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Secondary mandibular reconstruction using fibular free flaps (FFF) is a technical challenge for surgeons. Appropriate operation planning is crucial for postoperative quality control and is notably necessary for the (re-) achievement of a physiological condylar position, and the sensible expansion and shaping of the transplant. Computer-assisted planning may help to reconstruct mandibular defects in a patient-specific and precise manner. Herein, we present a newly-developed workflow for secondary mandibular reconstruction using FFF; it comprises digital planning and in-house manufacturing to perform precise secondary mandible reconstruction. This method utilizes a newly designed positioning device to ensure the precise positioning of the fibula segments in relation to each other and the mandibular stumps. The presented in-house-printed positioning device made it possible to achieve digital planning with high precision during surgery. [ABSTRACT FROM AUTHOR]

Background Fibula free flaps (FFF) are the gold standard tissue for the reconstruction of segmental mandibular defects. A comparison of miniplate (MP) and reconstruction bar (RB)-based fixation of FFFs has been previously described in a systematic review; however, long-term, single-center studies comparing the two plating methods are lacking. The authors aim to examine the complication profile between MPs and RBs at a single tertiary cancer center. We hypothesized that increased components and a lack of rigid fixation inherent to MPs would lead to higher rates of hardware exposure/failure. Methods A retrospective review was performed from a prospectively maintained database at Memorial Sloan Kettering Cancer Center. All patients who underwent FFF-based reconstruction of mandibular defects between 2015 and 2021 were included. Data on patient demographics, medical risk factors, operative indications, and chemoradiation were collected. The primary outcomes of interest were perioperative flap-related complications, long-term union rates, osteoradionecrosis (ORN), return to the operating room (OR), and hardware exposure/failure. Recipient site complications were further stratified into two groups: early (<90 days) and late (>90 days). Results In total, 96 patients met the inclusion criteria (RB = 63, MP = 33). Patients in both groups were similar with respect to age, presence of comorbidities, smoking history, and operative characteristics. The mean follow-up period was 17.24 months. In total, 60.6 and 54.0% of patients in the MP and RB cohorts received adjuvant radiation, respectively. There were no differences in rates of hardware failure overall; however, in patients with an initial complication after 90 days, MPs had significantly higher rates of hardware exposure (3 vs. 0, p = 0.046). Conclusion MPs were found to have a higher risk of exposed hardware in patients with a late initial recipient site complication. It is possible that improved fixation with highly adaptive RBs designed by computer-aided design/manufacturing technology explains these results. Future studies are needed to assess the effects of rigid mandibular fixation on patient-reported outcome measures in this unique population. [ABSTRACT FROM AUTHOR]

Though the gold standard method for mandible reconstruction of the defect from segmental mandibulectomy is by osseous flap or graft, using reconstruction plates is still indicated in some cases. Traditionally, the plate is bended immediately after the segmental mandibulectomy by freehand. However, it's difficult to fit well to the original position of mandible, which may result in more complications. This study therefore aimed to investigate whether using prebent plates on computer-aided 3D printing models could reduce the complication rate. Patients who received mandible reconstruction by reconstruction plate from 2018 to 2022 were enrolled and evaluated in this study. The data, including demographics, indications for surgery, pre-existed preoperative and postoperative therapies, classification of defects, and postoperative outcomes were collected and analyzed. A total of 52 patients were enrolled in our study. The prebent group exhibited a significantly lower complication rate than that of the immediately bent group (P = 0.012). Other risk factors of plate complications included postoperative adjuvant radiotherapy (P = 0.017) and previous surgery (P = 0.047). The complication-free survival rate was also better in the prebent group in a 3-year follow-up period (P = 0.012). Prebent plates on computer-aided printing models proved to be an effective approach to reduce the complications for mandibular reconstruction in segmental mandibulectomy. [ABSTRACT FROM AUTHOR]

With the development of computer-assisted surgery, digital guide plate was widely used in vascularized bone flap grafts for mandibular reconstruction. The purpose of this study was to design and manufacture a digital guide plate with drill-hole sharing for mandibular reconstruction and assess for surgical accuracy. 17 patients that required mandibular reconstruction using fibula free flap or iliac crest free flap were included in the study. The computed tomography (CT) data of the patient's mandible and pelvis or fibula were acquired preoperatively. A surgical simulation was then performed using computer-aided surgical simulation (CASS) technology based on above date, which allowed the design of two cutting guide and a repositioning guide for mandibular reconstruction. After surgery, the accuracy of reconstruction was evaluated by superimposing the postoperative image onto the preoperative image of mandible, recording the linear and angular deviation of landmarks, measuring the differences between the planned and actual outcomes. The osteotomy and repositioning of fibula or iliac crest segments were successfully performed as planned using surgical guides. The digital guide plate with drill-hole sharing showed excellent accuracy, When the iliac crest or the fibula free flap were used for mandibular reconstruction, the largest mean differences between the preoperative and postoperative were 1.11 mm and 2.8° or 1.3 mm and 3.87°. The digital guide plate with drill-hole sharing designed preoperatively provides a reliable method of for the mandibular reconstruction. This can assist surgeons in accurately performing osteotomy and repositioning fibula or iliac crest segments during the mandibular reconstruction. Abstract. [ABSTRACT FROM AUTHOR]

