- Email: [email protected]
Contemporary reconstruction of the mandible
Oral Oncology 46 (2010) 71–76
Contents lists available at ScienceDirect
Oral Oncology journal homepage: www.elsevier.com/locate/oraloncology
Review
Contemporary reconstruction of the mandible Mathew Bak, Adam S. Jacobson *, Daniel Buchbinder, Mark L. Urken Department of Otolaryngology-Head and Neck Surgery, Beth Israel Medical Center, Albert Einstein College of Medicine, New York, NY, USA
a r t i c l e
i n f o
Article history: Received 5 August 2009 Received in revised form 14 November 2009 Accepted 16 November 2009 Available online 29 December 2009 Keywords: Mandible reconstruction Fibular free flap Iliac crest free flap Scapular free flap Microvascular surgery Oral cancer
s u m m a r y Reconstruction of the mandible has evolved significantly over the last 40 years. Early attempts were often disfiguring and wrought with complications but with the introduction of free tissue transfer of well vascularized bone in the 1970’s there was a significant improvement in outcomes. In recent years the harvest, inset, and microvascular anatomosis have been refined to the point that success rates are reported as high as 99% throughout the literature. Focus has now shifted to optimizing functional and aesthetic outcomes after mandible reconstruction. This paper will be a review defect classification, goals of reconstruction, the various donor sites, dental rehabilitation, new advances, and persistent problems. Reconstruction of segmental mandibular defects after ablative surgery is best accomplished using free tissue transfer to restore mandibular continuity and function. Reestablishing occlusion and optimizing tongue mobility are important to post-operative oral function. Persistent problems in oro-mandibular reconstruction relate to the effects of radiation treatment on the native tissue and include xerostomia, dysgeusia, osteoradionecrosis and trismus. These problems continue to plague the oral cancer patient despite the significant advances that allow a far more complete functional restoration than could be accomplished a mere two decades ago. Ó 2009 Elsevier Ltd. All rights reserved.
Introduction Defects of the mandible following ablative surgery can be both disfiguring and disabling. Currently there are several well established reconstructive options for restoring mandibular continuity and oro-mandibular function. The challenge of the reconstruction is selecting and optimizing these techniques to produce the best functional and aesthetic result that is individualized for the patient. Historically, mandibular reconstruction has been a technical challenge for reconstructive surgeons. Early attempts at using non-vascularized, autogenous bone grafts and external and internal (i.e. plates) immobilization devices were compromised by salivary contamination and adjuvant radiation, leading to infection and graft resorption.1–3 Pedicled osteomyocutaneous flaps were first reported in the early 1970’s. A number of flaps were utilized, including the pectoralis major with rib, sternocleidomastoid with clavicle and trapezius with scapula.3–5 These techniques led to improved outcomes by bringing vascularized bone to restore the mandibular arch. Despite this advance, reconstructive success was still limited due to the inadequate vascularity of the bone and the lack of maneuverability of the soft tissue relative to the bone. * Corresponding author. Address: 10 Union Square East, Suite 5B, New York, New York 10003, USA. Tel.: +1 212 844 8775; fax: +1 212 844 6975. E-mail address: [email protected] (A.S. Jacobson). 1368-8375/$ - see front matter Ó 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.oraloncology.2009.11.006
The advent of microvascular surgery in the 1980’s revolutionized oro-mandibular reconstruction.6–9 In two separate reports Taylor, as well as Sanders and Mayou described the deep circumflex iliac artery and vein (DCIA/V) as a reliable and easily utilizable vascular pedicle to transfer iliac bone and the overlying skin as a free tissue transfer.6,7 In 1986, Swartz et al. introduced the scapular osteocutaneous free flap (SOFF) for use in head and neck reconstruction.8 In 1989, Hidalgo became the first to report the transfer of fibular bone to reconstruct a segmental defect of the mandible.9 Microvascular surgery has afforded the ability to transfer a substantial amount of bone and soft tissue with its own vascular supply to the head and neck, which has permitted successful reconstructive efforts, even in the face of contaminated wounds and previously irradiated recipient sites.10 Today, osteocutaneous free tissue transfer with titanium plate fixation is the gold standard for mandibular reconstruction. Since its advent, microvascular transfer has been refined, leading to a high rate of reproducibility and success rates approaching 100%.11,12 These advances have dramatically changed the approach to, and expectations of, patients afflicted with both benign and malignant neoplasms affecting the mandible as well as the palatomaxillary complex. The ability to reliably reconstruct segmental mandibular defects has led to a change in the surgical algorithm when the mandible is involved by the disease process. In addition, dental implants can restore functional mastication, which impacts greatly on patient acceptance of such devastating surgery.
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Classification of oro-mandibular defects
Reconstructive options using free tissue transfer
The TNM classification of oral cancer is based on the size and the extent of bone and soft tissue involvement. While this system provides a means for stratification, communication and prognostication regarding the oncologic outcomes of oral cancers, it does not provide a useful method for describing the reconstructive needs of an oral defect created in the treatment of both benign and malignant conditions. It is because of this, that our group introduced a classification system for oro-mandibular defects based on the anatomical subsites of the mandible as well as associated soft tissue defects. The shift to the use of an independent reconstructive classification system from the accepted oncologic system is based on the concept that segmental bone losses at different subsites impact oral function differently.13,14 Anterior segmental defects that result in the well known ‘‘Andy Gump Deformity”, challenges the patient’s ability to maintain oral intake and can also lead to airway obstruction necessitating a permanent tracheostomy. Lateral defects in a dentate mandible and segmental defects in an edentulous mandible may be tolerated better. However, loss of mandibular continuity has obvious effects on the mechanics of mastication, regardless of the location of the defect or status of the patient’s dentition. The overlying soft tissue structures lose support and contract, tethering the lip and tongue leading to oral incompetence, dysarthria, and a disturbance in the oral phase of swallowing; functional problems that are exacerbated by post-operative radiation therapy. In addition, the disturbance in facial appearance can have a significant impact on the patient’s feeling of self confidence and their desire to return to their pre-disease employment and social interactions.
