This study compared the clinically usable bone regions of the ilium and fibula for mandible reconstruction. Measurements were taken of 241 ilia, 91 mandibles, and 60 fibulas. The ilium offered a similar total usable bone length to the fibula but maintained a more constant bone thickness throughout, whereas the fibula's dimensions varied significantly. In some fibulas, only a small portion of the total bone length could actually be used. The study suggests the ilium may be a better donor site than the fibula, especially for women requiring occlusal rehabilitation after mandible reconstruction.

1. ORIGINAL COMMUNICATION
Regions of Ilium and Fibula Providing Clinically
Usable Bone for Mandible Reconstruction:
“A Different Approach to Bone Comparison”
ALIREZA GHASSEMI,1†
* LOVORKA SCHREIBER,2†
ANDREAS PRESCHER,3
ALI MODABBER,4
AND LLOYD NANHEKHAN5
1
Consultant, Oral and Maxillofacial Surgery, Teaching Hospital Klinikum-Lippe, Detmold,
Germany and Medical Faculty University of RWTH Aachen, Aachen, Germany
2
Private Dental Office, Nettetal, Germany
3
Professor, Institute for Molecular and Cellular Anatomy University of RWTH Aachen, Aachen, Germany
4
Associate Professor, Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Aachen, Germany
5
Consultant, Plastic Surgery University Hospital Leuven, Leuven, Belgium
A variety of donor sites are available for mandibular reconstruction. We present
here a different way of comparing two commonly-used bone flaps. The lengths
of the usable parts in a total of 241 coxal bones, 91 mandibles and 60 fibulas
were measured. The mandible was measured from condyle-to-condyle and the
harvestable bone length (HBL) and usable (UBL) bone lengths in fibula and ilium
were also measured. The bone thickness (BT) in 60 iliac crests was measured in
two parallel lines from the anterior superior iliac spine (ASIS) along the iliac
crest. The mandible was 32.17 mm shorter in females than in males. The total
ilium UBL was 171.12 mm in females and 178.80 mm in males. The mean HBL
of the fibula was 22.6 mm shorter in females than in males. However, in some
fibulas in both females and males, only 4.2% and 21.1% of the HBL respectively
could be used if the ultimate goal was to insert dental implants. We found signif-
icant correlations between BT and gender in both fibula and ilium (P 0.05). The
ilium offers constant BT throughout the usable bone area with a similar bone
length to the fibula. In contrast, the fibula showed variable bone dimensions, so
not all of it is clinically usable. This should especially be considered in females
when a mandibular reconstruction is planned with the goal of occlusal rehabilita-
tion. Clin. Anat. 29:773–778, 2016. VC 2016 Wiley Periodicals, Inc.
Key words: mandible reconstruction; ilium; fibula; usable bone regions
INTRODUCTION
Mandibular defects can result from trauma, infec-
tion, tumor resection, congenital malformation or
bisphosphonate-related bone necrosis (BRBN), and
cause functional and esthetic impairment (Schmel-
zeisen et al., 1996; G€urlek et al., 1998; Gurtner and
Evans, 2000; Miles et al., 2010). The success rate of
reconstructive surgery using vascularized flaps has
improved significantly in both functional and esthetic
terms, gradually changing the conceptual approach to
mandibular continuity reconstruction (Cordeiro et al.,
1999; Torroni et al., 2015). A variety of donor sites
are available for oromandibular reconstruction
Abbreviations used: AIIS, anterior inferior iliac spine; ASIS,
anterior superior iliac spine; BRBN, bisphosphonate-related
bone necrosis; BT, bone thickness; HBL, harvestable bone
length; UBL, usable bone length
*Correspondence to: Alireza Ghassemi, Teaching Hospital
Klinikum–Lippe, Oral and Maxillofacial Surgery, R€ontgenstr. 18,
32756 Detmold, Germany. E-mail: aghassemi@ukaachen.de
†
The first two authors contributed equally to the manuscript.
Received 3 March 2016; Revised 21 April 2016; Accepted 24
April 2016
Published online 17 June 2016 in Wiley Online Library
(wileyonlinelibrary.com). DOI: 10.1002/ca.22732
VVC 2016 Wiley Periodicals, Inc.
