This document discusses reconstruction of mandibular defects. It begins with an overview of anatomical facts, causes of defects, classifications, historical facts and options for reconstruction. Key options discussed include vascularized bone grafts like the fibula flap, which provides adequate bone stock and contour for reconstruction. Proper planning including templates and osteotomies is important for achieving optimal reconstruction with regard to structure, oral function and cosmesis. Post-operative care including fixation and monitoring for complications is also covered.

2.  INTRODUCTION
 ANATOMICAL FACTS
 CAUSES OF DEFECTS
 CLASSIFICATIONS
 HISTORICAL FACTS
 DIFFERENT OPTIONS
 POST OPERATIVE CARE
 COMPLICATIONS

4.  airway stability,
 speech,
 deglutition, and mastication,
 Smiling
 Determines shape of the lower face.

5.  Preservation of temporomandibular joint
function with maximal opening ability and
maintenance of occlusion
 Dental Rehabilitation

6.  Symmetry,
 preservation of lower
facial height
 anterior chin projection,
and
 correction of
submandibular soft-
tissue neck defects.

13.  Head n neck cancers ( SCC)
 Osteogenic carcinoma
 Mucoepidermopid carcinoma
 Sdenoid cystic carcinoma
 Leiomyosarcoma
 Fibrous histiocystoma
 Trauma : GUNSHOT WOUNDS

15.  Isolated
› any single bone tissue resection
 Compound
› two tissue layers, such as bone and oral lining or
bone and external skin
 Compoiste
› three-layer-defect involving the mucosal lining,bone,
and external skin
 En BLOC /extended composite
› Defect that also include loss of soft tissue

16.  H (hemimandible)—
› condyle and lateral segment that does not cross the
symphysis (midline).
 L (lateral)—
› lateral segment without a condylar component; not
crossing the symphysis.
 C (central)—
› bony region between the mental foramina.

18.  Smoking,
 diabetes,
 malnutrition,
 cardiovascular disease,
 liver cirrhosis,
 Renal failure,
 old age,
 local advanced disease,
 distal metastasis,
 recurrent or second primary cancer,
 postoperative radiation

19.  size,
 volume,
 and components of the involved soft tissue,
 the length and location of the mandibular
defect,
 the available recipient vessels, and
 the quality of the external skin.

20.  CT scan of mandible
 Lateral cephalogram
› For febrication of
template

24.  An ideal reconstruction should mimic the missing tissue with
regard to structure, geometry, and tissue character.
1. restoration of the bony scaffold,
2. adequate oral continence and
3. deglutition,
4. obliteration of dead space, and
5. re-establishment of optimal cosmesis.
 there is not a single free flap that meets all reconstructive
demands with regard to flap size, thickness, pliability, tissue
bulk, and skin turgor.
 Choosing an optimal flap for reconstruction should be based
on the clinical situation and the patient’s own preference.

25.  Prosthesis
 Nonvascularized bone graft,
 Pedicled osteomusculocutaneous flap,
 microsurgical osteocutaneous flap.

26.  Hausamen : 1886: plates &
screw for reconstruction
 Locking screws/plates with
vascularized bone grafts
 Mesh trays made of dacron :
1970s
 Titanium plates:
biocompatibility

27.  Decrease operating time
 Avoidance of bone graft
donar site
 Extensive oncological
resections
 absence of suitable bone
flaps,
 presence of significant
medical comorbidities

28.  risk of exposure
 infection
 risk of plate fracture
 preclusion of dental reconstruction;
 and a thin shape that does not provide adequate
bulk for reconstruction.
 Problematic in radiation therapy
 Functional limitations

30.  Skkoff : end of 19th
century
 Anterior or posterior iliac crest.
 Revascularization : recipient site
 For mandibular defect of < 5cm in size
 Complications
› Bone resorption
› Partial bone loss
› Pseudoarthrosis

32.  Hueston and McConchie :1968: pectoralis
major myocutaneous flap
 first pedicled rib graft with the PM
myocutaneous flap.
 PM myocutaneous flap with the sternum as a
bone graft.
 Composite pedicled myocutaneous flaps
transferred with clavicle bone graft