Background: Reconstruction of continuity defects following osteonecrosis in multimorbid patients is challenging. In all cases of the predescribed palliative treatment method for alloplastic mandible reconstruction, plate fractures were detected in follow‐up. We hypothesized that a modification could avoid these fractures, leading to stable long‐term results. Methods: This retrospective study compares the original method with a modification using single, laser‐sintered CAD–CAM plates instead of manually bent miniplates. The predescribed shuttering technique was used to reconstruct the mandible in its original shape with bone cement. Results: Uneventful wound healing was observed in 86% of the cases after modification of the method. No implant or plate fracture occurred. Conclusions: The presented method should be considered as a treatment option for mandible reconstruction in elderly, multimorbid patients in palliative situations. The results of this study suggest that the modification of the method leads to significantly improved long‐term stability. Donor site morbidity is avoided with this method of palliative surgery. [ABSTRACT FROM AUTHOR]

Background: Implant-supported dentures have become an essential means of restoring occlusal function after jaw reconstruction. Bone mineral density (BMD) may influence the success rate of implant denture restorations. This study aimed to explore whether the Hounsfield unit (HU) value can be used to monitor the changing trend of fibular BMD after jaw reconstruction. Results: A total of 54 patients who underwent maxillar/mandibular reconstruction with a fibula flap were included in this study. There was a significant correlation between the HU value and BMD at 1 week, 3 months, and 6 months after surgery, and both were significantly correlated with follow-up time. The difference between each pair of absorption rates (DAR) was less than 10% in 66.7% and 75.9% of patients at 3 and 6 months; however, the DAR was more than 20% in 12% and 13.8% of patients at 3 and 6 months, respectively. Conclusions: There is a significant correlation between HU value and BMD. The HU value can be used to roughly reflect the fibular BMD changing trend in a group of patients as opposed to an individual, and the HU value is not equivalent to BMD. Trial registration: ChiCTR, ChiCTR2300069661, retrospectively registered on 22 March 2023. Retrospectively registered, https://www.chictr.org.cn/showproj.html?proj=188953. [ABSTRACT FROM AUTHOR]

Reconstruction of defects of the jaws is mainly performed via free fibula flap. An incidence of 2–21% of overall flap failure is still described. We investigated the roles of volume, length and number of fibula flap segments on flap survival using novel three-dimensional segmentation tools. We also analyzed the role of other possible risk factors. Seventy-one consecutive patients with a follow up of at least three months and who underwent free fibula flap reconstruction in a single center between 2002 and 2022 have been evaluated. A total of 166 fibula segments were analyzed. Malignancies were the main reason of resection (45.1%). In 69% of the cases a reconstruction of the mandible was performed. The flaps were mainly divided in two segments (39%) (range 1–4), with a mean length of 2.52 cm and a mean volume was 3.37 cm3. Total flap failure (TFF) occurred in 12 cases, (16.9%), while partial flap failure (PFF) appeared in 3 patients (4.2%). Volume, length and number of fibula flap segments did not seem to influence flap failure incidence in uni- and multivariate analysis. Reconstruction of the maxilla and use of a recipient vessel different from the facial artery seemed to significantly impact on flap failure. Smoking and previous surgeries showed a higher trend to flap failure, but they did not reach statistical significance. Prospective and multicentric analysis on a wider population should be assessed. [ABSTRACT FROM AUTHOR]

Background: Computer Assisted Design and Computer Assisted Manufacturing (CAD/CAM) have revolutionized oncologic surgery of the head and neck. A multitude of benefits of this technique has been described, but there are only few reports of donor site comorbidity following CAD/CAM surgery. Methods: This study investigated comorbidity of the hip following deep circumflex iliac artery (DCIA) graft raising using CAD/CAM techniques. A cross-sectional examination was performed to determine range of motion, muscle strength and nerve disturbances. Furthermore, correlations between graft volume and skin incision length with postoperative donor site morbidity were assessed using Spearman's rank correlation, linear regression and analysis of variance (ANOVA). Results: Fifteen patients with a mean graft volume of 21.2 ± 5.7 cm3 and a mean incision length of 228.0 ± 30.0 mm were included. Patients reported of noticeable physical limitations in daily life activities (12.3 ± 11.9 weeks) and athletic activities (38.4 ± 40.0 weeks in mean) following surgery. Graft volume significantly correlated with the duration of the use of walking aids (R = 0.57; p = 0.033) and impairment in daily life activities (R = 0.65; p = 0.012). The length of the scar of the donor-site showed a statistically significant association with postoperative iliohypogastric nerve deficits (F = 4.4, p = 0.037). Patients with anaesthaesia of a peripheral cutaneous nerve had a larger mean scar length (280 ± 30.0 mm) than subjects with hypaesthesia (245 ± 10.1 mm) or no complaints (216 ± 27.7 mm). Conclusions: Despite sophisticated planning options in modern CAD/CAM surgery, comorbidity of the donor site following iliac graft harvesting is still a problem. This study is the first to investigate comorbidity after DCIA graft raising in a patient group treated exclusively with CAD/CAM techniques. The results indicate that a minimal invasive approach in terms of small graft volumes and small skin incisions could help to reduce postoperative symptomatology. Trial registration Retrospectively registered at the German Clinical Trials Register (DRKS-ID: DRKS00029066); registration date: 23/05/2022 [ABSTRACT FROM AUTHOR]

