Functional Mandibular Reconstruction With Double-Barrel Fibular Flap and Primary Osseointegrated Dental Implants Improve Facial Esthetic Outcome

journal club
JSS ACADEMY OF HIGHER EDUCATION & RESEARCH

JSS Dental College & Hospital
FUNCTIONAL MANDIBULAR RECONSTRUCTION

WITH DOUBLE-BARREL FIBULAR FLAP AND PRIMARY
OSSEOINTEGRATED DENTAL IMPLANTS IMPROVE
FACIAL ESTHETIC OUTCOME
Presenter
PRIYA PRABHAKARAN
III Year PG Student
DEPT.of Prosthodontics and
Crown & Bridge
Department of prosthodontics and crown &
06/01/2020 1
bridge
Introduction
Treatment
Reference
plan
CONTENTS
Review Of
conclusion Literature
Critical
evaluation
06/01/2020 Department of 3
facial deformity,
mandibular deviation,
impairment of basic oral functions
to achieve facial and dental rehabilitation

because the width

of the fibula is only
half the height of
the
natural mandible
Materials and Methods
From 2012 to 2015

26 patients
16 to 49 years old
Group A GROUP B
26
14 12
PATIENTS
SBFF DBFF
Patient Number Gender/Age (yr) Tumor Type Area of Implants, n Intraoral Skin
Reconstruction Paddle
Group A
1 M/20 ossifying fibroma 36-37 2 no
2 M/36 ameloblastoma 35-37 3 no

3 M/20 ameloblastoma 35-37 + ramus 3 no
6 F/30 ameloblastoma 47-43 + ramus 3 no
10 M/39 myxoma 33-37 3 no
11 M/42 myxoma 47-43 3 no
12 M/49 squamous 47-44 + ramus 3 yes
carcinoma
13 F/41 squamous 33-37 3 yes
carcinoma
14 M/31 osteosarcoma 33-37 + ramus 3 yes
Group B
4 F/24 ameloblastoma 47-45 3 no
11 M/40 squamous 47-43 3 yes

carcinoma
12 06/01/2020 F/38 osteosarcoma 34-37 + ramus

Department of 3 yes 9
Surgical Procedure
• Briefly, preoperative lower-leg Doppler ultrasonography was
applied to all patients to evaluate the peroneal circulation
before surgery. The fibular flap was harvested at the same
time as ablation of the diseased mandibular segment under
general anesthesia
The SBFF was used instead of the DBFF
the defect length of the mandibular body was longer

●
1) than 10 cm;
the height of the DBFF exceeded the height of the

2)
●
residual mandible;
patients also had severe systemic diseases, such as

●
3) hypertension and diabetes;
4) patients preferred to simplify the surgical procedure

●
• In group A, the SBFF was secured by a
reconstruction plate aligning to the alveolar
ridge.
• In group B, the lower barrel of the DBFF was
fixed to the residual mandible with a
reconstruction plate to maintain the inferior
mandibular border and the upper barrel was
aligned to the alveolar ridge by miniplates.
• When combined with soft tissue deficits, skin
paddles were dissected from the distal third of
the lower limb to cover intraoral defects and
provide a sentinel monitor of bone viability
• The decision of donor limb sides depended on
the position of the vascular pedicle.
• For anterior placement of the vascular pedicle,
fibular flaps were harvested from the
contralateral side of the lower limb;
conversely, for posterior placement of the
vascular pedicle, fibular flaps on the ipsilateral
side were harvested as described previously
• Osteotomypositions, angulations, fibula
barrel alignment, and inset of the skin paddle
should be carefully planned
• Implant placement and cover screw
• After 6 to 9 months, a second-stage surgery was
performed.
• The skin was removed and hard palate mucosa
grafts were placed around the dental implant
healing abutment in patients with intraoral skin
flaps
• Implant-loaded prostheses were placed and
function loading began 3 months after 2nd stage
surgery
• Outcome Assessment
• Routine follow-up visits were scheduled every
3 months in the first year after prosthesis
delivery and then every 6 months thereafter.
During each visit, clinical examination and
radiographic evaluations were performed.
• Facial Esthetic Evaluation
• photographs in frontal and lateral views for assessment of esthetic
outcome during their follow-up visit.
• The assessment was performed every 6 months, starting from
12 months after reconstructive surgery
• Photographs were reviewed by a blinded observer
• Each photograph was scored as “excellent” (score, 4) for a
symmetrical lower face and mandibular outline, “good” (score, 3)
for a slightly asymmetrical soft tissue outline including slightly
collapsed cheeks or lip deformities, “fair” (score, 2) for visible facial
scar or soft tissue asymmetry, or “poor” (score, 1) for obvious facial
asymmetry or rough scar.
Radiographic Assessment
• Scans were obtained immediately after
implant placement, before uncovering surgery,
at the time of prosthetic functional loading,
and every 6 months thereafter.
Results
• All 26 fibula grafts and associated skin paddles (when present) survived