There are three main donor sites for vascularized bone used in mandibular reconstruction: fibula, iliac and scapula. While there is a substantial experience in the use of the radial osteocutaneous flap, it is our opinion that it does not provide a sufficient amount of bone stock, and therefore plays very little role in our current approach to oro-mandibular reconstruction.15 The fibular osteocutaneous free flap (FOFF) is the workhorse donor site for mandibular reconstruction11 (Fig. 1). Multiple studies demonstrate a greater than 95% flap survival rate with skin paddle viability in over 90% of cases.16–19 It has become the first option in most centers performing mandibular reconstruction and the only donor site that permits reconstruction of total mandibular defects. The bone is readily osteotomized to contour the neomandible and it provides sufficient bone stock for dental implantation. A limitation of the FOFF is the amount of soft tissue that can be transferred for large compound oro-mandibular defects. Fibular bone also does not recreate the alveolar height of the native dentate mandible, which can influence lower lip position at rest and make dental rehabilitation more difficult, especially if the remaining mandible is dentate. Common donor site morbidities include poor appearance of the skin graft placed over the lateral calf as well as weakness of extension and flexion of the great toe.16,19,20 More serious complications are related to blood flow to the distal lower extremity after harvest of the peroneal artery. We recommend a pre-operative evaluation with Magnetic Resonance Angiography (MRA) or an ultrasound duplex study in all patients to rule out peripheral vascular disease and congenital vascular anomalies that would make composite flap transfer hazardous. The scapular osteocutaneous free flap (SOFF) is the most versatile composite flap used for mandibular reconstruction allowing for replacement of bone and restoring large soft tissue defects. The lateral border of the scapula can be harvested in conjunction with a horizontally oriented scapular or vertically oriented parascapular fasciocutaneous flap. The thoracodorsal artery can be included for transfer of the latissimus dorsi muscle with an overlying skin paddle. The angular branch of the thoracodorsal artery supplies the tip of the scapula allowing for separate orientation relative to the bone segment of the more cephalad portion of the scapula supplied by the circumflex scapular artery.21 Several series have demonstrated favorable flap survival rates (89–96%) with limited donor site morbidity.22–24 Although the range of flap survival would suggest a lower level of reliability, these are series that span a much longer period of time and therefore do not reflect the advances in microvascular surgery of the past decade. Our own experience with this donor site over the past 10 years, has been as favorable as that of fibular flap transfers. The variety of different flaps that can be harvested based on the subscapular system, as well as the ability to separate and rotate the different tissue components independent of one another, make this system favorable for large and complex oro-mandibular defects.24 This flap can be especially useful in the setting of salvage surgery after chemoradiation failure by including the latissimus dorsi muscle for coverage of vital vascular structures in the neck. The SOFF is also preferred by the authors for the geriatric patient undergoing a composite resection. The scapular donor site allows for early ambulation and does not further complicate lower extremity venous stasis, or arterial insufficiency, which are common co-morbidities in this patient population (Fig. 2). Disadvantages of the SOFF include decreased range of motion of the shoulder especially with performing tasks above the head. The intra-operative positioning required for harvesting the flap also makes it difficult for a two-team approach. The amount of bone that can be harvested is limited, especially in women of slighter
Goals of reconstruction The goals of mandibular reconstruction are to reestablish the form of the lower third of the face and to restore the patient’s ability to eat in public, be intelligible to both trained and untrained listeners, and to maintain an unencumbered airway that allows the freedom to perform all activities. Rarely are defects from head and neck malignancies limited to mandibular bone, so the soft tissues involved need to be considered in order to optimize oro-mandibular function. The greater the loss of tongue volume, the greater the negative impact on the patient’s prognosis for recovery of oral function. Thus, the approach to the reconstruction should start by addressing the impact of the surgery on the patient’s tongue. In most cases, optimizing tongue bulk and mobility is more critical to the post-operative functional recovery than management of the bony defect. Loss of mucosa from the floor of mouth is critical in the assessment of whether to restore this component of the defect with non-native tissue. Preventing the tongue from becoming tethered to the neomandible is vital to preservation of mobility. Restoring tongue bulk and preserving mobility allow for palatoglossal contact which is critical for improving articulation during speech and bolus manipulation during deglutition. Oral reconstruction must also address lower lip function by attempting to achieve oral competence while preserving the expressive motion of the lips that is so important to normal facial movement. With respect to the segmental defect in the mandible, the surgeon should assess the patient’s dentition and occlusion. Restoring mandibular continuity while maintaining proper occlussal relationships and providing a structure for dental implantation permits the neomandible to produce and withstand the masticatory forces necessary for complete oral function. At the same time, this reestablishes lower facial contour and with dental rehabilitation, a normal oral function.
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Figure 1 Anatomy of fibular free flap and example of segmental defect with fibular flap inset.
Figure 2 Anatomy of scapular free flap and example of segmental defect with scapula flap inset.
build.25 Its suitability for implant placement is limited to men and is also geographically limited to the proximal and distal portions of the lateral border.26
The iliac crest osteocutaneous free flap (ICOFF) supplies bone with height comparable to that of the native dentate mandible, which improves oral competence by supporting the lower lip26
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Figure 3 Anatomy of iliac crest free flap and example of segmental defect with iliac crest flap inset.
(Fig. 3). The harvested bone is primarily cancellous bone and is an excellent substrate for implantation due to its substantial height and thickness. The iliac bone can be contoured to fit most segmental mandibular defects. Opening osteotomies performed in the iliac bone allow reliable reconstruction of anterior mandibular defects.12 The hemi-mandible can be recreated from the ipsilateral ilium using the anterior superior iliac spine to restore the mandibular angle.27 By including the ascending branch of the DCIA, the internal oblique muscle can be harvested and used for intraoral mucosal defect reconstruction. The internal oblique muscle is thin, pliable and can be maneuvered independent of the bone more easily and more reliably than the overlying skin flap.28 The donor site morbidity is a primary concern related to the use of the iliac donor site.29 However, a critical appraisal of this donor site in patients who underwent harvest has not supported such claims.30 The issues related to the donor site include the challenge of restoring the abdominal wall to prevent hernia formation, as well as the rehabilitation required to achieve normal ambulation. Vascularized bone flaps are rigidly fixed and form a union to the native mandible allowing the reconstructed mandible to withstand masticatory forces. A variety of hardware systems have been developed to secure bone grafts and maintain occlussal relationships. Our preference is to use a 2.0–2.4 mm locking reconstruction plating system. The plate is bent to fit the contour of the native mandible prior to resection, ensuring three screws placed on either side of the resection for maximum stabilization. In secondary reconstructions and clinical situations where the tumor prevents application of the reconstruction plate prior to resection, the patient can be placed in maxillo-mandibular fixation or an external fixationbridge may be used to maintain proper alignment of the mandible segments.31 The locking plate functions as an external fixator, as the screw heads lock to the plate, which does not have to be perfectly contoured to the bone while still preventing motion of the bony segments.32 When the resection extends proximally to include the condyle and temporo-mandibular joint (TMJ), the goal of reconstruction