Porcine mandibular defect models are commonly used for the preclinical evaluation of reconstruction techniques. Existing studies vary in technique, complexity, and postoperative outcomes. The procedures are complex and often described without sufficient detail. We describe in detail a simple and reproducible method for creating a critical-size mandibular defect in a porcine model. Seven hemimandibular critical size defects were created in five male Yorkshire-Landrace pigs, three with unilateral defects and two with bilateral defects. A transverse incision was made over the mandibular body. Periosteum was incised and elevated to expose the mandibular body and a critical-size defect of 30 × 20 mm created using an oscillating saw. The implant was inserted and fixed with a titanium reconstruction plate and bicortical locking screws, and the wound closed in layers with resorbable sutures. Intraoral contamination was avoided. Dentition was retained and the mental nerve and its branches preserved. The marginal mandibular nerve was not encountered during dissection. All pigs retained normal masticatory function, and there were no cases of infection, wound breakdown, haematoma, salivary leak, or implant-related complications. The procedure can be performed bilaterally on both hemimandibles without affecting load-bearing function. All pigs survived until the end point of three months. Postoperative computed tomographic scans and histology showed new bone formation, and a three-point bend test showed the restoration of biomechanical strength. Straight-segment mandibulectomy is a simple and reproducible method for the creation of critical-size mandibular defects in a porcine model, simulating a load-bearing situation. [ABSTRACT FROM AUTHOR]

Background: To explore the masticatory performance in patients undergoing an osteo(cutaneous) free fibula (OFF) flap for mandible reconstruction by a prospective design. Methods: A total of 56 patients who had undergone OFF flap reconstructions for mandibular reconstruction secondary to malignant (squamous cell carcinoma) or benign (ameloblastoma) tumor resection were prospectively enrolled. They were asked to complete the masticatory performance test by the weigh method and the chew domain of the University of Washington quality of life questionnaire (version 4) preoperatively and at 3, 6, and 12 months postoperatively. The pair nonparametric test was used to analyze the dynamic change of masticatory performance and subjective chew function. Results: Fifty-one patients were included for analysis finally. The mean masticatory performance for patients with malignant tumors were 53.4% ± 10.3%, 36.4% ± 10.3%, 42.6% ± 9.6%, 52.8% ± 10.9%, and 53.1% ± 11.8% preoperatively, at 2 weeks, 3 months, 6 months, and 12 months postoperatively, respectively. Compared with the preoperative level, the masticatory performance had a significant reduction immediately after surgery (p < 0.001), followed by a return to the baseline level within three months. A similar trend was noted for those with benign tumors. The mean score of chew domain for patients with malignant tumors were 100 ± 0, 54.3 ± 32.9, 81.4 ± 24.5, and 92.9 ± 17.8 preoperatively, at 3 months, 6 months, and 12 months postoperatively, respectively. Compared with the preoperative level, the subjective chew function was greatly affected within the first three months (p < 0.001), and it gradually recovered to the baseline level in the following nine months. A similar trend was noted in patients with benign tumors. Conclusions: The masticatory performance and subjective chew function was significantly affected after OFF flap reconstructions in the short term, but both recovered to the preoperative levels within 9–12 months. [ABSTRACT FROM AUTHOR]

Reconstructing mandibular defects presents challenges to dental rehabilitation related to altered bone and soft tissue anatomy. Dental implants are the most reliable method to restore the lost dentition. Immediate dental implants have been placed for many years but with unacceptably low rates of dental/prosthetic success. Current virtual technology allows placement of both fibulas and guided implants in restoratively driven positions that also allow immediate dental rehabilitation. Inexpensive three-dimensional printing platforms can create provisional dental prostheses placed at the time of surgery. This article reviews our digital and surgical workflow to create an immediate dental prosthesis to predictably restore the dentition during major jaw reconstruction with fibula free flaps. [ABSTRACT FROM AUTHOR]

The purpose of this study was to investigate whether the time delay between 'out of house' proprietary virtual surgical planning (OH-VSP) of the mandibular resection for oral cancer and the actual surgery results in compromised margins and oncological disadvantage for the patient. Outcomes of patients who had OH-VSP of their mandibular resection and reconstruction were compared with those of patients who had the same surgery using a conventional non-VSP approach. The groups were similar in patient demographics, tumour stage and size, nodal status, and reconstruction complexity. VSP resulted in a significant reduction in operating time (P < 0.01). VSP did not affect bony (P = 0.49) or soft tissue (P = 0.22) margin status. In summary, VSP reduced the operating theatre time, and despite the time interval between bony resection planning and surgery, there was no compromise to the oncological safety of the operation. [ABSTRACT FROM AUTHOR]

Background: To determine whether virtual surgical planning and three‐dimensional printed cutting guides (3D/VSP) improved radiographic bone union compared to conventional methods (CM) in fibula free flap (FFF) reconstruction of the mandibles. Methods: Retrospective study from the years 2000–2018 at a tertiary hospital. Osseous union was evaluated by a radiologist blinded to each patient's treatment. Results: Two hundred sixty patients who underwent FFF tissue transfer, 28 with VSP and 3D cutting guides. Bony union was not achieved in 46 (20%) patients who underwent CM compared to 1 (4%) of patients with VSP and guides (p = 0.036). FFF complication was significantly higher in CM with 87 patients (38%) compared to three patients (11%) in 3D/VSP (p = 0.005). Median time to bony union for patients who underwent CM was 1.4 years compared to 0.8 years in 3D/VSP. Conclusions: 3D/VSP reduced the rate of radiographic nonunion and flap‐related complications in FFF reconstruction for mandibular defects. [ABSTRACT FROM AUTHOR]

