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Thariat J, Carsuzaa F, Beddok A, Deneuve S, Marcy PY, Merlotti A, Dejean C, Devauchelle B. Reconstructive flap surgery in head and neck cancer patients: an interdisciplinary view of the challenges encountered by radiation oncologists in postoperative radiotherapy. Front Oncol 2024; 14:1379861. [PMID: 38665951 PMCID: PMC11043495 DOI: 10.3389/fonc.2024.1379861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 03/21/2024] [Indexed: 04/28/2024] Open
Abstract
Background Major advances have been made in reconstructive surgery in the last decades to reduce morbidity in head and neck cancer. Flaps are now present in 80% of patients with oral cavity cancer to cover anatomic, functional, and cosmetic needs. However, gaps in interdisciplinary innovation transfer from surgery to postoperative radiotherapy (poRT) remain challenging. We aimed to provide an interdisciplinary view of the challenges encountered by radiation oncologists in planning head and neck postoperative radiotherapy. Methods A systematic and critical review was conducted to address areas of optimization in surgery and radiology that may be relevant to poRT. Results Despite extensive surgical literature on flap techniques and salvage surgery, 13 retrospective series were identified, where flap outcomes were indirectly compared between surgery alone or poRT. These low-evidence studies suggest that radiotherapy accelerates flap atrophy, fibrosis, and osteoradionecrosis and deteriorates functional outcomes. Preliminary evidence suggests that tumor spread occurs at the flap-tissue junction rather than in the flaps. One prospective 15-patient study showed 31.3% vs. 39.2% flap volume reduction without or with poRT. In an international consensus, experts recognized the needs for optimized flap-sparing poRT against flap-related functional deterioration and bone damage. CT, MRI, and PET-CT modalities show potential for the delineation of the junction area between native tissues and flap for flap segmentation and to characterize flap-specific changes quantitatively and correlate them with patterns of relapse or complications. Conclusion Flap management in poRT is insufficiently documented, but poRT seems to damage flaps. Current gaps in knowledge underscore the need for prospective flap assessment and interdisciplinary trials investigating flap morbidity minimization by flap-sparing poRT planning.
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Affiliation(s)
- Juliette Thariat
- Department of Radiotherapy, Centre François-Baclesse, Caen, France
- Corpuscular Physics Laboratory, IN2P3, Ensicaen, CNRS UMR 6534, Caen, France
- Faculté de Médecine de Caen, Université de Normandie, Caen, France
| | - Florent Carsuzaa
- Department of Otorhinolaryngology - Head and Neck Surgery, University Hospital of Poitiers, Poitiers, France
| | - Arnaud Beddok
- Institut Curie, PSL Research University, University Paris Saclay, Inserm LITO, Orsay, France
- Gordon Center for Medical Imaging, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Sophie Deneuve
- Surgical Oncology Department, Centre Léon Bérard, UNICANCER, Lyon, France
- Inserm, U1296 Unit, “Radiation: Defense, Health and Environment”, Centre Léon Bérard, Lyon, France
| | - Pierre-Yves Marcy
- Polyclinics ELSAN Group, Department of Radiodiagnostics and Interventional Imaging, PolyClinics Les Fleurs, Ollioules, France
| | - Anna Merlotti
- Radiotherapy Department, S. Croce & Carle Teaching Hospital, Cuneo, Italy
| | | | - Bernard Devauchelle
- Departement of Maxillofacial Surgery, University Hospital of Amiens Picardy, Research Unit, UR7516 CHIMERE, University of Picardy Jules Verne, Institut Faire Faces, Amiens, France
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Barton BM, Mamdani M, Lumley C, Blumberg J, Huang BY, Patel SN. Osseointegration and Bone Resorption of Scapula Tip Free Flaps in Mandibular Reconstruction. Laryngoscope 2023; 133:2597-2602. [PMID: 36651328 DOI: 10.1002/lary.30574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 11/05/2022] [Accepted: 01/05/2023] [Indexed: 01/19/2023]
Abstract
OBJECTIVES Bone resorption of more conventional vascularized bone grafts have been well described showing minimal resorption over time. Few studies have evaluated osseous union and bone resorption in scapula tip free flaps (STFF) in the reconstruction of mandibulectomy defects. We aimed to describe our series on STFF with respect to osseous union and bone resorption over time. METHODS Retrospective chart review of patients receiving STFF from January 2014-January 2017 (n = 25). A neuroradiologist analyzed follow-up CT scans to assess (1) STFF complete, partial, or no osseous union with native mandible and (2) STFF volume change over time in a subset with multiple follow-up scans (n = 18). RESULTS Twenty-three of 25 patients (92%) showed complete or partial STFF osseous union with native mandible either distally or proximally. STFF volume change ranged from +4.8 to -54% (median -0.5%) over median follow-up interval of 23 months. History of chemoradiation therapy, bisphophonate use, sex, age, or smoking history did not correlate with bone resorption. CONCLUSIONS STFFs shows high rates of osseous union and limited bone resorption that is equivalent to, or less than, vascularized fibular and iliac crest flaps. Clinically, this translates into both optimal healing and functional and cosmetic outcomes, especially in the setting of prior therapies. LEVEL OF EVIDENCE 4 Laryngoscope, 133:2597-2602, 2023.
