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Khayat S, Sada Urmeneta Á, González Moure B, Fernández Acosta D, Benito Anguita M, López López A, Verdaguer Martín JJ, Navarro Cuéllar I, Falahat F, Navarro Cuéllar C. Reconstruction of Segmental Mandibular Defects with Double-Barrel Fibula Flap and Osseo-Integrated Implants: A Systematic Review. J Clin Med 2024; 13:3547. [PMID: 38930078 PMCID: PMC11205098 DOI: 10.3390/jcm13123547] [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: 04/04/2024] [Revised: 05/26/2024] [Accepted: 06/10/2024] [Indexed: 06/28/2024] Open
Abstract
Background: Mandibular defects resulting from oncological treatment pose significant aesthetic and functional challenges due to the involvement of bone and soft tissues. Immediate reconstruction is crucial to address complications such as malocclusion, mandibular deviation, temporomandibular joint (TMJ) changes, and soft tissue retraction. These issues can lead to functional impairments, including difficulties in chewing, swallowing, and speech. The fibula flap is widely used for mandibular reconstruction due to its long bone segment and robust vascular supply, though it may not always provide adequate bone height for optimal dental rehabilitation. This systematic review aims to determine if the double-barreled fibula flap (DBFF) configuration is a viable alternative for mandibular reconstruction and to evaluate the outcomes of dental implants placed in this type of flap. Materials and Methods: This study adhered to the Cochrane Collaboration criteria and PRISMA guidelines and was registered on the International Platform of Registered Systematic Review and Meta-Analysis Protocols Database (INPLASY2023120026). We included clinical studies published in English, Spanish, or French that focused on adult patients undergoing segmental mandibulectomy followed by DBFF reconstruction and dental rehabilitation. Data sources included Medline/PubMed, the Cochrane Library, EMBASE, Scopus, and manual searches. Two reviewers independently screened and selected studies, with discrepancies resolved by a third reviewer. Data extraction captured variables such as publication year, patient demographics, number of implants, follow-up duration, flap survival, implant failure, and aesthetic outcomes. The risk of bias was assessed using the JBI appraisal tool, and the certainty of evidence was evaluated using the GRADE approach. Results: A total of 17 clinical studies were included, evaluating 245 patients and 402 dental implants. The average patient age was 43.7 years, with a mean follow-up period of 34.3 months. Flap survival was high, with a 98.3% success rate and only four flap losses. The implant failure rate was low at 1.74%. Esthetic outcomes were varied, with only three studies using standardized protocols for evaluation. The overall certainty of evidence for flap survival was moderate, low for implant failure, and very low for aesthetics due to the subjective nature of assessments and variability in reporting. Conclusions: The primary limitations of the evidence included in this review are the observational design of the studies, leading to an inherent risk of bias, inconsistency in reporting methods, and imprecision in outcome measures. Additionally, the subjective nature of aesthetic evaluations and the variability in assessment tools further limit the reliability of the findings. The DBFF technique demonstrates excellent outcomes for mandibular reconstruction, with high flap survival and low implant failure rates, making it a viable option for dental rehabilitation. However, the evidence for aesthetic outcomes is less certain, highlighting the need for more rigorous and standardized research. This review supports the DBFF as a good alternative for mandibular reconstruction with successful dental implant integration, although further studies are needed to enhance the reliability of aesthetic evaluations.
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Affiliation(s)
- Saad Khayat
- Maxillofacial Surgery Department, Hospital Gregorio Marañón, 28007 Madrid, Spain; (S.K.); (Á.S.U.); (B.G.M.); (D.F.A.); (M.B.A.); (A.L.L.); (J.J.V.M.); (I.N.C.)
| | - Ángela Sada Urmeneta
- Maxillofacial Surgery Department, Hospital Gregorio Marañón, 28007 Madrid, Spain; (S.K.); (Á.S.U.); (B.G.M.); (D.F.A.); (M.B.A.); (A.L.L.); (J.J.V.M.); (I.N.C.)
| | - Borja González Moure
- Maxillofacial Surgery Department, Hospital Gregorio Marañón, 28007 Madrid, Spain; (S.K.); (Á.S.U.); (B.G.M.); (D.F.A.); (M.B.A.); (A.L.L.); (J.J.V.M.); (I.N.C.)
| | - Diego Fernández Acosta
- Maxillofacial Surgery Department, Hospital Gregorio Marañón, 28007 Madrid, Spain; (S.K.); (Á.S.U.); (B.G.M.); (D.F.A.); (M.B.A.); (A.L.L.); (J.J.V.M.); (I.N.C.)
