Reconstruction of mandibular defects

Abstract

Defects requiring reconstruction in the mandible are commonly encountered and may result from resection of benign or malignant lesions, trauma, or osteoradionecrosis. Mandibular defects can be classified according to location and extent, as well as involvement of mucosa, skin, and tongue. Vascularized bone flaps, in general, provide the best functional and aesthetic outcome, with the fibula flap remaining the gold standard for mandible reconstruction. In this review, we discuss classification and approach to reconstruction of mandibular defects. We also elaborate upon four commonly used free osteocutaneous flaps, inclusive of fibula, iliac crest, scapula, and radial forearm. Finally, we discuss indications and use of osseointegrated implants as well as recent advances in mandibular reconstruction.

Keywords: Bone flap; condyle; fibular flap; mandible; osseointegrated implant; osteocutaneous flap.

Figure 1

Nonvascularized rib was used to bridge a left hemimandibulectomy defect in this patient. Early deviation of the mandibular midline to the left is seen on this Panorex. Ultimately, this form of reconstruction is doomed to failure, with the patient unable to masticate, and potential for failure of the bone graft, particularly after radiation therapy.

Figure 2

A large left CL-ms mandibular defect with involvement of floor of mouth and external skin was reconstructed using a free fibula flap. (A) Preoperative CT showing multicystic ameloblastoma involving left mandible, with gross erosion through external bony cortices. (B) Preoperative view showing erosion through skin over the chin. (C) Intraoperative defect. (D) Resected specimen. (E) Fibula flap after harvest. (F) Final result at closure.

Figure 3

A deep circumflex iliac artery (DCIA) flap was used to reconstruct a large right LC-s mandibular defect, where the fibula and radial forearm were not available due to previous reconstruction. (A) Intraoperative photograph showing the flap inset and held in place with a 2.4-mm reconstruction plate. (B) Harvested iliac crest osteocutaneous flap. (C) Complete dental restoration with osseointegrated implants, 14 months after surgery. (D) Panorex shows union of DCIA flap with native mandible on both sides. Part of the reconstruction plate has been removed to facilitate placement of osseointegrated implants. (E) Frontal view of patient, 14 months after surgery.