Oral cavity tumors are a prevalent cause of mandible reconstruction surgeries. The mandible is vital for functions like oralization, respiration, mastication, and deglutition. Current mandible reconstruction methods have low success rates due to complications like plate fracture or exposure, infections, and screw loosening. Autogenous bone grafts are commonly used but carry the risk of donor region morbidity. Despite technological advances, an ideal solution for mandible reconstruction remains elusive. Additive manufacturing in medicine offers personalized prosthetics from patient-specific medical images, allowing for the creation of porous structures with tailored mechanical properties that mimic bone properties. This study compared a commercial reconstruction plate with a lattice-structured personalized prosthesis under different biting and osseointegration conditions using Finite Element Analysis. Patient-specific images were obtained from an individual who underwent mandible reconstruction with a commercial plate and suffered from plate fracture by fatigue after 26 months. Compared to the commercial plate, the maximum von Mises equivalent stress was significantly lowered for the personalized prosthesis, hindering a possible fatigue fracture. The equivalent von Mises strains found in bone were within bone maintenance and remodeling intervals. This work introduces a design that doesn't require grafts for large bone defects and allows for dental prosthesis addition without the need for implants. • A lattice-structured personalized mandible prosthesis for mandible reconstruction is proposed. • Finite element analysis showed better mechanical response for personalized prosthesis when compared to commercial plate. • The personalized prosthesis presents low weight and stiffness and allows for direct dental prosthesis restoration. [ABSTRACT FROM AUTHOR]

Background: Computer‐aided design/computer‐aided manufacturing (CAD/CAM) surgical templates allow precise mandibular reconstructive surgery. However, their clinical accuracy is limited by manual plate bending. Digitally hydroformed plates maintain a digital workstream in virtual planning. Methods: Twelve patients with Brown's class IIc mandibular defects were randomized into two groups: group I (experimental), the reconstruction plate was digitally hydroformed, and group II (control), surgeries were performed CAD/CAM guided with the reconstruction plate manually prebent. The linear and angular deviations of reconstruction outcomes were compared to surgical simulation in both groups. Results: The mean linear and angular deviations of middle and posterior segments were 2.14 ± 0.79 mm, 3.71 ± 0.95 mm, 8.73° ± 1.91°, and 9.06° ± 0.96° in group I and 4.31 ± 0.78 mm, 6.74 ± 1.40 mm, 16.35° ± 0.72°, and 31.48° ± 3.38° in group II, respectively. Measurements in group I were significantly lower than group II (P <.005). Conclusion: Digital hydroforming for plate prebent is a reliable method that helps improving the clinical accuracy of CAD/CAM‐guided mandibular reconstruction surgery. [ABSTRACT FROM AUTHOR]

Background: Composite mandibular reconstruction requires multiple tissue components inset in different planes. Intrinsic chimeric flap design provides this, and may be best suited for these reconstructions. Methods: A retrospective review of mandible reconstructions with composite, intrinsic chimeric, or 2 free flaps was performed. Patient and flap characteristics and complications were analyzed. Results: Seventy‐five patients were reviewed. Defects reconstructed with intrinsic chimeric flaps had significantly more soft tissue needs than composite reconstructions. However, intrinsic chimeric bony defects were less complex. Despite significantly longer operative times for intrinsic chimeric flaps, there were no differences in complications or hospital stays. Intrinsic chimeric reconstruction resulted in significantly lower complication rates requiring an additional flap. This benefit was pronounced in through‐and‐through defects. Conclusion: Intrinsic chimeric flaps are a better option than composite flaps for reconstruction of mandibular defects with large soft tissue needs with no increased complication risk despite longer operative time. [ABSTRACT FROM AUTHOR]

Background: Segmental mandibulectomy impairs health‐related quality of life (QoL), by altering speech, mastication, swallowing, and facial aesthetics. Fibula free flap (FFF) used for mandible reconstruction is known to improve outcomes; however, minimal information exists in the literature regarding patient‐reported outcomes. We aim to assess how current studies evaluate patient perception following segmental mandibulectomy and FFF mandible reconstruction. Methods: Following Preferred Reporting Items for Systematic Reviews and Meta‐Analyses guidelines, a search was conducted for publications involving FFF mandible reconstruction from 2005 to 2017 using PubMed, Cochrane, EMBASE, Web of Science, and PsychInfo. Results: Of 2212 articles identified initially, only 7 studies were deemed suitable. Six studies used the University of Washington Quality of Life questionnaire, 3 Oral Health Impact Profile, and 1 used European Organization for Research and Treatment of Cancer Head and Neck (EORTC‐H&N35). Conclusions: There is a paucity of information in published reports on QoL outcomes following mandible reconstruction with FFF. In the era of patient‐centered health care, observations warrant attention from researchers for physician‐assessed patient‐reported measures to factor in QoL expectation during surgical decision‐making about the choice of reconstruction. [ABSTRACT FROM AUTHOR]

Background: The fibula free flap (FFF) constitutes the gold standard surgical approach for mandibular reconstruction. Mandible reconstruction is routinely performed in high-volume academic centers. To our best knowledge, this is the first case series exclusively dedicated on FFF conducted in community hospitals. This study evaluates our 10-year experience with FFF mandible reconstruction in two community hospitals.Methods: This is a retrospective review of all 12 patients who underwent partial or total mandibulectomy with concomitant mandible reconstruction using FFF from September 2005 through February 2015.Results: The majority of the patients were men (75%) with a mean age of 61 years. Eleven (91.7%) patients had malignancies of the head and neck, and 10 (83.3%) received preoperative XRT. Overall flap survival was 100%, with no arterial/venous thrombosis or malunion. Partial flap failure (with skin paddle necrosis) was reported in only 1 patient, but the bone was viable and survived. Recipient-site wound infection, hardware exposure, and orocutaneous fistula occurred among previously irradiated patients, and in those who were suffering from osteoradionecrosis.Conclusions: Our FFF outcomes were non-inferior to those reported in specialized university hospitals and are evidence that successful results can be obtained outside of high-volume academic centers. FFF represents a reliable surgical approach for mandible reconstruction in university and community hospitals.Level of Evidence: Level IV, therapeutic study. [ABSTRACT FROM AUTHOR]

