Native Mandible Research Articles

Evaluation of Clinical Outcomes of Osseointegrated Dental Implantation of Fibula Free Flaps for Mandibular Reconstruction.

Dental implantation has been used for oral rehabilitation to improve cosmesis and function. We aim to evaluate the clinical outcomes and success rates of primary and secondary dental implant placement in vascularized fibula bone grafts used for segmental mandibulectomy defects. A retrospective review was performed between November 2005 and July 2014 on all patients undergoing both fibula free tissue reconstruction of mandibular defects and endosseous dental implantation at an academic tertiary care referral hospital. Either primary (n = 20) or secondary (n = 26) dental implantation of the fibula was performed. Timing of implantation, location of implants, history of tobacco, alcohol, and radiation, reason for mandibulectomy, and outcomes related to these parameters. Forty-six patients (31 males, 15 females; mean age, 58.0 years) underwent dental implantation to the fibula graft. A total of 227 implants were placed, with a mean of 5 implants per patient (range, 2-7). Of these, 44 were placed into native mandible and 183 into fibula flap. Twenty patients underwent primary implantation and received 96 implants, while 26 patients underwent secondary implantation and received 131 implants. There were no flap failures and 22 implant-related complications in 16 patients (implant failure, n = 10; granulation or soft-tissue overgrowth, n = 6; exposed bone around implant, n = 6). An implant failure occurred in 10 patients (22%) resulting in removal of 15 implants. Nine of these patients underwent successful dental rehabilitation, 5 without further implantation, and 4 with replaced implants. One patient was not rehabilitated secondary to failed implantation. Therefore, there was a 93% overall implant survival rate (n = 212) and 98% overall implant-supported prosthesis success rate (n = 45) at a mean follow-up of 22 months. There was no difference in implant survival between primary (94%) (n = 90) and secondary (93%) (n = 122) implantation. Neither a history of preimplant or postimplant radiation exposure nor the diagnosis of osteoradionecrosis affected implant survival. Osseointegrated dental implantation is a relatively safe procedure with few complications. Vascularized fibula grafts are a suitable method of mandibular reconstruction and are amenable to successful primary and secondary endosseous implantation. 4.

Long-Term Operative Outcomes of Preoperative Computed Tomography-Guided Virtual Surgical Planning for Osteocutaneous Free Flap Mandible Reconstruction.

Osteocutaneous free flaps have become the primary reconstructive modality for segmental mandibulectomy defects. The advent of preoperative virtual surgical planning with stereolithic models and cutting templates has led to significant refinements in operative technique. In this article, the authors examine the value of computed tomography-guided preoperative virtual surgical planning on operative outcomes and efficiency after mandibular reconstruction with osteocutaneous free flaps. A retrospective review was performed of all patients undergoing free flap mandible reconstruction at a single cancer center from 2002 to 2013. Surgical technique and operative time were assessed, as were overall complications and outcomes. Postoperative computed tomographic scans were also examined to determine the accuracy of osteotomies with and without virtual surgical planning. Ninety-two patients underwent osteocutaneous free flap reconstruction of the mandible during the study period. In 43 patients, the shaping of the neomandible was performed based on the prefabricated stereolithic models. The remaining 49 patients underwent preoperative computed tomographic imaging to design patient-specific cutting guides for the native mandible and the osteocutaneous flap. The use of preoperative computed tomography-guided planning resulted in less burring, fewer osteotomy revisions, and less bone grafting. Virtual surgical planning also significantly decreased operative time (666 minutes versus 545 minutes; p < 0.005). Review of postoperative computed tomographic scans demonstrated decreased rates of bony nonunion with virtual surgical planning, and there were no significant differences in overall outcomes or complications between the groups. Preoperative virtual surgical planning has refined mandible reconstruction with osteocutaneous free flaps through the introduction of patient-specific models, prebent plates, and osteotomy guides. Virtual surgical planning decreases operative time and improves the accuracy of free flap mandibular reconstruction. Therapeutic, III.