completely after a single attempt at anastomosis.
• Postoperative recovery was uneventful in 22 patients; 4 patients developed
local infections that were treated with antibiotics and wound care
• . No serious donor site morbidity was observed in any patients. No local
recurrence or metastasis occurred during 31 to 45 months of follow-up
after reconstruction surgery, and all patients regained occlusion and mouth
opening.
• CBCT scan showed excellent union of the grafted fibula and the
residual mandible and the condyles remained at the normal position in the
articular fossae (Fig 2).
• Implants formed strong integration with the fibula. The implant-support
prostheses showed good occlusion with the remaining teeth in the mouth (
Fig 3).
Facial Esthetic Evaluation
• For patients in group A , the postoperative facial

appearance was significantly inferior to that of
patients in group B after 24 months (P = .047)
and 30 months (P = .043).
• This result suggested that the DBFF can help
maintain a symmetrical facial contour and slow
down the collapse of the lower face, leading to a
superior long-term esthetic outcome.
Months After Esthetic Score Group A: Group B: PValue
Surgery SBFF + Dental DBFF + Dental
Implantation (n = 14) Implantation (n = 12)
12 excellent (4) 10 12 .100

good (3) 3 0
fair (2) 1 0
poor (1) 0 0
18 excellent (4) 8 11 .065
good (3) 4 1
fair (2) 2 0
poor (1) 0 0
24 excellent (4) 6 10 .047∗
good (3) 4 1
fair (2) 4 1
poor (1) 0 0
30 excellent (4) 6 10 .043∗
good (3) 4 1
06/01/2020 fair (2) 3 Department of 1 26
• Forty implants were placed into the
reconstructed area of the 14 patients in group
A, and 33 implants were placed into the
reconstructed area of the 12 patients in group
B. Mean follow-up after prosthetic loading was
33.1 months (range, 25 to 36 months) in group
A and 32.6 months (range, 26 to 36 months) in
group B. In patients 12 to 14 in group A and 11
and 12 in group B
• Dental implantation was successful in 13 of 14
patients in group A and all patients in group B.
In one patient (patient 12 in group A), one
implant on the distal end failed to integrate
and was removed before prosthetic loading.
Peri-implant bone resorption
1 yr 2 yr 3 yr
Group Mesial Distal Mesial Distal Mesial Distal
A 0.51 ± 0.54 0.48 ± 0.55 0.60 ± 0.42 0.57 ± 0.39 0.74 ± 0.36 0.73 ± 0.34
B 0.50 ± 0.37 0.53 ± 0.40 0.63 ± 0.36 0.64 ± 0.48 0.75 ± 0.41 0.76 ± 0.32
Discussion
• vascularized fibular flapcan provide the longest bone
length of all osseous donor sites, and multiple
osteotomies allow precise adaptation of the straight
bone flap to the defect for better reconstruction of the
facial contour.12 The size of the peroneal vessels is suitable
for microvascular anastomoses. Multiple perforators can
be dissected to form several skin paddles, which allow
simultaneous reconstruction of multiple defects of the
intraoral mucosa or extraoral skin.13 The skin paddles are
thin and pliable, unlike the bulky paddles associated with
other osseous flaps
• Functional mandibular reconstruction did not become reality in a true
sense until dental implantology was introduced to reconstructive
surgery by Brånemark.
• Among the frequently used osseous flaps, the fibular flap is
considered very suitable for dental implantation because of the hard
and thick cortex and the ratio of the cortex to the medulla is closest to
the mandible