Aim: The aim of this study was to determine whether intra-oral de novo regenerated mucosa (D) that grew over free fibula flap reconstructed-mandibles resembled the donor tissue i.e. external skin (S) of the lateral leg, or the recipient site tissue, i.e. keratinized oral mucosa (K).Materials and Methods: Differential proteome analysis was performed with ten tissue samples from each of the three groups: de novo regenerated mucosa (D), external skin (S), and keratinized oral mucosa (K). Expression differences of cornulin and involucrin were validated by Western blot analysis and their spatial distributions in the respective tissues were ascertained by immunohistochemistry.Results: From all three investigated tissue types a total of 1188 proteins were identified, 930 of which were reproducibly and robustly quantified by proteome analysis. The best differentiating proteins were assembled in an oral mucosa proteome signature that encompasses 56 differentially expressed proteins. Principal component analysis of both, the 930 quantifiable proteins and the 56 oral mucosa signature proteins revealed that the de novo regenerated mucosa resembles keratinized oral mucosa much closer than extra-oral skin. Differentially expressed cornification-related proteins comprise proteins from all subclasses of the cornified cell envelope. Prominently expressed in intra-oral mucosa tissues were (i) cornifin-A, cornifin-B, SPRR3, and involucrin from the cornified-cell-envelope precursor group, (ii) S100A9, S100A8 and S100A2 from the S100 group, and (iii) cornulin which belongs to the fused-gene-protein group.Conclusion: According to its proteome signature de novo regenerated mucosa over the free fibula flap not only presents a passive structural surface layer but has adopted active tissue function. [ABSTRACT FROM AUTHOR]

The state-of-the-art surgery makes it possible to transfer tissue from donor site to recipient sites for reconstruction. In particular, free fibula becomes one of the common methods to repair mandibular (i.e., lower jawbone) defects. To guide one individual surgery, the 3D printing and finite element analysis (FEA) technologies have been employed in this study. The personalized model of titanium plate with screws was designed on the basis of computed tomography data with the help of the reverse engineering technology and 3D computational model via the PRO/E software. In order to refine the model, FEA results were used to guide the operation plan. Finally, the 3D-printed scaffold was used in the surgery. In conclusion, 3D printing technology and FEA for mandibular reconstruction surgery guidance can achieve good matches among fibula, human mandible and titanium plates, restore mandible functions, reduce the operation time and improve the success rate of surgery. Furthermore, this technology gives more freedom for physicians to discuss surgical plans with patients. [ABSTRACT FROM AUTHOR]

Paediatric patients with long-term mandibular continuity defects following segmental resection usually present severe functional and cosmetic deformities. Secondary mandibular reconstruction for these patients is very challenging. Literature reports on how to handle these patients are scarce. The aim of this study was to describe the authors’ experience in handling those paediatric patients who have not undergone primary reconstruction, for whom the final goal of treatment is to restore a symmetrical facial appearance, masticatory function, and speech. This was a retrospective analysis of the data of six patients who underwent radical mandible resection in childhood, without immediate bone restoration, and who then underwent a secondary mandibular reconstruction procedure after reaching adulthood, during the period 2009 to 2015. The multidisciplinary treatment procedure, selection of the donor site, and reconstructive approach are discussed. Key points in relation to secondary mandibular reconstruction with the aim of achieving not only good functional and cosmetic results, but also an improvement in the paediatric patient's psychological and social outcomes, are emphasized. [ABSTRACT FROM AUTHOR]

Purpose The primary objective of this study was to assess the difference in quality of life (QoL) in patients with dental rehabilitation using two or four implant-supported overdentures following segmental mandibulectomy defect reconstruction with fibula free flap. Material and methods This prospective, parallel designed, randomized clinical study was conducted with a 1:1 ratio. At baseline, all participants already had fibula flap reconstruction for segmental defects of the mandible and rehabilitation with conventional (non-implant supported) removable partial dentures. The participants were then randomized into two groups. Group I received implant supported overdentures on two implants, and Group II received four implants. QoL outcomes were evaluated using standardized questionnaires (EORTC_QLQ c30, H&N35, OHIP, DSI). Outcomes of treatment were evaluated at 6 months (T1) and 1 year (T2) following rehabilitation. Results A total of 52 patients were randomized into two treatment groups (26 each). After accounting for the loss to lack of follow-up, 22 patients in Group I and 24 patients in Group II were evaluated for QoL at the end of the study. There was a significant improvement in QoL with implant-assisted dental rehabilitation. However there were no significant differences in QoL between the two-implant and four-implant groups. Conclusion Implant-supported removable overdentures improve QoL outcomes in patients with reconstructed mandibles. This study showed no significant difference in QoL outcomes in patients with two- or four-implant supported removable prostheses. [ABSTRACT FROM AUTHOR]

Background Virtual surgical planning (VSP) has contributed to a number of technical innovations in mandible reconstruction. We report on these innovations and the overall evolution of mandible reconstruction using free fibula flaps at our institution. Methods We performed a retrospective chart review of all patients who underwent virtually planned free fibula flap reconstruction of the mandible. Comparisons were made between cohorts based on distinct eras related to the virtual planning approach. Results Seventy-six patients underwent a total of 78 VSP-assisted mandible reconstructions with free fibula flaps. Significant differences were noted among the groups with regard to mean number of segments, percentage of flaps that had at least 3 segments, percentage of flaps that had double-barrel components, and innovations per flap. Conclusion VSP-assisted mandible reconstruction has contributed to more complex surgeries at our institution. The technology ensures functional restoration, permitting an optimized aesthetic reconstruction that has not increased operative times or complications. © 2016 Wiley Periodicals, Inc. Head Neck 38: E2066-E2073, 2016 [ABSTRACT FROM AUTHOR]