The use of computer-aided design/manufacturing (CAD/CAM) technology to aid in the reconstruction of congenitally deficient pediatric mandibles: A case series

BackgroundMicrovascular reconstruction of the pediatric mandible, particularly when necessitated by severe, congenital hypoplasia, presents a formidable challenge. Complex cases, however, may be simplified by computer-aided design/computer-aided manufacturing (CAD/CAM) assisted surgical planning. This series represents the senior authors’ preliminary experiences with CAD/CAM assisted, microvascular reconstruction of the pediatric mandible. MethodsPresented are two patients with hemifacial/bifacial microsomia, both with profound mandibular hypoplasia, who underwent CAD/CAM assisted reconstruction of their mandibles with vascularized fibula flaps. Surgical techniques, CAD/CAM routines employed, complications, and long-term outcomes are reported. ResultsSuccessful mandibular reconstructions were achieved in both patients with centralization of their native mandibles and augmentation of deficient mandibular subunits. No long-term complications were observed. ConclusionsCAD/CAM technology can be utilized in pediatric mandibular reconstruction, and is particularly beneficial in cases of profound, congenital hypoplasia requiring extensive, multi-planar, bony reconstructions.

A novel 3D template for mandible and maxilla reconstruction: Rapid prototyping using stereolithography.

Introduction:Replication of the exact three-dimensional (3D) structure of the maxilla and mandible is now a priority whilst attempting reconstruction of these bones to attain a complete functional and aesthetic rehabilitation. We hereby present the process of rapid prototyping using stereolithography to produce templates for modelling bone grafts and implants for maxilla/mandible reconstructions, its applications in tumour/trauma, and outcomes for primary and secondary reconstruction.Materials and Methods:Stereolithographic template-assisted reconstruction was used on 11 patients for the reconstruction of the mandible/maxilla primarily following tumour excision and secondarily for the realignment of post-traumatic malunited fractures or deformity corrections. Data obtained from the computed tomography (CT) scans with 1-mm resolution were converted into a computer-aided design (CAD) using the CT Digital Imaging and Communications in Medicine (DICOM) data. Once a CAD model was constructed, it was converted into a stereolithographic format and then processed by the rapid prototyping technology to produce the physical anatomical model using a resin. This resin model replicates the native mandible, which can be thus used off table as a guide for modelling the bone grafts.Discussion:This conversion of two-dimensional (2D) data from CT scan into 3D models is a very precise guide to shaping the bone grafts. Further, this CAD can reconstruct the defective half of the mandible using the mirror image principle, and the normal anatomical model can be created to aid secondary reconstructions.Conclusion:This novel approach allows a precise translation of the treatment plan directly to the surgical field. It is also an important teaching tool for implant moulding and fixation, and helps in patient counselling.

Mandibular Reconstruction Based on the Concept of Double Arc Reconstruction.

The natural mandible has 2 arcs, the marginal arc and the occlusal arc. The marginal arc is situated along the lower margin of the mandible and affects the contour of the lower third of the face. The occlusal arc is situated along the dental arc and affects the stability of prosthodontics. The gap between these 2 arcs widens in the molar area. Our developed concept of "double arc reconstruction" involves making these 2 arcs for the reconstructed mandible. For the double-barrel fibula reconstruction, 2 bone segments are used to make both arcs. For reconstructions using the iliac crest, the double arc is made by inclination of the top of the bone graft toward the lingual side. Ten patients underwent double arc reconstruction: 2 underwent reconstruction with the double-barrel fibula, and 8 underwent reconstruction with the iliac crest. Four patients had a removable denture prosthesis, 1 had an osseointegrated dental implant, and 5 did not require further prosthodontic treatment. The shape of the reconstructed mandible after double arc reconstruction resembles the native mandible, and masticatory function is good with the use of a dental implant or removable denture prosthesis, or even without prosthodontics.

Osseointegrated implant-based dental rehabilitation in head and neck reconstruction patients.

Dental restoration is an integral part of head and neck cancer reconstruction. We evaluated the success rate of osseointegrated implants in patients with head and neck cancer, comparing outcomes between implants placed in fibula free flaps to those placed in native mandibular and maxillary bone. A total of 1132 implants were placed in 246 patients. The overall implant loss rate was 3.7% and was higher in fibula flaps (8.2%) compared to the native mandible (2.6%) and maxilla (2.2%), although these differences did not reach statistical significance (p = .059 and p = .053, respectively). The failure rate was 8.0% for implants placed after radiation and 3.6% in patients who did not undergo radiation (p = .097). Osteoradionecrosis (ORN) occurred in 19 patients (7.7%) after implant placement, and tobacco use was found to be a risk factor (p = .027). Osseointegrated implants are reliable in patients with head and neck cancer, including those undergoing bony free flap reconstruction. © 2015 Wiley Periodicals, Inc. Head Neck 38: E321-E327, 2016.