Clinical Anatomy 29:773–778 (2016)

2. (Moscoso et al., 1994; Disa and Cordeiro, 2000; Can-
non et al., 2012); the specific advantages and disad-
vantages of each particular flap are still debated. The
choice depends on many factors such as the length
and condition of the vascular pedicle, availability of
soft tissue, donor site morbidity, patient’s medical
condition, and last but not least the expected func-
tional and esthetic outcomes (Curtis et al., 1997; Eck-
ardt et al., 2007; Mochizuki et al., 2009; Gerressen
et al., 2013; Urken et al., 2015).
Modern reconstructive procedures should be aimed
first at restoring speech, swallowing and mastication,
and secondly should strive for a good esthetic out-
come (Schliephake et al., 1998; Rogers et al., 1998).
Functional rehabilitation without esthetic consideration
will have negative effects on the patient’s psychologi-
cal wellbeing (Villaret et al., 2008). Manchester
(1965) drew attention to the similarity and suitability
of the ilium for mandible reconstruction (Fig. 1). How-
ever, studies emphasizing flaps with a bony compo-
nent have focused on the generally available amount
of bone regardless of its real clinical usability (Frodel
et al., 1993; Beckers et al., 1998; Shimizu et al.,
2002; Khamanarong et al., 2005; S€onmez et al.,
2013; Zaker Shahrak et al., 2014). To our knowledge,
there has to date been no comparative study of clini-
cally usable bone dimensions in the two most impor-
tant flaps for mandibular reconstruction.
We measured the length and thickness of the clini-
cally usable area of the ilium and compared them with
the clinically usable bone areas of the fibula. Our
hypothesis was that the the advantage of the ilium
over the fibula in terms of clinically usable bone vol-
ume is greater than previously reported.
MATERIALS AND METHODS
The cadaver specimens for this study were obtained
after institutional approval from the Institute of Anat-
omy and Cell Biology of our University Hospital.
The lengths of useable bone parts in a total of 241
iliums (n 5 121) were measured from the anterior
inferior iliac spine (AIIS5 Ia) to the anterior superior
iliac spine (ASIS 5 Ib) and up to 3 cm before the ilio-
sacral joint (ISJ 5 Ic), as shown in Figure 1. From
these cadavers, 91 mandibles and 60 fibulas (n 5 30)
were available for measurements. The mandibles
were measured as shown in Figure 2 from condyle to
angle (Ma-Mb) and from angle to the protuberance of
the chin (Mb-Mc). The whole length (Ma-Ma) was cal-
culated as the sum of those two values. The fibula
length was measured from a point 8 cm below the
knee joint (Fa) to a point 8 cm above the ankle joint
(Fc), as shown in Figure 1. This part of the bone was
referred to as the harvestable bone length (HBL). We
then looked for the usable bone length (UBL), which
was defined as the part of the bone with
width 5 mm and height 10 mm. This criterion was
based on the minimum requirement for bone dimen-
sions for inserting adequate dental implants. We con-
sidered the anterior-posterior dimension of the fibula
as the height and the medial-lateral dimension as the
width. The bone thickness (BT) in 60 iliac crests
(n 5 30) was measured in two parallel lines from ASIS
along the iliac crest over a distance of 10 cm (Fig. 1).
The first line was 0.5 cm below and parallel to the iliac
crest. The second was 1.5 cm from the first. BT was
measured every 2 cm along each line.
Statistical Analysis
SAS Version 9.2 was used for all data analyses. Age-
related differences were assessed using Pearson’s cor-
relation coefficient. Differences and correlations con-
cerning body side and gender were analyzed by paired
and independent t-tests. Descriptive statistics recorded
were minimum, maximum and standard deviation. P
values 0.05 were considered statistically significant.
RESULTS
We measured the length and thickness of usable
bone in the fibula and the ilium, and the length of the
mandible. The specimens available were as follows:
UBL in 241 iliums (114 females, 127 males; age
range 40-99 years) and BT in 60 iliums (35
females, 25 males; age range 52-106 years)
Ninety-one mandibles (50 females, 41 males; age
range 40-99 years)
Fig. 1. Artistic illustration of the ilium and fibula
showing the locations of measurements.
774 Ghassemi et al.

3. BT, HBL and UBL in 60 fibulas (32 females, 28
males; age 43-100).
The total length of the mandible (Ma-Ma) in
females (mean 295.66; min-max 268–337 mm) was
32.17 mm shorter than in males (mean 327.83 mm;
min-max 289–354 mm).
