Modeling a fibula transplant in mandibular reconstructions: evaluation of the effects of a minimal number of osteotomies on the contour of the jaw

Abstract

The fibula osteocutaneous free flap has become the preferred method for most cases of mandibular reconstruction after oncologic surgical ablation. To recreate the parabolic form of the mandible, the fibula has to be divided up into segments using a closed wedge osteotomy technique. The number of osteotomies is preferably kept to a minimum so that segmental periosteal circulation is not compromised and also to keep operating time to a minimum. The limited number of osteotomies creates an angular contour. The aim of this study was to establish the degree to which overcorrection or undercorrection would occur when a subtotal reconstruction from ramus to ramus was simulated using five bony segments and four osteotomies. The study was carried out using 30 preserved jaws; the contour lines of the jaws were transferred onto tracing paper using a cardboard template. The contour of the mandible was divided into five sections (ramus, body, symphysis, body, and ramus). Because of the cutting off of the curvature in the original jaw outline, the lateral side of the body will become narrower and the chin broader. This also results in an underprojection (displacement) of the chin. To follow the original contour of the jaw as accurately as possible, all these anomalies must be minimized. The amount of under- and overprojection is calculated for a displacement of 1.0, 1.5, 2.5, 5.0, 7.5, and 10 mm of the chin. The most accurate reconstruction of the mandibular contour is achieved with a displacement of 1.5 or 2.5 mm. To preserve sufficient periosteal circulation, the minimum width of bone segments must be 15 mm or more. This concerns especially the symphysis section. On the basis of a fibula thickness of 14 mm, the internal bone width of the symphysis section is calculated. With a displacement of 1.5 mm, the average internal width of the bone segment is 14.8 mm, with a range of 9.9 to 23.0 mm (95 percent confidence interval, 12.8 to 16.7 mm). Therefore, a displacement of 2.5 mm with an internal bone width of 16.4 mm is preferred (range, 11.9 to 24.8 mm; 95 percent confidence interval, 15.5 to 18.2 mm). The loss of lateral projection is minimal (5.8 mm) and the resulting chin width is acceptable (average, 35.0 mm). In conclusion, we propose that in a subtotal procedure, an acceptable jaw reconstruction can be achieved with a limited number of osteotomies. The bone length of the symphysis section remains within safe limits. If the defect is of limited dimensions, then the resulting jaw contour is even more accurate.