Patient-specific reconstruction plates are the missing link in computer-assisted mandibular reconstruction: A showcase for technical description

IntroductionPreoperative planning of mandibular reconstruction has moved from mechanical simulation by dental model casts or stereolithographic models into an almost completely virtual environment. CAD/CAM applications allow a high level of accuracy by providing a custom template-assisted contouring approach for bone flaps. However, the clinical accuracy of CAD reconstruction is limited by the use of prebent reconstruction plates, an analogue step in an otherwise digital workstream. Technical reportIn this paper the integration of computerized, numerically-controlled (CNC) milled, patient-specific mandibular plates (PSMP) within the virtual workflow of computer-assisted mandibular free fibula flap reconstruction is illustrated in a clinical case. Intraoperatively, the bone segments as well as the plate arms showed a very good fit. Postoperative CT imaging demonstrated close approximation of the PSMP and fibular segments, and good alignment of native mandible and fibular segments and intersegmentally. Over a follow-up period of 12 months, there was an uneventful course of healing with good bony consolidation. ConclusionThe virtual design and automated fabrication of patient-specific mandibular reconstruction plates provide the missing link in the virtual workflow of computer-assisted mandibular free fibula flap reconstruction.

Implant-Based Rehabilitation in Oncology Patients Can Be Performed With High Long-Term Success

Radiotherapy and compromised vital bone and/or surrounding soft tissue can be a challenge to the successful osseointegration of dental implants. We evaluated the long-term results of dental implants in patients with oral cancer. To address the research purpose, we designed and implemented a retrospective cohort study that included patients with oral cancer who had received dental implants from 2003 to 2011. The data were collected from a clinical oncology database. The predictor variables included a set of heterogeneous variables grouped into logical sets of demographics, surgical treatment, dental rehabilitation, radiotherapy type, and tumor entity. The primary outcome variable was implant survival; the secondary outcome variable was peri-implantitis. The descriptive statistics, survival time analysis, Kaplan-Meier implant survival curves, and Cox hazard proportional modeling were computed. The study sample included 59 patients with oral cancer (20 women [33.9%], 39 men [66.1%]; mean age at tumor diagnosis, 55 years), who had had 272 implants placed during the study period. The mean follow-up period was 30.9 months (range 3 to 82). Of the 272 implants, 269 (98.9%) and 264 (97.1%) had survived for 2 and 5 years, respectively. During the observation period, 10 implants were lost (3.7%). Of the implant failures, 82% occurred in transplanted bone (4 fibula flaps, 4 iliac crests, and 2 native mandibles). We observed peri-implantitis caused by insufficiently attached gingiva and bone loss in 182 of the implants (67%). The factors associated with implant failure were peri-implantitis, insufficient soft and hard tissue, muscle dysfunction, and xerostomia. Implant-based rehabilitation in oncology patients can achieve a high long-term success rate, although risk factors such as impaired muscle function and a high frequency of peri-implantitis can affect healing.

Prototyped grafting plate for reconstruction of mandibular defects

To esthetically and functionally restore a 40-mm canine mandibular discontinuity defect using a custom-made titanium bone-grafting plate in combination with autologous iliac bone grafts. Individualized titanium bone-grafting plates were manufactured using a series of techniques, including reverse engineering, computer aided design, rapid prototyping and titanium casting. A 40-mm discontinuous defect in the right mandibular body was created in 9 hybrid dogs. The defect was restored immediately using the customized plate in combination with autologous cancellous iliac blocks. Sequential radionuclide bone imaging was performed to evaluate the bone metabolism and reconstitution of the grafts. The specimens were evaluated by biomechanical testing, 3-dimensional microcomputed tomographic scanning, and histological examination. The results revealed that the symmetry of the mandibles was reconstructed using the customized grafting plate, and the bony continuity of the mandibles was restored. By 12 weeks after the operation, the cancellous iliac grafts became a hard bone block, which was of comparable strength to native mandibles. A fibrous tissue intermediate was found between the remodelled bone graft and the titanium plate. The results indicate that the prototyped grafting plate can be used to restore mandibular discontinuous defects, and satisfactory aesthetical and functional reconstruction can be achieved.