Background: This study examined the usefulness of the fibula positioning guide for boosting the accuracy of mandible reconstructions. Methods: Thirty mandibular rapid prototype (RP) models were allocated to experimental (N = 15) and control (N = 15) groups. For reference, we prepared a reconstructed mandibular RP model with a three-dimensional printer, based on surgical simulation. In the experimental group, a fibula positioning guide template and fibula cutting guide, based on simulation, were used to reconstruct the mandible with a fibula graft. In the control group, only the fibula cutting guide, with reference to the reconstructed RP mandible model, was used to reconstruct the mandible with a fibula graft. The two mandibular reconstructions were compared to the surgical simulation by registering images with the non-surgical right side of the mandible. On the reconstructed side, 3D measurements were compared between the surgical simulation and actual surgery, and the sum of differences was taken as the total error. Results: The combined use of the fibula cutting and positioning guides produced a smaller total error (mean ± SD: 10.0 ± 7.9 mm) than the fibula cutting guide alone (12.8 ± 8.8 mm; p = 0.015). The greatest point error was the vertical error at the mesial point of the anterior fibula segment. The anteroposterior and lateral errors were not significantly different between groups. These results showed that these two methods were not significantly different, except in the total and vertical errors. Conclusions: Considering the CAD/CAM processes required for creating positioning devices, the benefit provided with a positioning guide justified its use over the fibula cutting guide alone. [ABSTRACT FROM AUTHOR]

Background Free fibula osteocutaneous flaps are the primary option for reconstruction after segmental mandibulectomies. This study evaluates the impact of CT-guided preoperative planning on operative outcomes after free fibula mandible reconstruction. Methods We conducted a retrospective review of all patients undergoing free fibula reconstruction of the mandible from 2002 to 2011. Results Fifty-seven patients underwent free fibula osteocutaneous flap reconstruction for head and neck cancers involving the mandible. Twelve patients had shaping of the neomandible performed on the back table while 20 patients underwent shaping in situ without the use of any adjunctive technology. The remaining 25 patients underwent preoperative CT imaging, which significantly decreased operative time (707 minutes vs 534 minutes; p < .0003) as well as overall costs ($24,532.50 vs $20,950.48). There were no significant differences in outcomes or complications. Conclusion Preoperative, patient-specific CT modeling, and cutting guide fabrication outweigh the costs associated with the additional technology without jeopardizing overall outcomes or increasing complication rates. © 2014 Wiley Periodicals, Inc. Head Neck 37: 1660-1664, 2015 [ABSTRACT FROM AUTHOR]

The reconstruction of mandibular defects using particulate grafts is a proven technique that restores the osseous anatomy effectively. Secondary osseous reconstruction can be accomplished with endoscopic assistance and reduced-access incisions if an intermediate spacer is placed during resection. Two patients required reconstruction after resection of mandibular ameloblastomas. We used a modified protocol that involved the implantation of a graft of particulate corticocancellous bone after removal of the spacer, and prepared the recipient site under endoscopic guidance with small extraoral incisions. The grafts healed uneventfully and matured into ossicles suitable for the placement of osseointegrated implants. [ABSTRACT FROM AUTHOR]

Objectives Segmental resection of the mandible causes functional, aesthetic and social problems affecting health-related quality of life (HRQoL). It is often assumed that reconstruction with composite free flaps guarantees better function and aesthetics than bridging the defect with reconstruction plates. Methods Using the European Organization for Research and Treatment of Cancer questionnaires (EORTC QLQ-C30 version 3.0 and EORTC QLQ-H&N35), we compared HRQoL in patients who received free fibula flaps versus reconstruction plates after segmental resection of the lateral mandible. Results Thirty-seven completed questionnaires (18 fibula reconstructions and 19 patients with reconstruction plates) were available. Reconstruction with a free fibula flap did not provide clear additional benefit to bridging the defect with a reconstruction plate after segmental resection of the lateral mandible. In particular aspects known to have the most impact on HRQoL like swallowing, speech and chewing were not influenced by the type of reconstruction. Conclusions Reconstruction of segmental defects of the lateral mandible with free fibula flap and reconstruction plate resulted in comparable HRQoL. If dental rehabilitation by means of dental implants is not anticipated in the fibula, then plate reconstruction with adequate soft tissue remains a suitable technique for the reconstruction of segmental defects of the lateral mandible. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background This study aimed to evaluate the accuracy of surgical outcomes in free iliac crest mandibular reconstructions that were carried out with virtual surgical plans and rapid prototyping templates. Methods This study evaluated eight patients who underwent mandibular osteotomy and reconstruction with free iliac crest grafts using virtual surgical planning and designed guiding templates. Operations were performed using the prefabricated guiding templates. Postoperative threedimensional computer models were overlaid and compared with the preoperatively designed models in the same coordinate system. Results Compared to the virtual osteotomy, the mean error of distance of the actual mandibular osteotomy was 2.06 ± 0.86 mm. When compared to the virtual harvested grafts, the mean error volume of the actual harvested grafts was 1412.22 ± 439.24 mm3 (9.12% ± 2.84%). The mean error between the volume of the actual harvested grafts and the shaped grafts was 2094.35 ± 929.12 mm3 (12.40% ± 5.50%). Conclusions The use of computer-aided rapid prototyping templates for virtual surgical planning appears to positively influence the accuracy of mandibular reconstruction. [ABSTRACT FROM AUTHOR]

