Malocclusion Management Following Mandibular Reconstruction With Free Fibula Flaps.

Combination of Autologous Protein-Rich Fibrin and Bone Graft: An Invaluable Option for Reconstruction of Segmental Mandibular Defects

The fibula free flap offers several advantages in mandibular reconstruction, including an optimal length and bone quality for dental implantation; therefore, the use of this flap has become a method of choice for mandibular reconstruction. Although the development of computer-assisted surgical planning has increased the accuracy of mandibular reconstruction, some unexpected outcomes still occur in clinical settings. The patient in this report underwent mandibular reconstruction with the fibula free flap because of mandibular resection resulting from an ameloblastoma. However, unexpected movement of the grafted fibula bone had been observed, and we could not achieve a proper occlusal relationship even with implant-supported prosthesis. To resolve this problem, we corrected the position of previously grafted fibula and implants by using orthognathic surgery: sagittal split osteotomy on body and angle area and vertical osteotomy on the mandibular symphysis. After the orthognathic surgery at the previously reconstructed mandible with fibula free flap, a favorable and stable occlusal relationship could be achieved. The result demonstrated that the sagittal split osteotomy at the previous fibula free flap site can be successfully carried out to establish the proper occlusion.

Residents' journal review

Symmetrical Midfacial Growth After Pediatric Mandibular Reconstruction With Free Fibula Flap

Fibular free flap necrosis after mandibular reconstruction surgery with osteoradionecrosis: Establishment and verification of an early warning model

The osteocutaneous radial forearm free flap (OC-RFFF) has been proposed as a safe and reliable free flap for head and neck reconstruction with low donor site morbidity. The purpose of this study is to compare the late complications (>30 days) associated with using the OC-RFFF versus the free fibula flap (FFF) for mandibular reconstruction following oncologic segmental resection. We conducted a single-institution, retrospective study composed of patients who underwent oncologic microvascular composite mandibular reconstruction with either the OC-RFFF or FFF. The primary predictor variable was the type of free flap used. The outcome variable was late complication postoperatively (>30 days). A total of 93 patients (28, OC-RFFF and 65, FFF) were analyzed. The majority of patients were male (62%) and with AJCC stage T4a disease (72%). Mean hospital length of stay was comparable between the two flap groups (p= .50). OC-RFFF was associated with more late complications (p= .03) compared to FFF. Nonunion occurred in 10.7% of OC-RFFF and 0% of FFF. Partial or complete flap failure was seen in 7.1% and 0% in the OC-RFFF and FFF, respectively. Two-year disease-free survival was comparable in both groups (p> .05). The results of this study suggest that the rate of nonunion and odds of having a late complication were significantly greater in the OC-RFFF compared to the FFF following oncologic mandibular reconstruction. However, flap success, early complications (<30 days), and length of hospital stay were comparable between the two flaps.

Comparative osteoradionecrosis rates in bony reconstructions for head and neck malignancy

Osseous free flaps have become the preferred method of mandibular reconstruction after oncologic surgical ablation. To elucidate the long-term effects of free flap mandibular reconstruction on bone mass, maintenance or reduction in bone height over time was used as an indirect measure of preservation or loss in bone mass. Factors potentially influencing bone mass preservation were evaluated; these included site of reconstruction (central, body, ramus), patient age, length of follow-up, adjuvant radiotherapy, and the delayed placement of osseointegrated dental implants. A retrospective analysis of patients undergoing osseous free flap mandible reconstruction for oncologic surgical defects between 1987 and 1995 was performed. Postoperative Panorex examinations were used to evaluate bone height and bony union after osteotomy. Fixation hardware was used as a reference to eliminate magnification as a possible source of error in measurement. There were 48 patients who qualified for this study by having at least 24 months of follow-up. There were 27 male and 21 female patients, with a mean age of 45 years (range, 5 to 75 years). Mandibular defects were anterior (24) and lateral (24). Osseous donor sites included the fibula (35), radius (6), scapula (4), and ilium (3). There were between zero and four segmental osteotomies per patient (excluding the ends of the graft). Nineteen percent of all patients had delayed placement of osseointegrated dental implants. Initial Panorex examinations were taken between 1 and 9 months postoperatively (mean, 2 months). Follow-up Panorex examinations were taken 24 to 104 months postoperatively (mean, 47 months). The bony union rate after osteotomy was 97 percent. Bone height measurements were compared by site and type of reconstruction. The mean loss in fibula height by site of reconstruction was 2 percent in central segments, 7 percent in body segments, and 5 percent in ramus segments. The mean loss in bone height after radial free flap mandible reconstruction was 33 percent in central segments and 37 percent in body segments; ramus segments did not lose height. The central and body segments reconstructed with scapular free flaps did not lose height, but one ramus segment lost 20 percent of height. There was no loss in bone height in mandibular body reconstruction with the ilium free flap. Fibula free flaps did not significantly lose bone height when evaluated with respect to age, follow-up, radiation therapy, or dental implant placement. The retention in bone height demonstrated in this study suggests that bone mass is preserved after osseous free flap mandible reconstruction. The greatest amount of bone loss was seen after multiply osteotomized radial free flaps were used for central mandibular reconstruction. The ability of the fibula free flap to maintain mass over time, coupled with its known advantages, further supports its use as the "work horse" donor site for mandible reconstruction.

