstruction with the radial-forearm osteocutaneous flap: experience with 60 consecutive cases.  Plast Reconstr Surg. 1999;  104 368-378 discussion 379-380
• 66 Kim J H, Rosenthal E L, Ellis T, Wax M K. Radial forearm osteocutaneous free flap in maxillofacial and oromandibular reconstructions.  Laryngoscope. 2005;  115 1697-1701
• 67 Leonhardt H, Pradel W, Mai R, Markwardt J, Lauer G. Prefabricated bony radial forearm flap for secondary mandible reconstruction after radiochemotherapy.  Head Neck. 2009;  31 1579-1587
• 68 Gürlek A, Miller M J, Jacob R F, Lively J A, Schusterman M A. Functional results of dental restoration with osseointegrated implants after mandible reconstruction.  Plast Reconstr Surg. 1998;  101 650-655 discussion 656-659
• 69 Urken M L, Buchbinder D, Costantino P D et al.. Oromandibular reconstruction using microvascular composite flaps: report of 210 cases.  Arch Otolaryngol Head Neck Surg. 1998;  124 46-55
• 70 Chang Y M, Santamaria E, Wei F C et al.. Primary insertion of osseointegrated dental implants into fibula osteoseptocutaneous free flap for mandible reconstruction.  Plast Reconstr Surg. 1998;  102 680-688
• 71 Urken M L, Buchbinder D, Weinberg H, Vickery C, Sheiner A, Biller H F. Primary placement of osseointegrated implants in microvascular mandibular reconstruction.  Otolaryngol Head Neck Surg. 1989;  101 56-73
• 72 Schmelzeisen R, Neukam F W, Shirota T, Specht B, Wichmann M. Postoperative function after implant insertion in vascularized bone grafts in maxilla and mandible.  Plast Reconstr Surg. 1996;  97 719-725
• 73 Roumanas E D, Markowitz B L, Lorant J A, Calcaterra T C, Jones N F, Beumer III J. Reconstructed mandibular defects: fibula free flaps and osseointegrated implants.  Plast Reconstr Surg. 1997;  99 356-365
• 74 Teoh K H, Huryn J M, Patel S et al.. Implant prosthodontic rehabilitation of fibula free-flap reconstructed mandibles: a Memorial Sloan-Kettering Cancer Center review of prognostic factors and implant outcomes.  Int J Oral Maxillofac Implants. 2005;  20 738-746
• 75 Sclaroff A, Haughey B, Gay W D, Paniello R. Immediate mandibular reconstruction and placement of dental implants. At the time of ablative surgery.  Oral Surg Oral Med Oral Pathol. 1994;  78 711-717
• 76 Kildal M, Wei F C, Chang Y M, Chen H C, Chang M H. Mandibular reconstruction with fibula osteoseptocutaneous free flap and osseointegrated dental implants.  Clin Plast Surg. 2001;  28 403-410
• 77 Seto I, Marukawa E, Asahina I. Mandibular reconstruction using a combination graft of rhBMP-2 with bone marrow cells expanded in vitro.  Plast Reconstr Surg. 2006;  117 902-908
• 78 von Wilmowsky C, Schwarz S, Kerl J M et al.. Reconstruction of a mandibular defect with autogenous, autoclaved bone grafts and tissue engineering: an in vivo pilot study.  J Biomed Mater Res A. 2010;  93 1510-1518
• 79 Boyne P J. Application of bone morphogenetic proteins in the treatment of clinical oral and maxillofacial osseous defects.  J Bone Joint Surg Am. 2001;  83(Pt 2, Suppl 1) S146-S150
• 80 Herford A S, Boyne P J. Reconstruction of mandibular continuity defects with bone morphogenetic protein-2 (rhBMP-2).  J Oral Maxillofac Surg. 2008;  66 616-624
• 81 Warnke P H, Springer I N, Wiltfang J et al.. Growth and transplantation of a custom vascularised bone graft in a man.  Lancet. 2004;  364 766-770