Bone Tissue Engineering by Way of Allograft Revitalization: Mechanistic and Mechanical Investigations Using a Porcine Model

"Allograft revitalization" is a process in which cadaveric bone is used to generate well-vascularized living bone. We had previously found that porcine allograft hemimandibles filled with autologous adipose-derived stem cells (ASCs) and recombinant human bone morphogenetic protein-2-soaked absorbable collagen sponge (rhBMP-2/ACS) were completely replaced by vascularized bone, provided the construct had been incubated within a periosteal envelope. The present study sought to deepen our understanding of allograft revitalization by investigating the individual contributions of ASCs and rhBMP-2 in the process and the mechanical properties of the revitalized allograft. Porcine allograft hemimandible constructs were implanted bilaterally into rib periosteal envelopes in 8 pigs. To examine the contributions of ASCs and rhBMP-2, the following groups were assessed: group 1, periosteum alone; group 2, periosteum+ASCs; group 3, periosteum+rhBMP-2/ACS; and group 4, periosteum+ASCs+rhBMP-2/ACS. After 8 weeks, the allograft constructs were harvested for micro-computed tomography (CT) and histologic analyses and 3-point bending to assess the strength. On harvesting, the constructs receiving rhBMP-2/ACS had significantly greater bone shown by micro-CT than those receiving periosteum only (51,463 vs. 34,310 mm3; P = .031). The constructs receiving ASCs had increased bone compared to group 1 (periosteum only), although not significantly (P = .087). The combination of rhBMP-2/ACS with ASCs produced bone (50,399 mm3) equivalent to that of the constructs containing rhBMP-2/ACS only. The 3-point bending tests showed no differences between the 4 groups and a nonimplanted allograft or native mandible (P = .586), suggesting the absence of decreased strength of the allograft bone when revitalized. These data have shown that rhBMP-2/ACS significantly stimulates new bone formation by way of allograft revitalization and that the revitalized allograft has equivalent mechanical strength to native bone.

Simulated surgery and cutting guides enhance spatial positioning in free fibular mandibular reconstruction

The free fibular flap is the workhorse for mandibular reconstruction. Three-dimensional (3D) planning, with use of cutting guides and prebent plates, has been introduced. The purpose of this study is to evaluate the interfragmentary gap size and symmetry between conventional freehand preparation versus those using 3D planning. A retrospective review was performed. Conventional free form and 3D planned fibular reconstructions performed by the senior authors at a single institution were included. Reconstructions were further subdivided into "body only" and "complex." Demographic and intraoperative data were collected. Postoperative CT scans were analyzed using Materialize software. Interfragmentary gap distances (mm) and symmetry (degrees) were assessed. Nineteen fibular reconstructions met inclusion criteria, ten conventional free form, and nine 3D planned reconstructions. Interfibular gaps measured 0.36 ± 0.50 mm in the 3D group versus 1.88 ± 1.09 mm in the non-3D group (P = 0.004). Overall symmetry (a ratio between right and left angles) measured versus 1.027 ± 0.08 in the 3D-planned versus 1.024 ± 0.09 in the non-3D group in (P = 0.944). Within only mandibular body reconstructions, symmetry was similar between the two techniques: 1.05 ± 0.12 in the 3D group versus 0.97 ± 0.05 in the non-3D group (P = 0.295). 3D planning lessens interfibular gap dimensions and may enhance axial symmetry. Space between native mandible and fibula is not appreciably altered using planning. Future efforts will focus on the accuracy and reproducibility of the 3D planned to actual results as well as clinical significance and efficiency benefits.

Regenerating Mandibular Bone Using rhBMP‐2: Part 1—Immediate Reconstruction of Segmental Mandibulectomies

To describe a surgical technique using a regenerative approach and internal fixation for immediate reconstruction of critical size bone defects after segmental mandibulectomy in dogs. Prospective case series. Dogs (n = 4) that had reconstruction after segmental mandibulectomy for treatment of malignant or benign tumors. Using a combination of extraoral and intraoral approaches, a locking titanium plate was contoured to match the native mandible. After segmental mandibulectomy, the plate was secured and a compression resistant matrix (CRM) infused with rhBMP-2, implanted in the defect. The implant was then covered with a soft tissue envelope followed by intraoral and extraoral closure. All dogs that had mandibular reconstruction healed with intact gingival covering over the mandibular defect and had immediate return to normal function and occlusion. Mineralized tissue formation was observed clinically within 2 weeks and solid cortical bone formation within 3 months. CT findings at 3 months showed that the newly regenerated mandibular bone had ∼50% of the bone density and porosity compared to the contralateral side. No significant complications occurred. Mandibular reconstruction using internal fixation and CRM infused with rhBMP-2 is an excellent solution for immediate reconstruction of segmental mandibulectomy defects in dogs.