is to maintain its near normal range of motion, in order to preserve mandibular excursion. Loss of the TMJ can result in malocclusion, difficulty with mastication, trismus and loss of posterior mandibular height.33 Many options for reconstruction of condylar defects have been reported, but it remains a challenge.33–35 An ideal reconstruction achieves joint mobility, while withstanding the loading forces during mastication and avoiding ankylosis. Alloplastic materials have been used in joint reconstruction, but have been mostly abandoned due to complications. Prosthetic titanium implants were used, but can cause erosion of the glenoid fossa and migration of the implant into the middle fossa.36 Proplast and silastic have also been used but can cause problems such as extrusion, foreign body reaction, infection and joint ankylosis.37 Autogenous grafts such as costochondral bone and cartilage are non-reactive and have the ability to remodel, however in the setting of adjuvant radiation therapy, they can undergo resorption and fracture and the limited amount of non-vascularized bone can lead to complications related to the hardware.36 Fixation of the neocondyle to either the lateral lip of the glenoid fossa or the articular cartilage is required to prevent drift of the neocondyle. Interposition of soft tissue into the joint space is important to prevent ankylosis.38 Dental rehabilitation Dental rehabilitation with osseointegrated implants is an integral part of mandibular reconstruction following ablative surgery. Dental rehabilitation supported with endosteal implants helps restore functional mastication, facial aesthetics and support for the lower lip. While several studies have demonstrated that implant supported dental rehabilitation can be performed in a reproducible manner, the ability to restore functional mastication is very dependent on the status of the native or reconstructed tongue with respect to its ability to manipulate food between the opposing incisal surfaces. This requires both intact motor and sensory supply in order to achieve that goal.12
M. Bak et al. / Oral Oncology 46 (2010) 71–76
Planning for implantation begins prior to surgical resection. Patients being considered for implants should demonstrate good oral hygiene, have a reasonable inter-incisal opening, a favorable prognosis for survival and anticipated favorable post-operative swallowing function. Implant placement is done in two stages: fixture placement followed by exposure of the implant and placement of the transmucosal attachment. Following placement, the implant is allowed to integrate for 4 months in the mandible and 6 months for maxillary implants. The trans-mucosal attachment is then placed and two weeks later the denture is attached and load bearing follows.39 Vascularized bone flaps for mandibular reconstruction have facilitated the use of primary implant placement. Advantages of implanting at the time of the primary reconstruction include having optimal bone exposure in the primary setting, reduced time to dental rehabilitation and avoidance of hyperbaric oxygen therapy if radiation therapy is planned.40 Primary implantation does not affect external beam treatment planning or delay therapy. It also optimizes the time for integration to occur prior to the onset of the damaging effects of radiation on the bone. Conventional implant stability is determined both clinically and radiographically. An implant is considered a success if it is immobile, does not cause pain with manipulation, and demonstrates no peri-implant radioluceny on radiographic examination. In addition there should be peri-implant vertical bone loss less than 0.2 mm per year, after the first year from implantation. We reported on 728 fixtures in 183 head and neck cancer patients with an overall success rate of 95% and 88% in patients who subsequently had radiation.41 New advances Medical modeling is a new tool for the reconstructive surgeon and has many applications for mandibular reconstruction. Although it is not necessarily cost-effective or required for all cases, it is extremely helpful in cases with primary bone malignancies as well as cases with involvement of the outer table of the mandible which makes it impossible to perform direct plate contouring prior to resection. Technological advances in medical imaging and rapid prototyping allows for the production of three-dimensional models. In cases where the mandible has been previously resected or destroyed by osteoradionecrosis, a digitally created ‘‘virtual” mandibular arch based on mirroring or a CT dataset with an appropriate occlussal relationship to the maxilla permits the reconstructive surgeon to contour a plate preoperatively or intra-operatively that will provide the patient with optimal post-operative occlusion. Three-dimensional modeling of the bone graft can also produce templates for contouring osteotomies, which saves the surgeon time and maximizes bone to bone contact to promote a strong bony union. Persistent problems Long term problems with mandibular reconstruction are related to wound healing especially in the setting of radiation. The problem of osteoradionecrosis is ideally managed with segmental resection and reconstruction using free composite flaps. Despite the advance of importing vascularized bone into this unfavorable environment, there is no guarantee that the disease will not progress in the native proximal and distal segments of the remaining native mandible. Such patients may have problems with nonunion, exposed bone and pathologic fractures. Post-operative radiation therapy can cause spontaneous ORN and loosening of hardware. Radiation therapy also causes tissue fibrosis, xerostomia, loss of taste and trismus in up to 47% of pa-
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tients.42,43 Severe trismus is a significant problem for patients undergoing mandible reconstruction as it limits the ability to safely secure an airway, limits oral intake, oral hygiene, dental rehabilitation and tumor surveillance.44 While a coronoidectomy, followed by intensive physical therapy, can be performed to alleviate trismus, the results are often disappointing. The damaging effects of radiation also pose continued problems for the survival (rate of osseo-integration) of implants and the longevity of dental rehabilitation. Implant failure can be a significant problem even in patients who undergo the optimal approach with primary placement and radiation at six weeks following surgery. Continued research in this area will hopefully yield new strategies with durable and predictable results. Conclusions Reconstruction of segmental mandibular defects after ablative surgery is best accomplished using free tissue transfer to restore mandibular continuity and function. Reestablishing occlusion and optimizing tongue mobility are important to post-operative oral function. Persistent problems in oro-mandibular reconstruction relate to the effects of radiation treatment on the native tissue and include xerostomia, dysgeusia, osteoradionecrosis and trismus. These problems continue to plague the oral cancer patient despite the significant advances that allow a far more complete functional restoration than could be accomplished a mere two decades ago. Conflict of Interest Statement None declared. Financial disclosures None. References 1. Tidstrom KD, Keller EE. Reconstruction of mandibular discontinuity with autogenous iliac bone graft: report of 34 consecutive patients. J Oral Maxillofac Surg 1990;48(4):336–46. [discussion 347]. 2. Foster RD, Anthony JP, Sharma A, Pogrel MA. 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(1):66–71. 3. Conley J. Use of composite flaps containing bone for major repairs in the head and neck. Plast Reconstr Surg 1972;49(5):522–6. 4. Panje W, Cutting C. Trapezius osteomyocutaneous island flap for reconstruction of the anterior floor of the mouth and the mandible. Head Neck Surg 1980;3(1):66–71. 5. Cuono CB, Ariyan S. Immediate reconstruction of a composite mandibular defect with a regional osteomusculocutaneous flap. Plast Reconstr Surg 1980;65(4):477–84. 6. Taylor GI, Townsend P, Corlett R. Superiority of the deep circumflex iliac vessels as the supply for free groin flaps. Plast Reconstr Surg 1979;64(5):595–604. 7. Sanders R, Mayou BJ. A new vascularized bone graft transferred by microvascular anastomosis as a free flap. Br J Surg 1979;66(11):787–8. 8. Swartz WM, Banis JC, Newton ED, Ramasastry SS, Jones NF, Acland R. The osteocutaneous scapular flap for mandibular and maxillary reconstruction. Plast Reconstr Surg 1986;77(4):530–45. 9. Hidalgo DA. Fibula free flap: a new method of mandible reconstruction. Plast Reconstr Surg 1989;84(1):71–9. 10. Gurtner GC, Evans GR. Advances in head and neck reconstruction. Plast Reconstr Surg 2000;106(3):672–82. [quiz 683]. 11. Hidalgo DA, Pusic AL. Free-flap mandibular reconstruction: a 10-year follow-up study. Plast Reconstr Surg 2002;110(2):438–49. [discussion 450–1]. 12. Urken ML, Buchbinder D, Costantino PD, et al. Oromandibular reconstruction using microvascular composite flaps: report of 210 cases. Arch Otolaryngol Head Neck Surg 1998;124(1):46–55. 13. Urken ML, Weinberg H, Vickery C, Buchbinder D, Lawson W, Biller HF. Oromandibular reconstruction using microvascular composite free flaps. Report of 71 cases and a new classification scheme for bony, soft-tissue, and neurologic defects. Arch Otolaryngol Head Neck Surg 1991;117(7):733–44.