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Affiliation(s)
- Blair M Barton
- Department of Otorhinolaryngology, Ochsner Medical Center, New Orleans, Louisiana, U.S.A
| | - Mohammed Mamdani
- Department of Otolaryngology-Head & Neck Surgery, University of North Carolina-Chapel Hill, Chapel Hill, North Carolina, U.S.A
| | - Catherine Lumley
- Department of Otolaryngology-Head & Neck Surgery, University of North Carolina-Chapel Hill, Chapel Hill, North Carolina, U.S.A
| | - Jeffrey Blumberg
- Department of Otolaryngology-Head & Neck Surgery, University of North Carolina-Chapel Hill, Chapel Hill, North Carolina, U.S.A
| | - Benjamin Y Huang
- Department of Radiology, University of North Carolina-Chapel Hill, Chapel Hill, North Carolina, U.S.A
| | - Samip N Patel
- Department of Otolaryngology, Mayo Clinic, Jacksonville, Florida, U.S.A
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3
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Chen H, Li Y, Sun Y, Chen X, Pu Y, Sun G. Changes in condylar position and morphology after mandibular reconstruction by vascularized fibular free flap with condyle preservation. Clin Oral Investig 2023; 27:6097-6109. [PMID: 37632578 DOI: 10.1007/s00784-023-05225-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 08/16/2023] [Indexed: 08/28/2023]
Abstract
OBJECTS Changes in condylar position and morphology after mandibular reconstruction are important to aesthetic and functional rehabilitation. We evaluated changes in condylar position and morphology at different stages after mandibular reconstruction using vascularized fibular free flap with condyle preservation. MATERIALS AND METHODS A total of 23 patients who underwent mandibular reconstruction with fibular flap were included in this retrospective study. CT data of all patients were recorded before surgery (T0), 7 to 14 days after surgery (T1), and at least 6 months after surgery (T2). Five parameters describing the condylar position and 4 parameters describing the morphology were measured in sagittal and coronal views of CT images. The association between clinical characteristics and changes in condylar position and morphology was analyzed. A finite element model was established to investigate the stress distribution and to predict the spatial movement tendency of the condyle after reconstruction surgery. RESULTS The condylar position changed over time after mandibular reconstruction. The ipsilateral condyles moved inferiorly after surgery (T0 to T1) and continually move anteriorly, inferiorly, and laterally during long-term follow-up (T1 to T2). Contrary changes were noted in the contralateral condyles with no statistical significance. No morphological changes were detected. The relationship between clinical characteristics and changes in condylar position and morphology was not statistically significant. A consistent result was observed in the finite element analysis. CONCLUSION Condylar positions showed obvious changes over time after mandibular reconstruction with condylar preservation. Nevertheless, further studies should be conducted to evaluate the clinical function outcomes and condylar position. CLINICAL RELEVANCE These findings can form the basis for the evaluation of short-term and long-term changes in condylar position and morphology among patients who have previously undergone mandibular reconstruction by FFF with condyle preservation.
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Affiliation(s)
- Haoliang Chen
- Department of Oral and Maxillofacial Surgery, Nanjing Stomatological Hospital, Medical School of Nanjing University, 30 Zhongyang Road, Nanjing, 210008, People's Republic of China
| | - Yongheng Li
- School of Biological Science & Medical Engineering, Southeast University, Nanjing, China
| | - Yawei Sun
- Department of Oral and Maxillofacial Surgery, Nanjing Stomatological Hospital, Medical School of Nanjing University, 30 Zhongyang Road, Nanjing, 210008, People's Republic of China
| | - Xin Chen
- Department of Oral and Maxillofacial Surgery, Nanjing Stomatological Hospital, Medical School of Nanjing University, 30 Zhongyang Road, Nanjing, 210008, People's Republic of China
| | - Yumei Pu
- Department of Oral and Maxillofacial Surgery, Nanjing Stomatological Hospital, Medical School of Nanjing University, 30 Zhongyang Road, Nanjing, 210008, People's Republic of China
| | - Guowen Sun
- Department of Oral and Maxillofacial Surgery, Nanjing Stomatological Hospital, Medical School of Nanjing University, 30 Zhongyang Road, Nanjing, 210008, People's Republic of China.
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Kasper R, Scheurer M, Pietzka S, Sakkas A, Schramm A, Wilde F, Ebeling M. MRONJ of the Mandible—From Decortication to a Complex Jaw Reconstruction Using a CAD/CAM-Guided Bilateral Scapula Flap. Medicina (B Aires) 2023; 59:medicina59030535. [PMID: 36984535 PMCID: PMC10052135 DOI: 10.3390/medicina59030535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 02/26/2023] [Accepted: 03/03/2023] [Indexed: 03/12/2023] Open
Abstract
Medication-related osteonecrosis of the jaw (MRONJ) has been an integral part of the maxillofacial patient population for some time. The therapeutic concept ranges from conservative approaches over less extended decortications to major jaw resections, which can result in a considerable loss of quality of life. Based on three case reports, this paper presents the long-term history of patients with MRONJ of the mandible, whose disease ultimately resulted in partial or total mandibular resection and subsequent multisegmental reconstruction using a microvascular anastomosed bone flap. Furthermore, a suitable alternative for complex mandibular reconstruction is demonstrated when using a free fibula flap is not possible. The options are limited, particularly when multisegmental restoration of mandibular continuity is required. One case presents a mandible reconstruction using a CAD/CAM-guided bilateral scapular free flap (CAD/CAM = Computer-Aided Design and Manufacturing), which has not been described for this purpose before. Due to the complexity, computer-assisted surgery and patient-specific implants seem reasonable, which is why a special focus was applied to this topic.
