Vascularized bone flaps versus nonvascularized bone grafts for mandibular reconstruction: An outcome analysis of primary bony union and endosseous implant success

Abstract

Background Functional restoration following resection or traumatic injury to the mandible depends on the reliability of the bony reconstruction to heal primarily and support endosseous implants. Although vascularized bone flaps (VBF) and nonvascularized bone grafts (NVBG) are both widely used to reconstruct the mandible, indications for each remain ill‐defined. The purpose of this study was to compare bone graft/flap healing and success of implant placement in patients reconstructed with VBF versus NVBG. Methods Over the past 10 years, 75 consecutive mandibular reconstructions were performed (26 free bone grafts, 49 vascularized bone flaps). Etiology of the defect, history of irradiation, bone defect size, number of operations, graft/flap success, and dental implant success rates were determined and compared. Bone graft/flap success was defined as complete bony union. Implant success was defined as complete osseointegration. Mean follow‐up was 3 years. Results Free flaps were used primarily for malignant disease (78%, 38/49). Bone grafts were used primarily for benign disease (88%, 23/26). History of prior irradiation: 11% (3/26) NVBG versus 45% (22/49) VBF. Length of bony defect (mean): 8.1 cm NVBG versus 9.4 cm VBF. Successful bony union, any size defect: 69% (18/26) NVBG versus 96% (47/49) VBF (p < .0005); lateral defects only: 75% (15/20) NVBG versus 100% (17/17) VBF (p < .05). Number of operations to achieve bony union (mean), any size defect: 2.3 NVBG versus 1.1 VBF (p < .001); lateral defects only: 1.9 NVBG versus 1.0 VBF (p < .005). Twenty‐two patients (29%) had a total of 104 endosseous implants placed (NVBG: 8 patients, 33 implants; VBF: 14 patients, 71 implants). Immediate implants placed: 0/33 NVBG versus 54% (38/71) VBF. Overall implant success: 82% (27/33) NVBG versus 99% (70/71) VBF (p < .0001). Implant success in VBF patients with a history of RT: 100% (15/15). Conclusions Despite the fact that patients reconstructed with VBFs were older, had larger defects, and were treated primarily for malignant disease and therefore had a higher incidence of irradiation to the affected mandible than in patients treated with NVBGs, the incidence of bony union was higher, requiring fewer operations to achieve union, and the implant success rate was significantly greater than for NVBG patients. Results were similar when considering lateral defects only. Based on these results, VBFs are indicated in most cases of mandibular reconstruction; NVBGs are effective for short bone defects (<5–6 cm), in nonirradiated tissue, and/or in patients determined to be too medically compromised to tolerate the additional operative time required for a free‐flap reconstruction. © 1999 John Wiley & Sons, Inc. Head Neck 21: 66–71, 1999.

Treatment rationale for pathological fractures of the mandible: a series of 44 fractures

“…5). When deciding to use non-vascularized versus vascularized bone in these types of cases, POGREL et al 30 and FOSTER et al 14 noted an increased complication rate when non-vascularized bone is utilized for treatment of continuity defects greater then 6 cm. POGREL et al recommended avoiding non-vascularized bone when possible in the irradiated patient; it should be reserved for defects less then 6 cm, and adequate intraoral lining is required.…”

Dental rehabilitation in 101 primarily reconstructed jaws after segmental resections – Possibilities and problems. An 18-year study

“…Shorter periods were found only for the nine removable prostheses as these did not require any healing time for implants. Foster et al (1999) reported considerably shorter times, 10 months, from the reconstruction of jaw continuity until dental restorations were completed. In their study dental implants were, however, already installed in the jaw reconstruction in spite of the risk of improper positioning (Schoen et al, 2004).…”

Reconstruction of the mandible using preshaped 2.3mm titanium plates, autogenous particulate cortico-cancellous bone grafts and platelet rich plasma: a report on eight patients

“…The introduction of microvascular surgery as an aid in the transplantation of composite grafts has provided the reconstructive surgeon with a means to bridge large bony defects with adequate soft tissue coverage. The success rate of vascularized bone grafting is high and it is the treatment of choice for primary reconstruction 8,22 . Most of the techniques mentioned, however, have their shortcomings in creating an adequate alveolar ridge in which oral implants can be inserted to facilitate prosthodontic rehabilitation.…”