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14. Boyd JB, Mulholland RS, Davidson J, et al. The free flap and plate in oromandibular reconstruction: long-term review and indications. Plast Reconstr Surg 1995;95(6):1018–28. 15. Villaret DB, Futran NA. The indications and outcomes in the use of osteocutaneous radial forearm free flap. Head Neck 2003;25(6):475–81. 16. Yim KK, Wei FC. Fibula osteoseptocutaneous flap for mandible reconstruction. Microsurgery 1994;15(4):245–9. 17. Wei FC, Seah CS, Tsai YC, Liu SJ, Tsai MS. Fibula osteoseptocutaneous flap for reconstruction of composite mandibular defects. Plast Reconstr Surg 1994;93(2):294–304. [discussion 305–6]. 18. Jones NF, Monstrey S, Gambier BA. Reliability of the fibular osteocutaneous flap for mandibular reconstruction: anatomical and surgical confirmation. Plast Reconstr Surg 1996;97(4):707–16. [discussion 717–8]. 19. Hidalgo DA, Rekow A. A review of 60 consecutive fibula free flap mandible reconstructions. Plast Reconstr Surg 1995;96(3):585–96. [discussion 597–602]. 20. Daniels TR, Thomas R, Bell TH, Neligan PC. Functional outcome of the foot and ankle after free fibular graft. Foot Ankle Int 2005;26(8):597–601. 21. Coleman 3rd JJ, Sultan MR. The bipedicled osteocutaneous scapula flap: a new subscapular system free flap. Plast Reconstr Surg 1991;87(4):682–92. 22. Sullivan MJ, Baker SR, Crompton R, Smith-Wheelock M. Free scapular osteocutaneous flap for mandibular reconstruction. Arch Otolaryngol Head Neck Surg 1989;115(11):1334–40. 23. Coleman SC, Burkey BB, Day TA, et al. Increasing use of the scapula osteocutaneous free flap. Laryngoscope 2000;110(9):1419–24. 24. Urken ML, Bridger AG, Zur KB, Genden EM. The scapular osteofasciocutaneous flap: a 12-year experience. Arch Otolaryngol Head Neck Surg 2001;127(7):862–9. 25. Frodel Jr JL, Funk GF, Capper DT, et al. Osseointegrated implants: a comparative study of bone thickness in four vascularized bone flaps. Plast Reconstr Surg 1993;92(3):449–55. [discussion 456–8]. 26. Moscoso JF, Keller J, Genden E, et al. Vascularized bone flaps in oromandibular reconstruction. A comparative anatomic study of bone stock from various donor sites to assess suitability for enosseous dental implants. Arch Otolaryngol Head Neck Surg 1994;120(1):36–43. 27. Manchester WM. Some technical improvements in the reconstruction of the mandible and temporomandibular joint. Plast Reconstr Surg 1972;50(3): 249–56. 28. Urken ML, Vickery C, Weinberg H, Buchbinder D, Lawson W, Biller HF. The internal oblique-iliac crest osseomyocutaneous free flap in oromandibular reconstruction. Report of 20 cases. Arch Otolaryngol Head Neck Surg 1989;115(3):339–49.
29. Hidalgo DA. Condyle transplantation in free flap mandible reconstruction. Plast Reconstr Surg 1994;93(4):770–81. [discussion 782–3]. 30. Rogers SN, Lakshmiah SR, Narayan B, et al. A comparison of the long-term morbidity following deep circumflex iliac and fibula free flaps for reconstruction following head and neck cancer. Plast Reconstr Surg 2003;112(6):1517–25. [discussion 1526–7]. 31. Ung F, Rocco JW, Deschler DG. Temporary intraoperative external fixation in mandibular reconstruction. Laryngoscope 2002;112(9):1569–73. 32. Militsakh ON, Wallace DI, Kriet JD, Girod DA, Olvera MS, Tsue TT. Use of the 2.0 mm locking reconstruction plate in primary oromandibular reconstruction after composite resection. Otolaryngol Head Neck Surg 2004;131(5):660–5. 33. Disa JJ, Cordeiro PG. Mandible reconstruction with microvascular surgery. Semin Surg Oncol 2000;19(3):226–34. 34. Engroff SL. Fibula flap reconstruction of the condyle in disarticulation resections of the mandible: a case report and review of the technique. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005;100(6):661–5. 35. Obeid G, Guttenberg SA, Connole PW. Costochondral grafting in condylar replacement and mandibular reconstruction. J Oral Maxillofac Surg 1988;46(3): 177–82. 36. Shenaq SM, Klebuc MJ. TMJ reconstruction during vascularized bone graft transfer to the mandible. Microsurgery 1994;15(5):299–304. 37. Dolwick MF, Aufdemorte TB. Silicone-induced foreign body reaction and lymphadenopathy after temporomandibular joint arthroplasty. Oral Surg Oral Med Oral Pathol 1985;59(5):449–52. 38. Genden EMBD, Urken ML. Mandible reconstruction and osseointegrated implants. 2nd ed. New York: Thieme; 2002. p. 591–600. 39. Buchbinder DSHH. Oral cancer: diagnosis, management and rehabilitation. New York: Thieme; 2007. 40. Marunick MT, Roumanas ED. Functional criteria for mandibular implant placement post resection and reconstruction for cancer. J Prosthet Dent 1999; 82(1):107–13. 41. Samouhi PBD. Rehabilitation of oral cancer patients with dental implants. In: Curr Opin Otolaryngol Head Neck Surg; 2000. p. 305–13. 42. Ichimura K, Tanaka T. Trismus in patients with malignant tumours in the head and neck. J Laryngol Otol 1993;107(11):1017–20. 43. Buchbinder D, Currivan RB, Kaplan AJ, Urken ML. Mobilization regimens for the prevention of jaw hypomobility in the radiated patient: a comparison of three techniques. J Oral Maxillofac Surg 1993;51(8):863–7. 44. Bhrany AD, Izzard M, Wood AJ, Futran ND. Coronoidectomy for the treatment of trismus in head and neck cancer patients. Laryngoscope 2007;117(11):1952–6.