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Affiliation(s)
- Robin Kasper
- Department of Oral and Plastic Maxillofacial Surgery, Military Hospital Ulm, Academic Hospital of the University of Ulm, 89081 Ulm, Germany
- Correspondence:
| | - Mario Scheurer
- Department of Oral and Plastic Maxillofacial Surgery, Military Hospital Ulm, Academic Hospital of the University of Ulm, 89081 Ulm, Germany
| | - Sebastian Pietzka
- Department of Oral and Plastic Maxillofacial Surgery, Military Hospital Ulm, Academic Hospital of the University of Ulm, 89081 Ulm, Germany
- Department of Oral and Maxillofacial Surgery, University Hospital Ulm, 89081 Ulm, Germany
| | - Andreas Sakkas
- Department of Oral and Plastic Maxillofacial Surgery, Military Hospital Ulm, Academic Hospital of the University of Ulm, 89081 Ulm, Germany
- Department of Oral and Maxillofacial Surgery, University Hospital Ulm, 89081 Ulm, Germany
| | - Alexander Schramm
- Department of Oral and Plastic Maxillofacial Surgery, Military Hospital Ulm, Academic Hospital of the University of Ulm, 89081 Ulm, Germany
- Department of Oral and Maxillofacial Surgery, University Hospital Ulm, 89081 Ulm, Germany
| | - Frank Wilde
- Department of Oral and Plastic Maxillofacial Surgery, Military Hospital Ulm, Academic Hospital of the University of Ulm, 89081 Ulm, Germany
- Department of Oral and Maxillofacial Surgery, University Hospital Ulm, 89081 Ulm, Germany
| | - Marcel Ebeling
- Department of Oral and Plastic Maxillofacial Surgery, Military Hospital Ulm, Academic Hospital of the University of Ulm, 89081 Ulm, Germany
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Slijepcevic AA, Wax MK, Hanasono M, Ducic Y, Petrisor D, Thomas CM, Shnayder Y, Kakarala K, Pipkorn P, Puram SV, Rich J, Rezaee R, Pittman A, Troob S. Post-operative Outcomes in Pediatric Patients Following Facial Reconstruction With Fibula Free Flaps. Laryngoscope 2023; 133:302-306. [PMID: 35656557 DOI: 10.1002/lary.30219] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 03/16/2022] [Accepted: 05/03/2022] [Indexed: 01/20/2023]
Abstract
EDUCATIONAL OBJECTIVE Assess outcomes of pediatric facial reconstruction with fibula free flaps. OBJECTIVES Free flap reconstruction of complex maxillofacial defects in pediatric patients is rare. Post-operative complications, donor site morbidity, impact on craniofacial growth, and oro-dental rehabilitation are unknown. Our study assesses the outcomes of pediatric maxillofacial reconstruction with composite fibula free flaps. STUDY DESIGN Retrospective chart review. METHODS Multi-institutional retrospective chart review from 2000 to 2020 on pediatric patients undergoing maxillomandibular reconstruction with fibula free flaps. RESULTS Eighty-seven patients underwent 89 surgeries; 5 maxillary and 84 mandibular defects. Median age: 12 years. Defects were acquired following resection of sarcoma/carcinoma 44% or benign tumors 50%. 73% of cases had immediate free flap reconstruction. Closing osteotomies were reported in 74%; 1 in 40%, 2 in 27%, and more than 2 in 6.7%. Hardware was used in 98% and removed in 25%. 9.2% demonstrated long-term hardware exposure, greater than 3 months following reconstruction. Short-term complications: wound infection 6.7%, flap salvage/failure 2.2%, fistula 1.1%, and compromised craniofacial growth: 23%. Two patients developed trismus. Long-term fibula donor site complications: hypertrophic scarring: 3.4%, dysesthesia: 1.1%, and long-term gait abnormality: 1.1%. Dental rehabilitation was performed in 33%. Post-operative speech outcomes showed 94% with fully intelligible speech. CONCLUSION Pediatric maxillary and mandible defects repaired with fibula free flaps demonstrated complication rates comparable to the adult free flap population. Long-term follow-up did not demonstrate adverse outcomes for craniofacial growth. Hardware for flap retention was utilized and remained in place with minimal exposure. Post-operative gait abnormality is rare. LEVEL OF EVIDENCE 3 Laryngoscope, 133:302-306, 2023.
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Affiliation(s)
- Allison A Slijepcevic
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Mark K Wax
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Matthew Hanasono
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Yadranko Ducic
- Otolaryngology and Facial Plastic Surgery Associates, Fort Worth, Texas, USA
| | - Daniel Petrisor
- Department of Oral and Maxillofacial Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Carissa M Thomas
- Department of Otolaryngology, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Yelizaveta Shnayder
- Department of Otolaryngology-Head and Neck Surgery, University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Kiran Kakarala
- Department of Otolaryngology-Head and Neck Surgery, University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Patrik Pipkorn
- Department of Otolaryngology-Head and Neck Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Sidharth V Puram
- Department of Otolaryngology-Head and Neck Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Jason Rich
- Department of Otolaryngology-Head and Neck Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Rod Rezaee
- Ear, Nose and Throat Institute-University Hospital and Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Amy Pittman
- Department of Otolaryngology-Head and Neck Surgery, Loyola Medicine, Maywood, Illinois, USA
| | - Scott Troob
- Department of Otolaryngology-Head and Neck Surgery, Columbia University, New York, New York, USA
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Use of a Fibula Free Flap for Mandibular Reconstruction in Severe Craniofacial Microsomia in Children with Obstructive Sleep Apnea. J Clin Med 2023; 12:jcm12031124. [PMID: 36769772 PMCID: PMC9917725 DOI: 10.3390/jcm12031124] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 01/17/2023] [Accepted: 01/28/2023] [Indexed: 02/04/2023] Open
Abstract
This is a retrospective study describing a multi-stage protocol for the management of severe mandibular hypoplasia in craniofacial microsomia (CFM) with accompanying obstructive sleep apnea (OSA). Patients with severe mandibular hypoplasia require reconstruction functionality and esthetical features. In the cohort, reconstructions based on free fibular flaps (FFF) may be the most effective way. Patients aged 4-17 years with severe mandibular hypoplasia were treated with FFF, which initially improved the respiratory function assessed on polysomnography (AHI). In the next stages of treatment of cases with respiratory deterioration, it was indicated to perform distraction osteogenesis (DO) of the mandible and the structures reconstructed with FFF. All surgeries were planned in accordance with virtual surgery planning VSP. The aim of the study was to prospectively assess the effectiveness of multi-stage mandibular reconstruction in craniofacial microsomia with the use of a free fibula flap in terms of improving respiratory failure due to obstructive sleep apnea (OSA). The FFF reconstruction method, performed with virtual surgical planning (VSP), is proving to be an effective alternative to traditional methods of mandibular reconstruction in patients with severe CFM with OSA.
