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One of the most important steps in achieving aesthetical and functional result in mandible reconstruction with fibula free flap is positioning of the bony part relative to the basis of the native mandible. Positioning fibular bony part continuing inferior mandible border may produce a high discrepancy between the residual mandible and fibula bone that results in difficulty in denture rehabilitation. Positioning fibular bony part continuing alveolar mandible border creates asymmetric jowls and changed shape of jawline in border-line zone. The double-barrel technique solves this problem, but needs a meticulous preoperative planning and precision free fibula flap modelling.

The reconstruction of defects in the mandible are still challenging. Despite several adequate microvascular bone reconstruction techniques, there is a need for ectopic bone endocultivation without drawbacks by donor-site morbidity. The omentum majus is described as a good vascularized fleece with undifferentiated cells with potential for bone culturing. In the omentum majus of six rabbits, two hydroxyapatite blocks were incorporated for 12 weeks each. The blocks were prepared with recombinant human bone morphogenetic protein-2 (rhBMP-2) or VEGF 165 + rhBMP-2 and wrapped into the omentum. For ectopic bone endocultivation observation computed tomography (CT) scans were performed, and fluorescence markers were applied. After harvesting the block, histological sections were performed with hematoxylin and eosin and toluidine blue staining. In the CT scans, the Hounsfield units of the blocks increased within the trail. In some sections, new bone formation was observed within the hydroxyapatite blocks, however, the histological staining showed soft-tissue invasion only, no gross bone formation was observed. The ectopic bone endocultivation in the omentum majus is technically a good approach. An adequate mixture of osteoinductive proteins is still missing.

This article includes updates in the management of mandibular trauma and reconstruction as they relate to maxillomandibular fixation screws, custom hardware, virtual surgical planning, and protocols for use of computer-aided surgery and navigation when managing composite defects from gunshot injuries to the face., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: The reconstruction of alveolar ridges for implant placement is still a challenging surgical procedure, especially in the case of extensive vertical and horizontal bone atrophy., Objective: The objective of the present study was to evaluate the quantity and quality of newly regenerated bone; clinically by means of direct clinical measuring, ridges augmented by autogenous cortical bone associated with autogenous particulate bone graft in the posterior lower jaw defect., Methods: For the preliminary study, a bone defects in partially edentulous in patient aged 52 years were selected to receive horizontal ridge augumentation prior autolougous bone block and particulate graft. The donor site was the ramus of the same side. Prior the clinical evaluation, periapical X-ray and the cone beam computerized tomography (CBCT) was observed the quality, quantity and the stability the soft and hard tissue healing process, final result and the outcome., Result: The bone augmentation achieved with this technique created the ideal bone volume of hard and soft tissue, in quantity and quality, for placement of implants., Conclusion: The surgical technique was found to be easy in terms of technique and surgical trauma.

Background: The principle reconstructive modality for segmental mandibulectomy defects is the osteocutaneous free fibula flap. Preoperative CT angiography has been recommended to assess the quality of arterial inflow to the flap and donor limb. However, the impact of the venous system on flap viability has not been explored., Methods: A retrospective review of all patients undergoing free fibula flap mandible reconstruction was performed at a single tertiary cancer center from 2002 to 2015. Overall complications, including operative reexploration and total flap losses, were evaluated., Results: One hundred seven patients underwent free fibula flap reconstruction of the mandible. Nine patients underwent multiple free flaps and were excluded from this study. Of the remaining 98 patients, 8 patients required operative exploration for microvascular compromise. All patients were found to have venous thrombosis. There were 3 total flaps losses with a salvage rate of 62.5% and overall flap survival of 96.9%. The size of the vena comitantes in the compromised flaps were significantly larger than those of the remaining patients (4.4 mm vs 3.1 mm; P < .0001). Although the total operative times were similar between the 2 groups (585.2 minutes vs 563.3 minutes), the ischemia time was significantly shorter in those cases that required operative takeback (76.5 minutes vs 104.0 minutes; P < .04)., Conclusion: Venous thrombosis of free fibula flaps is more common than arterial thrombosis. Venous stasis in larger vena comitantes may be a contributing factor to microvascular compromise. Anticoagulation and/or handsewn anastomosis may be beneficial if the veins are larger than 4.0 mm in size., (© 2017 Wiley Periodicals, Inc.)

Mandibular reconstruction in osteoradionecrosis or salvage surgery can often be complicated by the lack of suitable recipient vessels in the ipsilateral neck and the associated requirement for significant extraoral skin reconstruction. The scapula tip with its long vascular pedicle and option of a chimeric soft tissue component offers a versatile reconstructive solution in such cases. This article reports four consecutive cases of mandibular reconstruction with poor ipsilateral vascular options and additional soft tissue requirements in which the scapula tip was justified and preferred. The blood supply to the lateral scapula through the circumflex scapular system is well established in the literature and this would be the preferred reconstruction in class I mandibular defects associated with a significant soft tissue requirement. The scapula tip would suit cases where the ipsilateral recipient vessels are compromised, and so justify the potential for mandibular reconstruction with inferior bone stock., (Crown Copyright © 2017. Published by Elsevier Ltd. All rights reserved.)