Contents lists available at ScienceDirect
Oral Oncology journal homepage: www.elsevier.com/locate/oraloncology
Review
Contemporary reconstruction of the mandible Mathew Bak, Adam S. Jacobson *, Daniel Buchbinder, Mark L. Urken Department of Otolaryngology-Head and Neck Surgery, Beth Israel Medical Center, Albert Einstein College of Medicine, New York, NY, USA
a r t i c l e
i n f o
Article history: Received 5 August 2009 Received in revised form 14 November 2009 Accepted 16 November 2009 Available online 29 December 2009 Keywords: Mandible reconstruction Fibular free flap Iliac crest free flap Scapular free flap Microvascular surgery Oral cancer
s u m m a r y Reconstruction of the mandible has evolved significantly over the last 40 years. Early attempts were often disfiguring and wrought with complications but with the introduction of free tissue transfer of well vascularized bone in the 1970’s there was a significant improvement in outcomes. In recent years the harvest, inset, and microvascular anatomosis have been refined to the point that success rates are reported as high as 99% throughout the literature. Focus has now shifted to optimizing functional and aesthetic outcomes after mandible reconstruction. This paper will be a review defect classification, goals of reconstruction, the various donor sites, dental rehabilitation, new advances, and persistent problems. Reconstruction of segmental mandibular defects after ablative surgery is best accomplished using free tissue transfer to restore mandibular continuity and function. Reestablishing occlusion and optimizing tongue mobility are important to post-operative oral function. Persistent problems in oro-mandibular reconstruction relate to the effects of radiation treatment on the native tissue and include xerostomia, dysgeusia, osteoradionecrosis and trismus. These problems continue to plague the oral cancer patient despite the significant advances that allow a far more complete functional restoration than could be accomplished a mere two decades ago. Ó 2009 Elsevier Ltd. All rights reserved.
Introduction Defects of the mandible following ablative surgery can be both disfiguring and disabling. Currently there are several well established reconstructive options for restoring mandibular continuity and oro-mandibular function. The challenge of the reconstruction is selecting and optimizing these techniques to produce the best functional and aesthetic result that is individualized for the patient. Historically, mandibular reconstruction has been a technical challenge for reconstructive surgeons. Early attempts at using non-vascularized, autogenous bone grafts and external and internal (i.e. plates) immobilization devices were compromised by salivary contamination and adjuvant radiation, leading to infection and graft resorption.1–3 Pedicled osteomyocutaneous flaps were first reported in the early 1970’s. A number of flaps were utilized, including the pectoralis major with rib, sternocleidomastoid with clavicle and trapezius with scapula.3–5 These techniques led to improved outcomes by bringing vascularized bone to restore the mandibular arch. Despite this advance, reconstructive success was still limited due to the inadequate vascularity of the bone and the lack of maneuverability of the soft tissue relative to the bone. * Corresponding author. Address: 10 Union Square East, Suite 5B, New York, New York 10003, USA. Tel.: +1 212 844 8775; fax: +1 212 844 6975. E-mail address: [email protected] (A.S. Jacobson). 1368-8375/$ - see front matter Ó 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.oraloncology.2009.11.006
The advent of microvascular surgery in the 1980’s revolutionized oro-mandibular reconstruction.6–9 In two separate reports Taylor, as well as Sanders and Mayou described the deep circumflex iliac artery and vein (DCIA/V) as a reliable and easily utilizable vascular pedicle to transfer iliac bone and the overlying skin as a free tissue transfer.6,7 In 1986, Swartz et al. introduced the scapular osteocutaneous free flap (SOFF) for use in head and neck reconstruction.8 In 1989, Hidalgo became the first to report the transfer of fibular bone to reconstruct a segmental defect of the mandible.9 Microvascular surgery has afforded the ability to transfer a substantial amount of bone and soft tissue with its own vascular supply to the head and neck, which has permitted successful reconstructive efforts, even in the face of contaminated wounds and previously irradiated recipient sites.10 Today, osteocutaneous free tissue transfer with titanium plate fixation is the gold standard for mandibular reconstruction. Since its advent, microvascular transfer has been refined, leading to a high rate of reproducibility and success rates approaching 100%.11,12 These advances have dramatically changed the approach to, and expectations of, patients afflicted with both benign and malignant neoplasms affecting the mandible as well as the palatomaxillary complex. The ability to reliably reconstruct segmental mandibular defects has led to a change in the surgical algorithm when the mandible is involved by the disease process. In addition, dental implants can restore functional mastication, which impacts greatly on patient acceptance of such devastating surgery.
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M. Bak et al. / Oral Oncology 46 (2010) 71–76
Classification of oro-mandibular defects
Reconstructive options using free tissue transfer
The TNM classification of oral cancer is based on the size and the extent of bone and soft tissue involvement. While this system provides a means for stratification, communication and prognostication regarding the oncologic outcomes of oral cancers, it does not provide a useful method for describing the reconstructive needs of an oral defect created in the treatment of both benign and malignant conditions. It is because of this, that our group introduced a classification system for oro-mandibular defects based on the anatomical subsites of the mandible as well as associated soft tissue defects. The shift to the use of an independent reconstructive classification system from the accepted oncologic system is based on the concept that segmental bone losses at different subsites impact oral function differently.13,14 Anterior segmental defects that result in the well known ‘‘Andy Gump Deformity”, challenges the patient’s ability to maintain oral intake and can also lead to airway obstruction necessitating a permanent tracheostomy. Lateral defects in a dentate mandible and segmental defects in an edentulous mandible may be tolerated better. However, loss of mandibular continuity has obvious effects on the mechanics of mastication, regardless of the location of the defect or status of the patient’s dentition. The overlying soft tissue structures lose support and contract, tethering the lip and tongue leading to oral incompetence, dysarthria, and a disturbance in the oral phase of swallowing; functional problems that are exacerbated by post-operative radiation therapy. In addition, the disturbance in facial appearance can have a significant impact on the patient’s feeling of self confidence and their desire to return to their pre-disease employment and social interactions.