Osseous free flaps have become the preferred method of mandibular reconstruction after oncologic surgical ablation. To elucidate the long-term effects of free flap mandibular reconstruction on bone mass, maintenance or reduction in bone height over time was used as an indirect measure of preservation or loss in bone mass. Factors potentially influencing bone mass preservation were evaluated; these included site of reconstruction (central, body, ramus), patient age, length of follow-up, adjuvant radiotherapy, and the delayed placement of osseointegrated dental implants. A retrospective analysis of patients undergoing osseous free flap mandible reconstruction for oncologic surgical defects between 1987 and 1995 was performed. Postoperative Panorex examinations were used to evaluate bone height and bony union after osteotomy. Fixation hardware was used as a reference to eliminate magnification as a possible source of error in measurement. There were 48 patients who qualified for this study by having at least 24 months of follow-up. There were 27 male and 21 female patients, with a mean age of 45 years (range, 5 to 75 years). Mandibular defects were anterior (24) and lateral (24). Osseous donor sites included the fibula (35), radius (6), scapula (4), and ilium (3). There were between zero and four segmental osteotomies per patient (excluding the ends of the graft). Nineteen percent of all patients had delayed placement of osseointegrated dental implants. Initial Panorex examinations were taken between 1 and 9 months postoperatively (mean, 2 months). Follow-up Panorex examinations were taken 24 to 104 months postoperatively (mean, 47 months). The bony union rate after osteotomy was 97 percent. Bone height measurements were compared by site and type of reconstruction. The mean loss in fibula height by site of reconstruction was 2 percent in central segments, 7 percent in body segments, and 5 percent in ramus segments. The mean loss in bone height after radial free flap mandible reconstruction was 33 percent in central segments and 37 percent in body segments; ramus segments did not lose height. The central and body segments reconstructed with scapular free flaps did not lose height, but one ramus segment lost 20 percent of height. There was no loss in bone height in mandibular body reconstruction with the ilium free flap. Fibula free flaps did not significantly lose bone height when evaluated with respect to age, follow-up, radiation therapy, or dental implant placement. The retention in bone height demonstrated in this study suggests that bone mass is preserved after osseous free flap mandible reconstruction. The greatest amount of bone loss was seen after multiply osteotomized radial free flaps were used for central mandibular reconstruction. The ability of the fibula free flap to maintain mass over time, coupled with its known advantages, further supports its use as the “work horse” donor site for mandible reconstruction. (Plast. Reconstr. Surg. 103: 1371, 1999.)

The morbidity at the donor-site in the free fibula flap is a well-studied fact in the adult population, but in children, there are few reports of the long-term adverse effects at the donor site. In this study, we evaluate donor-site morbidity, complications, and functional outcome in pediatric patients undergoing free fibula flap harvest for mandibular or maxillary reconstruction, and the relation between pain and walking abilities. A retrospective study of 22 pediatric patients undergoing free fibula flap harvest for mandibular and maxillary reconstruction between 2003 and 2014 was conducted. A certified point evaluation system was used, analyzing several factors like pain, walking ability, restriction in activities, gait alteration, paresthesia, and cosmetic appearance, and the relationship between variables. Mean age follow up of patient was 8.5 years (range 2-13 years). Pain was reported in 27% (n = 6), paresthesia and numbness 9% (n = 2), walking ability alteration in 50% (n = 11), restriction in activities in 18% (n = 4), gait alteration in 23% (n = 5), and cosmetic appearance alteration in the 14% (n = 3). We compare the pain and the gait alteration and did not find any relation between pain and gait alteration (P = 0.6016) and there was no relation between restriction in activities and walking ability (P = 0.1455). Free fibula flap is the gold standard for head and neck reconstruction, but the morbidity at the donor site, especially in a growing child, should not be ignored or minimized when counseling patients and their families.More studies, with more population and with a long-term follow-up should be carried out to determine the impact on the daily activities on the pediatric population.

