Mandibular Reconstruction
after Head and Neck Tumor
Treatment, a Systematic Review
Jonas Emanuelsson
Jonathan Viblom
Master thesis 30 ECTS
MSc. Dental Surgery
Dept. Oral and Maxillofacial Surgery
Tutor: Mats Sjöström, Linda Pettersson
ABSTRACT
Objectives
This systematic literature review examined the literature about mandibular
reconstruction after cancer treatment with segmental resection, with focus on
success rate for the reconstruction, patient survival rate, dental rehabilitation
and how this effect the patients QOL, oral function and aesthetics.
Material and methods
A search was performed in Pubmed, a database of scientific articles, based on
four keywords (Mandibular, Reconstruction, Cancer, Segmental). After
screening using our inclusion and exclusion criteria’s, 89 articles were chosen.
A data base in excel was established to sort the information we needed for our
study.
Results
Sixty out of the 89 included articles were in full text and 29 were abstracts. The
median year of publication was 2006 (range 1977 to 2013). A total of 5629
patients were included in the literature review. Of these, 3783 patients were
included in articles that had categorized by gender and we found that 65.4%
were males and 34.6% were females.
The total success rate for reconstruction therapies including plate, vascularizedand non-vascularized bone transplant was 86.4% in 3219 patients (range from
70.4% in the plate group to 92.3% in the non-vascular group). The mean follow
up time were 46.9 mounts (range 0.2 – 216 months).
Conclusion
This literature review indicates a focus on success rates for different kinds of
reconstruction techniques. The overall success rate for non- and vascularized
bone reconstruction techniques were very high compared to plate
reconstruction only. To evaluate patient-related factors such as function,
aesthetics and quality of life, further prospective randomized studies is required.
-2-
INTRODUCTION
Primary tumors
The mandible is primarily made of bone which is a highly specialized form of
connective tissue. Tumors that originate from connective tissue are called
sarcomas (Mosby’s Dental Dictionary, 2nd edition (2008)). Several variants of
sarcoma exist but the most common variants are osteosarcoma which
constitutes about 35% of sarcoma cases followed by chondrosarcoma (25.8%),
Ewing´s sarcoma (16%) and chordoma (8.4%). (Dorfman et al., 1995; Coleman
et al., 2012).
The incidence and ratio between these four variants of sarcomas varies in
different age groups. Chondrosarcoma is the most common variant in adults
over the age of 30 years while Ewing’s sarcoma and Osteosarcoma accounts
for more than 90% of the cases in the age group of 0-9 years, and
Osteosarcoma is the most common variant in the age group of 10-19 years.
The primary site for sarcoma differs between the age groups. The proportion of
sarcomas originating in the skull and face is highest in patients between 30-59
years of age. Most cases of osteosarcoma affecting the face and skull area is
seen in persons between 30-39 years of age (Francis et al., 2012).
Benignant bone tumors affecting the mandible does not spread to other tissues
and usually have a relatively good prognosis. Among the benign tumors
affecting the mandible is mainly odontomas and ameloblastomas. (Regezi et al.,
1978).
Secondary tumors
The most common secondary tumors affecting the mandibular bone originate
from epidermoid cells which form the tissue types in the floor of the mouth and
gingiva. Cancer originated from this tissue is for example squamous cell
carcinoma. The most common secondary tumors caused by malignancies
originating outside the head and neck area are spread by metastasis from
3
primary tumors in the breast (women) and lung tissue (men) (Weber et al.
2003). Other primary malignancies that can cause metastasis in the mandible
are adrenal gland, colon, genital, thyroid tissues for women and prostate,
kidney, bone and adrenal gland for men. Most common site for secondary tumor
of the mandible is posteriorly to the wedge starting in the molar region. The
mean age for patients with metastasis in the mandible is 50 to 60 years (N.
Zachariades., 1989; Hirshberg et al., 1994; Jham et al., 2011).
Treatment alternatives
When a patient is afflicted by malignancies in the mandible, you have to plan
the treatment in order to cure the patient. The normal treatment alternatives are
irradiation, chemotherapy and/or resection. This review will focus on the
resection therapy but it will also include the irradiation therapy as these
treatments often are given together (Bak et al., 2010). There are two kinds of
resections of the mandible. The first type is called a “rim resection” a technique
where you leave a base of the mandible meaning that you don’t split the
mandible in sections. The other type of resection is based on a technique where
you split the mandible in to sections during cancer removal, called segmental
resection (Rogers et al., 2004).
One decision is if the treatment should include irradiation therapy and if the
irradiation therapy should be performed before or after resection of the
mandible. However, the literature is inconclusive according the result if the
radiation is given before or after surgery (Choi et al., 2004).
A major side effect of irradiation therapy is the risk for osteoradionecrosis
(ORN). Research on ORN has recently undergone a “shift” from the thought
that the tissue is hypo-cellular, hypo-vascular and hypo-oxygen. Today it is
considered that ORN is caused by the cell damage in the bone due to an acute
inflammation, free radicals and a chronic activation of fibroblasts triggered by a
series of growth hormones. This side effects results in a tissue more vulnerable
to trauma with reduced capacity for healing. For example, dental extractions
performed after irradiation results in higher risk for complications (Koga et al
2008). Previously ORN was treated by a hyperbaric chamber where the high
4
pressure and the high oxygen content of the air would re-oxygenate the tissue
and improve the conditions for healing (Teng and Futran, 2005). Today, the
treatment of ORN with hyperbaric oxygen is questioned. Clayman (1997) have
shown low incidence (5%) of ORN following careful dental extraction on patients
post radiation therapy, without the use of hyperbaric oxygen treatment. New
articles describe the pathogenesis of ORN as radiation-induced fibrosis (Lyons
et al., 2008).
The main goal with mandibular reconstruction is to restore the patient’s function
with focus on speech, range of motion, aesthetics, chewing, swallowing, and
Quality of life (QOL). With today’s techniques the surgeons can restore this to
an acceptable level but there is room for improvement (Hidalgo and Pusic,
2002).
Previous, the main goal of the resection and reconstruction were made in order
to make the patient survive the malignancy, resulting in a suboptimal esthetic
result. Reconstruction was generally made with two methods. The first method
was based on a reconstructing rail or mesh, made of metal (titanium or stainless
steel) filled with bone grafts taken from the hip, or hydroxyapatite (Dumbach et
al., 1994). The second method included endogenous non vascular bone grafts.
The deciding factor in choosing between treatments was mainly patient’s life
expectancy (Kanchanarak et al., 1999). These methods have different treatment
outcomes according to graft survival.
Today’s surgical techniques have progressed further partly in the planning of the
operation with MRI, 3D models, titanium plates and better instruments resulting
in an improving treatment outcome. Today the surgeons uses free bone grafts
taken from the fibula, iliac crest or scapula and transplants it with both the skin,
muscles and bones with its own vascular supply and anastomose it into the
reception site. The selection of donor site is based on access, surgery
technicalities, height in the restored mandible, how much bone and soft tissue
that is needed and so on (Bak et al., 2010).