| | - Marta Benito Anguita
- Maxillofacial Surgery Department, Hospital Gregorio Marañón, 28007 Madrid, Spain; (S.K.); (Á.S.U.); (B.G.M.); (D.F.A.); (M.B.A.); (A.L.L.); (J.J.V.M.); (I.N.C.)
| | - Ana López López
- Maxillofacial Surgery Department, Hospital Gregorio Marañón, 28007 Madrid, Spain; (S.K.); (Á.S.U.); (B.G.M.); (D.F.A.); (M.B.A.); (A.L.L.); (J.J.V.M.); (I.N.C.)
| | - Juan José Verdaguer Martín
- Maxillofacial Surgery Department, Hospital Gregorio Marañón, 28007 Madrid, Spain; (S.K.); (Á.S.U.); (B.G.M.); (D.F.A.); (M.B.A.); (A.L.L.); (J.J.V.M.); (I.N.C.)
- Surgery Department, School of Medicine, Universidad Complutense de Madrid, 28040 Madrid, Spain
| | - Ignacio Navarro Cuéllar
- Maxillofacial Surgery Department, Hospital Gregorio Marañón, 28007 Madrid, Spain; (S.K.); (Á.S.U.); (B.G.M.); (D.F.A.); (M.B.A.); (A.L.L.); (J.J.V.M.); (I.N.C.)
| | - Farzin Falahat
- Maxillofacial Surgery Department, Hospital Clínico San Carlos, 28040 Madrid, Spain
| | - Carlos Navarro Cuéllar
- Maxillofacial Surgery Department, Hospital Gregorio Marañón, 28007 Madrid, Spain; (S.K.); (Á.S.U.); (B.G.M.); (D.F.A.); (M.B.A.); (A.L.L.); (J.J.V.M.); (I.N.C.)
- Surgery Department, School of Medicine, Universidad Complutense de Madrid, 28040 Madrid, Spain
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Chang YM, Tsai CY, Wei FC. Fibula Jaw-during-Admission. J Plast Reconstr Aesthet Surg 2023; 82:247-254. [PMID: 37207438 DOI: 10.1016/j.bjps.2023.01.010] [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: 11/28/2022] [Accepted: 01/29/2023] [Indexed: 02/11/2023]
Abstract
BACKGROUND Fibula Jaw-in-a-Day (JIAD) is considered the most advanced approach for segmental mandibular defect reconstruction and dental rehabilitation. However, it has limitations and challenges for further pursuit. We propose Fibula Jaw-during-Admission (JDA) as a solution. MATERIALS AND METHODS From 2019 to 2021, six patients received fibula "Jaw-during-Admission." Segmental mandibulectomy, fibula transfer, and immediate dental implantation were performed simultaneously during a single surgery. Intraoral scans were used to fabricate temporary light occlusion contact dental prostheses while on the ward prior to discharge during the first and second week post operation. The prostheses were installed before discharge and changed to permanent ones with normal occlusal contact in the clinic at about six months after X-ray confirmation of bone healing. RESULTS All six surgeries succeeded. Four patients received palatal muco-periosteal graft after debridement of peri-implant overgrown granulation tissue. Follow-up ranged from 12 to 34 months (average 21.2 months) and revealed good function and appearance in all patients. CONCLUSION Fibula JDA is superior to the Fibula JIAD approach for simultaneous mandibular reconstruction with fibula and dental rehabilitation. There is no need for postoperative intermaxillary fixation. The surgery can be performed more reliably with less stress. It provides an additional opportunity for dental rehabilitation if initial dental prosthesis installation during JIAD fails. Postreconstruction intraoral scans provide greater precision and more flexibility in milling dental prosthesis which are mapped to the reconstructed mandible during the postoperative period.
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Affiliation(s)
- Yang-Ming Chang
- Department of Oral and Maxillofacial Surgery, Chang Gung Memorial Hospital, Taiwan
| | - Chi-Ying Tsai
- Department of Oral and Maxillofacial Surgery, Chang Gung Memorial Hospital, Taiwan
| | - Fu-Chan Wei
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University and Medical College, Taiwan.
