The Algorithm For Reconstruction of Mandibular Defects

Our experience clearly indicates that osseous free flaps have a very high success rate and should be used for most primary mandible reconstructions. The functional and esthetic outcomes are good-to-excellent for the majority of patients. The algorithm for flap selection is driven principally by the extent and site of bone and skin/soft tissue loss. (Figure 19-7). The fibula donor site should be the first choice for a vast majority of patients, particularly those with large bony defects requiring anterior reconstruction and multiple osteotomies. The radius is sometimes a better alternative for the rare patient that requires a large quantity of thin pliable skin for intraoral lining and/or who has a small lateral bony defect (though donor site morbidity is high). Patients with extensive skin and soft-tissue defects with minimal bone defects that do not require osteotomy tend to be the best candidates for the scapula flap. The ileum is recommended only when no other options are available. Osteointegra-tion is recommended in cases where bone is not irradiated and particularly for patients with anterior defects.

Scapular Soft Tissue Flap

Figure 19-6. A, Typical intraoral view of anterior vestibule reconstructed with skin island of fibula flap. B, C, and D, Panoramic roentgenographs of reconstructed mandible in the same patient. B, Titanium miniplates and screws remain in place for 6 months, to allow for bony union. C, The hardware is then removed in the region of the mandible where implants will be placed. Note excellent bony union of the fibular segments. D, Six osseointegrated implants have been inserted into the fibula. E Intraoral view of dental restoration after fixation of a permanent prosthesis to the implants.

Figure 19-6. A, Typical intraoral view of anterior vestibule reconstructed with skin island of fibula flap. B, C, and D, Panoramic roentgenographs of reconstructed mandible in the same patient. B, Titanium miniplates and screws remain in place for 6 months, to allow for bony union. C, The hardware is then removed in the region of the mandible where implants will be placed. Note excellent bony union of the fibular segments. D, Six osseointegrated implants have been inserted into the fibula. E Intraoral view of dental restoration after fixation of a permanent prosthesis to the implants.

Scapular Soft Tissue Flap
B

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Scapular Soft Tissue Flap

Bone defect

Skin, soft-tissue defect

Short, ascending ramus ± condyle

+ Large soft tissue + External skin

Flap

Scapula

Short lateral segment

Long segment or multiple osteotomies (hemimandible, central segment)

+ Large intraoral lining

+ Small/moderate intraoral or external skin

Radius

Fibula

+ Extensive intraoral and external skin

Fibula + forearm

Figure 19-7. Algorithm for reconstruction of mandibular defects using osteocutaneous free flaps.

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