5
Occlusal rehabilitation is based on factors such as facial height, lip support and
aesthetics. One important factor for the choice of reconstruction is if the
occlusion should be with removable prosthesis or dental implants (Schrag et al.,
2006).
The most common postoperative occlusal rehabilitation for patients undergoing
mandibular reconstruction is dental implants. This technique is fairly new and its
technology have improved over the years and today the success rate is around
85-90% in terms of survival of the implants (Jacobsen et al., 2012).
Complications
The mandible is a very important part in the facial structure. It is not only the
aesthetics that is suffering from the resection and reconstruction, but also the
function. The patient can have functional problems with swallowing, speech and
chewing after the resection and reconstruction (Hidalgo and Pusic, 2002). The
reconstruction itself can be affected with graft detachment, clots and hematoma.
An inevitable complication is numbness, because of the removal of n. alveolaris
inferior during the resection. To improve the sensory function, transplanting
nerve in to the resected area, can regain function of the nerve (Shibahara et al.,
1999; Gennaro et al., 2013).
The literature about the prognosis of mandible reconstruction is comprehensive
but definitive prognosis is difficult to predict (Boyd et al., 1995; Hidalgo and
Pusic, 2002; Virgin et al., 2010). The literature reports about different
techniques, different diagnosis of the malignancy and different measurements
for success. The main focus in the literature is success rate of flap survival
while factors descriebing function, estetic and QOL are neglected.
The aim of this study is to investigate and evaluate the literature which
discusses mandibular reconstruction after cancer treatment including segmental
resection of the mandible.
6
MATERIALS AND METHODS
Objectives for literature review
The aim of this study is to investigate and evaluate the literature describing
mandibular reconstruction after cancer treatment including segmental resection
of the mandible.
Search strategy
A systematic literature review based on four keywords (Mandibular,
Reconstruction, Cancer, Segmental) was performed in PubMed, a database of
scientific articles, October 21, 2013 (See Table 1: Search strategy)
The articles were then entered into Endnote in order to get an easy overview.
After manual review of the abstracts we sorted out the articles meeting our
exclusion/inclusion criteria. (See Figure 1: Process of selection)
Inclusion criteria
Published and reviewed examined human studies on patients who have
undergone segmental resection of the mandible as part of treatment of cancer
in the head and neck area. The studies needed to be published in scientific
journals with a review system to be included. Articles (at least the abstracts)
must be published in English.
Exclusion criteria
Case reports and articles with less than 10 patients, patients with known
comorbidity, ex. HIV and Diabetes and Rim resections.
Data extraction
One hundred and eight of the 208 articles did not fulfill the inclusion criteria and
were excluded. The 100 remaining articles were reviewed by the two reviewers
independently. During the review, data extraction was performed and data was
placed in a database created in Excel. Data about function, aesthetics and
7
quality of life was excluded in table 2, due to a very large amount of information
that was not suitable to present in that format.
We extracted information out of the articles using the following variables:
Author, article type (full text or abstract), publication year, number of patients,
average age, sex, type of operation, reconstruction technique (Plate,
Vascularized bone graft or non-vascularized bone graft), origin of bone grafts,
size of the resection, success rate of reconstruction, postop follow-up, survival
rate, dental rehabilitation, aesthetics, function, QOL, and radiation or not. If
information could not be contained in an article it was not included in the
summation of the current variable. Along with the data extraction and full text
review, a second exclusion was done and additionally, 11 articles were excluded
as these did not meet the criteria. All variables where later summarized.
Ethical consideration
Since this is a literature study, all data will be reported anonymously. There is no
possibility for personal identification which excludes ethical problems.
RESULTS
Literature review
Out of the 89 included articles, 60 were in full text and 29 were abstracts. The
large numbers of abstracts were the result of articles without full text in English
or articles published back in time before the start of publications on the internet.
The median year of publication was 2006 (range 1977 – 2013).
A total of 5629 patients were included in the study. Of these, 3783 patients were
included in articles that had categorized by gender and we found that 65.4%
were males and 34.6% were females (mean age 52.6 years, range 5 month’s –
88 years of age).
8
The overall success rate (the number of reconstructions with no or minor
complications, that did not need further surgery or to be redesigned) for
reconstruction in the groups; vascular, non-vascular and plate were extracted
from 62 unique articles. The success rate was 86.4% in 3219 patients, with a
range from 70.4% in the plate group to 92.3% in the non-vascular group. Of the
articles included; 59 articles published data about follow up time. The mean
follow up time were 46.9 months (range 0.2 – 216 months).
Size and position of the segmental resection of the mandible
Of the included articles; 51 published data about mandibular resection. Two
perspectives on this subject can be recognized. While some of the included
articles report the size of the resection, other articles talk about the location of
the resection. Twenty articles published data about the size and 31 articles
published data about the site of the resection. Three of the included articles
published data of both the size and location of the resection.
The size of resection ranged from 2 to 26 cm with a mean value of
approximately 8.1 cm. The mean values ranged from 6.7 cm in the first quartile
to 8.9 cm in the last quartile, ie half of the participants had a reconstruction size
comprising between these two values.
The site of the resection varies depending on the location of the cancer, but is
also related to the extent of the tumour. The extent of the resection is dependent
on type and size of the malignancy and the approach of the surgeon. Based on
data extracted from the 31 articles (2029 patients), the most commonly found
mandibular site of resection is the lateral part of the mandible with 43.1% of the
cases. Next comes the anterior-lateral part (16.1%) followed by the anteriorlateral-posterior (11.4%) site of removal. The fourth most common site of
resection is the removal of the anterior part of the mandible which was carried
out in 9.3% of the cases. A resection of the mandibular condyle was performed
in 7.2% of cases. A very small proportion (0.1%) was reported to have the
resection localized lateral-posterior.
9
Reconstruction
After segmental resection of the mandible, a reconstruction of the resected area
is usually performed. Our statistics about the three different reconstruction
methods can be viewed in Tabel 2: Results of reconstruction.
Vascular reconstruction
Of the articles included; 15 unique articles explored the outcome of vascular
reconstruction (some articles investigate 2 or more techniques).
A total of 641 patients were reconstructed with a success rate of 90.6%, with a
range from 83.3% to 94.3%. The most common graft site were Fibula, used in
393 reconstructions. Fibula was also the most publicized graft site with 11
articles. The most successful graft site were Scapula with a success rate of
94.3%.
Non vascular reconstruction
Of the articles included; 31 unique articles explored the outcome of nonvascular reconstruction (some articles investigate two or more techniques).
A total of 1764 patients were reconstructed with a success rate of 92.3%, with a
range from 89.5% to 100%. The most common graft site in non-vascular
reconstruction was fibula, used in 1195 reconstructions. Fibula was also the
most publicized graft site with 28 articles. The most successful graft site was
Ilium with 100%.
Plate
Of the articles included; 16 unique articles explored the outcome of plate
reconstruction. All plates that did not include a graft of bone were included in the
group plate. A total of 814 patients were reconstructed with a success rate of
70.4%.