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Khadembaschi D, Brierly GI, Chatfield MD, Beech N, Batstone MD. Systematic review and pooled analysis of survival rates, success, and outcomes of osseointegrated implants in a variety of composite free flaps. Head Neck 2020; 42:2669-2686. [PMID: 32400954 DOI: 10.1002/hed.26238] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 04/02/2020] [Accepted: 04/22/2020] [Indexed: 09/19/2023] Open
Abstract
The aim of this review was to provide an update on survival rates of osseointegrated implants into common composite free flaps used for maxillary and mandibular reconstructions and identify factors affecting outcomes. PubMed, Medline, Embase, and Cochrane databases were searched. Included studies reported implant survival by flap type. Results were pooled and survival was estimated with the Kaplan-Meier method. Variables affecting survival were assessed using Cox regression. Thirty-two of the 2631 articles retrieved were included, totaling 2626 implants placed into fibula, iliac crest, scapula, and radial forearm free flaps. Pooled survival showed 94% 5-year survival of implants in fibula and iliac crest with no difference between groups (P = .3). Factors effecting survival included radiotherapy (HR 2.3, 95% CI 1.2-4.6, P = .027) and malignant disease (HR 2.2, 95%CI 1.6-3.1, P < .001). Implant survival appears adequate across common flap types; however, there are limited numbers reported in less common flaps.
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Affiliation(s)
- Darius Khadembaschi
- Faculty of Medicine, University of Queensland, Herston, Queensland, Australia
| | - Gary I Brierly
- Department of Maxillofacial Surgery, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Mark D Chatfield
- Faculty of Medicine, University of Queensland, Herston, Queensland, Australia
| | - Nicholas Beech
- Department of Maxillofacial Surgery, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Martin D Batstone
- Department of Maxillofacial Surgery, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
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Success of dental implants in vascularised fibular osteoseptocutaneous flaps used as onlay grafts after marginal mandibulectomy. Br J Oral Maxillofac Surg 2016; 54:1090-1094. [PMID: 27516164 DOI: 10.1016/j.bjoms.2016.07.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Accepted: 07/10/2016] [Indexed: 11/23/2022]
Abstract
We have evaluated the survival of dental implants placed in vascularised fibular flap onlay grafts placed over marginal mandibulectomies and the effects on marginal bone loss of different types of soft tissue around implants under functional loading. From 2001-2009 we studied a total of 11 patients (1 woman and10 men), three of whom had had ameloblastoma and eight who had had squamous cell carcinomas resected. A total of 38 dental implants were placed either at the time of transfer of the vascularised fibular ostoseptocutaneous flaps (nine patients with 30 implants) or secondarily (two patients with eight implants). Four patients were given palatal mucosal grafts to replace intraoral skin flaps around the dental implants (n=13), and the other seven had the skin flaps around the dental implants thinned (n=25) at the second stage of implantation of the osteointegrated teeth. All vascularised fibular osteoseptocutaneous flaps were successfully transferred, and all implants survived a mean (range) of 73 (33-113) months after occlusal functional loading. The mean (SD) marginal bone loss was 0.5 (0.3) mm on both mesial and distal sides in patients who had palatal mucosal grafts, but 1.8 (1.6) mm, and 1.7 (1.5) mm, respectively, on the mesial and distal sides in the patients who had had thinning of their skin flaps. This difference is significant (p=0.008) with less resorption of bone in the group who had palatal mucosal grafts. Palatal mucosa around the implants helps to reduce resorption of bone after functional loading of implants.