Double barrel fibula flap with dental rehabilitation for mandibular reconstruction

Purpose: The vascularized free fibula flap (VFFF) has become the popular reconstruction method after mandibular resection due to advantages of enough bone graft length and accepting dental implants. However, using a single fibula bone may have height discrepancy between the native mandible and grafted fibula which results in subsequent difficulty in wearing conventional dentures or osseintegrated implants. Several options could be used to resolve this problem such as delayed onlay bone graft, iliac bone reconstruction, fibula distraction and double barrel fibula flap graft. This article describes our experience in reconstruction of segmental mandible defect with double barrel fibula flap and denture rehabilitation.

Virtual Surgical Planning in Complex Composite Maxillofacial Reconstruction

Complex osteocutaneous maxillofacial reconstruction requiring multiple free flaps and with an extensive zone of injury can be fraught with complications and difficulty. Often, the remnants of native mandible are malpositioned and the skeletal structure of the upper face is distorted. The authors seek to extend the use of virtual planning to complex maxillofacial reconstruction by presenting their early experience in these difficult patients. A retrospective chart review of 10 consecutive patients who underwent complex maxillofacial reconstruction using virtual surgical planning was undertaken. The authors define complex maxillofacial reconstruction as that requiring an osteocutaneous flap in which multiple osteotomies were required in addition to at least one of the following: need for multiple free flaps, history of osteoradionecrosis, and ballistic injury. Synthes Proplan CMF surgical planning was performed using computed tomographic scanning of the maxillofacial area and the donor site. Jigs and cutting guides were created and plates were prebent. The flap was harvested and osteotomized using the jigs and inset. Postoperative computed tomographic scanning was performed to evaluate the reconstruction. Ten consecutive patients who met the criteria underwent review. There were no intraoperative complications. Postoperative computed tomographic scans showed excellent contour of the osseous flaps. All patients had functional mandibular range of motion. Use of virtual surgical planning allows for complex maxillofacial reconstruction with multiple simultaneous free flaps to be performed reliably and successfully. The use of prefabricated jigs and precontoured plates eases osteocutaneous flap molding and inset, allowing for a more complex procedure to be successful.

Mandibular reconstruction with a fibular osteocutaneous free flap in an 8-month-old girl with a 12-year follow-up

The purpose of this article is to describe a case of an 8-month-old girl who was diagnosed with a melanotic neuroectodermal tumor and was submitted to a right hemimandibulectomy and immediate reconstruction with a fibular osteocutaneous free flap. At 12-year follow-up, the longest reported in a patient this young, the transferred bone had grown much like the native mandible, and the patient had adequate mandibular contour and function. No revisions were needed, although orthopedic surgery was performed to correct an ankle valgus deviation on the donor leg. It is the opinion of the authors that microsurgical mandible reconstruction in very young patients is efficient and that the surrounding structures contribute to the remodeling of the bone segment to achieve characteristics similar to those of the native mandible.

Union and Bone Resorption of Free Fibular Flaps in Mandibular Reconstruction

The purpose of this study was to evaluate bony union and resorption after free fibular flap reconstruction for mandibular reconstruction. A total of 112 patients with composite resection and reconstruction with a fibular free flap were included. Computed tomography scan images taken after the reconstruction and approximately 1 year postoperatively were assessed to evaluate union (n = 60) and bone resorption (n = 24) of the neomandible. Most of the fibulas healed well (n = 34) and there was radiologic nonunion in 20% of the neomandibles at the time of evaluation (mean = 15 months). There was a statistically significant reduction in bone height in the native mandible (p = 0.02) and the anterior part of the fibular graft (p = 0.02). There was a statistically significant reduction in mandibular and fibular graft height. However, the bone resorption was clinically minimal. Sufficient maintenance of height and good bony union support the use of free fibular flap in mandibular reconstruction.