• Because cell vitality is preserved in vascularized grafted bones,
the osteoblasts proliferate rapidly leading to
active osteogenesis around the interface of the implant and bone,
forming the initial stability of the implants.
• Moreover, the enriched blood supply helps control peri-implant bone
resorption
• When implants were placed into the SBFF or DBFF, no
difference in peri-implant bone resorption was detected
during the first 3 years.
• A stable peri-implant environment is essential to
the osseointegration of implants.
• A high incidence of peri-implantitis was reported when
implants were exposed through the skin paddles.4
• Because cutaneous tissue cannot firmly attach to the
implant, bacteria invade the peri-implant space and cause
inflammation, leading to peri-implantitis and marginal
bone resorption
• 14 of 15 implants were successfully placed and maintained.
The success rate (93.3%) is consistent with those reported
by other investigators
• for mandibular reconstruction, the conventional fibula graft
is not a perfect option. The natural width of the fibula is 1.2
to 1.5 cm on average, which covers only half the vertical
height of the mandible. When aligning the fibula at the
inferior mandibular margin, dental implants should support
elongated supra-structures to reach the occlusal plane, with
the risk of undesirable leverage forces and implant overload,
which can shorten the service lifespan of implants
• Based on the present study, the authors found
that using the DBFF markedly improved the
long-term assessment of facial symmetry and
lower face plumpness in patients. The
potential reason was that the DBFF restored
not only the mandibular contour but also the
alveolar region that would normally support
the lower lip.
• Shen et al20 used an SBFF and a low-profile
reconstruction plate with dental implantation
to achieve esthetic and functional mandibular
reconstruction. However, they pointed out
that this approach is selectively fashioned for
patients with benign disease and adequate
overlying soft tissue
Against
• Photographs and radiographs
• Cbct
Etiology
• Acquired segmental defects of the mandible are most commonly secondary
to ablative tumor therapy or avulsive traumatic injury.
• Other less common causes include inflammatory or infectious conditions that
result in devitalisation of the mandibular bone requiring its debridement.
• Segmental defects secondary to tumour therapy may result from the
management of aggressive benign tumours arising within the mandible such
as ameloblastoma or myxoma or from malignancies carcinomas/sarcomas)
arising in the associated soft tissue envelope that invade or extend to the
mandible.
• Management of oral squamous cell carcinoma is the most common
malignancy resulting in acquired segmental defects of the mandible. Avulsive
segmental wounds most commonly arise from high-velocity injuries such as
firearms, industrial accidents, and occasionallymotor vehicle collisions.
Goals of Reconstruction
• Establish continuity
• Establish alveolar height
• Establish arch form
• Establish arch width
• Maintain bones
• Improve facial contours
Timing of Reconstruction
• it is widely accepted that immediate
reconstruction may be performed without risk
for a delayed diagnosis of recurrent disease
Cardinal Prerequisites of Successful Bone Grafting
1. Bone transplantation into healthy tissues.