There are three main donor sites for vascularized bone used in mandibular reconstruction: fibula, iliac and scapula. While there is a substantial experience in the use of the radial osteocutaneous flap, it is our opinion that it does not provide a sufficient amount of bone stock, and therefore plays very little role in our current approach to oro-mandibular reconstruction.15 The fibular osteocutaneous free flap (FOFF) is the workhorse donor site for mandibular reconstruction11 (Fig. 1). Multiple studies demonstrate a greater than 95% flap survival rate with skin paddle viability in over 90% of cases.16–19 It has become the first option in most centers performing mandibular reconstruction and the only donor site that permits reconstruction of total mandibular defects. The bone is readily osteotomized to contour the neomandible and it provides sufficient bone stock for dental implantation. A limitation of the FOFF is the amount of soft tissue that can be transferred for large compound oro-mandibular defects. Fibular bone also does not recreate the alveolar height of the native dentate mandible, which can influence lower lip position at rest and make dental rehabilitation more difficult, especially if the remaining mandible is dentate. Common donor site morbidities include poor appearance of the skin graft placed over the lateral calf as well as weakness of extension and flexion of the great toe.16,19,20 More serious complications are related to blood flow to the distal lower extremity after harvest of the peroneal artery. We recommend a pre-operative evaluation with Magnetic Resonance Angiography (MRA) or an ultrasound duplex study in all patients to rule out peripheral vascular disease and congenital vascular anomalies that would make composite flap transfer hazardous. The scapular osteocutaneous free flap (SOFF) is the most versatile composite flap used for mandibular reconstruction allowing for replacement of bone and restoring large soft tissue defects. The lateral border of the scapula can be harvested in conjunction with a horizontally oriented scapular or vertically oriented parascapular fasciocutaneous flap. The thoracodorsal artery can be included for transfer of the latissimus dorsi muscle with an overlying skin paddle. The angular branch of the thoracodorsal artery supplies the tip of the scapula allowing for separate orientation relative to the bone segment of the more cephalad portion of the scapula supplied by the circumflex scapular artery.21 Several series have demonstrated favorable flap survival rates (89–96%) with limited donor site morbidity.22–24 Although the range of flap survival would suggest a lower level of reliability, these are series that span a much longer period of time and therefore do not reflect the advances in microvascular surgery of the past decade. Our own experience with this donor site over the past 10 years, has been as favorable as that of fibular flap transfers. The variety of different flaps that can be harvested based on the subscapular system, as well as the ability to separate and rotate the different tissue components independent of one another, make this system favorable for large and complex oro-mandibular defects.24 This flap can be especially useful in the setting of salvage surgery after chemoradiation failure by including the latissimus dorsi muscle for coverage of vital vascular structures in the neck. The SOFF is also preferred by the authors for the geriatric patient undergoing a composite resection. The scapular donor site allows for early ambulation and does not further complicate lower extremity venous stasis, or arterial insufficiency, which are common co-morbidities in this patient population (Fig. 2). Disadvantages of the SOFF include decreased range of motion of the shoulder especially with performing tasks above the head. The intra-operative positioning required for harvesting the flap also makes it difficult for a two-team approach. The amount of bone that can be harvested is limited, especially in women of slighter
Goals of reconstruction The goals of mandibular reconstruction are to reestablish the form of the lower third of the face and to restore the patient’s ability to eat in public, be intelligible to both trained and untrained listeners, and to maintain an unencumbered airway that allows the freedom to perform all activities. Rarely are defects from head and neck malignancies limited to mandibular bone, so the soft tissues involved need to be considered in order to optimize oro-mandibular function. The greater the loss of tongue volume, the greater the negative impact on the patient’s prognosis for recovery of oral function. Thus, the approach to the reconstruction should start by addressing the impact of the surgery on the patient’s tongue. In most cases, optimizing tongue bulk and mobility is more critical to the post-operative functional recovery than management of the bony defect. Loss of mucosa from the floor of mouth is critical in the assessment of whether to restore this component of the defect with non-native tissue. Preventing the tongue from becoming tethered to the neomandible is vital to preservation of mobility. Restoring tongue bulk and preserving mobility allow for palatoglossal contact which is critical for improving articulation during speech and bolus manipulation during deglutition. Oral reconstruction must also address lower lip function by attempting to achieve oral competence while preserving the expressive motion of the lips that is so important to normal facial movement. With respect to the segmental defect in the mandible, the surgeon should assess the patient’s dentition and occlusion. Restoring mandibular continuity while maintaining proper occlussal relationships and providing a structure for dental implantation permits the neomandible to produce and withstand the masticatory forces necessary for complete oral function. At the same time, this reestablishes lower facial contour and with dental rehabilitation, a normal oral function.
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Figure 1 Anatomy of fibular free flap and example of segmental defect with fibular flap inset.
Figure 2 Anatomy of scapular free flap and example of segmental defect with scapula flap inset.
build.25 Its suitability for implant placement is limited to men and is also geographically limited to the proximal and distal portions of the lateral border.26
The iliac crest osteocutaneous free flap (ICOFF) supplies bone with height comparable to that of the native dentate mandible, which improves oral competence by supporting the lower lip26
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Figure 3 Anatomy of iliac crest free flap and example of segmental defect with iliac crest flap inset.
(Fig. 3). The harvested bone is primarily cancellous bone and is an excellent substrate for implantation due to its substantial height and thickness. The iliac bone can be contoured to fit most segmental mandibular defects. Opening osteotomies performed in the iliac bone allow reliable reconstruction of anterior mandibular defects.12 The hemi-mandible can be recreated from the ipsilateral ilium using the anterior superior iliac spine to restore the mandibular angle.27 By including the ascending branch of the DCIA, the internal oblique muscle can be harvested and used for intraoral mucosal defect reconstruction. The internal oblique muscle is thin, pliable and can be maneuvered independent of the bone more easily and more reliably than the overlying skin flap.28 The donor site morbidity is a primary concern related to the use of the iliac donor site.29 However, a critical appraisal of this donor site in patients who underwent harvest has not supported such claims.30 The issues related to the donor site include the challenge of restoring the abdominal wall to prevent hernia formation, as well as the rehabilitation required to achieve normal ambulation. Vascularized bone flaps are rigidly fixed and form a union to the native mandible allowing the reconstructed mandible to withstand masticatory forces. A variety of hardware systems have been developed to secure bone grafts and maintain occlussal relationships. Our preference is to use a 2.0–2.4 mm locking reconstruction plating system. The plate is bent to fit the contour of the native mandible prior to resection, ensuring three screws placed on either side of the resection for maximum stabilization. In secondary reconstructions and clinical situations where the tumor prevents application of the reconstruction plate prior to resection, the patient can be placed in maxillo-mandibular fixation or an external fixationbridge may be used to maintain proper alignment of the mandible segments.31 The locking plate functions as an external fixator, as the screw heads lock to the plate, which does not have to be perfectly contoured to the bone while still preventing motion of the bony segments.32 When the resection extends proximally to include the condyle and temporo-mandibular joint (TMJ), the goal of reconstruction