Computer‐assisted design and rapid prototype modeling in microvascular mandible reconstruction

To evaluate the use of computer-assisted design and rapid prototype modeling to improve the speed and accuracy of mandibular reconstruction. Case-control study. Between 2005 and 2011, 38 subjects underwent fibula free flap mandibular reconstruction using computer-assisted design and rapid prototype modeling. Titanium plates were prebent using the models prior to surgery. Direct plate bending on the native mandible to accurately restore occlusion would not have been possible in 11 patients with exophytic tumors, nine patients with pathologic fractures, and 10 patients with a prior segmental mandibulectomy. Computer-generated cutting guides were utilized to facilitate fibular osteotomies. The mean operative time for subjects was 8.8 ± 1.0 hours compared to the mean operative time defect-matched control group, for whom computer-assisted design and models were not used, of 10.5 ± 1.4 hours (P = .0006). Comparison of the preoperative and postoperative mandibles demonstrated that the mean change in position of selected bony landmarks (condyles, gonions, and gnathion) was less in the subject group than in the control group (4.11 ± 3.09 mm vs. 6.92 ± 5.64 mm, respectively; P = .001) Comparison of postoperative mandibles with preoperative virtual plans showed a mean deviation of 2.40 ± 2.06 mm from planned fibular segment lengths and 3.51 ± 2.69° from planned angles between fibular segments. Computer-assisted design and rapid prototype modeling have the potential to increase the speed and accuracy of mandibular reconstruction. We believe these technologies are particularly useful for cases in which the original architecture of the mandible has been distorted or destroyed.

Microvascular reconstruction of the mandible: An argument for the fibula osteocutaneous free flap

Introduction/objectiveThe fibula osteocutaneous free flap has been a workhorse for mandibular reconstruction since Hidalgo's original description for its use for this purpose. The objective of this manuscript is to review the use of the fibula flap in mandibular reconstruction and to answer some of the commonly held misconceptions as to why some surgeons view it as an inferior reconstructive option to the vascularized iliac crest flap. Materials/methodsReview of the literature as it relates to the use of the fibula free flap in mandibular reconstruction and the senior author's experience. ResultsThe bicortical nature of the fibula provides a stable platform for endosseous implant placement, thus allowing for comprehensive oral rehabilitation and improving the quality of life in reconstructed patients. The fibula osteocutaneous free flap, however, is the longest vascularized bone flap available, allowing for reconstruction of the entire mandible. Given these attributes, it would seem unlikely that doubts regarding the adequacy of the fibula free flap in mandibular reconstruction exists. However, the principal arguments challenging the use of the fibula osteocutaneous free flap are the lack of height of the reconstructed fibula compared to the native mandible, unreliable skin perforators to support a skin paddle, insufficient soft tissue coverage, and the presence of vascular anomalies which may preclude its use. These presumed shortcomings are circumvented with various proven techniques to increase fibular height and anatomic studies demonstrating the cutaneous perforator patterns. ConclusionsWith these simple solutions in mind, the fibula osteocutaneous free flap will likely remain a workhorse for mandibular reconstruction, allowing for the reconstruction of virtually any oromandibular defect. It allows for both aesthetic, as well as, functional reconstruction of the mandible.