Background The purpose of this study was to evaluate the efficacy of preoperative versus intraoperative mandibular contouring using rapid prototyping technology. Methods Ten patients requiring mandibular reconstruction had a preoperative mandibular plate contoured to a fabricated 3D mandibular model based on preoperative imaging. A traditional intraoperative plate was also contoured. Two surgeons blinded to the study compared the plates with respect to conformance, surface-area contact, and best overall match. A cost-benefit analysis was then performed. Results The average time to contour was 867 ± 243 seconds and 833 ± 289 seconds for the preoperative and intraoperative plates, respectively ( p = .83). Interobserver analysis revealed no statistically significant differences in conformance ( p = .38) or surface area contact ( p = .14). In 7 of 9 cases, the preoperative plate was selected for the final reconstruction. In 1 case, an intraoperative plate was not contoured because of the lateral extent of the tumor. Conclusion In cases of mandibular distortion secondary to disease, pathologic fracture or defects involving multiple mandibular subsites this method is particularly advantageous. © 2013 Wiley Periodicals, Inc. Head Neck 36: 828-833, 2014 [ABSTRACT FROM AUTHOR]

Background The purpose of this study was to evaluate bony union and resorption after free fibular flap reconstruction for mandibular reconstruction. Methods 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. Results 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). Conclusions 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. [ABSTRACT FROM AUTHOR]

Abstract: In our previous studies, prototyped individual bone-grafting trays have been used to restore discontinuous mandibular defects. However, the attempts have shown that the trays have shielded the graft from stress, which caused considerable resorption of bone. To eliminate the shielding, we designed a flexible tray. Finite element analysis was used to compare the distribution of strain on the bone grafts that were placed in flexible and conventional trays. The analogue computation suggested that most of the strain on the graft in the flexible tray resulted in a beneficial mechanical environment, while in the conventional tray more than half of graft was in the lowest class of strain (disuse – <50μstrains). Animal experiments were conducted on hybrid dogs, and the prototype flexible tray was used to carry particles of autologous cancellous iliac bone to reconstruct a 40mm defect in the mandibular body. Sequential radionuclide bone imaging was used to monitor the bone metabolism. Animals were killed at 4, 12 and 24 weeks, and specimens processed for quantitative histological examination. The data from the flexible trays were compared with those from the conventional trays, as in our previous study. The results showed that bone metabolism was more active in the flexible tray than in the conventional tray during the early stages. There was increased bony adaptation in the flexible tray. These results indicate that the flexible tray can efficiently eliminate the shielding from stress, and allow more occlusive force to be conducted on to the bone graft, which results in better remodelling of the graft. [Copyright &y& Elsevier]

Abstract: Purpose: The purpose of this study was to evaluate and analyze statistical shapes of the outer mandible contour of Caucasian and Chinese people, offering data for the production of preformed mandible reconstruction plates. Methods: A CT-database of 925 Caucasians (male: n =463, female: n =462) and 960 Chinese (male: n =469, female: n =491) including scans of unaffected mandibles were used and imported into the 3D modeling software Voxim (IVS-Solutions, Chemnitz, Germany). Anatomical landmarks (n =22 points for both sides) were set using the 3D view along the outer contour of the mandible at the area where reconstruction plates are commonly located. We used morphometric methods for statistical shape analysis. Results: We found statistical relevant differences between populations including a distinct discrimination given by the landmarks at the mandible. After generating a metric model this shape information which separated the populations appeared to be of no clinical relevance. The metric size information given by ramus length however provided a profound base for the production of standard reconstruction plates. Conclusion: Clustering by ramus length into three sizes and calculating means of these size-clusters seem to be a good solution for constructing preformed reconstruction plates that will fit a vast majority. [Copyright &y& Elsevier]

Background. The purpose of this study was to evaluate outcomes of free flap reconstruction for advanced osteoradionecrosis (ORN) defects and develop an algorithm to guide surgical planning. Methods. All cases involving free flap reconstruction for ORN of the mandible between 1998 and 2008 were reviewed. A defect classification scheme was developed. Flap selection and outcomes were analyzed and evaluated by defect type. Results. Seventy-five free flaps and 13 pedicle flaps were performed in 63 patients. Total flap loss was 5%. Overall surgical complication was 32%. Complication rates were higher with bone flaps than with soft tissue flaps (p ¼ .018). A full oral diet was tolerated in 57% of patients, whereas 26% required partial tube feeding, and 16% were tube-feeding dependent. Conclusion. Free flap reconstruction of advanced ORN defects can be safely performed in a variety of flap configurations with good outcomes. The classification scheme may assist in flap selection. [ABSTRACT FROM AUTHOR]

