Reconstruction of major defects of the jaws

Abstract

Prosthetic replacements in the 19th and early 20th century were superseded by pedicled flaps and obturators. These have subsequently been superseded by free tissue transfer which currently is the mainstay of reconstructive jaw surgery. Although malignant and benign processes of the jaws are the predominant cause of segmental defects, a significant proportion still occurs due to trauma, or even iatrogenic causes such as radiotherapy. The varied aetiologies demand a nuanced approach to reconstruction and although the techniques remain similar the timing can be quite different. The maxilla and the mandible are both amenable to composite reconstruction with bone. The fibula, iliac crest, scapula, distal radius and medial femoral condyle are the most commonly utilised donor sites for vascularised reconstruction. Each has strengths and weaknesses and the requirements of the defect, and patient preference should outweigh surgeon preference. Osseointegrated implants allow reliable rehabilitation of the dentition by anchoring facial prostheses. Their integration into composite flaps is highly reliable although soft tissue management can be challenging. Virtual surgical planning and 3D printing have already impacted on the surgical workflow and improved the reliability and accuracy of results. If this technology can be applied to tissue typing and human tissue (instead of just plastic and metal) a fully prefabricated and vascularised jaw without donor site morbidity would be the ultimate aim.

Oral Cancer

“…The reconstruction of the surgical defect is then completed and this is well described in the following paper in this supplement …”

Systematic review and pooled analysis of survival rates, success, and outcomes of osseointegrated implants in a variety of composite free flaps

“…1 Advances in reconstructive surgery in recent decades have resulted in the use of vascularized bone grafts (VBGs) as the ideal contemporary choice for reconstruction. 2 A variety of donor sites, including free fibula flap (FFF), deep circumflex iliac artery flap (DCIA), scapula, and radial forearm free flaps (RFFFs), can be used and have been found to be highly successful. 3 In addition to these commonly used flaps, the medial femoral condyle has been utilized specifically for maxillary defects.…”

“…One of the ultimate aims of reconstruction with VBGs is to create a sound bony foundation for osseointegrated implants to support a dental prosthesis, to further restore masticatory function, speech, and aesthetics. 2 There has been some investigation into the success of implants into VBG's examining factors such as timing of implant placement, 5 patient satisfaction in maxillary reconstructions, 6 the impact of extra-oral skin in peri-implant disease, 7 and a comparison of implants in patients with cancer who received a fibula free flap compared to a soft tissue flap. 8 A systematic review of implants in bone flaps concluded that the timing of implant placement and radiotherapy are factors affecting survival, although there was limited evidence.…”

Full-Digital Workflow for Fabricating a Custom-Made Direct Metal Laser Sintering (DMLS) Mandibular Implant: A Case Report

“…Reconstruction of the mandible is always a challenging clinical task due to the complexity of anatomy, function, and aesthetic role [12]. In particular, restoring form and function plays a pivotal role [13].…”