Free-Flap Reconstruction of the Mandible

Abstract

Mandible reconstruction has evolved over the years with advances in surgical options and three-dimensional technology. Although nonvascularized bone grafting is still used, vascularized flaps show advantages with immediate reconstruction, the possibility of immediate dental implants, and the ability to reconstruct composite defects of both soft tissue and bone. This article discusses current vascularized techniques for mandible reconstruction. While each reconstructive method has advantages and disadvantages, a defect-based reconstruction focused on full rehabilitation allows surgeons to plan and counsel the patient for the best available reconstruction.

Keywords: complications; free flaps; mandible reconstruction.

Fig. 1

Posterior body and ramus (lateral) defect.

Fig. 2

Ramus/condyle defect.

Fig. 3

Anterior mandible defect.

Fig. 4

Long-span defect.

Fig. 5

Tunneling technique. (Reproduced with permission of Ducic et al. 10 )

Fig. 6

( A ) Fibula harvest with the peroneus longus exposed. ( B ) Fibula lateralized after completion of osteotomy.

Fig. 7

( A ) Iliac crest free-flap markings. ( B ) Completed harvest of the iliac crest, with the pedicle length shown.

Fig. 8

( A ) Radial forearm osteocutaneous flap harvested. ( B ) Prophylactic internal fixation of the radius.

Fig. 9

( A ) Scapula osteocutaneous flap harvest position. ( B ) Scapula osteocutaneous flap harvested.

Fig. 10

Virtual surgical planning cutting guides.

Fig. 11

( A ) Patient-specific prebent mandible reconstruction plate. ( B ) Patient-specific milled reconstruction plate with implant positions. ( C ) Immediate prosthesis fitting precisely on a three-dimensional printed patient model. ( D ) Endosseous dental implants placed in the attached fibula.

Fig. 12

( A ) Implant placement guides from virtual surgical planning. ( B ) Placement of endosseous implants with three-dimensional printed guide.

Fig. 13

Correct angulation of implants.

Fig. 14

( A ) Immediate prosthesis in harmonious form with the osteotomized fibula. ( B ) Immediate prosthesis and fibula inset in the oral cavity.

Fig. 15

Postoperative panoramic radiograph.