Free Vascularized Flaps for Reconstruction of the Mandible: Complications, Success, and Dental Rehabilitation

doi:10.1016/j.joms.2011.08.024

Journal of Oral and Maxillofacial Surgery

Volume 70, Issue 7, July 2012, Pages 1692-1698

Part of this study was presented at the Second World Congress of the International Academy of Oral Oncology, Toronto, Ontario, Canada, July 2009.

https://doi.org/10.1016/j.joms.2011.08.024 Get rights and content

Purpose

To evaluate complications and success of mandibular reconstruction with free fibula flaps, iliac crest flaps, and forearm flaps with reconstruction plates and to evaluate dental rehabilitation after these reconstructions.

Patients and Methods

Eighty-three patients with segmental mandibular defects were included. Correlation analyses were used to determine the relationship between reconstruction type and clinical parameters with recipient-site complications and success. The dental rehabilitation was evaluated in successfully reconstructed survivors.

Results

Multivariate analyses showed significant correlations between flap type and success (P < .0001). Of the patients, 51 (61%) were alive 2 years after the reconstruction. Mandibular reconstruction with a free forearm flap and reconstruction plate was associated with higher complication rates at the recipient site and higher failure rates compared with reconstruction with free vascularized bone flaps. Of the 32 successfully reconstructed survivors, 14 (44%) had a complete dental rehabilitation, of which 10 had dental implants and 4 did not. Only 6 (29%) of the edentulous survivors ultimately had an implant-supported prosthesis.

Conclusions

Reconstruction of the mandible with a free vascularized bone flap is superior to reconstruction with a free forearm flap with a reconstruction plate. Complete dental rehabilitation was reached in fewer than half of the surviving patients.

Section snippets

Patients and Methods

From departmental records, we selected patients who had undergone reconstruction of the mandible between 1998 and 2008 with free vascularized fibula or iliac crest or with a free forearm flap with a reconstruction plate. For this retrospective study, ethics approval was not required according to the rules and regulations of the institutional review board. Segmental resections had been performed because of a malignancy, benign disease, trauma, or infection. Patients who had undergone irradiation

Results

Pertinent clinical data are listed in Table 1. In total, 83 patients underwent reconstruction of the mandible with a fibula flap (n = 46), iliac crest flap (n = 22), or free forearm flap with a reconstruction plate (n = 15). Seventy-eight segmental resections had been performed because of a malignancy. Antibiotic prophylaxis was given for at least 1 week postoperatively in all patients. The surgical approach was intraoral as well as extraoral in 81 patients. In 2 patients, only an extraoral

Discussion

Flap type was significantly associated with success 1 and 2 years after reconstruction. Patients with free vascularized bone flaps performed significantly better than those with free forearm flaps with reconstruction plates. Only 2 mandibular reconstructions with free forearm flaps with reconstruction plates were successful after 2 years. Free forearm flaps with reconstruction plates are notorious for developing major complications with time.1, 21, 22, 23 Wei et al²² explain this by the

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Cited by (77)