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7
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Taxis J, Nobis CP, Grau E, Kesting M, Moest T. Retrospective three-dimensional analysis of bone resorption volumes of free microvascular scapular and fibular grafts. Br J Oral Maxillofac Surg 2022; 60:1417-1423. [PMID: 36153162 DOI: 10.1016/j.bjoms.2022.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 05/16/2022] [Accepted: 08/17/2022] [Indexed: 12/31/2022]
Abstract
Defects in head and neck regions are standardly treated with microvascular grafts, such as free scapular (SFF) and fibular flaps (FFF), which are subject to a certain amount of bone resorption over time. The aim of this study was the 3-dimensional evaluation of bone resorption volume in both grafts. Over a period of 10 years, computed tomograms (CT) of patients with mandibular reconstructions with SFFs and FFFs were examined. The respective grafts were segmented as well as 3-dimensionally measured. Furthermore, factors such as gender, age, nicotine abuse, previous disease with type 2 diabetes, and adjuvant therapies, were examined for their influence. A total of 211 CT scans from 67 patients (40 SFFs and 27 FFFs) were included in the study. SFFs showed slightly higher median bone volumes (87.60% at 730 days and 86.55% at 1500 days) than FFFs (84.40% at 730 days and 82.10% at 1500 days). When final volumes were considered, FFFs had higher mean volume values (88.22%) than SFFs (83.82%), with significant correlation between resorption volume and time progression (r = 0.357, p = 0.024). All previously mentioned factors had no significant effect on bone resorption. Bone volumes of FFFs showed postoperative volume reductions similar to those of SFFs, with isolated SFFs having markedly lower volume values. The choice of a microvascular graft for reconstruction in the mandible proves difficult regarding bone resorption. The presented results may support decisions about future transplantations.
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Affiliation(s)
- Juergen Taxis
- Department of Oral and Maxillofacial Surgery, University Hospital Erlangen, Glueckstraße 11, 91054 Erlangen, Germany.
| | - Christopher-Philipp Nobis
- Department of Oral and Maxillofacial Surgery, University Hospital Erlangen, Glueckstraße 11, 91054 Erlangen, Germany.
| | - Elisabeth Grau
- Department of Oral and Maxillofacial Surgery, Leipzig University Medical Center, Liebigstraße 12, 04103 Leipzig, Germany.
| | - Marco Kesting
- Department of Oral and Maxillofacial Surgery, University Hospital Erlangen, Glueckstraße 11, 91054 Erlangen, Germany.
| | - Tobias Moest
- Department of Oral and Maxillofacial Surgery, University Hospital Erlangen, Glueckstraße 11, 91054 Erlangen, Germany.
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Carsuzaa F, Verillaud B, Marcy PY, Herman P, Dufour X, Favier V, Thariat J. Interdisciplinary challenges and aims of flap or graft reconstruction surgery of sinonasal cancers: What radiologists and radiation oncologists need to know. Front Oncol 2022; 12:1013801. [PMID: 36203460 PMCID: PMC9530815 DOI: 10.3389/fonc.2022.1013801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Accepted: 08/25/2022] [Indexed: 11/13/2022] Open
Abstract
In sinonasal cancer surgery, a fundamental challenge is to understand the postoperative imaging changes after reconstruction. Misinterpretation of post-operative imaging may lead to a misdiagnosis of tumor recurrence. Because radiotherapy planning is based on imaging, there are many gaps in knowledge to be filled in the interpretation of postoperative imaging to properly define radiotherapy tumor volumes in the presence of flaps. On the other hand, radiotherapy may be responsible for tissue fibrosis or atrophy, the anatomy of the reconstructed region and the functional outcomes may change after radiotherapy compared to surgery alone. This narrative review illustrates the interdisciplinary aims and challenges of sinonasal reconstructive surgery using flaps or grafts. It is particularly relevant to radiologists and radiation oncologists, at a time when intensity modulated radiotherapy and proton therapy have the potential to further contribute to reduction of morbidity.