Objective: The vascularised free fibular flap is considered to be a reliable choice for reconstruction of oromandibular defects, especially after resection of malignant tumours in the area. This study evaluates the functional outcome of this method., Method: From January 2001 - May 2014, 37 patients were treated at the University Hospital of Linköping using the free fibular flap. The authors present the results from 17. This study reviewed their records and used the University of Washington Quality-of-Life questionnaire (UW-QoL), the Head and Neck Performance Status Scale (PSS), and interviews to assess their outcome., Results and Conclusions: Functional evaluation showed a significant decrease in chewing (16 out of 17 patients), appearance (n = 10), salivation (n = 6), sensitivity in the mouth and skin (n = 16), occlusive problems in the mouth (n = 13), and range of mouth opening (n = 12). The remaining domains showed acceptable results, although most of them probably could not compare with the preoperative function. Out of 17 patients, six had to adjust their eating in public significantly, three thought their activity to be considerably restricted and two their recreation to be notably diminished. Common postoperative complications were infections or fistula in the mandible (n = 6), partial or complete rejection of the cutaneous flap (n = 4), and rupture of some of the sutures (n = 3). Nine patients required at least one more operation to repair defects, and six required a new soft tissue flap.

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., (Copyright © 2016 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.)

Objectives: The objective of this study was to assess the difference in success rates of implants when using two or four implant-supported-overdentures following segmental mandibular reconstruction with fibula free flap., Methods and Designs: This prospective, parallel designed, randomized clinical study was conducted with 1:1 ratio. At baseline, all participants already had segmental reconstruction of mandible with free fibula flap. The participants were randomized into two groups: Group-I received implant-supported-overdentures on two tissue-level implants and Group-II received implant-supported-overdentures on four tissue-level implants. Success rates of the implants were evaluated at 3 months, 6 months and 12 months following implant loading using marginal bone level changes as well as peri-implant indices (Buser et al., 1990)., Results: 52 patients were randomized into two treatment groups (26 each), out of which 18 patients (36 implants) of Group-I and 17 patients (68 implants) of Group-II were evaluated. One implant in Group-I was lost due to infective complications and one patient in the same group had superior barrel necrosis. There was a statistically significant increase at both time points (p = 0.03, p = 0.04 at 6 months, 12 months) in the amount of marginal bone loss in Group-I (0.4 mm, 0.5 mm at 6 months, 12 months) as compared to Group-II (0.1 mm, 0.2 mm at 6 months, 12 months). There were no clinically significant changes peri-implant parameters between both groups. Peri-implant soft tissue hyperplasia was seen in both groups, 32% of implants at 3-months, 26% at 6-months and 3% at 12-months follow-up., Conclusion: The results of this study show that patients with 2-implant-supported-overdentures had higher marginal bone loss as compared to patients with 4-implant-supported-overdentures. There were no clinically significant differences in peri-implant soft tissue factors in patients with 2- or 4-implant-supported-overdentures. Hyperplastic peri-implant tissues are common in the early implant-loading phase and tend to decrease over time under appropriate management., (Copyright © 2016 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Background: Osteoradionecrosis may develop on the residual mandible or reconstructed fibula because of inadequate soft tissue coverage and compromised tissue perfusion post mandibular reconstruction, and radiation. This study was to investigate the incidence of osteoradionecrosis following class III mandibular defect reconstructions with an OPAC flap versus a fibula OSC flap., Methods: A retrospective review of a consecutive series of mandibular reconstructions between 1999 and 2010 was performed. Mandibular defects and corresponding flap types were analyzed with emphasis on outcome, complications, and rates of osteoradionecrosis among the two subgroups., Results: A total of 121 fibula flaps were performed, consisting of 53 OPAC and 68 fibula OSC flaps. Complications trended higher for OPAC flaps in partial and total flap loss rates as well as venous congestion when compared with the OSC flap cohort. The OPAC group had statistically significant lower rates of osteoradionecrosis and plate exposure than the OSC group (P = 0.04)., Conclusion: The OPAC flap may be preferable to fibula OSC flap in mandibular reconstruction given its lower rates of osteoradionecrosis and plate exposure. This flap type may be the flap of choice for class III defects where additional vascularized tissue may be critical for addressing significant soft tissue deficiency. J. Surg. Oncol. 2016;114:399-404. © 2016 Wiley Periodicals, Inc., (© 2016 Wiley Periodicals, Inc.)