33.  Pectoralis major osteomusculocutaneous flap
 Trapezius osteomusculocutaneous flap
 Temporalis osteomuscular flap

34.  Traditional PM flap + the fifth rib as a bony
scaffold
 Blood supply : periosteal-muscular plexus
 Disadvantages:
› Blood supply not always reliable
› The strength of the fifth rib is not as good for
hardware fixation or osseous integration
› Risks of pneumothorax and hemothorax

35.  Scapula spine + pedicled trapezius muscle
 Upto 10cm of bone
 Limitations
› Restricted quality of bone
› Shoulder mobility

36.  The vascularized cranial bone with the
temporalis muscle.
 based on :the superficial temporal Artery
 as the outer cortex
› inadequate bone stock for hardware fixation and can
easily fracture during shaping
 as a full-thickness bone graft.
› more durable
› donor site cosmesis is a major concern.

39.  McKee : 1978: microvascular free rib graft for
mandibular defects.
 Taylor et al. :1975: free fibula flap use
 Hidalgo:free fibula flap for mandibular
reconstruction.

40.  Circumflex iliac osteocutaneous flap
 Scapular osteomusculocutaneous flap
 Radius with radial forearm flap
 Fibula osteoseptocutaneous flap

41.  Introduced by : Taylor : 1979
 Advantages:
› Reliable blood supply
› Good contour of neomandible : natural curve
 split lateral iliac crest chimeric flap based on
the lateral femoral circumflex vessels to
provide vascularized bone and soft tissue for
complex mandibular reconstruction.

42.  Small or moderate-sized mandibular defects of
type I-a to II-a.

47.  bulky skin paddle
 abdominal wall weakness,
 hernia,
 contour deformity,
 Limits early mobilization
› harvest the inner cortex of the iliac as part of this
flap

48.  Lateral border of the scapula, scapular and/or
parascapular skin, and the latissimus dorsi
muscle
 based on the subscapular artery
 The lateral border of the scapula : circumflex
scapular artery
 can be harvested up to a length of 14 cm
 Skin pedicle : as long as 30cm

49. subscapular
artery
scapular
artery
parascapular
artery

50.  valuable options for coverage of large complex
oromandibular reconstruction

55.  bone quality of the scapula is not as good
 intraoperative change in position,
 Weakness & decreased range of shoulder
motion

56.  inner volar cortex of the distal radius
 Length of segment : 10-12 cm
 Skin & pedicle are of best quality
 Bone : the worst

57.  bone defect that is limited to the ramus and the
proximal body with a large associated intraoral
soft-tissue defect.

60.  Post operative radius fractures
› Postoperative full-length plaster cast for 3–4 weeks
› the use of a dynamic compression plate for rigid

61.  reconstructive standard for successful
mandibular reconstruction
 Wei et al. demonstrated the reliability of
harvesting the fibula bone flap along with a skin
paddle based on identifiable septocutaneous
perforators

62.  The bone is available with enough length
 The straight quality of the bone with adequate
height thickness.
 Flap contouring process
 vascular pedicle has sufficient length
 for filling adjacent soft-tissue defects in the
submandibular portion.

63.  signs and symptoms of peripheral vascular
disease or
 an abnormal pedal pulse examination.
› overt peroneal artery atherosclerotic disease

64.  Simple intermaxillary fixation is performed to
obtain good dental occlusion
 reconstruction plate
 with at least two or three screws on each end.
 Template

65.  four possible arteries
1. the facial artery,
2. superior thyroid artery,
3. Superficial temporal artery, and
4. the transverse cervical artery.
 May be demaged by operative scars, radiations
fibrosis, neck dissection.
 Veins:
› External juglar vein
› Internal juglar vein: less kinking

66.  unique triangular bone,
 peroneal vessels, usually
› one artery
› two concomitant veins,
 located on the posteromedial aspect of the
fibula, posterior to the fascia of the posterior
tibialis, inside the flexor hallucis longus (FHL),
and anterior to the posterior crucial septum.

67.  The skin paddle :
› based on
osteocutaneous
perforators, which run
inside the posterior
crucial septum
 The lateral surface is the
safest and preferred site
for reconstruction plate
fixation
 Soleus along with the
flap: better soft tissue
coverage & contour.

68.  The left fibula
osteocutaneous flap is
transferred to left
mandibular defect type
II-a
 The pedicle of peroneal
vessels is placed toward
the right side to reach
the recipient vessels of
the ipsilateral side.