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Affiliation(s)
- Florent Carsuzaa
- Department of Oto-Rhino-Laryngology-Head and Neck Surgery, University Hospital of Poitiers, Poitiers, France
- Laboratoire Inflammation, Tissus Epithéliaux et Cytokines (LITEC), University of Poitiers, Poitiers, France
- *Correspondence: Florent Carsuzaa,
| | - Benjamin Verillaud
- Department of Oto-Rhino-Laryngology-Head and Neck Surgery, Hôpital Lariboisière, Paris, France
| | - Pierre-Yves Marcy
- Department of Radiology, Clinique du Cap d’Or, La Seyne-sur-mer, France
| | - Philippe Herman
- Department of Oto-Rhino-Laryngology-Head and Neck Surgery, Hôpital Lariboisière, Paris, France
| | - Xavier Dufour
- Department of Oto-Rhino-Laryngology-Head and Neck Surgery, University Hospital of Poitiers, Poitiers, France
- Laboratoire Inflammation, Tissus Epithéliaux et Cytokines (LITEC), University of Poitiers, Poitiers, France
| | - Valentin Favier
- Department of Oto-Rhino-Laryngology-Head and Neck Surgery, Hôpital Gui de Chauliac, University Hospital of Montpellier, Montpellier, France
| | - Juliette Thariat
- Department of Radiation Oncology, Centre François Baclesse, Caen, France
- Laboratoire de Physique Corpusculaire UMR6534 IN2P3 ENSICAEN CNRS, Normandy University, Caen, France
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Bone grafting in maxillofacial trauma. Curr Opin Otolaryngol Head Neck Surg 2022; 30:260-264. [PMID: 35906979 DOI: 10.1097/moo.0000000000000809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The purpose of this article is to review the recent grafting strategies in maxillofacial trauma. RECENT FINDINGS Recent technological advancements have applications in the management of maxillofacial trauma; advancements in imaging modalities such as 3D imaging can help surgeons in both the preoperative and intraoperative periods. These may be coupled with navigational systems to further facilitate complex reconstructions. 3D printing has been used in reconstruction and 3D, 4D, and 5D bioprinting technologies continue to improve and to find new uses, and stem cells and growth factors in maxillofacial trauma are also among the most studied topics. Maxillofacial traumas have decreased in number during the COVID-19 pandemic, as more conservative approaches have been preferred in COVID pandemic conditions. SUMMARY Preoperative planning is the most important step in the reconstruction of maxillofacial trauma defects, and early bone and soft tissue reconstructions are recommended in severe maxillofacial traumas. Autogenous grafts are the gold standard in bone grafting. Nonvascularized grafts are planned according to the size, shape, and location of the defect, with vascularized bone flaps preferred in large defects, wide soft tissue defects, and contaminated defects. Alloplastic grafts or xenografts may be used if autogenous grafts are not available.
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10
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Long-term Growth, Functional, and Aesthetic Outcomes after Fibula Free Flap Reconstruction for Mandibulectomy Performed in Children. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2022; 10:e4449. [PMID: 35923991 PMCID: PMC9333495 DOI: 10.1097/gox.0000000000004449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 05/19/2022] [Indexed: 11/26/2022]
Abstract
Background: The long-term outcome of mandible reconstruction when performed in children has not been well documented. Methods: This is a retrospective case series of patients who underwent immediate oncologic mandible reconstruction with a fibula free flap at younger than 18 years of age over a 20-year period, by a single surgeon, who had long-term follow-up. Results: A total of 10 patients met inclusion criteria. Patient age ranged from 3 years and 8 months to 17 years and 9 months (mean 11 years). The etiology was malignant tumors in seven patients and benign locally aggressive tumors in three patients. All fibula flaps survived. All donor sites were closed primarily. The mean follow-up duration was 10 years and 5 months (range 3–20 years). The mean patient age at follow-up was 21 years and 10 months (range 8 years and 9 months to 30 years and 9 months). All patients achieved a regular diet and normal speech. Final occlusion was normal in seven of 10 patients. The aesthetic outcome, as evaluated by clinical examination, was a symmetric mandible in eight patients (in the other two the aesthetic asymmetry and malocclusion was minor and did not require operative intervention). Dental implants were ultimately placed in three patients. Leg function was normal in eight patients. Achilles lengthening and tendon transfer was required in one patient, and one patient developed ankle pain associated with running. Conclusion: Mandible reconstruction in children with the fibula free flap provides excellent aesthetic and functional outcomes that are durable over time.
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11
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Gao N, Fu K, Cai J, Chen H, He W. The role of folded fibular flap in patients' reconstruction of mandibular defects: a retrospective clinical study. Sci Rep 2021; 11:23853. [PMID: 34903811 PMCID: PMC8668899 DOI: 10.1038/s41598-021-03331-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 11/29/2021] [Indexed: 11/09/2022] Open
Abstract
This study has analyzed 41 patients with mandibular ameloblastoma who underwent a partial mandibulectomy and reconstruction by folding the free fibular flap. In the preoperative and postoperative (6 months and 24 months after surgery), the Quality of Life (QOL) of these patients was assessed by using the University of Washington Quality of Life Questionnaire (UW-QOL) and the medical outcome study short form-36 (SF-36) questionnaires. SPSS 20.0 statistical software was used to conduct statistical analysis on the base data of the two groups of patients. Independent sample t test was conducted for sf-36 and UW-QOL scores at two time points in each group. The SF-36 survey showed that body pain (54.54 ± 8.10), general health (55.27 ± 7.54), and health changes (58.29 ± 9.60) decreased significantly at 6 months after surgery, but the mean score at 24 months after surgery all exceeded the preoperational level. At 24 months after the surgery, the vitality (80.41 ± 3.74), social function (81.61 ± 4.07), emotional role (82.39 ± 4.07), psychological health (81.66 ± 4.37) and total score (704.00 ± 31.53) all returned to the preoperative level, which was statistically significant compared with 6 months after surgery. However, there was no significant difference compared with the preoperative level. The UW-QOL survey showed that chewing (56.68 ± 7.23), speech (54.54 ± 7.7) and taste (62.29 ± 10.15) have significantly changed at 6 months after the surgery, and the difference was statistically significant at 24 months after surgery. Saliva generation decreased slightly (80.76 ± 3.35) at 6 months after surgery, but quickly returned to the preoperative level (81.59 ± 4.06). The total score of the patients almost recovered to the preoperative level at 24 months after surgery. The folded the fibular flap can not only repair the defects of soft tissue and bone tissue, but also restore the height of the alveolar ridge to, avoid the imbalance of crown and root ratio after implantation and reduce the occurrence of peri-implant inflammation, so that a true functional reconstruction can be realized.
