Mandibular Reconstruction Using the Free Vascularized Fibula Graft: An Overview of Different Modifications

Abstract

The reconstruction of the mandible is a complex procedure because various cosmetic as well as functional challenges must be addressed, including mastication and oral competence. Many surgical techniques have been described to address these challenges, including non-vascularized bone grafts, vascularized bone grafts, and approaches related to tissue engineering. This review summarizes different modifications of the free vascularized fibula graft, which, since its introduction by Hidalgo in 1989, has become the first option for mandibular reconstruction. The fibula free flap can undergo various modifications according to the individual requirements of a particular reconstruction. Osteocutaneous flaps can be harvested for reconstruction of composite defects. 'Double-barreling' of the fibula can, for instance, enable enhanced aesthetic and functional results, as well as immediate one-stage osseointegrated dental implantation. Recently described preoperative virtual surgery planning to facilitate neomandible remodeling could guarantee good results. To conclude, the free fibula bone graft can currently be regarded as the "gold standard" for mandibular reconstruction in case of composite (inside and outside) oral cavity defects as well as a way of enabling the performance of one-stage dental implantation.

Reconstruction of a mandibular segmental defect with a customized 3-dimensional–printed titanium prosthesis in a cat with a mandibular osteosarcoma

“…In dogs, reported techniques include free cortical ulnar and rib autografts with autogenous cancellous bone graft following segmental mandibulectomy, 2,3 rib allograft with recombinant human bone morphogenetic protein 2 following segmental mandibulectomy, 4 and absorbable compression resistant matrix (containing collagen, hydroxyapatite, and tricalcium phosphate soaked in recombinant human bone morphogenetic protein 2) following segmental mandibulectomy 5,6 and bilateral rostral mandibulectomy. 7 Common techniques used in humans for reconstruction of segmental mandibular defects include vascularized free osteocutaneous grafts, [8][9][10] particularly fibular osteocutaneous grafts, and distraction osteogenesis. 11 The increase in the availability of CT planning has resulted in advances in the management of mandibular defects in humans, including creation of 3-D models of the affected mandible for surgical planning (such as prebending and improved fitting of titanium plates, optimization of bone-to-bone contact, and shorter duration of surgery), 9,[12][13][14][15][16][17][18][19] creation of prefabricated intraoperative guides (for optimization of the length and number of fibular grafts, improved fitting of titanium plates, and improved postoperative cosmetic appearance and function), 9,16,[19][20][21] and development of CAD-CAM customized and patientspecific 3-D-printed reconstruction plates 9,22 and prostheses.…”

“…7 Common techniques used in humans for reconstruction of segmental mandibular defects include vascularized free osteocutaneous grafts, [8][9][10] particularly fibular osteocutaneous grafts, and distraction osteogenesis. 11 The increase in the availability of CT planning has resulted in advances in the management of mandibular defects in humans, including creation of 3-D models of the affected mandible for surgical planning (such as prebending and improved fitting of titanium plates, optimization of bone-to-bone contact, and shorter duration of surgery), 9,[12][13][14][15][16][17][18][19] creation of prefabricated intraoperative guides (for optimization of the length and number of fibular grafts, improved fitting of titanium plates, and improved postoperative cosmetic appearance and function), 9,16,[19][20][21] and development of CAD-CAM customized and patientspecific 3-D-printed reconstruction plates 9,22 and prostheses. 23 Customized 3-D printing of mandibular prostheses provides several theoretical advantages over other techniques, such as the ability to design the prosthesis to match the geometry and weight of the original mandible to better withstand the bending, torsion, and shear forces associated with mastication as well as the incorporation of tissue engineering technology into the prosthesis to promote its osseous integration.…”

A Rare Case of Malignant Transformation of Oral Lichen Planus of the Mandible

“…We recently described the versatility of the free vascularized fibula graft for mandibular reconstruction. 9 Based on the defect, an osseous, osteo-septo-cutaneous, or osteomyocutaneous flap can be used. The skin island can provide tissue for reconstruction of both external and oral cavity soft-tissue defects.…”

Potential application of tissue engineering for the reconstruction of facial bones

“…Starting in 1970, various vascularized flaps were developed to fill the large tissue defect after surgical removal of relatively advanced cancer in the maxillofacial region. For example, a large mandibular segmental defect can be reconstructed with a free vascularized fibula graft (Kokosis et al , ) and those vascularized free flaps have become the gold standard for the treatment of relatively large jaw defects. On the other hand, morbidity at the donor site and long surgical times are major shortcomings of this novel treatment.…”