A variety of donor sites are available for mandibular reconstruction. We present here a different way of comparing two commonly-used bone flaps. The lengths of the usable parts in a total of 241 coxal bones, 91 mandibles and 60 fibulas were measured. The mandible was measured from condyle-to-condyle and the harvestable bone length (HBL) and usable (UBL) bone lengths in fibula and ilium were also measured. The bone thickness (BT) in 60 iliac crests was measured in two parallel lines from the anterior superior iliac spine (ASIS) along the iliac crest. The mandible was 32.17 mm shorter in females than in males. The total ilium UBL was 171.12 mm in females and 178.80 mm in males. The mean HBL of the fibula was 22.6 mm shorter in females than in males. However, in some fibulas in both females and males, only 4.2% and 21.1% of the HBL respectively could be used if the ultimate goal was to insert dental implants. We found significant correlations between BT and gender in both fibula and ilium (P≤ 0.05). The ilium offers constant BT throughout the usable bone area with a similar bone length to the fibula. In contrast, the fibula showed variable bone dimensions, so not all of it is clinically usable. This should especially be considered in females when a mandibular reconstruction is planned with the goal of occlusal rehabilitation. Clin. Anat. 29:773-778, 2016. © 2016 Wiley Periodicals, Inc., (© 2016 Wiley Periodicals, Inc.)

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&#95;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., (Copyright © 2016 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

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., (© 2016 Wiley Periodicals, Inc.)

Background: The purpose of this study was to assess the impact of bone harvest length and multiple osteotomies on osteocutaneous radial forearm free flap (RFFF) complication rates., Methods: A retrospective chart review was conducted for patients undergoing osteocutaneous RFFF reconstruction during an 8-year period., Results: One hundred fifty-five osteocutaneous RFFF procedures were performed. Recipient-site flap complications were 18 of 55 (32.7%) when bone harvest length was less than 7 cm and 40 of 100 (40.0%) when it was ≥7 cm. No osteotomies were performed in 69 of 155 cases with a corresponding complication rate of 30.4% (21 of 69). One osteotomy was utilized in 69 of 155 flaps, whereas 17 of 155 required more than 1 osteotomy; complications were experienced in 42% (29 of 69) and 47% (8 of 17) of these cases, respectively., Conclusion: Osteocutaneous RFFF complication rates were only slightly higher when the bone length was ≥7 cm or when multiple osteotomies were required., (© 2015 Wiley Periodicals, Inc.)

Reconstruction after surgical treatment of head and neck cancers can be challenging. Goals for reconstruction include restoration of appearance as well as function when appropriate. Commonly encountered sites requiring reconstruction include the soft tissues of the face (including the critical areas of the eyes, ears, nose, and lips), scalp, tongue and oral cavity, maxilla, mandible, and pharynx. Advanced reconstructive techniques using microsurgery may be preferable to simpler techniques to obtain optimal outcomes. In this article, techniques for reconstruction in these areas as well as anticipated outcomes are discussed., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Mandibular reconstruction has been experiencing an amazing evolution. Several different approaches are used to reconstruct this bone and therefore have a fundamental role in the recovery of oral functions., Objectives: This review aims to highlight the persistent problems associated with the approaches identified, whether bone grafts or prosthetic devices are used. A brief summary of the historical evolution of the surgical procedures is presented, as well as an insight into possible future pathways., Study Design: A literature review was conducted from September to December 2012 using the PubMed database. The keyword used was "mandible reconstruction." Articles published in the last three years were included as well as the relevant references from those articles and the "historical articles" were referred. This research resulted in a monograph that this article aims to summarize., Results: Titanium plates, bone grafts, pediculate flaps, free osteomyocutaneous flaps, rapid prototyping, and tissue engineering strategies are some of the identified possibilities. The classical approaches present considerable associated morbidity donor-site-related problems., Conclusion: Research that results in the development of new prosthetics devices is needed. A new prosthetic approach could minimize the identified problems and offer the patients more predictable, affordable, and comfortable solutions., Clinical Relevance: This review, while affirming the evolution and the good results found with the actual approaches, emphasizes the negative aspects that still subsist. Thus, it shows that mandible reconstruction is not a closed issue. On the contrary, it remains as a research field where new findings could have a direct positive impact on patients' life quality. The identification of the persistent problems reveals the characteristics to be considered in a new prosthetic device. This could overcome the current difficulties and result in more comfortable solutions. Medical teams have the responsibility to keep patients informed about the predictable problems related with each elected approach, even understanding that a perfect reconstruction is a secondary goal when compared with maintenance of life., (© The International Society for Prosthetics and Orthotics 2014.)

Bending of large titanium plates for mandibular reconstruction is a tedious task. This is usually done by trial and error over an intraoperatively bent template. By means of rapid prototype technology, accurate three-dimensional models can be obtained. Using these models, it is possible to design, obtain, and adapt custom hardware for individual surgical cases. Reductions of operating room time when using this technology have been reported from 17% to 60%, with an average of 20%. This translates to reduction of cost and risks, improving the overall surgical outcome. The purpose of this article is to establish the indications and contraindication for the use three-dimensional models and prebent plates. We present our experience with five cases in which prebent reconstruction plates were used for mandibular reconstruction. No significant complications occurred, and satisfactory results were achieved in all cases. We found that the models required to obtain the hardware are extremely accurate, have multiple reported applications, and represent a valuable surgical tool in the planning and execution of reconstructive surgery.