is to maintain its near normal range of motion, in order to preserve mandibular excursion. Loss of the TMJ can result in malocclusion, difficulty with mastication, trismus and loss of posterior mandibular height.33 Many options for reconstruction of condylar defects have been reported, but it remains a challenge.33–35 An ideal reconstruction achieves joint mobility, while withstanding the loading forces during mastication and avoiding ankylosis. Alloplastic materials have been used in joint reconstruction, but have been mostly abandoned due to complications. Prosthetic titanium implants were used, but can cause erosion of the glenoid fossa and migration of the implant into the middle fossa.36 Proplast and silastic have also been used but can cause problems such as extrusion, foreign body reaction, infection and joint ankylosis.37 Autogenous grafts such as costochondral bone and cartilage are non-reactive and have the ability to remodel, however in the setting of adjuvant radiation therapy, they can undergo resorption and fracture and the limited amount of non-vascularized bone can lead to complications related to the hardware.36 Fixation of the neocondyle to either the lateral lip of the glenoid fossa or the articular cartilage is required to prevent drift of the neocondyle. Interposition of soft tissue into the joint space is important to prevent ankylosis.38 Dental rehabilitation Dental rehabilitation with osseointegrated implants is an integral part of mandibular reconstruction following ablative surgery. Dental rehabilitation supported with endosteal implants helps restore functional mastication, facial aesthetics and support for the lower lip. While several studies have demonstrated that implant supported dental rehabilitation can be performed in a reproducible manner, the ability to restore functional mastication is very dependent on the status of the native or reconstructed tongue with respect to its ability to manipulate food between the opposing incisal surfaces. This requires both intact motor and sensory supply in order to achieve that goal.12
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Planning for implantation begins prior to surgical resection. Patients being considered for implants should demonstrate good oral hygiene, have a reasonable inter-incisal opening, a favorable prognosis for survival and anticipated favorable post-operative swallowing function. Implant placement is done in two stages: fixture placement followed by exposure of the implant and placement of the transmucosal attachment. Following placement, the implant is allowed to integrate for 4 months in the mandible and 6 months for maxillary implants. The trans-mucosal attachment is then placed and two weeks later the denture is attached and load bearing follows.39 Vascularized bone flaps for mandibular reconstruction have facilitated the use of primary implant placement. Advantages of implanting at the time of the primary reconstruction include having optimal bone exposure in the primary setting, reduced time to dental rehabilitation and avoidance of hyperbaric oxygen therapy if radiation therapy is planned.40 Primary implantation does not affect external beam treatment planning or delay therapy. It also optimizes the time for integration to occur prior to the onset of the damaging effects of radiation on the bone. Conventional implant stability is determined both clinically and radiographically. An implant is considered a success if it is immobile, does not cause pain with manipulation, and demonstrates no peri-implant radioluceny on radiographic examination. In addition there should be peri-implant vertical bone loss less than 0.2 mm per year, after the first year from implantation. We reported on 728 fixtures in 183 head and neck cancer patients with an overall success rate of 95% and 88% in patients who subsequently had radiation.41 New advances Medical modeling is a new tool for the reconstructive surgeon and has many applications for mandibular reconstruction. Although it is not necessarily cost-effective or required for all cases, it is extremely helpful in cases with primary bone malignancies as well as cases with involvement of the outer table of the mandible which makes it impossible to perform direct plate contouring prior to resection. Technological advances in medical imaging and rapid prototyping allows for the production of three-dimensional models. In cases where the mandible has been previously resected or destroyed by osteoradionecrosis, a digitally created ‘‘virtual” mandibular arch based on mirroring or a CT dataset with an appropriate occlussal relationship to the maxilla permits the reconstructive surgeon to contour a plate preoperatively or intra-operatively that will provide the patient with optimal post-operative occlusion. Three-dimensional modeling of the bone graft can also produce templates for contouring osteotomies, which saves the surgeon time and maximizes bone to bone contact to promote a strong bony union. Persistent problems Long term problems with mandibular reconstruction are related to wound healing especially in the setting of radiation. The problem of osteoradionecrosis is ideally managed with segmental resection and reconstruction using free composite flaps. Despite the advance of importing vascularized bone into this unfavorable environment, there is no guarantee that the disease will not progress in the native proximal and distal segments of the remaining native mandible. Such patients may have problems with nonunion, exposed bone and pathologic fractures. Post-operative radiation therapy can cause spontaneous ORN and loosening of hardware. Radiation therapy also causes tissue fibrosis, xerostomia, loss of taste and trismus in up to 47% of pa-
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tients.42,43 Severe trismus is a significant problem for patients undergoing mandible reconstruction as it limits the ability to safely secure an airway, limits oral intake, oral hygiene, dental rehabilitation and tumor surveillance.44 While a coronoidectomy, followed by intensive physical therapy, can be performed to alleviate trismus, the results are often disappointing. The damaging effects of radiation also pose continued problems for the survival (rate of osseo-integration) of implants and the longevity of dental rehabilitation. Implant failure can be a significant problem even in patients who undergo the optimal approach with primary placement and radiation at six weeks following surgery. Continued research in this area will hopefully yield new strategies with durable and predictable results. Conclusions Reconstruction of segmental mandibular defects after ablative surgery is best accomplished using free tissue transfer to restore mandibular continuity and function. Reestablishing occlusion and optimizing tongue mobility are important to post-operative oral function. Persistent problems in oro-mandibular reconstruction relate to the effects of radiation treatment on the native tissue and include xerostomia, dysgeusia, osteoradionecrosis and trismus. These problems continue to plague the oral cancer patient despite the significant advances that allow a far more complete functional restoration than could be accomplished a mere two decades ago. Conflict of Interest Statement None declared. Financial disclosures None. References 1. Tidstrom KD, Keller EE. Reconstruction of mandibular discontinuity with autogenous iliac bone graft: report of 34 consecutive patients. J Oral Maxillofac Surg 1990;48(4):336–46. [discussion 347]. 2. Foster RD, Anthony JP, Sharma A, Pogrel MA. 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(1):66–71. 3. Conley J. Use of composite flaps containing bone for major repairs in the head and neck. Plast Reconstr Surg 1972;49(5):522–6. 4. Panje W, Cutting C. Trapezius osteomyocutaneous island flap for reconstruction of the anterior floor of the mouth and the mandible. Head Neck Surg 1980;3(1):66–71. 5. Cuono CB, Ariyan S. Immediate reconstruction of a composite mandibular defect with a regional osteomusculocutaneous flap. Plast Reconstr Surg 1980;65(4):477–84. 6. Taylor GI, Townsend P, Corlett R. Superiority of the deep circumflex iliac vessels as the supply for free groin flaps. Plast Reconstr Surg 1979;64(5):595–604. 7. Sanders R, Mayou BJ. A new vascularized bone graft transferred by microvascular anastomosis as a free flap. Br J Surg 1979;66(11):787–8. 8. Swartz WM, Banis JC, Newton ED, Ramasastry SS, Jones NF, Acland R. The osteocutaneous scapular flap for mandibular and maxillary reconstruction. Plast Reconstr Surg 1986;77(4):530–45. 9. Hidalgo DA. Fibula free flap: a new method of mandible reconstruction. Plast Reconstr Surg 1989;84(1):71–9. 10. Gurtner GC, Evans GR. Advances in head and neck reconstruction. Plast Reconstr Surg 2000;106(3):672–82. [quiz 683]. 11. Hidalgo DA, Pusic AL. Free-flap mandibular reconstruction: a 10-year follow-up study. Plast Reconstr Surg 2002;110(2):438–49. [discussion 450–1]. 12. Urken ML, Buchbinder D, Costantino PD, et al. Oromandibular reconstruction using microvascular composite flaps: report of 210 cases. Arch Otolaryngol Head Neck Surg 1998;124(1):46–55. 13. Urken ML, Weinberg H, Vickery C, Buchbinder D, Lawson W, Biller HF. Oromandibular reconstruction using microvascular composite free flaps. Report of 71 cases and a new classification scheme for bony, soft-tissue, and neurologic defects. Arch Otolaryngol Head Neck Surg 1991;117(7):733–44.