69.  An osteomyocutaneous
peroneal artery
combined flap was
harvested
 with a skin paddle of 12 ×
8 cm based on two
septocutaneous
perforators

70.  Mandibular defect
type II-a included
a bone defect of 9
cm in length;
 a buccal mucosal
and adjunct soft-
tissue defect
 tailored template
for measurement
of the length,
angle, and
number of
osteotomies

71.  The
osteotomy
was
performed to
obtain three
bone
segments to
simulate the
tailored paper
ruler
templates on
the back table.

72.  The three fibula
segments were
fixed to the
reconstruction
plate with one
screw for each.
The pedicle was
placed forward to
right-sided and
curved to reach
the ipsilateral
superior thyroid
artery and facial
vein

73.  The soleus muscle
could be flipped
over on top of the
fibula and the
reconstruction
plate to prevent
 exposure of the
reconstruction
plate and
 potential
osteoradionecrosis
 better cheek
contouring.

75.  further osteotomies are performed with an
electric saw according to the tailored paper ruler
templates
 Protect the vascular pedicle and septocutaneous
perforators to the skin paddle during the
osteotomies to prevent injury to these
structures

76.  flap is inset from the osteotomized fibula segments
that are contoured to fit the reconstruction plate.
 single screw fixation for each bone segment:
minimize vascular compromise
 One skin paddle :for the intraoral lining, and
 a second skin paddle :for the external cheek
 soleus muscle : placed on top of the fibula and
reconstruction plate to :
› improve cosmesis
› prevent possible osteoradionecrosis
› plate exposure after postoperative radiation

77.  Intermaxillary fixation with screws or wires
 titanium reconstruction plate : to bridge both
residual mandibular ends, with at least two
screws for each end
 Errors:
› prognathism,
› retrognathia,
› increased or decreased lower facial height,.
› asymmetry caused by a twist in the flap, or
› a shift in the midline to one side as a result of unequal
lengths of the mandible body.

79.  Watertight closure of the intraoral wound
 Contamination of the miniplates
 Orocutaneous fistula
 Suction drains
 positioned away from the microvascular
anastomoses.

80.  malocclusion
 Trismus
 Options :
› avascular bone graft,
› Rounding off the end of the fibula
› costochondral graft attached to the fibula end
› a titanium condyle prosthesis

81.  Dead space created by the extirpation of masticator
muscles, the buccal fat pad, and the parotid gland
 can lead to fluid accumulation and infection
 sunken appearance from soft-tissue contracture, trismus,
plate exposure, and impaired speech and swallowing
function
 exacerbated by postoperative radiotherapy.
 Radial forearm flap,
 anterolateral thigh, rectus abdominis,
 pectoralis major flaps

84.  Transferred to ICU for 3-7 days
 Tracheostomy /ETT
 Restricted neck movements
 Prophylactic antibiotics— 7 days
 PPI--- 3 days
 Hydration status/IOP monitering
 Enteral feeding

85.  Every hour : for 24 hours
 Every 2 hours : next 24 hours
 Every 4 hours : 3rd
post op till discharge
 Physical examination
 Hand held doppler
 Irrigation of oral cavity for hygeine : 3rd
day
 Mobilization
 Weight bearing : 3rd
week
 Follow up : periodic panorex radiographs

87.  appear within 1 week postoperatively,
 re-exploration,
 wound dehiscence,
 partial skin paddle loss.

88.  occur between 1 week and 1 month
postoperatively,
 infection,
 skin flap loss,
 wound dehiscence,
 donor site morbidity, and
 fibula bone loss.

89.  beyond the 1-month period
 infection,
 malocclusion,
 donor site morbidity,
 skin flap loss,
 radiotherapy-related orocutaneous fistula or
osteoradionecrosis

90.  hypovascularity,
 hypocellularity, and
 local tissue hypoxia
 Radiation-related osteoradionecrosis, neck contractures, and
wound-healing problems with subsequent plate exposure are
frequent in patients undergoing fibula osteocutaneous flap
for mandibular reconstruction
 preventing osteoradionecrosis :
› Enough soft tissue and bone coverage in the irradiated
field

91.  MAR28,2013PI
 A 23 year old female underwent
right hemi-mandibulectomy and a
neck dissection for a primary
sarcoma of the mandible 2 years
ago. She had a post-operative
radiation but no reconstruction
was done. She now wants a
correction of her deformity.
 a) what problems do you
anticipate in the procedure and
how can you avoid them?