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Outcome of Osseointegrated Dental Implants in Double-Barrel and Vertically Distracted Fibula Osteoseptocutaneous Free Flaps for Segmental Mandibular Defect Reconstruction. Plast Reconstr Surg 2014; 134:1033-1043. [DOI: 10.1097/prs.0000000000000623] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Wang F, Huang W, Zhang C, Sun J, Kaigler D, Wu Y. Comparative analysis of dental implant treatment outcomes following mandibular reconstruction with double-barrel fibula bone grafting or vertical distraction osteogenesis fibula: a retrospective study. Clin Oral Implants Res 2013; 26:157-65. [DOI: 10.1111/clr.12300] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/25/2013] [Indexed: 11/29/2022]
Affiliation(s)
- Feng Wang
- Department of Oral and Maxillofacial Implantology; Ninth People's Hospital Affiliated with Shanghai Jiao Tong University; School of Medicine; Shanghai Key Laboratory of Stomatology; Shanghai China
| | - Wei Huang
- Department of Oral and Maxillofacial Implantology; Ninth People's Hospital Affiliated with Shanghai Jiao Tong University; School of Medicine; Shanghai Key Laboratory of Stomatology; Shanghai China
| | - Chenping Zhang
- Department of Oral and Maxillofacial Surgery; Ninth People's Hospital Affiliated with Shanghai Jiao Tong University; School of Medicine; Shanghai Key Laboratory of Stomatology; Shanghai China
| | - Jian Sun
- Department of Oral and Maxillofacial Surgery; Ninth People's Hospital Affiliated with Shanghai Jiao Tong University; School of Medicine; Shanghai Key Laboratory of Stomatology; Shanghai China
| | - Darnell Kaigler
- Department of Periodontics and Oral Medicine and Biomedical Engineering; University of Michigan; Michigan Center of Oral Health Research; Ann Arbor MI USA
| | - Yiqun Wu
- Department of Oral and Maxillofacial Implantology; Ninth People's Hospital Affiliated with Shanghai Jiao Tong University; School of Medicine; Shanghai Key Laboratory of Stomatology; Shanghai China
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Iliac Crest Flap for Mandibular Reconstruction After Advanced Stage Mandibular Ameloblastoma Resection. Ann Plast Surg 2012; 69:529-34. [DOI: 10.1097/sap.0b013e31821d06f3] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Harnessing the Potential of the Free Fibula Osteoseptocutaneous Flap in Mandible Reconstruction. Plast Reconstr Surg 2010; 125:305-314. [DOI: 10.1097/prs.0b013e3181c2bb9d] [Citation(s) in RCA: 85] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Schrag C, Chang YM, Tsai CY, Wei FC. Complete rehabilitation of the mandible following segmental resection. J Surg Oncol 2006; 94:538-45. [PMID: 17061277 DOI: 10.1002/jso.20491] [Citation(s) in RCA: 86] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Segmental resection of the mandible leads to significant patient morbidity. Loss of mandibular support to the teeth, tongue and lip causes dysfunctional mastication, swallowing, speech, airway protection and oral competence. Patients also suffer disfigurement following segmental mandibulectomy because the mandible is an important aesthetic landmark. The degrees to which dysfunction and disfigurement occur depend both on the location of the mandibular segment removed and the amount of surrounding soft tissue excised. Between January 1985 and December 2004, 780 fibula osteoseptocutaneous flaps have been used for head and neck reconstruction at the Chang Gung Memorial Hospital, Taiwan. The fibula flap has proven to be the bony flap of choice because it has a lengthy bicortical segment of bone available, a reasonably long vascular pedicle, large diameter vessels, good bone quality, and is easily contoured with multiple osteotomies. The flap can be harvested while ablation is being performed. In addition, a reliable, mobile, thin skin component can always be included to address the soft tissue reconstructive requirements. A chimeric design employing a portion of the soleus muscle can provide further reconstructive options. Ideally complete rehabilitation of the mandible involves placement of titanium osseointegrated implants, which allow dental restoration. Primary placement of implants is preferred in patients without cancer. Selection of candidates to receive osseointegrated implants is paramount. The temporomandibular joint remains a challenge to reconstruct adequately.
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Affiliation(s)
- Christiaan Schrag
- Department of Plastic Surgery, Chang Gung Memorial Hospital, Taipei, Taiwan
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Mehta RP, Deschler DG. Mandibular reconstruction in 2004: an analysis of different techniques. Curr Opin Otolaryngol Head Neck Surg 2004; 12:288-93. [PMID: 15252248 DOI: 10.1097/01.moo.0000131444.50445.9d] [Citation(s) in RCA: 85] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The field of mandibular reconstruction has evolved dramatically over the past fifty years. Numerous advances in microsurgical technique, plating technology and instrumentation, and an understanding of donor site angiosomes have made consistent and reliable mandibular reconstruction possible. Refinements in technique continue to improve the functional and aesthetic outcomes of oromandibular reconstruction. This review discusses the current state-of-the-art techniques for mandibular reconstruction and highlights the latest innovations in technique. RECENT FINDINGS The most common indication for oromandibular reconstruction remains ablative surgery for advanced neoplastic processes of the oral cavity and oropharynx. Reconstruction of these complex three-dimensional composite bony and soft-tissue defects is paramount for rehabilitation of form and function. Vascularized osseous free tissue transfer is the state-of-the-art for mandibular reconstruction. The long-term excellent functional and aesthetic outcomes of this technique have recently been reported. The most commonly used free flaps for mandibular reconstruction are the fibula, iliac crest, and scapula. Each of these typically accepts endosseous implants improving functional outcomes. The use of mandibular reconstruction plates and coverage with a soft-tissue flap remains a reconstructive option for selected patients. The latest refinements in technique include temporary intraoperative external fixation, the use of periosteal free flaps, distraction osteogenesis, and development of biodegradable biopolymer scaffolds for mandibular defects. SUMMARY Oromandibular reconstruction, although a challenge for the head and neck reconstructive surgeon, is now reliable and highly successful with excellent long-term functional and aesthetic outcomes.