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14. Boyd JB, Mulholland RS, Davidson J, et al. The free flap and plate in oromandibular reconstruction: long-term review and indications. Plast Reconstr Surg 1995;95(6):1018–28. 15. Villaret DB, Futran NA. The indications and outcomes in the use of osteocutaneous radial forearm free flap. Head Neck 2003;25(6):475–81. 16. Yim KK, Wei FC. Fibula osteoseptocutaneous flap for mandible reconstruction. Microsurgery 1994;15(4):245–9. 17. Wei FC, Seah CS, Tsai YC, Liu SJ, Tsai MS. Fibula osteoseptocutaneous flap for reconstruction of composite mandibular defects. Plast Reconstr Surg 1994;93(2):294–304. [discussion 305–6]. 18. Jones NF, Monstrey S, Gambier BA. Reliability of the fibular osteocutaneous flap for mandibular reconstruction: anatomical and surgical confirmation. Plast Reconstr Surg 1996;97(4):707–16. [discussion 717–8]. 19. Hidalgo DA, Rekow A. A review of 60 consecutive fibula free flap mandible reconstructions. Plast Reconstr Surg 1995;96(3):585–96. [discussion 597–602]. 20. Daniels TR, Thomas R, Bell TH, Neligan PC. Functional outcome of the foot and ankle after free fibular graft. Foot Ankle Int 2005;26(8):597–601. 21. Coleman 3rd JJ, Sultan MR. The bipedicled osteocutaneous scapula flap: a new subscapular system free flap. Plast Reconstr Surg 1991;87(4):682–92. 22. Sullivan MJ, Baker SR, Crompton R, Smith-Wheelock M. Free scapular osteocutaneous flap for mandibular reconstruction. Arch Otolaryngol Head Neck Surg 1989;115(11):1334–40. 23. Coleman SC, Burkey BB, Day TA, et al. Increasing use of the scapula osteocutaneous free flap. Laryngoscope 2000;110(9):1419–24. 24. Urken ML, Bridger AG, Zur KB, Genden EM. The scapular osteofasciocutaneous flap: a 12-year experience. Arch Otolaryngol Head Neck Surg 2001;127(7):862–9. 25. Frodel Jr JL, Funk GF, Capper DT, et al. Osseointegrated implants: a comparative study of bone thickness in four vascularized bone flaps. Plast Reconstr Surg 1993;92(3):449–55. [discussion 456–8]. 26. Moscoso JF, Keller J, Genden E, et al. Vascularized bone flaps in oromandibular reconstruction. A comparative anatomic study of bone stock from various donor sites to assess suitability for enosseous dental implants. Arch Otolaryngol Head Neck Surg 1994;120(1):36–43. 27. Manchester WM. Some technical improvements in the reconstruction of the mandible and temporomandibular joint. Plast Reconstr Surg 1972;50(3): 249–56. 28. Urken ML, Vickery C, Weinberg H, Buchbinder D, Lawson W, Biller HF. The internal oblique-iliac crest osseomyocutaneous free flap in oromandibular reconstruction. Report of 20 cases. Arch Otolaryngol Head Neck Surg 1989;115(3):339–49.
29. Hidalgo DA. Condyle transplantation in free flap mandible reconstruction. Plast Reconstr Surg 1994;93(4):770–81. [discussion 782–3]. 30. Rogers SN, Lakshmiah SR, Narayan B, et al. A comparison of the long-term morbidity following deep circumflex iliac and fibula free flaps for reconstruction following head and neck cancer. Plast Reconstr Surg 2003;112(6):1517–25. [discussion 1526–7]. 31. Ung F, Rocco JW, Deschler DG. Temporary intraoperative external fixation in mandibular reconstruction. Laryngoscope 2002;112(9):1569–73. 32. Militsakh ON, Wallace DI, Kriet JD, Girod DA, Olvera MS, Tsue TT. Use of the 2.0 mm locking reconstruction plate in primary oromandibular reconstruction after composite resection. Otolaryngol Head Neck Surg 2004;131(5):660–5. 33. Disa JJ, Cordeiro PG. Mandible reconstruction with microvascular surgery. Semin Surg Oncol 2000;19(3):226–34. 34. Engroff SL. Fibula flap reconstruction of the condyle in disarticulation resections of the mandible: a case report and review of the technique. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005;100(6):661–5. 35. Obeid G, Guttenberg SA, Connole PW. Costochondral grafting in condylar replacement and mandibular reconstruction. J Oral Maxillofac Surg 1988;46(3): 177–82. 36. Shenaq SM, Klebuc MJ. TMJ reconstruction during vascularized bone graft transfer to the mandible. Microsurgery 1994;15(5):299–304. 37. Dolwick MF, Aufdemorte TB. Silicone-induced foreign body reaction and lymphadenopathy after temporomandibular joint arthroplasty. Oral Surg Oral Med Oral Pathol 1985;59(5):449–52. 38. Genden EMBD, Urken ML. Mandible reconstruction and osseointegrated implants. 2nd ed. New York: Thieme; 2002. p. 591–600. 39. Buchbinder DSHH. Oral cancer: diagnosis, management and rehabilitation. New York: Thieme; 2007. 40. Marunick MT, Roumanas ED. Functional criteria for mandibular implant placement post resection and reconstruction for cancer. J Prosthet Dent 1999; 82(1):107–13. 41. Samouhi PBD. Rehabilitation of oral cancer patients with dental implants. In: Curr Opin Otolaryngol Head Neck Surg; 2000. p. 305–13. 42. Ichimura K, Tanaka T. Trismus in patients with malignant tumours in the head and neck. J Laryngol Otol 1993;107(11):1017–20. 43. Buchbinder D, Currivan RB, Kaplan AJ, Urken ML. Mobilization regimens for the prevention of jaw hypomobility in the radiated patient: a comparison of three techniques. J Oral Maxillofac Surg 1993;51(8):863–7. 44. Bhrany AD, Izzard M, Wood AJ, Futran ND. Coronoidectomy for the treatment of trismus in head and neck cancer patients. Laryngoscope 2007;117(11):1952–6.