Dental rehabilitation
Of the articles included; 29 articles reported about dental rehabilitation.
10
A total of 1425 patients were included. Of these patients, 467 received dental
rehabilitation with removable prosthesis or implants. Implants were the most
common treatment option with 87.6% of the 467 patients.
Irradiation
Of the articles included; 38 articles discussed radiation as an adjuvant therapy
to surgery in the treatment of cancer of the mandible. 62.4%, or 1605 of a total
of 2573 patients received radiotherapy as adjuvant therapy to surgery. Of these
1605, 500 (31%) patients received radiotherapy preoperatively, while 415 (26%)
received radiation therapy postoperatively. For the other 690 (42.9%) patients
who received radiotherapy the time was not specified including a very small
proportion (n = 12, ie, 0.8%) who received radiotherapy, both preoperatively and
postoperatively.
Patient survival rate
We sorted the material from the articles and created three groups. First group; 1
year survival or less; five articles reported a total of 566 patients with a survival
rate of 86.0% (range 74-95%). The patient´s cancer types were: 519 malign
tumors, 0 benign tumors and 47 were undefined.
Second group; 2-4 years of survival; 19 articles reported a total of 1524 patients
with a survival rate of 70.4% (range 50-100%). The patient’s cancer types were:
1033 malign tumors, 138 benign tumors and 283 were undefined.
Third group: 5 years of survival or more; 14 articles reported a total of 1089
patients with a survival rate of 71.8% (range 40-100%). The patient´s cancer
types were: 674 malign tumors, 119 benign tumors and 366 were undefined.
Aesthetics
Of the articles included; 22 articles investigated the aesthetic outcome of
restorations after the treatment of cancer. Thirteen articles featured useful
statistical data with quite varying results regarding the perceived aesthetic level
11
of the patients. This is exemplified by Young et al. (2007) reporting less than
30% of patients have gained an acceptable appearance compared with other
studies in which over 95% were considered to have gained an acceptable
appearance (Patel et al., 1996; Politi et al., 2012).
Function
Of the articles included; 30 articles investigated the functional outcome of
restorations after treatment. Fourteen of these articles presented statistics
about the subject.
The oral function can include many areas, such as the ability to speak and eat.
Three of the 14 articles examined the proportion of patients who had received a
normalized speaking ability. These articles showed that approximately 75% of
patients regained normal speech ability (range 36%-100%).
Nine of the 14 articles examined the proportion of patients who had received a
normalized eating ability, which includes the ability to chew and swallow.
Only seven of these articles presented statistics on both of these functions. Two
of the articles presented statistics only about the ability to chew. The studies
show that half of the patients regained the ability to swallow (58.8%, range 25.8
-81%) and chew (53.1% 25.4 – 81%).
Limitations in the ability to eat mean that the food must be modified in order to
be eaten. Seven of articles have looked at the type of food that patients can eat.
In these studies it can be seen that the patients were divided into four different
groups, those who can eat solid / regular food, those who tolerate soft foods,
those who can only eat liquid food, and those who are dependent on tube
feeding. These studies showed that almost half of the patients (48.6%) regained
the ability to eat a regular diet (Range 25.8 – 65%) and slightly fewer than half
of the patients tolerated soft food (42.9%, range 22.7 – 94%). Ten percent of the
patients could only ingestion liquid food (range 0.9 -27.3%) and 9.8% were
dependent on tube feeding (range 5 -15.9%).
12
Quality of life
Of the articles included; four articles investigated the quality of life (QOL) after
cancer treatment. Factors examined included the extent to which the mental
and physical well-being had been affected by the cancer treatment. Young et al.
(2007) came to the following; of their patient population (26 patients), 58%
stated that their wellbeing was good. Sixty five percent reported that their mood
was positive and 77% stated that they did not feel physical pain. Boffano et al.
(2011) indicated that 70% of their patients (total 10 patients) had retained the
sensory function of the nervus alveolaris inferior. Dholam et al. (2011) did a
statistical analysis of speech, swallowing parameters and quality of life and
found no significant difference because of the paucity of numbers. Garrett, et al.
(2006) looked at how facial appearance affected the social life and came up
with the following conclusions; the patients satisfaction with facial appearance
was approximately 65% both prior to and after surgery. On the question about if
appearance affect social life, approx. 85% said this was a fact prior to resection.
Postoperatively approximately 75% stated this as a fact.
DISCUSSION
This review examined the literature about mandibular reconstruction after
cancer treatment with segmental resection. Main focus has been to examine
success rate for the reconstructions, patient survival rate, dental rehabilitation
and how this effects the patients QOL, oral function and aesthetics.
Of the 89 articles, 60 articles were in full text. In the remaining 29 articles, only
the abstract could be reviewed due to difficulties in interpreting these on their
original language. Though we cannot evaluate the scientific level of evidence in
these articles, all of the articles have been published in scientific journals and
therefore they have been controlled by a review group. We have chosen to trust
the validity of these review groups, due to the fact that their function is to
evaluate the validity of articles before publication in reputable scientific journals.
We found that there is no major difference in success rate between vascularized
13
bone vs. non- vascularized bone transplants for method of reconstruction. Our
findings with a success rate of 90-92% for bone transplants lies roughly in line
with other research done on the subject. However, recent studies have shown
success rates up to 96% on mandibular reconstructions (Virgin et al., 2010). We
found that the reconstruction method using only plate had a lower frequency of
success than the other two methods using bone transplant. Why plate have a
lower success rate could be explained by the risk of penetration through soft
tissue due to high friction between plate and the mucosa. If radiation is given, it
creates fibrosis making the soft tissue even more sensible. Another known
reason for failure is plate fracture during heavy loading. The plate technique
was more common back in time. Today it is mostly used in patients with spread
cancer with bad prognosis and who have a lateral defect of the mandible. The
plate reconstruction is less invasive for the patient (less blood loss, shorter time
in surgery), why it´s still used in this patient group (Miyamoto et al., 2012).
Some of the patients don’t get any reconstructive therapy at all, mostly due to
bad tumor prognosis.
Fibula is the most common donor site in both the vascularized and nonvascularized groups. The use of fibula over other bone transplants can be
explained by; easy access and the possibility to reconstruct major resections
due to its length, although the use of Iliac and other donor sites is increasing.
The disadvantage of fibula against Iliac, which is the second most common
donor site, is that Iliac have a more suitable height that can better facilitates
implant placement.
Although we have a large patient material, interpretation of the success rate
should be done with caution because the follow up time varies widely between
the studies, from one week to 216 months.
The average age of the 5629 patients included in our study is 52.6 years. The
age variation is however very great. In some studies exists individuals younger
than a year old, while in other studies exists individuals who are nearly ninety
14
years old. This large variation in age is explained by; the fact that the material
studied is extensive and includes many different types of tumors, which is age
related. As an example, we have studies on children (Benoit et al., 2013) where
the mean age was eight years.