Adding the bone length from Ia-Ib (females: mean
35.42 mm, SD 4.23; males: mean 35.85 mm, SD
4.25) to that from Ib-Ic (females: mean 135.70 mm,
SD 10.51; males: mean 142.95 mm, SD 12.32)
yielded a total UBL (Ia-Ic) of 171.12 mm in females
(min-max: 140–205) and 178.80 mm in males (min-
max: 150–215). The mean UBL of the iliac crest in
females was 7.68 mm shorter than males. The UBL of
the iliac crest was slightly but not significantly longer
on the right side (175.36 mm) than the left
(174.89 mm). The BTs in the iliac crest at point 2.6 in
females and points 2.4, 2.5 and 2.6 in males were
5 mm (Table 2). We found significant correlations
between the variables BT (1.1, 1.2, 2.2, 1.5, 2.5,
1.6, 2.6) and gender (P 0.05). There were no signifi-
cant correlations between the variables and age or
body side (Pearson’s correlation coefficients -0.3
and 0.3).
There was a significant difference between genders
in regard to both HBL (P 5 0.0006) and UBL
(P 5 0.002) for the fibula. The mean HBL of the fibula
(Table 1) in females was 22.6 mm shorter than in
males. In some fibulas in both females and males, only
4.2% and 21.1% respectively of the HBL could be used
satisfactorily if dental implant insertions were planned.
Although the body side differences were very minor for
both HBL (P 5 0.2693) and UBL (P 5 0.4956), we found
that some fibulas were unusable for adequate occlusal
rehabilitation (Table 1). We found no correlation
between HBL or UBL and age (Pearson’s correlation
coefficients5 20.213 and 20.155).
Fig. 2. Artistic illustration of the mandible showing the distances that were
measured.
TABLE 1. Measured HBL and UBL (Height 10 mm, width 5 mm) of Fibula Bone
Males Females Right Left
N528 N532 N560 N560
HBL (mm)
Min–max 158.6–252.9 146.6–224.1 144.5–254.6 108.6–256.6
Mean; SD 208.5; 27.8 185.9; 17.1 197.7; 24.6 195.2; 28.7
UBL (mm)
Min–max 38.4–252.6 7.3–224.1 0–251.2 0–256.6
Mean; SD 178.9; 50.2 133.2; 57.8 156.6; 62.0 152.5; 63.9
UBL (%)
Min–max 21.1–100.0 4.2–100.0 0–100.0 0–100.0
Mean; SD 85.7; 20.7 70.7; 28.6 78.3; 28.9 77.2; 28.2
Usable Bone Regions for Mandible Reconstruction 775

4. DISCUSSION
For practical clinical purposes we measured the
UBLs of the ilium and fibula. UBL was defined as a
bone length of 10 mm and a bone height of 5 mm
and is the optimal requirement for inserting dental
implants to allow for occlusal rehabilitation. We also
measured the mean length of the mandible to estab-
lish the total length of bone needed for complete man-
dible reconstruction (2 3 Ma-Mb-Mc5 Ma-Ma), as
shown in Figure 2. The thickness and height of the ini-
tial mandible were not measured, since for insertion
of dental implants an optimal length of 10 mm and a
height of 5 mm of the bone flap are favored irre-
spective of the measurements of the initial mandible.
The ilium was measured from the AIIS (Ia) to the
ASIS (Ib) and from there to the ISJ (Ic), minus 3 cm
for retaining joint stability (Fig. 1). In the fibula the
proximal and distal 8 cm are preserved for the pur-
pose of stability when the flap is harvested. We meas-
ured the HBL and compared it to the clinically usable
bone length of the fibula.
In articles published to date, the dimension of the
ilium starting from the ASIS to the ISJ has been
measured, taking no account of the portion from the
ASIS to the AIIS, which can also be used effectively in
bony reconstruction (Fig. 3). The mean total length of
the mandible was 295.6 mm in females and
327.83 mm in males. The mean UBL in the ilium (Ia-
Ic) was 171.12 mm in females and 178.80 mm in
males. In comparison, the UBL in the fibula was
133.2 mm in females and 178.9 mm in males. The
HBL from the fibula differed significantly between
females and males. In some females only 4.2% of
HBL could be used, and in some males only 21.1%.