Summary: Osteoradionecrosis (ORN) of the mandible is a significant complication of radiation therapy for head and neck cancer. In this condition, bone within the radiation field becomes devitalized and exposed through the overlying skin or mucosa, persisting as a non-healing wound for three months or more. In 1926, Ewing first recognized the bone changes associated with radiation therapy and described them as “radiation osteitis”. In 1983, Marx proposed the first staging system for ORN that also served as a treatment protocol. This protocol advocated that patients whose disease progressed following conservative therapy (hyperbaric oxygen (HBO), local wound care, debridement) were advanced to a radical resection with a staged reconstruction utilizing a non-vascularized bone graft. Since the introduction of Marx’s protocol, there have been advances in surgical techniques (i.e. microvascular surgery), as well as in imaging techniques, which have significantly impacted on the diagnosis and management of ORN. High resolution CT scans and orthopantamograms have become a key component in evaluating and staging ORN, prior to formulating a treatment plan. Patients can now be stratified based on imaging and clinical findings, and treatment can be determined based on the stage of disease, rather than determining the stage of disease based on a patient’s response to a standardized treatment protocol. Reconstructions are now routinely performed immediately after resection of the diseased tissue rather than in a staged fashion. Furthermore, the transfer of well-vascularized hard and soft tissue using microvascular surgery have brought the utility of HBO treatment in advanced ORN into question. [ABSTRACT FROM AUTHOR]

Summary: Reconstruction of the mandible has evolved significantly over the last 40years. 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. [Copyright &y& Elsevier]

Background. The purpose of this study was to address questions concerning the functional outcome following mandibular reconstruction with vascularized fibula flap in skeletally immature children Methods. Eleven patients 14 years old or younger who underwent mandibular reconstruction using a free fibula flap were evaluated. Results. The mean follow-up was 3.4 years. One flap loss occurred and required a second fibula flap. Panorex radiographs showed good bone union and growth in all patients. Functional outcomes were normal according to age in all patients. Two patients had long-term malocclusion. No patients had to undergo corrective orthognathic surgery. Donor-site morbidities consisted of great toe flexion contracture (n = 4) and a valgus deformity (n = 1). All patients had a normal gait, and there were no discrepancies in leg length Conclusion. A mandible reconstructed using a vascularized fibula flap appears to grow accordingly as the child grows, with minimal disturbance to the growth pattern of the midface. © 2007 Wiley Periodicals, Inc. Head Neck 2008 [ABSTRACT FROM AUTHOR]

The objective of this investigation was to evaluate the indications for and the functional and cosmetic results of mandible reconstruction using free vascularized fibular flaps. It was also designed to assess the patients’ quality of life, daily activities, and self-esteem, with special emphasis on patient satisfaction. We conducted a retrospective chart review of all patients who underwent osseus or osteocutaneous free flap reconstruction of the mandible over a 10-year period (1992–2002). Those in whom a vascularized fibular flap was used were included in the study and invited for a follow-up comprehensive physical examination and x-ray evaluation. A questionnaire was also administered to evaluate patient satisfaction. Twenty-six patients were included in the study. Fourteen patients died after an average of 2 years and 9 months postoperatively due to their prognosis despite surgical intervention and adjuvant therapy. Of the remaining 12 patients, 6 appeared for the follow-up evaluation, 2 were unavailable for follow-up, and 4 denied participating. Of these 6 patients, all experienced a decrease in pain and were satisfied with their results. At the time of the latest follow-up, they experienced some difficulties swallowing, and in 3 patients, their articulation was impaired. All 6 patients would undergo the procedure again. Reconstruction of the mandible using a vascularized fibular graft produces satisfactory functional and cosmetic results. In benign lesions, the procedure is highly indicated. However, in the case of malignancy, most patients do not survive their primary tumor. Given the patients limited life expectancy, the improvement in their quality of life as a result of the improved appearance and function of the reconstructed mandible needs to be weighed against the potential morbidity of the operative intervention on an individual basis. [ABSTRACT FROM AUTHOR]

Background The free fibular osteocutaneous flap is a commonly used flap for mandible and buccal mucosa reconstruction in head and neck cancer surgery. However, the skin paddle restriction from the intermuscular septum often limits the soft tissue reconstruction. Methods We have proposed a new modified chimeric fibular osteocutaneous flap design based on the combination of a traditional fibular flap and a peroneal artery perforator fasciocutaneous flap to overcome the restriction from intermuscular septum. Results We successfully applied this modified chimeric free fibular osteocutaneous flap design to 2 patients after buccal cancer wide excision surgery. Conclusion The modified free chimeric fibular flap can be easily applied to a segmental defect over the mandible and adjacent soft tissue without restrictions between the bone and the skin paddle. Furthermore, this skin paddle design can also serve as an extra skin paddle to reconstruct an outer cheek skin defect. © 2012 Wiley Periodicals, Inc. Head Neck, 2013 [ABSTRACT FROM AUTHOR]

Objective: Three-dimensional (3D) computational modeling represents an invaluable surgical tool for complex reconstructive cases. There exists limited data on 3D imaging to evaluate the use of the scapular tip free flap in complex, anterolateral mandibular reconstructions. The purpose of this study is to radiographically assess the scapular tip free flap in anterolateral defects of the mandible.Methods: A retrospective case series of 50 patients was performed on head and neck cancer patients treated at Michigan Medicine from 2013 to 2018. Patients who had pre-operative computed tomography neck and thorax for review were included.Results: The scapular tip was able to cover defects from the ipsilateral mandibular angle to the symphysis in all cases. On average, the bone extended to cover defects from the mandibular angle to 17 mm (SD ± 3.6 mm) beyond the mandibular symphysis, which equates to 70% (95% CI 0.66-0.74) of the distance from the symphysis to the contralateral mental foramen.Conclusion: Use of the scapular tip as a donor site for reconstruction of the mandibular body can be evaluated pre-operatively utilizing 3D imaging. All patients were able to achieve posterior coverage to the vertical plane of the mandibular condyle and contralateral extension across the symphysis on average extends almost three-fourths of the distance to the mandibular foramen. The extent of contralateral coverage can be more accurately delineated utilizing the patient's pre-operative imaging. [ABSTRACT FROM AUTHOR]