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Affiliation(s)
- Ning Gao
- Department of Oral and Maxillofacial Surgery, First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China
| | - Kun Fu
- Department of Oral and Maxillofacial Surgery, First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China
| | - Jinghua Cai
- Department of Oral and Maxillofacial Surgery, First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China
| | - Hao Chen
- Department of Oral and Maxillofacial Surgery, First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China
| | - Wei He
- Department of Oral and Maxillofacial Surgery, First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China.
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Ou Q, Wu P, Zhou Z, Pan D, Tang JY. Complication of osteo reconstruction by utilizing free vascularized fibular bone graft. BMC Surg 2020; 20:216. [PMID: 33008361 PMCID: PMC7531124 DOI: 10.1186/s12893-020-00875-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 09/21/2020] [Indexed: 12/19/2022] Open
Abstract
The success of free vascularized fibular bone graft (FVFBG) has accelerated the osteo reconstruction which results from trauma, resection of a tumor or an infectious bone segment, or correction of congenital deformity. But the complication behind should not be overlooked. The failure could necessitate a second surgery, which prolong the rehabilitation period and produce further health cost. Worst, the patients may suffer a permanent impaired ankle function, or a sustained morpho-functional loss on reconstructive area which are hard to save. To provide an overview of the complication related to reconstruction by FVFBG, a narrative review is conducted to identify the complications including their types and rates, the contributing factors, the approaches to measure and the techniques to avoid. Methodologically, by quick research on Pubmed and abstract reading of reviews, we characterize five reconstructive areas where FVFBG were most frequently applied: extremities, mandible, spine, osteonecrosis of femoral head, and penile. Following, the complications on different reconstructive areas are retrieved, studied and presented in five (or more specifically, six) separate sections. By the way, meaningful difference between FVFBG and other bone flap was presented in a few words if necessary. Donor-site morbidities were studied and summarized as a whole. In these literatures, the evidences documented on limb and mandibular reconstruction have the fullest detail, followed by the spine and lastly the penile. In conclusion, FVFBG, though a mature technique, needs further deep and comprehensive study and maybe device-based assistance to achieve better reconstructive effect and minimize donor-site damage.
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Affiliation(s)
- Qifeng Ou
- Department of Orthopedics, Hand and Microsurgery, Xiangya Hospital, Central South University, No.87 XiangYa Road, Changsha, 410008, Hunan, China
| | - Panfeng Wu
- Department of Orthopedics, Hand and Microsurgery, Xiangya Hospital, Central South University, No.87 XiangYa Road, Changsha, 410008, Hunan, China
| | - Zhengbing Zhou
- Department of Orthopedics, Hand and Microsurgery, Xiangya Hospital, Central South University, No.87 XiangYa Road, Changsha, 410008, Hunan, China
| | - Ding Pan
- Department of Orthopedics, Hand and Microsurgery, Xiangya Hospital, Central South University, No.87 XiangYa Road, Changsha, 410008, Hunan, China
| | - Ju-Yu Tang
- Department of Orthopedics, Hand and Microsurgery, Xiangya Hospital, Central South University, No.87 XiangYa Road, Changsha, 410008, Hunan, China.
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Tang Q, Li Y, Yu T, Chen X, Zhou Z, Huang W, Liang F. Association between condylar position changes and functional outcomes after condylar reconstruction by free fibular flap. Clin Oral Investig 2020; 25:95-103. [PMID: 32440937 DOI: 10.1007/s00784-020-03338-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 05/11/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Stable and appropriate condyle positioning is necessary for maintaining temporomandibular joint function. It is unclear if this position remains stable in patients after free fibular flap (FFF) condylar reconstruction. We investigated whether condylar position deviated after reconstruction, and whether this affected functional recovery. MATERIALS AND METHODS We retrospectively reviewed 43 patients who underwent conventional FFF condylar reconstruction, and 5 patients who underwent reconstruction by computer-assisted three-dimensional (3D) printing methods. Three-dimensional models were built from cone-beam computed tomography images obtained immediately postoperatively and 1-year postoperatively. The glenoid fossa and fibular condyle centers were used to measure the fibular condyle position in the models. Clinical examination indices, including maximum mouth opening (MMO), pain during chewing/mouth opening, and patient satisfaction with mastication and 1-year outcomes were assessed. RESULTS Fibular condyle position changed significantly over 1 year in both groups (P < 0.05). Clinical examination at 1 year after the surgery showed that in the conventional group, the MMO range was ≥ 35 mm in 76.7% of patients and < 35 mm in 23.3% of patients; 4.7% experienced pain during chewing/mouth opening, and 7% were dissatisfied with treatment outcomes. In the 3D printing group, all patients had an MMO range exceeding 35 mm, none had pain, and all were satisfied with functional outcomes. CONCLUSIONS The position of the fibular condyle deviates after reconstructive surgery, but it is unlikely to affect functional recovery. CLINICAL RELEVANCE These findings can form the basis for evaluation of functional outcomes of patients who have previously undergone condylar reconstruction by FFF.