Furthermore, in some fibulas from females, we found
that no part was usable if occlusal rehabilitation was
planed. In contrast, some fibulas proved usable in
their entirety (Table 1). This should be taken into the
consideration if occlusal rehabilitation is planned. We
TABLE 2. The Thickness of Iliac Bone in Usable Area
Females Males Right Left
n535 n525 n560 n560
BT 1.1 min–max 1.05–2.10 1.10–2.20 1.10–2.30 1.00–2.20
mean; SD 1.53; 0.24 1.70; 0.28 1.59; 0.32 1.63; 0.28
BT 1.2 min–max 1.25–2.20 1.40–2.10 1.30–2.30 1.20–2.10
mean; SD 1.71; 0.23 1.72; 0.16 1.71; 0.23 1.72; 0.24
BT 1.3 min–max 1.35–2.95 1.40–2.05 1.30–2.90 1.30–3.00
mean; SD 1.81; 0.34 1.73; 0.20 1.78; 0.32 1.77; 0.34
BT 1.4 min–max 1.20–2.65 1.50–2.35 1.10–2.90 1.20–2.70
mean; SD 1.97; 0.26 1.92; 0.26 1.94; 0.34 1.96; 0.28
BT 1.5 min–max 1.05–2.15 1.40–2.65 1.00–2.50 0.80–3.10
mean; SD 1.64; 0.31 1.84; 0.30 1.71; 0.34 1.73; 0.42
BT 1.6 min–max 0.90–1.55 1.05–2.15 0.90–2.00 0.60–2.30
mean; SD 1.20; 0.19 1.44; 0.24 1.28; 0.24 1.31; 0.30
BT 2.1 min–max 0.65–1.40 0.75–1.70 0.40–2.10 0.60–1.70
mean; SD 0.98; 0.19 1.18; 0.23 1.05; 0.27 1.08; 0.25
BT 2.2 min–max 0.70–1.55 0.85–1.60 0.60–2.20 0.50–1.60
mean; SD 1.02; 0.23 1.16; 0.18 1.06; 0.30 1.10; 0.25
BT 2.3 min–max 0.75–1.95 0.75–1.80 0.60–2.30 0.60–2.30
mean; SD 1.16; 0.30 1.22; 0.28 1.17; 0.34 1.20; 0.34
BT 2.4 min–max 0.70–1.70 0.45–1.70 0.50–2.00 0.40–1.90
mean; SD 1.24; 0.24 1.37; 0.30 1.29; 0.34 1.31; 0.29
BT 2.5 min–max 0.60–1.55 0.45–1.80 0.40–1.80 0.50–2.10
mean; SD 1.08; 0.24 1.28; 0.30 1.14; 0.33 1.19; 0.35
BT 2.6 min–max 0.40–1.35 0.35–1.55 0.30–1.70 0.40–1.80
mean; SD 0.92; 0.23 1.11; 0.25 0.96; 0.28 1.04; 0.31
BT, bone thickness; HBL, harvestable bone length; Max, maximum; Min, minimum; SD, standard deviation; UBL,
usable bone length.
Fig. 3. The ilium was osteotomized to replicate the
mandible.
776 Ghassemi et al.

5. performed two series of measurements of the ilium
BT. The first series were made 5 mm caudal to the
iliac crest and the second series 20 mm caudal and
parallel to the first. We selected these regions for the
following practical reasons. First, clinically, we never
need 20 mm of bone height when replacing the
mandible, and in general 15 mm should suffice for
insertion of dental implants. Second, a bone stock of
20 mm is more than sufficient to replicate the original
mandibular shape to achieve the best esthetic out-
come (Modabber et al., 2012). Third, we should also
consider the topographical anatomy of the nourishing
vessels along the inner surface of the ilium, which lie
between 5 mm and 20 mm below the crest (Urken
et al., 1995; Ting et al., 2009; Ghassemi et al.,
2013a). Many previous studies have also reported the
BT of the ilium, but they measured areas that would
never be used clinically (Beckers et al., 1998; Shimizu
et al., 2002; Khamanarong et al., 2005; S€onmez
et al., 2013). The average BT of usable bone from
ASIS to posterior was greater than 5.75 mm, making
it suitable for dental implantation. We found no signifi-
cant correlations between the iliac crest BT and age or
body side. The small differences between right and
left sides were not significant. However, we found a
significant correlation between BT (1.1, 1.2, 2.2, 1.5,
2.5, 1.6, 2.6) and gender. The first rows of measure-
ments (5 mm below the crest) in both males and
females had BT 6 mm, which is enough for insertion
of dental implants. At many points we observed a
thicker bone in males than in females, but the opposite
held at other points (Table 2). When the second level
of BT of the iliac crest in males was measured, three
points showed a BT of 6 mm or less, and in females
just one point showed a minimum BT of 6 mm. When
the left and right sides were compared, a total of eight
points on the right and left had BT 6 mm. The points
were mostly 60 mm behind the ASIS.