Tenants of Mandibular Reconstruction in Segmental Defects
2023, Otolaryngologic Clinics of North America
Implant retained prosthesis on a free fibula flap: A challenging procedure for prosthetic and soft tissue management
2023, Journal of Prosthetic Dentistry
A 39-year-old woman who had undergone fibular flap reconstruction and simultaneous implant placement after the surgical removal of a cemento-ossifying fibroma was experiencing mild discomfort 3 years later and requested an implant-supported prosthesis to restore her edentulous left maxillary quadrant. Initially, an interim removable partial denture was provided and later duplicated with clear resin. The interim prosthesis identified the excessive thickness of the grafted cutaneous soft tissue and the inadequate emergence angle of the nonfunctioning implants. By using the interim prosthesis as a surgical guide, vestibuloplasty was performed to thin the peri-implant soft tissue and the excessive skin graft from the initial maxillofacial surgery. Concurrently, the emergence angle of the implant was corrected with angled multi-unit abutments. A tissue compression stent was then made and attached to the abutments to guide the soft tissue healing process. When the peri-implant soft tissue had stabilized, a definitive implant-supported prosthesis was provided.
Risk factors associated with postoperative complications following free flap reconstruction of head and neck defects
2022, Journal of Stomatology, Oral and Maxillofacial Surgery
Citation Excerpt :
Some studies reported that no significant differences were found between the flap failure rate and the types of flap. [25–27] Van Gemert JT et al. [28] conducted a research to evaluate postoperative complications and success rate of mandibular reconstruction with free fibula flaps, iliac crest flaps, and forearm flaps, respectively. They concluded that mandibular reconstruction with a forearm free flap and reconstruction plate was associated with higher complication rates at the recipient site and higher failure rates compared with reconstruction with vascularized bone free flaps.
Free flap reconstruction of head and neck defects is routinely performed with a high success rate nowadays. However, postoperative complications are still commonly observed. The aim of this study is to investigate risk factors correlated with postoperative complications following free flap reconstruction of head and neck defects.
A retrospective study of all patients undergoing free flap reconstruction of head and neck defects between January 2018 and January 2020 at Sun Yat-sen Memorial Hospita, Guangzhou, China was performed. Preoperative, intraoperative, and postoperative data were collected retrospectively. The primary outcome variables were postoperative complications, which were divided into medical and surgical complications. All patients were grouped by either complications or no complications. Univariate and multivariate logistic regression models were used to identify risk factors predicting complications.
850 patients underwent free flap reconstruction of head and neck defects during the study period (Male: 65.29%; Mean [SD] age: 54.90 [13.78] years). Postoperative complications developed in 125 (14.71%) patients, among which, 101 (11.88%) patients developed surgical complications, 29 (3.41%) patients developed medical complications and 5 (0.59%) patients developed both surgical and medical complications. Total flap necrosis was observed in 11 (1.29%) patients. After multivariate analysis, several risk factors incluing postoperative ICU admission, coronary heart disease, post radiotherapy surgery and flap types were identified correlated with postoperative complications.
Our study identified related variables for a higher risk of postoperative complications development following free flap reconstruction of head and neck defects. Early detection of these risk factors will improve prognosis.
The role of computer aided design/computer assisted manufacturing (CAD/CAM) and 3- dimensional printing in head and neck oncologic surgery: A review and future directions
2022, Oral Oncology
Citation Excerpt :
Patients requiring extensive mandibular or maxillary resection are often left edentulous, with limited subsequent dental rehabilitative options as clinicians grapple with the challenge of restoring functionally and anatomically complex defects that vary greatly between patients [17]. Patients without dental rehabilitation have had rapid rates of adjacent bone loss, poor quality of life, and high rates of weight loss, but new reconstructive techniques aimed at dental rehabilitation have improved these outcomes [17,100–103]. Different techniques of dental rehabilitation have had varying levels of occlusal achievement, including free bone grafts, alloplastic surgical reconstruction trays and plates, or pedicled flaps with rib or calvarial bone [104].
Microvascular free flap reconstruction has remained the standard of care in reconstruction of large tissue defects following ablative head and neck oncologic surgery, especially for bony structures. Computer aided design/computer assisted manufacturing (CAD/CAM) and 3-dimensionally (3D) printed models and devices offer novel solutions for reconstruction of bony defects. Conventional free hand techniques have been enhanced using 3D printed anatomic models for reference and pre-bending of titanium reconstructive plates, which has dramatically improved intraoperative and microvascular ischemia times. Improvements led to current state of the art uses which include full virtual planning (VP), 3D printed osteotomy guides, and patient specific reconstructive plates, with advanced options incorporating dental rehabilitation and titanium bone replacements into the primary surgical plan through use of these tools. Limitations such as high costs and delays in device manufacturing may be mitigated with in house software and workflows. Future innovations still in development include printing custom prosthetics, ‘bioprinting’ of tissue engineered scaffolds, integration of therapeutic implants, and other possibilities as this technology continues to rapidly advance. This review summarizes the literature and serves as a summary guide to the historic, current, advanced, and future possibilities of 3D printing within head and neck oncologic surgery and bony reconstruction. This review serves as a summary guide to the historic, current, advanced, and future roles of CAD/CAM and 3D printing within the field of head and neck oncologic surgery and bony reconstruction.
Comparison of the complications of mandibular reconstruction using fibula versus iliac crest flaps: an updated systematic review and meta-analysis
2022, International Journal of Oral and Maxillofacial Surgery
Citation Excerpt :
Supplementary Material Table S1 presents a summary of the included articles. There was one RCT8, 12 cohort studies1,2,7,9,15,16,27–32, and five case series33–37. These studies included 942 patients (425 with an iliac flap and 517 with a fibula flap).
The aim of this study was to review and compare the complications of mandibular reconstruction using the fibula or iliac crest flap. PubMed, Embase, and the Cochrane Library were systematically searched for available papers published up to May 2020. The primary outcomes were the number of failures, the number of patients with major donor site complications, and the number of patients with recipient site complications. Eighteen studies involving 942 patients were included (one randomized controlled trial, 12 cohort studies, and five case series). There was no difference between the fibula flap and the iliac crest flap regarding the odds ratio of failure (P = 0.563), donor site complications (P = 0.756), or recipient site complications (P = 0.452). There was no difference in the dental outcomes between the two flaps (P = 0.296). The sensitivity analyses suggest that the meta-analyses were robust. There was no publication bias. This meta-analysis suggests no difference between the fibula flap and the iliac crest flap regarding the odds ratios of failure, donor site complications, recipient site complications, and dental outcomes. The recent development of computer-aided design, 3D printing, and other technologies could optimize the surgical design, improve the success rate of the surgery, and reduce complications. Nevertheless, all non-randomized studies will be at a relatively high risk of bias. Therefore, caution should be exercised when interpreting the results of the analyses.
Optimal placement of fixation system for scaffold-based mandibular reconstruction
2022, Journal of the Mechanical Behavior of Biomedical Materials
Citation Excerpt :
All interfaces between the scaffold, host bone, soft tissue layer, teeth, fixation plate and screws are assigned tie constraints. Tie constraints between the screws and plate simulate the function of locking screws, which offer superior performance in preventing screw loosening when compared with non-locking screws (van Gemert et al., 2012; Patel and Karlis, 2013). The mechanical properties of the system materials are summarised in Table 2, which are all assumed to be isotropic and linear elastic (Yoda et al., 2018).
A current challenge in bone tissue engineering is to create favourable biomechanical conditions conducive to tissue regeneration for a scaffold implanted in a segmental defect. This is particularly the case immediately following surgical implantation when a firm mechanical union between the scaffold and host bone is yet to be established via osseointegration. For mandibular reconstruction of a large segmental defect, the position of the fixation system is shown here to have a profound effect on the mechanical stimulus (for tissue regeneration within the scaffold), structural strength, and structural stiffness of the tissue scaffold-host bone construct under physiological load. This research combines computer tomography (CT)-based finite element (FE) modelling with multiobjective optimisation to determine the optimal height and angle to place a titanium fixation plate on a reconstructed mandible so as to enhance tissue ingrowth, structural strength and structural stiffness of the scaffold-host bone construct. To this end, the respective design criteria for fixation plate placement are to: (i) maximise the volume of the tissue scaffold experiencing levels of mechanical stimulus sufficient to initiate bone apposition, (ii) minimise peak stress in the scaffold so that it remains intact with a diminished risk of failure and, (iii) minimise scaffold ridge displacement so that the reconstructed jawbone resists deformation under physiological load. First, a CT-based FE model of a reconstructed human mandible implanted with a bioceramic tissue scaffold is developed to visualise and quantify changes in the biomechanical responses as the fixation plate's height and/or angle are varied. The volume of the scaffold experiencing appositional mechanical stimulus is observed to increase with the height of the fixation plate. Also, as the principal load-transfer mechanism to the scaffold is via the fixation system, there is a significant ingress of appositional stimulus from the buccal side towards the centre of the scaffold, notably in the region bounded by the screws. Next, surrogate modelling is implemented to generate bivariate cubic polynomial functions of the three biomechanical responses with respect to the two design variables (height and angle). Finally, as the three design objectives are found to be competing, bi- and tri-objective particle swarm optimisation algorithms are invoked to determine the most optimal Pareto solution, which represents the best possible trade-off between the competing design objectives. It is recommended that consideration be given to placing the fixation system along the upper boundary of the mandible with a small clockwise rotation about its posterior end. The methodology developed here forms a useful decision aid for optimal surgical planning.