Biomechanical feasibility of non-locking system in patient-specific mandibular reconstruction using fibular free flaps

Mandibular reconstruction has evolved significantly since its inception in the early 1900s. Currently, the fibula free flap (FFF) is considered the gold standard for mandibular and maxillary reconstructions, particularly for extensive defects, and the introduction of Extended Reality (XR) and virtual surgical planning (VSP) is revolutionizing maxillofacial surgery. This study focuses on evaluating the accuracy of using in-house cutting guides for mandibular reconstruction with FFF supported by virtual surgical planning (VSP). Planned and intraoperative osteotomies obtained from postoperative CT scans were compared in 17 patients who met the inclusion criteria. The proposed analysis included measurements of deviation angles, thickness at the centre of gravity, and the maximum thickness of the deviation volume. Additionally, a mandibular resection coding including 12 configurations was defined to classify and analyze the precision of mandibular osteotomies and investigate systematic errors. Preoperative, planned, and postoperative models have been inserted in an interactive VR environment, VieweR, to enhance surgical planning and outcome analysis. The results proved the efficiency of adopting customized cutting guides and highlighted the critical role of advanced technologies such as CAD/CAM and VR in modern maxillofacial surgery. A novel coding system including 12 possible configurations was developed to classify and analyze the precision of mandibular osteotomies. This system considers (1) the position of the cutting blade relative to the cutting plane of the mandibular guide; (2) the position of the intersection axis between the planned and intraoperative osteotomy relative to the mandible; (3) the direction of rotation of the intraoperative osteotomy plane around the intersection axis from the upper view of the model. This study demonstrates the accuracy and reliability of in-house cutting guides for mandibular reconstruction using fibula free flaps (FFF) supported by virtual surgical planning (VSP). The comparison between planned and intraoperative osteotomies confirmed the precision of this approach, with minimal deviations observed. These findings highlight the critical role of CAD/CAM and XR technologies in modern maxillofacial surgery, offering improved surgical precision and optimizing patient outcomes.

Free fibular flap (FFF) is the main modality in the reconstruction of maxillofacial defects. Micrognathia is a condition where the mandible is smaller than it should be. Micrognathia is typically treated with mandibular distraction osteogenesis, bilateral sagittal split osteotomy, and conventional costochondral graft. In cases in which these procedures cannot be performed, FFF becomes a suitable alternative. Publications regarding the use of FFF in cases of micrognathia are currently still limited. In this case, we present the use of FFF in the reconstruction of a severely micrognathic mandible in an adult patient. A 28-year-old woman with micrognathia was referred to Dr. Ciptomangunkusumo Hospital for reconstruction. The patient had previously undergone temporomandibular joint (TMJ) reconstruction surgery with interpositional TMJ arthroplasty 10 years prior due to an ankylosing TMJ that prevented the opening of the jaw. The treatment for ankylosing TMJ was necessitated due to the patient's inability to open their mouth, resulting in significant challenges with alimentation, speech, and facial morphology. Here the authors reported mandibular lengthening reconstruction in the anteroposterior axis with FFF. A surgical osteotomy was performed on the posterior segment of the bilateral mandibular ramus, then the segmented fibula was inserted into the resulting defect. Flap refinement was also performed following FFF. Postsurgical evaluation revealed notable enhancements in the patient's esthetic appearance, occlusal function, and amelioration of obstructive sleep apnea symptoms. FFF for mandibular reconstruction is feasible and effective in improving esthetic and functional outcomes in patients with micrognathia.

Precision and safety are crucial in performing fibula osteotomy during mandibular reconstruction with free fibula flap (FFF). However, current clinical methods, such as template-guided osteotomy, have the potential to cause damage to fibular vessels. To address the challenge, this paper introduces the development of the surgical robot for fibula osteotomies in mandibular reconstruction surgery and propose an algorithm for sensor-aware hybrid force–motion control for safe osteotomy, which includes three parts: osteotomy motion modeling from surgeons’ demonstrations, Dynamic-system-based admittance control and osteotomy sawed-through detection. As a result, the average linear variation of the osteotomized segments was 1.08±0.41mm, and the average angular variation was 1.32±0.65∘. The threshold of osteotomy sawed-through detection is 0.5 at which the average offset is 0.5mm. In conclusion, with the assistance of surgical robot for mandibular reconstruction, surgeons can perform fibula osteotomy precisely and safely.

BackgroundCondylar dislocation can arise as a complication in patients who required mandibular and/or condylar reconstruction and were operated on with fibula free flap (FFF) using surgical guides designed using simulation surgery. Surgeons should be aware of the complications in these present cases when planning and performing reconstructions as well as predicting prognoses.Cases presentationTwo cases showed condylar dislocation in mandibular reconstruction using a FFF fixed with a reconstruction plate. Three cases showed condylar dislocation in mandibular reconstruction using a fibula free flap fixed with a mini-plate.ConclusionDespite the lack of clinical symptoms in these cases following mandibular reconstruction using an FFF, the mandibular condyle was severely displaced away from the glenoid fossa. A surgeon must have sufficient time to consider the use of a long flap with thickness similar to that of the mandible, ways to minimize span and bending, and methods of fixation. The patient, moreover, should be educated on condylar dislocation. Customized CAD/CAM-prototyped temporomandibular condyle-connected plates may be a good alternative even if virtual simulation surgery is to be performed before surgery. These considerations may help reduce the incidence of complications after mandibular reconstruction.