2. Wide contact between adjacent bone and the
graft.
3. Recipient area with adequate blood supply.
4. Positive fixation.
Reconstructive Options Used for Reconstruction
of Mandible
• Reconstruction Plates
• Techniques for Autogenous Bone Replacement
• 1. Non-vascularized bone grafts
• 2. Vascularized free flaps
Out of the two, the technique to be used is
determined by the following factors:
• Quality of the soft tissue environment (the

history of radiation, previous graft failure and
infection produces lots of scarring comprising the
soft tissue bed)
• Adequacy of the soft tissue (associated lining
and
cover requirement)
• Size and contour of defect.
• Experience of the surgeon.
Recent Advances
• Transport Disc Distraction Osteogenesis
• Modular Endoprosthesis
• Tissue-Engineering
• Implant placement is done in two stages: fixture
placement followed by exposure of the implant
and placement of the trans mucosal attachment.
• Following placement, the implant is allowed to
integrate for 4 months in the mandible and 6
months for maxillary implants.
• The trans-mucosal attachment is then placed
and 2 weeks later the denture is attached and
load bearing follows
The modular endoprosthesis for mandibular body replacement. Part
2: Finite element analysis of endoprosthesis reconstruction of the
mandible
• a novel method for alloplastic mandible

reconstruction with replacement of the mandibular
body and the ascending ramus/ condyle unit
(Tideman and Lee, 2006; Lee et al., 2008).
• The endoprosthesis is a metallic device fixed into
the medullary space of the mandibular stump post-
resection. Initial designs had stems cemented into
the medullary space with bone cements
Conclusion
• Although there are many options for mandibular

reconstruction, vascularized bone flaps are unique in
that they permit reconstruction of the oromandibular
complex even though the recipient bed is often
compromised by salivary contamination and prior
irradiation.
• In contrast to nonvascularized bone grafts, vascularized
bone grafts remain capable of healing to the adjacent
native mandible and eventually withstand the loading
forces associated with mastication.
Thank you

Functional Mandibular Reconstruction With Double-Barrel Fibular Flap and Primary Osseointegrated Dental Implants Improve Facial Esthetic Outcome

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journal club

JSS ACADEMY OF HIGHER EDUCATION & RESEARCH

FUNCTIONAL MANDIBULAR RECONSTRUCTION

impairment of basic oral functions

to achieve facial and dental rehabilitation

because the width

Materials and Methods

From 2012 to 2015

2 M/36 ameloblastoma 35-37 3 no

1 M/30 ossifying fibroma 34-37 3 no

2 M/38 ossifying fibroma 36-37 2 no

3 F/33 ameloblastoma 35-37 + ramus 3 no

4 F/24 ameloblastoma 47-45 3 no

5 F/16 ameloblastoma 47-44 3 no

6 M/29 ameloblastoma 47-46 2 no

7 F/24 ameloblastoma 35-37 + ramus 3 no

8 F/22 ameloblastoma 34-37 3 no

9 M/42 ameloblastoma 34-37 2 no

10 M/46 ameloblastoma 47-44 3 no

11 M/40 squamous 47-43 3 yes

12 06/01/2020 F/38 osteosarcoma 34-37 + ramus

the defect length of the mandibular body was longer

the height of the DBFF exceeded the height of the

patients also had severe systemic diseases, such as

3) hypertension and diabetes;

4) patients preferred to simplify the surgical procedure

• All 26 fibula grafts and associated skin paddles (when present) survived

• For patients in group A , the postoperative facial

12 excellent (4) 10 12 .100

Group Mesial Distal Mesial Distal Mesial Distal

A 0.51 ± 0.54 0.48 ± 0.55 0.60 ± 0.42 0.57 ± 0.39 0.74 ± 0.36 0.73 ± 0.34

B 0.50 ± 0.37 0.53 ± 0.40 0.63 ± 0.36 0.64 ± 0.48 0.75 ± 0.41 0.76 ± 0.32

1. Bone transplantation into healthy tissues.

• Quality of the soft tissue environment (the

• a novel method for alloplastic mandible

• Although there are many options for mandibular

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