Pectoralis Major Flap with Sternum

Sir:FigureThe vast majority of segmental bony defects of the mandible are treated with free vascularized bone flaps. There are certain patients, however, who are poor candidates for free tissue transfer but still require vascularized bone. These include patients who have no recipient vessels or donor sites, or are too ill for a lengthy procedure. The following case is one such patient. The patient was a 73-year-old man with a history of a T1N2bM0 squamous cell carcinoma of the tongue. Previous treatment included surgical excision and bilateral neck dissections in 2003, followed by irradiation (total, 160 Gy) to the oral cavity and neck. He subsequently developed osteoradionecrosis, treated with serial sequestrectomies, followed by recurrences in 2008 and 2009, requiring excision. He presented to our institution with another recurrence in 2011 and was scheduled for a composite resection of the body of the mandible and floor of the mouth. On examination, his neck was as solid as wood from the mandibular angle to the clavicle. On computed tomography, he had bilateral severe atherosclerosis of the carotids and no remaining branches of the external carotids. He had bilateral congenital club feet, for which he underwent nine operative procedures and was ambulatory only with orthoses. Finally, he had severe chronic obstructive pulmonary disease and hepatitis C and was an active smoker and alcoholic. Clearly, this patient was a poor candidate for free tissue transfer; however, his tumor was causing severe pain and ulceration and was growing rapidly. To achieve intraoral skin coverage, vascularized bony reconstruction, and neck coverage, we opted for a pedicled pectoralis major muscle flap with skin and a vascularized split sternum. The pectoralis major with a vascularized sternum was described by Green et al. in 19811 and further refined by Robertson2,3 but has been lost to history in the era of free tissue transfer. The technique involves a skin island oriented vertically over the lateral aspect of the lower third of the sternum (Fig. 1). The medial incision is made, and the anterior table of the ipsilateral lower third of the sternum is osteotomized with the oscillating saw. A curved osteotome separates the anterior and posterior tables. The skin incision is continued along the costal margin to create a rotation flap to close the donor site. The pectoralis muscle is elevated in the submuscular plane until the lateral border of the sternum is encountered. The sternocostochondral junction is separated with sharp Mayo scissors (Fig. 2). The remainder of the myo-osseocutaneous flap is elevated in standard fashion.4 The native mandible was burred down to create a step-cut in which the sternum was press-fit. Osteosynthesis was achieved with 8-mm nonlocking screws (Fig. 3). The patient had an uneventful hospital course and was discharged to home on postoperative day 6. After 2 weeks, the patient developed an orocutaneous fistula; however, on surgical débridement, the bone remained well vascularized by the muscle.Fig. 1: The skin island is centered over the ipsilateral border and the inferior half of the sternum. The bony sternal segment is marked over the ipsilateral half and the inferior third of the sternum, not including the xiphoid. The incision is designed to continue inferolaterally, creating a fasciocutaneous rotation flap to close the donor defect.Fig. 2: The medial incision is made first, and the anterior table of the ipsilateral lower third of the sternum is osteotomized with the oscillating saw. A curved osteotome separates the anterior and posterior tables. The skin incision is continued along the costal margin to create the rotation flap. The pectoralis muscle is elevated in the submuscular plane until the lateral border of the sternum is encountered. The sternocostochondral junction is separated with sharp Mayo scissors.Fig. 3: The native mandible was burred down to create a step-cut in which the sternum was press-fit. Osteosynthesis was achieved with 8-mm nonlocking screws. Different orientations of the bone and skin island are possible, depending on whether intraoral or extraoral skin is required.Free vascularized bone flaps are standard treatment for segmental mandibular defects. Occasionally, however, for reasons of donor-site, recipient-site, or patient disease, free tissue transfer is inadvisable. In these cases, pectoralis major flap with vascularized sternum represents one of the few remaining options for this subset of patients. Jesse Creed Selber, M.D., M.P.H. Shadi Ghali, M.D. University of Texas M. D. Anderson Cancer Center, Houston, Texas DISCLOSURE The authors have no financial interest to declare in relation to the content of this article.

Double-Barrel Fibula Vascularized Free Flap With Dental Rehabilitation for Mandibular Reconstruction

The vascularized free fibula flap has become the most popular reconstruction method after mandibular resection because of adequate bone graft length and acceptance of dental implants. However, using 1 fibula bone may produce a height discrepancy between the native mandible and the grafted fibula that results in subsequent difficulty in wearing conventional dentures or osteointegrated implants. Several options can be used to resolve this problem such as delayed onlay bone graft, iliac bone reconstruction, fibula distraction, and double-barrel fibula flap graft. This article describes the reconstruction of segmental mandible defects with the double-barrel fibula flap and denture rehabilitation. This procedure was used in 7 patients. A donor site fibula corresponding to at least twice the length of the mandibular defect was harvested. Double-barrel free fibula grafting was performed in 6 patients for primary reconstruction and 1 patient for secondary reconstruction, including 3 cases of osteocutaneous flap with skin islands in the reconstruction of a composite defect from a malignant tumor. Prosthodontic treatment was completed in all 7 patients. Four patients received secondary implant-supported dental reconstruction, and 3 patients who received radiation (6,000 cGy) after graft surgery had conventional removable partial dentures. Microvascular fibula transfers were completely successful, and all skin paddles survived without necrosis. The original mandibular contour was maintained by a reconstruction plate; the reconstruction mandibular length was 6.5 to 10 cm, the reconstruction height of the double-barrel fibula was 3.0 to 3.8 cm, and all patients were satisfied with the postoperative facial esthetics and chewing function from the implant-supported denture and removable partial prostheses. Mandibular segmental defects can be esthetically and functionally reconstructed by a double-barrel vascularized fibula flap that not only matches the height of the native mandible but also allows osteointegrated dental implantation for dental rehabilitation.