Our goal was to obtain systematic and objective
data defining the dimensions of clinically usable bone
for optimal reconstruction with the possibility of occlu-
sal rehabilitation using dental implants. This was
defined as the area with sufficient bone height and
width for insertion of implants, additionally offering a
similar shape to the lost mandible in order to achieve
the best esthetic outcome. We present here a realistic
approach to the bone measurements, differing from
previous reports focused on mandible reconstruction.
The ilium demonstrated unlimited vertical height and
acceptable width of clinically usable areas. It has a
natural curvature that resembles the hemi-mandible,
as mentioned by Manchester (1972) (Fig. 3). No other
donor site can supply similar bone suitable for restor-
ing the esthetic contour and offer adequate bone for
insertion of osseo-integrated implants (Riediger,
1988). Bone can be harvested by extending the resec-
tion posteriorly up to the ISJ if needed. This bone can
be contoured to reconstruct the anterior mandibular
arch with few osteotomies through the outer cortex,
which can be planned using preoperative navigated
planning (Modabber et al., 2012). Although limited in
dimensions, implant placement in the fibula and the
chance of osseo-integration are facilitated and the
thick bicortical bone material offers a good basis for
primary implant stability (Wu et al., 2008). One major
disadvantage of the fibula is its irregular shape (Fig.
4). Furthermore, the inadequate height of the recon-
structed segments can create a large distance to the
occlusal plane, which makes prosthetic rehabilitation
difficult. To overcome this problem, the fibular bone
can be used in a “double barrel” fashion, distracted or
placed in the upper part of the neighboring mandible
(B€ahr et al., 1998; Siciliano et al., 1998; Wang et al.,
2012; Shen et al., 2013; Chang et al., 2014). The
large amount of bone provided by the vascularized
iliac crest makes it favorable for reconstruction in both
edentulous and dentate patients. Furthermore, owing
to its anatomical shape and sufficient bone height, it
provides a replicate of the mandible with excellent
esthetic results and excellent functional rehabilitation.
There is no need for bone distraction, double barrel
procedure, or other additional procedures (Schwarz
et al., 2009; Ghassemi et al., 2009; Ghassemi et al.,
2013b). Nevertheless, the free vascularized fibula flap
is a good competitor, superior in vascular pedicle
length and offering mostly sufficient bone width for
insertion of dental implants.
Overall, the ilium appears more reliable than the
fibula in terms of clinically usable bone dimensions.
The ilium offers constant BT throughout the usable
bone area with a similar bone length to the fibula. In
contrast, the fibula showed variable bone dimensions
and part of it is not clinically usable. This should espe-
cially be considered in females preoperatively when
mandibular reconstruction is planned with the inten-
tion of implant insertion.
ACKNOWLEDGMENT
Many thanks to those who donated their bodies to
science.
REFERENCES
B€ahr W, Stoll P, W€achter R. 1998. Use of the “double barrel” free
vascularized fibula in mandibular reconstruction. J Oral Maxillofac
Surg 56:38–44.
Beckers A, Schenk C, Klesper B, Koebke J. 1998. Comparative den-
sitometric study of iliac crest and scapula bone in relation to
Fig. 4. The fibula was osteotomized to replicate the
mandible.
Usable Bone Regions for Mandible Reconstruction 777

6. osseous integrated dental implants in microvascular mandibular
reconstruction. J Craniomaxillofac Surg 26:75–83.
Cannon TY, Strub GM, Yawn RJ, Day TA. 2012. Oromandibular recon-
struction. Clin Anat 25:108–119.
Chang YM, Wallace CG, Hsu YM, Chen YF, Tsai CY, Wei FC. 2014.
Outcome of osseointegrated dental implants in double-barrel and
vertically distracted fibula osteoseptocutaneous free flaps for
segmental mandibular defect reconstruction. Plast Reconstr Surg
134:1033–1043.