Another study, Boffano et al. (2011) with low average age of the patients, had
odontogenic myxoma as diagnose and this tumor mostly affects young adults
(Barros et al., 1969). Another study (Puxedduet et al., 2004) had a much higher
average age of the participants with a mean age of 62.5 years. All participants
in this study had been diagnosed with squamous cell carcinoma, a form of
tumor that usually affects people over the age of 50 (Chen et al., 1999).
In our study we concluded that 65.4% were males and 34.6% were females.
The fact that the gender distribution looks like this in our study can be supported
by the fact that oral cancer affects more men than women. Rosenquist et al.
(2005) showed that men were over-represented when a total of 91 men,
compared with 41 women were subjected to oral and oropharyngeal squamous
cell carcinoma. This corresponds to 68.9% men and 31.1% women, which is
close to the gender distribution we have seen in our study.
In our study, we have chosen not to include articles in which co-morbidity, such
as Diabetes Mellitus noted to occur in the population studied. We have chosen
to do so because this can be assumed to affect the statistics relating the
survival of patients or the success rate of free flaps and implants. We can,
however not, ignore that there are probably individuals in the studies we have
selected, who have other diseases as well, such as Diabetes Mellitus. This is a
relatively common disease that also appears to increase the risk of oral cancer.
Diabetes can cause inflammatory lesions in the oral mucosa. A correlation
between oral lesions in diabetic patients and a higher risk for premalignant
status is supported by studies, for example, a study of Ujpál et al. (2004) and
Goutzanis et al. (2007). The probability that Diabetes Mellitus is represented
among the individuals in our study is therefore quite high.
15
The degree of malignancy of the tumors shows great diversity in our review.
This is shown in studies discussing the use of radiation therapy as part of
treatment and the size of the mandibular resection performed.
Puxeddu et al. (2004) reported that all participants had squamous cell
carcinoma, the size of the resection was 6.9 cm (range 5.2 to 9 cm), and the
survival rate of the patients was 50% at study end. The proportion that received
adjuvant radiation therapy in this study was 75%. On the other hand, Chaine et
al. (2009) reported a study where all participants had giant mandibular
ameloblastoma. The size of the resection was 12 cm (range 7-16 cm) and the
survival rate was 100% at study end. If radiotherapy was a part of the therapy
was not specified by Chaine et al. However, the patients were probably not
given radiotherapy, as this treatment normally is not used for this type of cancer
(Rosenstein et al., 2001).
The results we found on survival rate were better then we expected but we have
a sprawling patient materiel with various tumors. For example Lindqvist et al.
(1992) reported that patient survival was 20% at five year follow up for patients
with malign cancers stage III or IV. We found that studies with longer follow up
tended to have a higher proportion of patients with benign tumors, which could
explain the good survival rates in these groups. The range between the studies
that presented the best vs. the worst survival rates varied greatly in the groups.
In our data, some studies have been included although their main objective was
to check on implant survival. We believe that these articles probably have
chosen “healthy patients” for their study which results in a much higher survival
rate compared to a article that have a “random” group of reconstructed patients.
Our findings show that dental rehabilitation is not common. The articles that
brought up the subject included a total of 1425 patients. Only one third of these
patients received dental rehabilitation. The reason that so few individuals chose,
for example dental implant treatment can be explained by the fact, it´s a very
expensive treatment that is not state-subsidized in those parts of the world
where these studies where made (Zitzmann et al., 2005). Oral cancer is also
16
more common in people with low socioeconomic status (Warnakulasuriya,
2009). In these patients, it can be assumed that the ability to pay for expensive
dental restorations are lower than average for other patient categories which
explains why so few chose this treatment option. Another explanation for the
low percentage of patients who received implants may be to the fact that
implant treatment is invasive and time consuming.
Regarding QOL and aesthetics we found that more research needs to be done.
These topics are hard to evaluate because of its nature. There should also be
some kind of standardized question formulas and/or indexes so that comparison
between studies can be done. This kind of data should originate from the
patient and not be evaluated by the surgeon. Function is easier to measure in
some cases for example when you measure the ability eating solid food vs. tube
feeding dependent. It is harder to measure the ability to be understood through
speech, because it depends on the ability of the receiver to understand the
conversation. In our study we found that most of the patients regained their
ability to speech but the ability to chew and swallow was more affected, the
latter could be explained by the loss of teeth and loss of masticatory muscles
after segmental resection of the mandible. To strengthen this thesis more
studies needs to be done.
A small number of articles included in this review investigated the opinion about
aesthetic results after mandibular reconstruction. Our study indicates that the
vast majority of patients are satisfied with the aesthetic results after mandibular
reconstruction. However, the numbers of patients are too small to draw any
general conclusions regarding this subject.
ACKNOWLEDGEMENTS
We would like to express our gratitude’s to the following people. A special
thanks to our tutors Mats Sjöström and Linda Pettersson for their help and
guidance during the process of this study. We would also like to thank Lina
Holmström for helping us retrieving full-text studies not available on the internet.
17
REFERENCES
Full-text articles and abstracts (shown in square brackets) from articles
published in journals.
[Abler A, Roser M, Weingart D (2005). On the indications for and morbidity of
segmental resection of the mandible for squamous cell carcinoma in the lower
oral cavity. Mund Kiefer Gesichtschir 9(3):137-142.]
Adekeye EO (1980). Ameloblastoma of the jaws: a survey of 109 Nigerian
patients. J Oral Surg 38(1):36-41.
Anthony JP, Foster RD, Kaplan MJ, Singer MI, Pogrel MA (1997). Fibular free
flap reconstruction of the "true" lateral mandibular defect. Ann Plast Surg
38(2):137-146.
Aramany MA, Myers EN (1977). Intermaxillary fixation following mandibular
resection. J Prosthet Dent 37(4):437-444.
Arden RL, Rachel JD, Marks SC, Dang K (1999). Volume-length impact of
lateral jaw resections on complication rates. Arch Otolaryngol Head Neck Surg
125(1):68-72.
Aydin A, Emekli U, Erer M, Hafiz G (2004). Fibula free flap for mandible
reconstruction. Kulak Burun Bogaz Ihtis Derg 13(3-4):62-66.
Bak M, Jacobson AS, Buchbinder D, Urken ML (2010). Contemporary
reconstruction of the mandible. Oral Oncol 46(2):71-76.
[Barnard NA, Vaughan ED (1991). Osteosynthetic titanium mini-plate fixation of
composite radial forearm flaps in mandibular reconstruction. J Craniomaxillofac
Surg 19(6):243-248.]
18
Barros, R.E., Dominguez, F.V., Cabrini, R.L. Myxoma of the jaws(1969) Oral
Surgery, Oral Medicine, Oral Pathology, 27 (2), pp. 225-236.
Baumann DP, Yu P, Hanasono MM, Skoracki RJ (2011). Free flap
reconstruction of osteoradionecrosis of the mandible: a 10-year review and
defect classification. Head Neck 33(6):800-807.
Beecroft WA, Sako K, Razack MS, Shedd DP (1982). Mandible preservation in
the treatment of cancer of the floor of the mouth. J Surg Oncol 19(3):171-175.