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: Conflict of Interest Disclosures: None of the authors reported any disclosures.

View full text

Surgical oncology and reconstructionFree Vascularized Flaps for Reconstruction of the Mandible: Complications, Success, and Dental Rehabilitation

Purpose

Patients and Methods

Results

Conclusions

Section snippets

Patients and Methods

Results

Discussion

Int J Oral Maxillofac Surg

J Oral Maxillofac Surg

Oral Surg Oral Med Oral Pathol Oral Radiol Endod

Oral Oncol

Br J Oral Maxillofac Surg

J Oral Maxillofac Surg

Br J Plast Surg

J Oral Maxillofac Surg

Int J Oral Maxillofac Surg

Mandible reconstruction with microvascular surgery

Semin Surg Oncol

Oromandibular reconstruction

Facial Plast Surg

Free-flap mandibular reconstruction: A 10-year follow-up study

Plast Reconstr Surg

Reconstruction of the mandible with osseous free flaps: A 10-year experience with 150 consecutive patients

Plast Reconstr Surg

Vascularized bone flaps versus nonvascularized bone grafts for mandibular reconstruction: An outcome analysis of primary bony union and endosseous implant success

Head Neck

Complete rehabilitation of the mandible following segmental resection

J Surg Oncol

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

Plast Reconstr Surg

Reconstruction of the lateral mandibulectomy defect: Management based on prognosis and location and volume of soft tissue resection

Laryngoscope

Behavior of implants in bone grafts or free flaps after tumor resection

Clin Oral Implants Res

Surgical oncology and reconstruction
Free Vascularized Flaps for Reconstruction of the Mandible: Complications, Success, and Dental Rehabilitation