Cordeiro PG, Disa JJ, Hidalgo DA, Hu QY. 1999. Reconstruction of
the mandible with osseous free flaps: A 10-year experience with
150 consecutive patients. Plast Reconstr Surg 104:1314–1320.
Curtis DA, Plesh O, Miller AJ, Curtis TA, Sharma A, Schweitzer R,
Hilsinger RL, Schour L, Singer M. 1997. A comparison of mastica-
tory function in patients with or without reconstruction of the
mandible. Head Neck 19:287–296.
Disa JJ, Cordeiro PG. 2000. Mandible reconstruction with microvas-
cular surgery. Semin Surg Oncol 19:226–234.
Eckardt A, Meyer A, Laas U, Hausamen JE. 2007. Reconstruction of
defects in the head and neck with free flaps: 20 years experi-
ence. Br J Oral Maxillofac Surg 45:11–15.
Frodel JL, Funk GF, Capper DT, Fridrich KL, Blumer JR, Haller JR,
Hoffman HT. 1993. Osseointegrated implants: A comparative
study of bone thickness in four vascularized bone flaps. Plast
Reconstr Surg 92:449–455.
Gerressen M, Pastaschek C, Riediger D, Hilgers RD, H€olzle F, Noroozi
N, Ghassemi A. 2013. Free Flap Reconstructions of Head and
Neck Region in 406 Cases: A 13-Year Experience. J Oral Maxillo-
fac Surg 71:628–635.
Ghassemi A, Ghassemi M, Riediger D, Hilgers RD, Gerressen M.
2009. Comparison of donor-site Engraftment after harvesting
vascularized and nonvascularized iliac bone grafts. J Oral Maxillo-
fac Surg 67:1589–1594.
Ghassemi A, Furkert R, Prescher A, Riediger D, Knobe M, Odey D.,
Gerressen M, 2013a. Variants of the supplying vessels of the
vascularized iliac bone graft and their relationship to important
surgical landmarks. Clin Anat 26:509–521.
Ghassemi A, Ghassemi M, Modabber A, Knobe M, Fritz U, Riediger
D, Hilgers RD, Gerressen M. 2013b. Functional long-term results
after the harvest of vascularised iliac bone grafts bicortically with
the anterior superior iliac spine included. Br J Oral Maxillofac
Surg 51:47–50.
G€urlek A, Miller MJ, Jacob RF, Lively JA, Schusterman MA. 1998.
Functional results of dental restoration with osseointegrated
implants after mandible reconstruction. Plast Reconstr Surg 101:
650–655.
Gurtner GC, Evans GR. 2000. Advances in head and neck recon-
struction. Plast Reconstr Surg 106:672–682.
Khamanarong K, Kosuwon W, Sirichativapee W, Saejung S,
Thepsuthammarat K. 2005. Thicknesses of the Iliac Crest Appro-
priate for Anterior Cervical Interbody Fusion Grafts. J Med Assoc
Thai 88:1892–1895.
Manchester WM. 1965. Immediate reconstruction of the mandible
and temporomandibular joint. Br J Plast Surg 18:291–303.
Manchester WM. 1972. Some technical improvements in the recon-
struction of the mandible and temporomandibular joint. Plast
Reconstr Surg 50:249–256.
Miles BA, Goldstein DP, Gilbert RW, Gullane PJ. 2010. Mandible
reconstruction. Otolaryngol Head Neck Surg 18:317–322.
Mochizuki Y, Matsushima E, Omura K. 2009. Perioperative assess-
ment of psychological state and quality of life of head and neck
cancer patients undergoing surgery. Int J Oral Maxillofac Surg
38:151–159.
Modabber A, Gerressen M, Stiller M, Noroozi N, F€uglein A, H€olzle F,
Riediger D, Ghassemi A. 2012. Computer-assisted mandibular
reconstruction with vascularized iliac crest bone graft. Aesthetic
Plast Surg 36:653–659.
Moscoso JF, Keller J, Genden E, Weinberg H, Biller HF, Buchbinder D,
Urken ML. 1994. Vascularized bone flaps in oromandibular
reconstruction. A comparative anatomic study of bone stock
from various donor sites to assess suitability for enosseous den-
tal implants. Arch Otolaryngol Head Neck Surg 120:36–43.
Riediger D. 1988. Restoration of masticatory function by microsurgi-
cally revascularized iliac crest bone grafts using enosseous
implants. Plast Reconst Surg 81:861–877.