Benoit MM, Vargas SO, Bhattacharyya N, McGill TA, Robson CD, Ferraro N et
al. (2013). The presentation and management of mandibular tumors in the
pediatric population. Laryngoscope. 123(8):2035-2042.
[Bianchi B, Ferri A, Ferrari S, Leporati M, Copelli C, Ferri T et al. (2013).
Mandibular resection and reconstruction in the management of extensive
ameloblastoma. J Oral Maxillofac Surg 71(3):528-537.]
Bilodeau EA, Chiosea S (2011). Oral squamous cell carcinoma with mandibular
bone invasion: intraoperative evaluation of bone margins by routine frozen
section. Head Neck Pathol 5(3):216-220.
Blackwell KE, Buchbinder D, Urken ML (1996). Lateral mandibular
reconstruction using soft-tissue free flaps and plates. Arch Otolaryngol Head
Neck Surg 122(6):672-678.
Blackwell KE, Lacombe V (1999). The bridging lateral mandibular
reconstruction plate revisited. Arch Otolaryngol Head Neck Surg 125(9):988993.
Boffano P, Gallesio C, Barreca A, Bianchi FA, Garzino-Demo P, Roccia F
(2011a). Surgical treatment of odontogenic myxoma. J Craniofac Surg
19
22(3):982-987.
Boffano P, Viterbo S, Barreca A, Berrone S (2011b). Pathologic mandibular
fracture as the presenting manifestation of multiple myeloma. J Craniofac Surg
22(4):1312-1315.
[Boyd JB, Mulholland RS, Davidson J, Gullane PJ, Rotstein LE, Brown DH et al.
(1995). The free flap and plate in oromandibular reconstruction: long-term
review and indications. Plast Reconstr Surg 95(6):1018-1028.]
Brown JS, Kalavrezos N, D'Souza J, Lowe D, Magennis P, Woolgar JA (2002).
Factors that influence the method of mandibular resection in the management
of oral squamous cell carcinoma. Br J Oral Maxillofac Surg 40(4):275-284.
Burkey BB, Hoffman HT, Baker SR, Thornton AF, McClatchey KD (1990).
Chondrosarcoma of the head and neck. Laryngoscope 100(12):1301-1305.
Cantu G, Bimbi G, Colombo S, Riccio S, Squadrelli M, Napoli U et al. (2009).
Autologous freeze-treated bone for mandibular reconstruction after malignant
tumor resection: a study of 72 patients. Am J Otolaryngol 30(6):383-389.
Carlson ER (2002). Disarticulation resections of the mandible: a prospective
review of 16 cases. J Oral Maxillofac Surg 60(2):176-181.
Chaine A, Pitak-Arnnop P, Dhanuthai K, Ruhin-Poncet B, Bertrand JC, Bertolus
C (2009). A treatment algorithm for managing giant mandibular ameloblastoma:
5-year experiences in a Paris university hospital. Eur J Surg Oncol 35(9):9991005.
[Chana JS, Chang YM, Wei FC, Shen YF, Chan CP, Lin HN et al. (2004).
Segmental mandibulectomy and immediate free fibula osteoseptocutaneous
flap reconstruction with endosteal implants: an ideal treatment method for
20
mandibular ameloblastoma. Plast Reconstr Surg 113(1):80-87.]
Chang SY, Huang JJ, Tsao CK, Nguyen A, Mittakanti K, Lin CY et al. (2010).
Does ischemia time affect the outcome of free fibula flaps for head and neck
reconstruction? A review of 116 cases. Plast Reconstr Surg 126(6):1988-1995.
Chang YM, Santamaria E, Wei FC, Chen HC, Chan CP, Shen YF et al. (1998).
Primary insertion of osseointegrated dental implants into fibula
osteoseptocutaneous free flap for mandible reconstruction. Plast Reconstr Surg
102(3):680-688.
Chen YK, H.C. Huang, L.M. Lin et al. Primary oral squamous cell carcinoma: An
analysis of 703 cases in southern Taiwan Oral Oncol, 35 (1999), p. 173
Choi, S., D. L. Schwartz, D. G. Farwell, M. Austin-Seymour, and N. Futran,2004,
Radiation therapy does not impact local complication rates after free flap
reconstruction for head and neck cancer: Arch Otolaryngol Head Neck Surg, v.
130, p. 1308-12.7
Coleman, H. and S. Sukumar, 2012, Malignant tumours of the jaws: SADJ, v.
67, p. 578-80.
Clayman L. Clinical controversies in oral and maxillofacial surgery: part two.
Management of dental extractions in irradiated jaws: a protocol without
hyperbaric oxygen therapy. J Oral Maxillofac Surg 1997; 55:275-281
Cordeiro PG, Disa JJ, Hidalgo DA, Hu QY (1999). Reconstruction of the
mandible with osseous free flaps: a 10-year experience with 150 consecutive
patients. Plast Reconstr Surg 104(5):1314-1320.
Dholam KP, Bachher GK, Yadav PS, Quazi GA, Pusalkar HA (2011).
Assessment of quality of life after implant-retained prosthetically reconstructed
21
maxillae and mandibles postcancer treatments. Implant Dent 20(1):85-94.
Disa JJ, Winters RM, Hidalgo DA (1997). Long-term evaluation of bone mass in
free fibula flap mandible reconstruction. Am J Surg 174(5):503-506.
[Disa JJ, Hidalgo DA, Cordeiro PG, Winters RM, Thaler H (1999). Evaluation of
bone height in osseous free flap mandible reconstruction: an indirect measure
of bone mass. Plast Reconstr Surg 103(5):1371-1377.]
Dor P (1980). [Complications of post-irradiation radiotherapy mandibular
resection: problems of reconstruction (author's transl)]. Acta Chir Belg 79(1):2126.
Dorfman, H. D., and B. Czerniak, 1995, Bone cancers: Cancer, v. 75, p. 203-10
Dumbach, J., H. Rodemer, W. J. Spitzer, and E. W. Steinhäuser, 1994,
Mandibular reconstruction with cancellous bone, hydroxylapatite and titanium
mesh: J Craniomaxillofac Surg, v. 22, p. 151-5.
Ettl T, Driemel O, Dresp BV, Reichert TE, Reuther J, Pistner H (2010).
Feasibility of alloplastic mandibular reconstruction in patients following removal
of oral squamous cell carcinoma. J Craniomaxillofac Surg 38(5):350-354.
[Evans GR, Schusterman MA, Kroll SS, Miller MJ, Reece GP, Robb GL et al.
(1994). The radial forearm free flap for head and neck reconstruction: a review.
Am J Surg 168(5):446-450.]
Farwell DG, Kezirian EJ, Heydt JL, Yueh B, Futran ND (2006). Efficacy of small
reconstruction plates in vascularized bone graft mandibular reconstruction.
Head Neck 28(7):573-579.
22
Francis, M., and G Lawrence , 2012, Bone Sarcoma Incidence and Survival:
NCIN, R12, p. 2-13.