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Affiliation(s)
- Ritvik P Mehta
- Department of Otology and Laryngology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts 02114, USA
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Chang YM, Coskunfirat OK, Wei FC, Tsai CY, Lin HN. Maxillary Reconstruction with a Fibula Osteoseptocutaneous Free Flap and Simultaneous Insertion of Osseointegrated Dental Implants. Plast Reconstr Surg 2004; 113:1140-5. [PMID: 15083013 DOI: 10.1097/01.prs.0000110326.17712.97] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The fibula osteoseptocutaneous flap is a good option for reconstruction of three-dimensional composite maxillary defects. This flap provides both bone and soft-tissue reconstruction and allows osseointegrated dental implantation, either simultaneously or in a second-stage procedure. Simultaneous placement of osseointegrated dental implants reduces operative sessions and allows faster oral rehabilitation for properly selected patients. The defects may result from trauma or resection of benign tumors or low-grade malignancies. Between August of 1999 and July of 2001, three patients underwent maxillary reconstruction with the fibula osteoseptocutaneous flap and simultaneous osseointegrated dental implants. The cause of the defect was trauma in two cases and resection of an adenoid cystic carcinoma in the other. The mean length of the fibula used for bony reconstruction was 4.7 cm. One osteotomy was performed in one case and no osteotomy was necessary in the other two. Skin islands of 8 x 2.5 cm and 16 x 3.5 cm were used for two patients. For the other patient, a double skin island was used for both nasal (6 x 4 cm) and oral (6 x 5 cm) reconstructions. Two osseointegrated implants were inserted into the fibular bone for each patient. Six months after the first-stage procedure, palatal rotation flaps or mucosa grafts were used to cover the exposed implant necks and prepare the implants for prostheses. One month after the second-stage procedure, prostheses were placed. An implant-supported prosthesis was used for one patient and implant/tissue-supported prostheses were used for the others. At a mean follow-up time of 30 months (range, 16 to 38 months), all patients were able to use the dental prosthesis for chewing (beginning 6 weeks after the final procedure) and all patients were satisfied with the cosmetic results.
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Affiliation(s)
- Yang-Ming Chang
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital and Medical College, Chang Gung University, Taipei, Taiwan
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Chana JS, Chang YM, Wei FC, Shen YF, Chan CP, Lin HN, Tsai CY, Jeng SF. Segmental mandibulectomy and immediate free fibula osteoseptocutaneous flap reconstruction with endosteal implants: an ideal treatment method for mandibular ameloblastoma. Plast Reconstr Surg 2004; 113:80-7. [PMID: 14707625 DOI: 10.1097/01.prs.0000097719.69616.29] [Citation(s) in RCA: 118] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Thirteen patients with large ameloblastomas of the mandible underwent segmental mandibulectomy and immediate reconstruction, with simultaneous placement of osseointegrated implants. All patients received palatal mucosal grafts around the dental implants 6 to 10 months after surgical treatment and received implant-supported prostheses another 1 to 2 months later. There were five female and eight male patients, with a mean age of 32 years (range, 17 to 50 years). The mean length of the mandibular defect was 8.8 cm (range, 5 to 13 cm). All free fibula flap procedures were successful, with no reexplorations or partial flap losses. There was no clinical or radiographic evidence of failure during the osseointegration process for any implant. With functional occlusal loading, the marginal bone loss around the implants was less than 1.5 mm in a mean follow-up period of 40 months (range, 18 to 70 months). There were no recurrences during that time. The technique described allows improved access to the bone at the time of reconstruction, immediate assessment of alveolar ridge relationships, and accurate fixation of the implant-fibula construct. The advantages of this procedure include a reduced risk of recurrence with segmental resection, reliable mandibular reconstruction, and reduction of the number of surgical procedures, allowing full oral rehabilitation in a shorter time. It is concluded that segmental mandibulectomy and immediate vascularized fibula osteoseptocutaneous flap reconstruction, with simultaneous placement of osseointegrated implants, represent an ideal treatment method for large ameloblastomas of the mandible.
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Affiliation(s)
- Jagdeep S Chana
- Department of Oral and Maxillofacial Surgery, Chang Gung Memorial Hospital, Taipei, Taiwan
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