Rogers SN, Humphris G, Lowe D, Brown JS, Vaughan ED. 1998. The
impact of surgery for oral cancer on quality of life as measured
by the Medical Outcomes Short Form 36. Oral Oncol 34:171–
179.
Schliephake H, Schmelzeisen R, Sch€onweiler R, Schneller T,
Altenbernd C. 1998. Speech, deglutition and life quality after
intraoral tumor resection. A prospective study. Int J Oral Maxillo-
fac Surg 27:99–105.
Schmelzeisen R, Neukam FW, Shirota T, Specht B, Wichmann M.
1996. Postoperative function after implant insertion in vascular-
ized bone grafts in maxilla and mandible. Plast Reconstr Surg
97:719–725.
Schwarz DA, Jamali AM, Kakwan MS, Fregene A, Arman KG,
Buchman SR. 2009. Biomechanical assessment of regenerate
integrity in irradiated mandibular distraction osteogenesis. Plast
Reconstr Surg 123:114–122.
Shen Y, Guo X, Sun J, Li J, Shi J, Huang W, Ow A. 2013. Double-bar-
rel vascularised fibula graft in mandibular reconstruction: A 10-
year experience with an algorithm. J Plast Reconstr Aesthet Surg
66:364–371.
Shimizu T, Ohno K, Matsuura M, Segawa K, Michi K. 2002. An ana-
tomical study of vascularized iliac bone grafts for dental implan-
tation. J Craniomaxillofac Surg 30:184–188.
Siciliano S, Lengele B, Reychler H. 1998. Distraction osteogenesis of
a fibula free flap used for mandibular reconstruction: Preliminary
report. J Craniomaxillofac Surg 26:386–390.
S€onmez TT, Prescher A, Salama A, Kanatas A, Zor F, Mitchell D,
Zaker Shahrak A, Karaaltin MV, Knobe M, K€ulahci Y, Altuntas SH,
Ghassemi A, H€olzle F. 2013. Comparative clinicoanatomical study
of ilium and fibula as two commonly used bony donor sides for
maxillofacial reconstruction. Br J Oral Maxillofac Surg 51:736–
741.
Ting JW, Rozen WM, Grinsell D, Stella DL, Ashton MW. 2009. The in
vivo anatomy of the deep circumflex iliac artery perforators:
Defining the role for the DCIA perforator flap. Microsurgery 29:
326–329.
Torroni A, Marianetti TM, Romandini M, Gasparini G, Cervelli D, Pelo
S. 2015. Mandibular reconstruction with different techniques.
J Craniofac Surg 26:885–890.
Urken ML, Cheney ML, Sullivan MJ, Biller HF. 1995. Atlas of Regional
and Free Flaps for Head and Neck Reconstruction. New York:
Raven Press. p 1–379.
Urken ML, Buchbinder D, Weinberg H, Vickery C, Shreiner A, Parker
R, Schaefer J, Som P, Shapiro A, Lawson W, Biller HF. 2015.
Functional evaluation following microvascular oromandibular
reconstruction of the oral cancer patient: A comparative study of
reconstructed and nonreconstructed patients. Laryngoscope
125:1512.
Villaret AB, Cappiello J, Piazza C, Pedruzzi B, Nicolai P. 2008. Quality
of life in patients treated for cancer of the oral cavity requiring
reconstruction: A prospective study. Acta Otorhinolaryngol Ital
28:120–125.
Wang JJ, Chen J, Ping FY, Yan FG. 2012. Double-step transport dis-
traction osteogenesis in the reconstruction of unilateral large
mandibular defects after tumour resection using internal distrac-
tion devices. Int J Oral Maxillofac Surg 41:587–595.
Wu YQ, Huang W, Zhang ZY, Zhang ZY, Zhang CP, Sun J. 2008. Clini-
cal outcome of dental implants placed in fibula-free flaps for oro-
facial reconstruction. Chin Med J 121:1861–1865.
Zaker Shahrak A, Zor F, Kanatas A, Acikel C, Sapountzis S, Nicoli F,
Altuntas SH, Knobe M, Chen HC, Prescher A, H€olzle F, S€onmez
TT. 2014. Morphological and morphometric evaluation of the
ilium, fibula and scapula bones for oral and maxillofacial recon-
struction. Microsurgery 34:638–645.
778 Ghassemi et al.