[Fujiki M, Miyamoto S, Sakuraba M, Nagamatsu S, Hayashi R (2013). A
comparison of perioperative complications following transfer of fibular and
scapular flaps for immediate mandibular reconstruction. J Plast Reconstr
Aesthet Surg 66(3):372-375.]
[Garrett N, Roumanas ED, Blackwell KE, Freymiller E, Abemayor E, Wong WK
et al. (2006). Efficacy of conventional and implant-supported mandibular
resection prostheses: study overview and treatment outcomes. J Prosthet Dent
96(1):13-24.]
Gennaro, P., G. Gabriele, M. Della Monaca, A. Facchini, and V. Mitro, 2013,
Mandibular nerve fascicular cross-face for sensitive recovery after
mandibulectomy: A new technique: J Plast Surg Hand Surg, v. 47, p. 228-31.
Goutzanis L, Vairaktaris E, Yapijakis C, Kavantzas, Nkenke E, Derka S,
Vassiliou S, Acil Y, Kessler P, Stavrianeas N, Perrea D, Donta I, Skandalakis P,
Patsouris E: Diabetes may increase risk for oral cancer through the insulin
receptor substrate-1 and focal adhesion kinase pathway. Oral Oncol 43:165–
173, 2007
Group CSoO-HaNSOS (2004). Osteogenic sarcoma of the mandible and
maxilla: a Canadian review (1980-2000). J Otolaryngol 33(3):139-144.
Hamaker RC, Singer MI, Shockley WW, Pugh N, Shidnia H (1983). Irradiated
mandibular autografts. Cancer 52(6):1017-1021.
[He Y, Zhang ZY, Zhu HG, Sader R, He J, Kovacs AF (2010). Free fibula
osteocutaneous flap for primary reconstruction of T3-T4 gingival carcinoma. J
23
Craniofac Surg 21(2):301-305.]
[Head C, Alam D, Sercarz JA, Lee JT, Rawnsley JD, Berke GS et al. (2003).
Microvascular flap reconstruction of the mandible: a comparison of bone grafts
and bridging plates for restoration of mandibular continuity. Otolaryngol Head
Neck Surg 129(1):48-54.]
[Heller KS, Dubner S, Keller A (1995). Long-term evaluation of patients
undergoing immediate mandibular reconstruction. Am J Surg 170(5):517-520.]
[Hidalgo DA (1989). Fibula free flap: a new method of mandible reconstruction.
Plast Reconstr Surg 84(1):71-79.]
Hidalgo, D. A., and A. L. Pusic, 2002, Free-flap mandibular reconstruction: a 10year follow-up study: Plast Reconstr Surg, v. 110, p. 438-49; discussion 450-1.
Hirshberg, A., P. Leibovich, and A. Buchner, 1994, Metastatic tumors to the
jawbones: analysis of 390 cases: J Oral Pathol Med, v. 23, p. 337-41.
Hundepool AC, Dumans AG, Hofer SO, Fokkens NJ, Rayat SS, van der Meij EH
et al. (2008). Rehabilitation after mandibular reconstruction with fibula free-flap:
clinical outcome and quality of life assessment. Int J Oral Maxillofac Surg
37(11):1009-1013.
Iino M, Fukuda M, Nagai H, Hamada Y, Yamada H, Nakaoka K et al. (2009).
Evaluation of 15 mandibular reconstructions with Dumbach Titan Mesh-System
and particulate cancellous bone and marrow harvested from bilateral posterior
ilia. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 107(4):e1-8.
Irjala H, Kinnunen I, Aitasalo K (2012). Mandibular reconstruction using free
bone flap after preoperative chemoradiation. Eur Arch Otorhinolaryngol
269(5):1513-1518.
24
[Jeng SF, Kuo YR, Wei FC, Su CY, Chien CY (2005). Reconstruction of
extensive composite mandibular defects with large lip involvement by using
double free flaps and fascia lata grafts for oral sphincters. Plast Reconstr Surg
115(7):1830-1836.]
Jacobsen, C., A. Kruse, H. T. Lübbers, R. Zwahlen, S. Studer, W. Zemann, B.
Seifert, and K. W. Grätz, 2012, Is Mandibular Reconstruction Using
Vascularized Fibula Flaps and Dental Implants a Reasonable Treatment?: Clin
Implant Dent Relat Res.
Jham, B., A. R. Salama, S. A. McClure, and R. A. Ord, 2011, Metastatic tumors
to the oral cavity: a clinical study of 18 cases: Head Neck Pathol, v. 5, p. 355-8.
[Ji T, Zhang CP (2006). A retrospective study of 541 cases with segmental
resection of mandible. Zhonghua Kou Qiang Yi Xue Za Zhi 41(12):705-708.]
Julieron M, Germain MA, Schwaab G, Margainaud JP, Salvan D, Marandas P et
al. (1996). Free bone flaps in esthetic and functional rehabilitation after
segmental mandibulectomy. Apropos of 38 cases. Ann Otolaryngol Chir
Cervicofac 113(6):353-358.
Kadota C, Sumita YI, Wang Y, Otomaru T, Mukohyama H, Fueki K et al. (2008).
Comparison of food mixing ability among mandibulectomy patients. J Oral
Rehabil 35(6):408-414.
Kanchanarak, C., P. Sittitrai, and R. Charoensil, 1999, Mandibular
reconstruction: free flap vs AO plate: J Med Assoc Thai, v. 82, p. 126-30.
[Kim PD, Blackwell KE (2007). Latissimus-serratus-rib free flap for
oromandibular and maxillary reconstruction. Arch Otolaryngol Head Neck Surg
133(8):791-795.]
25
[Knott PD, Suh JD, Nabili V, Sercarz JA, Head C, Abemayor E et al. (2007).
Evaluation of hardware-related complications in vascularized bone grafts with
locking mandibular reconstruction plate fixation. Arch Otolaryngol Head Neck
Surg 133(12):1302-1306.]
[Koch WM, Yoo GH, Goodstein ML, Eisele DW, Richtsmeier WJ, Price JC
(1994). Advantages of mandibular reconstruction with the titanium hollow screw
osseointegrating reconstruction plate (THORP). Laryngoscope 104(5 Pt 1):545552.]
Koga DH, Salvajoli JV, Alves FA (2008). Dental extractions and radiotherapy in
head and neck oncology: review of the literature. Oral Dis 14(1):40-44.
Kovács A, Kiss G, Fehér A, Borbély L, Roszik M (1994). Radial forearm flap in
maxillo-facial surgery. Acta Chir Hung 34(3-4):365-374.
[Kroll SS, Schusterman MA, Reece GP (1992). Costs and complications in
mandibular reconstruction. Ann Plast Surg 29(4):341-347.]
[Kudo K, Shoji M, Yokota M, Fujioka Y (1992). Evaluation of mandibular
reconstruction techniques following resection of malignant tumors in the oral
region. J Oral Maxillofac Surg 50(1):14-21.]