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Affiliation(s)
- Qinchao Tang
- Department of Oral and Maxillofacial Surgery, College of Stomatology, Guangxi Medical University, 10 Shuangyong Road, Nanning, 530021, Guangxi, China
- Guangxi Key Laboratory of Oral and Maxillofacial Rehabilitation and Reconstruction, Nanning, Guangxi, China
- Guangxi Key Laboratory of Oral and Maxillofacial Surgery Disease Treatment, Nanning, Guangxi, China
- Guangxi Clinical Research Center for Craniofacial Deformity, Nanning, Guangxi, China
| | - Yixing Li
- Department of Oral and Maxillofacial Surgery, College of Stomatology, Guangxi Medical University, 10 Shuangyong Road, Nanning, 530021, Guangxi, China
- Department of Oral and Maxillofacial Surgery, Affiliated Stomatological Hospital, Guangxi Medical University, Nanning, Guangxi, China
| | - Tao Yu
- Department of Oral and Maxillofacial Surgery, College of Stomatology, Guangxi Medical University, 10 Shuangyong Road, Nanning, 530021, Guangxi, China
- Guangxi Key Laboratory of Oral and Maxillofacial Rehabilitation and Reconstruction, Nanning, Guangxi, China
- Guangxi Key Laboratory of Oral and Maxillofacial Surgery Disease Treatment, Nanning, Guangxi, China
- Guangxi Clinical Research Center for Craniofacial Deformity, Nanning, Guangxi, China
| | - Xueru Chen
- Department of Oral and Maxillofacial Surgery, College of Stomatology, Guangxi Medical University, 10 Shuangyong Road, Nanning, 530021, Guangxi, China
- Guangxi Key Laboratory of Oral and Maxillofacial Rehabilitation and Reconstruction, Nanning, Guangxi, China
- Guangxi Key Laboratory of Oral and Maxillofacial Surgery Disease Treatment, Nanning, Guangxi, China
- Guangxi Clinical Research Center for Craniofacial Deformity, Nanning, Guangxi, China
| | - Zhuoqian Zhou
- Department of Oral and Maxillofacial Surgery, College of Stomatology, Guangxi Medical University, 10 Shuangyong Road, Nanning, 530021, Guangxi, China
- Guangxi Key Laboratory of Oral and Maxillofacial Rehabilitation and Reconstruction, Nanning, Guangxi, China
- Guangxi Key Laboratory of Oral and Maxillofacial Surgery Disease Treatment, Nanning, Guangxi, China
- Guangxi Clinical Research Center for Craniofacial Deformity, Nanning, Guangxi, China
| | - Wanqian Huang
- Department of Oral and Maxillofacial Surgery, College of Stomatology, Guangxi Medical University, 10 Shuangyong Road, Nanning, 530021, Guangxi, China
- Guangxi Key Laboratory of Oral and Maxillofacial Rehabilitation and Reconstruction, Nanning, Guangxi, China
- Guangxi Key Laboratory of Oral and Maxillofacial Surgery Disease Treatment, Nanning, Guangxi, China
- Guangxi Clinical Research Center for Craniofacial Deformity, Nanning, Guangxi, China
| | - Feixin Liang
- Department of Oral and Maxillofacial Surgery, College of Stomatology, Guangxi Medical University, 10 Shuangyong Road, Nanning, 530021, Guangxi, China.
- Guangxi Key Laboratory of Oral and Maxillofacial Rehabilitation and Reconstruction, Nanning, Guangxi, China.
- Guangxi Key Laboratory of Oral and Maxillofacial Surgery Disease Treatment, Nanning, Guangxi, China.
- Guangxi Clinical Research Center for Craniofacial Deformity, Nanning, Guangxi, China.
- Department of Oral and Maxillofacial Surgery, Affiliated Stomatological Hospital, Guangxi Medical University, Nanning, Guangxi, China.
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Shokri T, Wang W, Vincent A, Cohn JE, Kadakia S, Ducic Y. Osteoradionecrosis of the Maxilla: Conservative Management and Reconstructive Considerations. Semin Plast Surg 2020; 34:106-113. [PMID: 32390778 DOI: 10.1055/s-0040-1709144] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
The implementation of radiotherapy in the multimodal treatment of advanced head and neck cancer has greatly improved survival rates. In some patients, however, this benefit comes at the potential expense of the tissue surrounding the primary site of malignancy. Osteoradionecrosis (ORN) of the facial bones, in particular the maxilla, is a debilitating complication of radiation therapy. Exposure to ionizing radiation results in devitalization of underlying bone with necrosis of adjacent soft tissue. Controversy surrounding appropriate early intervention in ORN persists and no consensus for clinical treatment has been established. In the present article, we review the pathophysiology of maxillary ORN and discuss the role of both conservative medical therapy and reconstruction.
