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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)
(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.
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
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.
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.
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2016 ghassemi-clinically-usable-fib-ilium

  • 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
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