Li L, Blake F, Heiland M, Schmelzle R, Pohlenz P (2007). Long-term evaluation
after mandibular reconstruction with fibular grafts versus microsurgical fibular
flaps. J Oral Maxillofac Surg 65(2):281-286.
[Lindqvist C, Söderholm AL, Laine P, Paatsama J (1992). Rigid reconstruction
plates for immediate reconstruction following mandibular resection for malignant
tumors. J Oral Maxillofac Surg 50(11):1158-1163.]
26
Louis MY, Rame JP, De Raucourt D, Mayaleh HA (2010). Revascularized free
scapular flaps in mandibular reconstruction. Report of 93 cases (April 1997 October 2009). Rev Laryngol Otol Rhinol (Bord) 131(4-5):263-268.
Lyons, A., Ghazali, N (2008). Osteoradionecrosis of the jaws: current
understanding of its pathophysiology and treatment. Br J Oral Maxillofac Surg
46(8):653-660.
[Malata CM, McLean NR, Alvi R, McKiernan MV, Milner RH, Piggot TA (1997).
An evaluation of the Würzburg titanium miniplate osteosynthesis system for
mandibular fixation. Br J Plast Surg 50(1):26-32.]
Maurer P, Pistner H, Schubert J (2006). [Computer assisted chewing power in
patients with segmental resection of the mandible]. Mund Kiefer Gesichtschir
10(1):37-41.
[Millsopp L, Brandom L, Humphris G, Lowe D, Stat C, Rogers S (2006). Facial
appearance after operations for oral and oropharyngeal cancer: a comparison
of casenotes and patient-completed questionnaire. Br J Oral Maxillofac Surg
44(5):358-363.]
Miyamoto S, Sakuraba M, Nagamatsu S, Kamizono K, Hayashi R (2012).
Comparison of reconstruction plate and double flap for reconstruction of an
extensive mandibular defect. Microsurgery 32(6):452-457.
Obiechina AE, Ogunlade SO, Fasola AO, Arotiba JT (2003). Mandibular
segmental reconstruction with iliac crest. West Afr J Med 22(1):46-49.
[Okoturo E, Ogunbanjo O, Akinleye A, Bardi M (2011). Quality of life of patients
with segmental mandibular resection and immediate reconstruction with plates.
J Oral Maxillofac Surg 69(8):2253-2259.]
27
Patel SG, Deshmukh SP, Savant DN, Bhathena HM (1996). Comparative
evaluation of function after surgery for cancer of the alveolobuccal complex. J
Oral Maxillofac Surg 54(6):698-703; discussion 703-694.
[Pellini R, Mercante G, Spriano G (2012). Step-by-step mandibular
reconstruction with free fibula flap modelling. Acta Otorhinolaryngol Ital
32(6):405-409.]
[Politi M, Toro C (2012). Iliac flap versus fibula flap in mandibular reconstruction.
J Craniofac Surg 23(3):774-779.]
Puxeddu R, Ledda GP, Siotto P, Pirri S, Salis G, Pelagatti CL et al. (2004). Freeflap iliac crest in mandibular reconstruction following segmental
mandibulectomy for squamous cell carcinoma of the oral cavity. Eur Arch
Otorhinolaryngol 261(4):202-207.
Regezi JA, DA Kerr, RM Courtney Odontogenic tumors: an analysis of 706
casesJOralSurg,36(1978),pp.771–778
Rivas B, Carrillo JF, Granados M (2000). Oromandibular reconstruction for
oncologicalpurposes.AnnPlastSurg44(1):29-35.
Robey AB, Spann ML, McAuliff TM, Meza JL, Hollins RR, Johnson PJ (2008).
Comparison of miniplates and reconstruction plates in fibular flap reconstruction
of
the
mandible.
Plast
Reconstr
Surg
122(6):1733-1738.
Rogers SN, Devine J, Lowe D, Shokar P, Brown JS, Vaugman ED (2004).
Longitudinal health-related quality of life after mandibular resection for oral
cancer: a comparison between rim and segment. Head Neck 26(1):54-62.
28
Rosenstein T, MA Pogrel, RA Smith, JA. Regez.Cystic ameloblastoma-behavior
and treatment of 21 cases. J Oral Maxillofac Surg, 59 (2001), pp. 1311–1316.
Rosenquist K. Risk factors in oral and oropharyngeal squamous cell carcinoma:
a population-based case-control study in southern Sweden. Swed Dent J
Suppl2005; 179: 1–66.
Sarukawa S, Noguchi T, Oh-iwa I, Sunaga A, Uda H, Kusama M et al. (2012).
Bare bone graft with vascularised iliac crest for mandibular reconstruction. J
Craniomaxillofac. Surg. 40(1):61-66.
Schliephake H, Schmelzeisen R, Husstedt H, Schmidt-Wondera LU (1999).
Comparison of the late results of mandibular reconstruction using
nonvascularized or vascularized grafts and dental implants. J Oral Maxillofac
Surg 57(8):944-950; discussion 950-941.
Schrag, C., Y. M. Chang, C. Y. Tsai, and F. C. Wei, 2006, Complete rehabilitation
of the mandible following segmental resection: J Surg Oncol, v. 94, p. 538-45.
Shibahara, T., H. Noma, Y. Takasaki, T. Nomura, and M. Fujikawa, 1999, Repair
of the mandibular nerve by autogenous grafting after ablative surgery of the
mandible: Bull Tokyo Dent Coll, v. 40, p. 1-6.
Shpitzer T, Gullane PJ, Neligan PC, Irish JC, Freeman JE, Van den Brekel M et
al. (2000). The free vascularized flap and the flap plate options: comparative
results of reconstruction of lateral mandibular defects. Laryngoscope
110(12):2056-2060.
Simon EN, Merkx MA, Kalyanyama BM, Shubi FM, Stoelinga PJ (2013).
Immediate reconstruction of the mandible after resection for aggressive
odontogenic tumours: a cohort study. Int J Oral Maxillofac Surg 42(1):106-112.
29
Suh JD, Blackwell KE, Sercarz JA, Cohen M, Liu JH, Tang CG et al. (2010).
Disease relapse after segmental resection and free flap reconstruction for
mandibular osteoradionecrosis. Otolaryngol Head Neck Surg 142(4):586-591.
Söderholm AL, Lindqvist C, Laine P, Kontio R (1988). Primary reconstruction of
the mandible in cancer surgery. A report of 13 reconstructions according to the
principles of rigid internal fixation. Int J Oral Maxillofac Surg 17(3):194-197.
Teng, M. S., and N. D. Futran, 2005, Osteoradionecrosis of the mandible: Curr
Opin Otolaryngol Head Neck Surg, 13:217-21.
[Trignano E, Fallico N, Faenza M, Rubino C, Chen HC (2013). Free fibular flap
with periosteal excess for mandibular reconstruction. Microsurgery. 33(7):527533]
Tsuchiya S, Nakatsuka T, Sakuraba M, Kimata Y, Sakurai H, Nakagawa M et al.