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Affiliation(s)
- Tom Shokri
- Department of Otolaryngology, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Weitao Wang
- Otolaryngology and Facial Plastic Surgery Associates, Fort Worth, Texas
| | - Aurora Vincent
- Otolaryngology and Facial Plastic Surgery Associates, Fort Worth, Texas
| | - Jason E Cohn
- Department of Otolaryngology-Head and Neck Surgery, Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania
| | - Sameep Kadakia
- Department of Plastic and Reconstructive Surgery, Wright State University, Dayton, Ohio
| | - Yadranko Ducic
- Otolaryngology and Facial Plastic Surgery Associates, Fort Worth, Texas
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15
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Virtual Surgical Planning for Mandible Reconstruction With a Double Barrel Fibula Flap and Immediate Implant Placement. J Craniofac Surg 2020; 31:e41-e43. [PMID: 31449213 DOI: 10.1097/scs.0000000000005842] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
This brief clinical report describes our experience with virtual surgical planning in a case of mandibulectomy and mandibular reconstruction with a double barrel vascularized osteofasciocutaneous fibula free flap and immediate implant placement in a case of mandibular ameloblastoma. Fibular segments were positioned to obtain the best result both for masticatory function and for aesthetic facial appearance. Furthermore, in this particular case, as well as being positioned for future masticatory rehabilitation, the implants have served to stabilize the fibula segments in the reconstructive intraoperative phase. A superimposition of programed surgery and 6 months postoperative computed tomography scan was performed and results are presented.
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Biomechanical Analysis of Various Reconstructive Methods for the Mandibular Body and Ramus Defect Using a Free Vascularized Fibula Flap. BIOMED RESEARCH INTERNATIONAL 2020; 2020:8797493. [PMID: 32258153 PMCID: PMC7094202 DOI: 10.1155/2020/8797493] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Revised: 12/11/2019] [Accepted: 01/02/2020] [Indexed: 11/17/2022]
Abstract
Several different methods exist for reconstructing the mandibular body and ramus defect with the use of a free vascularized fibula flap, but none have adequately addressed the long-term mechanical stability and osseointegration. The aim of this study is to compare the biomechanics of different surgical methods and to investigate the best approach for reconstructing the mandibular body and ramus defect. Five finite element models based on different reconstructive methods were simulated. Stress, strain, and displacement of connective bone sections were calculated for five models and compared. The models were printed using a 3D printer, and stiffness was measured using an electromechanical universal testing machine. The postoperative follow-up cone beam computed tomography (CBCT) was taken at different time points to analyze bone mineral density of connective bone sections. The results showed that the “double up” (DU) model was the most efficient for reconstructing a mandibular body and ramus defect by comparing the mechanical distribution of three sections under vertical and inclined loading conditions of 100 N. The stiffness detection showed that stiffness in the DU and “double down” (DD) models was higher compared with the “single up” (SU), “single down” (SD), and “distraction osteogenesis” (DO) models. We used the DU model for the surgery, and postoperative follow-up CBCT showed that bone mineral density of each fibular connective section increased gradually with time, plateauing at 12 weeks. We conclude that a free vascularized fibula flap of the DU type was the best approach for the reconstruction of the mandibular body and ramus defect. Preoperative finite element analysis and stiffness testing were shown to be very useful for maxillofacial reconstruction.
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Zhang HQ, Li QX, Wang YY, Wang ZS, Lin ZY, Sha LJ, Zhang DM, Liu J, Wang JJ, Li JS, Fan S. Combination of biomechanical evaluation and accurate placement of dental implants: a new concept of virtual surgery in maxillary and mandibular functional reconstruction. Br J Oral Maxillofac Surg 2019; 58:62-68. [PMID: 31718915 DOI: 10.1016/j.bjoms.2019.10.310] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 10/18/2019] [Indexed: 11/17/2022]
Abstract
Biomechanics are crucial for bony regeneration and survival of implants in functional maxillary and mandibular reconstructions. However, we know of no study that has included an analysis of biomechanics to guide the optimal position of a fibular graft in virtual surgery. This study was designed to evaluate the combination of biomechanics and accurate placement of implants for virtual surgery in reconstruction of the jaw using fibular grafts. Thirty-one patients had maxillary or mandibular reconstruction with vascularised fibular grafts and the immediate placement of dental implants. Virtual studies were made preoperatively to evaluate the biomechanics and to assess the position of the fibular grafts with minimal distribution of stress. All operations proceeded accurately and with no complications with a mean (range) of 14 (6-20) months' follow-up. According to the individual biomechanical evaluations, the optimal position for the fibular graft is probably the middle of the mandibular body or below the bottom of the maxillary sinus. The combination of biomechanical evaluation and accurate placement of dental implants is a new concept that could achieve good biomechanical positioning of fibular grafts in the jaw and a desirable level of accuracy for functional reconstruction.
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Affiliation(s)
- H-Q Zhang
- Department of Oral and Maxillofacial Surgery, Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, Guangzhou, 510120, China
| | - Q-X Li
- Department of Oral and Maxillofacial Surgery, Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, Guangzhou, 510120, China
| | - Y-Y Wang
- Department of Oral and Maxillofacial Surgery, Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, Guangzhou, 510120, China
| | - Z-S Wang
- Department of Oral and Maxillofacial Surgery, Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, Guangzhou, 510120, China
| | - Z-Y Lin
- Department of Oral and Maxillofacial Surgery, Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, Guangzhou, 510120, China
| | - L-J Sha
- Department of Operating Room, Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, Guangzhou, 510120, China
| | - D-M Zhang
- Department of Oral and Maxillofacial Surgery, Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, Guangzhou, 510120, China
| | - J Liu
- Trustworthy (Beijing) Technology co., Ltd, Beijing, 100102, China
| | - J-J Wang
- Trustworthy (Beijing) Technology co., Ltd, Beijing, 100102, China
| | - J-S Li
- Department of Oral and Maxillofacial Surgery, Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, Guangzhou, 510120, China; Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation of Sun Yat-Sen Memorial Hospital, Guangzhou, 510120, China.
| | - S Fan
- Department of Oral and Maxillofacial Surgery, Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, Guangzhou, 510120, China; Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation of Sun Yat-Sen Memorial Hospital, Guangzhou, 510120, China.
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