(2013). Clinical factors associated with postoperative complications and the
functional outcome in mandibular reconstruction. Microsurgery 33(5):337-341.
[Ueyama Y, Naitoh R, Yamagata A, Matsumura T (1996). Analysis of
reconstruction of mandibular defects using single stainless steel A-O
reconstruction plates. J Oral Maxillofac Surg 54(7):858-862; discussion 862853.]
Ujpál M, O. Matos, G. Bíbok, A. Somogyi, G. Szabó, Z. Suba (2004) Diabetes
and oral tumors in Hungary. Epidemiological correlations Diabetes Care, 27:770–
774
Urken ML, Buchbinder D, Weinberg H, Vickery C, Sheiner A, Parker R et al.
(1991). Functional evaluation following microvascular oromandibular
reconstruction of the oral cancer patient: a comparative study of reconstructed
and nonreconstructed patients. Laryngoscope 101(9):935-950.
30
van Gemert JT, van Es RJ, Van Cann EM, Koole R (2009). Nonvascularized
bone grafts for segmental reconstruction of the mandible--a reappraisal. J Oral
Maxillofac Surg 67(7):1446-1452.
van Gemert JT, van Es RJ, Rosenberg AJ, van der Bilt A, Koole R, Van Cann
EM (2012). Free vascularized flaps for reconstruction of the mandible:
complications, success, and dental rehabilitation. J Oral Maxillofac Surg
70(7):1692-1698.
Vayvada H, Mola F, Menderes A, Yilmaz M (2006). Surgical management of
ameloblastoma in the mandible: Segmental mandibulectomy and immediate
reconstruction with free fibula or deep circumflex iliac artery flap (evaluation of
the long-term esthetic and functional results). J Oral Maxillofac Surg
64(10):1532-1539.
Villaret AB, Cappiello J, Piazza C, Pedruzzi B, Nicolai P (2008). Quality of life in
patients treated for cancer of the oral cavity requiring reconstruction: a
prospective study. Acta Otorhinolaryngol Ital 28(3):120-125.
Virgin FW, Iseli TA, Iseli CE, Sunde J, Carroll WR, Magnuson JS et al. (2010).
Functional outcomes of fibula and osteocutaneous forearm free flap
reconstruction for segmental mandibular defects. Laryngoscope 120(4):663667.
Vu DD, Schmidt BL (2008). Quality of life evaluation for patients receiving
vascularized versus nonvascularized bone graft reconstruction of segmental
mandibular defects. J Oral Maxillofac Surg 66(9):1856-1863.
Warnakulasuriya S: Significant oral cancer risk associated with low
socioeconomic status. Evidence-Based Dentistry 2009, 10(1):4-5.
31
[Young CW, Pogrel MA, Schmidt BL (2007). Quality of life in patients
undergoing segmental mandibular resection and staged reconstruction with
nonvascularized bone grafts. J Oral Maxillofac Surg 65(4):706-712.]
Zachariades N, 1989, Neoplasm metastatic to the mouth, jaws and surrounding
tissues: J Craniomaxillofac Surg, v. 17, p. 283-90.
Zender CA, Mehta V, Pittman AL, Feustel PJ, Jaber JJ (2012). Etiologic causes
of late osteocutaneous free flap failures in oral cavity cancer reconstruction.
Laryngoscope 122(7):1474-1479.
Zenn MR, Hidalgo DA, Cordeiro PG, Shah JP, Strong EW, Kraus DH (1997).
Current role of the radial forearm free flap in mandibular
reconstruction. Plast Reconstr Surg 99(4):1012-1017.
Zhang Y, Zhang J, Yu G (1999). Long-term complications associated with
immediate plate reconstruction for mandibular defect following tumor-surgery.
Zhonghua Kou Qiang Yi Xue Za Zhi 34(4):205-207.
Zitzmann NU, Sendi P, Marinello CP (2005). An economic evaluation of implant
treatment in edentulous patients - Preliminary results. Int J Prosthodont
18(1):20-27.
32
Table 1: Search strategy.
Database
Search details
Hits
Selected
articles
PubMed
(“mandibular reconstruction”[MeSH Terms] OR
(“mandibular”[All Fields] AND “reconstruction”[All Fields]) OR
“mandibular reconstruction”[All Fields]) AND segmental[All
Fields] AND (“neoplasms”[MeSH Terms] OR “neoplasms”[All
Fields] OR “cancer”[All Fields])
33
208
208
Table 2: Results of reconstruction.
VASCULAR
Fibula
Radialis
Iliac
Scapula
Rib
Patients
393
60
71
106
11
Success
355
50
66
100
10
Failure
38
10
5
6
1
Success rate
90.33%
83.33%
92.95%
94.33%
90.90%
Number of articles
11
7
7
3
2
TOTAL
641
581
60
90.63%
15 Unique
NON VASCULAR
Fibula
Radialis
Iliac
Scapula
Rib
Ilium
Patients
1195
315
172
46
30
6
Success
1101
293
154
45
29
6
Failure
94
22
18
1
1
0
Success rate
92.13%
93.01%
89.53%
97.82%
96.66%
100,00%
Number of articles
28
11
11
8
2
2
TOTAL
1764
1628
136
92.29%
31 Unique
PLATE
Plate
Patients
814
Success
573
Failure
241
Success rate
70.40%
Number of articles
16
TOTAL
814
573
241
70.40%
16 Unique
2782
437
86.42%
62
OVERALL TOTAL 3219
34
Authors (year)
Number of
Patients
Techunique
Site (Bone)
Size and position of resection (with Follow up
or wthout temporomandibular joint) mean + range
Survival rate
Success rate (loss of
plate and/or fractures)
Dental
Mean age
rehabilitation
Implants/protheses
Aesthetics
Function
(included or (included
not)
or not)
Quality of Irradiation
life
(included or
not)
Abstract/ Full
text
Abler , et al. (2005) 152 (112 had
segmental
resection)
Reconstruction plate
X
X
x
x
x
x
No
No
No
x
Ab
Adekeye , et al.
(1980)
109
autogenous bone grafts or a
Bowerman-Conroy prosthesis
X
X
8y
67,9% (74/109) 8y The bone transplants
post op
had 100% succesrate.
x
No
No
No
X
Full
Anthony , et al.
(1997)
17
free flap
Fibula
mean 6,3 cm (range 2,5-9 cm)
5,5 y
12/17 (70,6%) 21 82,4% (14/17)
3/17
m post op
(18%) fracture plate,
malocklusion
71% dental
mean age 54 y
rehabilitation (35% (range 29-76 y)
in form of
osseointegrated
implants.)
Yes
Yes
No
92% was irradiated Full
Aramany , et al.
(1977)
17
immediate intermaxillary fixation X
X
X
X
X
X
X
No
No
No
X
Arden , et al. (1999) 31
30 patients; stainless steel plate
and 1 patient; Vitallium plate
mean 5,4 cm (range 3-10cm)
7y
X
83,9% (26/31) Success
X
rates. 5/31 (16,1%)
Complications; fractured
plate.
mean 57 y (range
41-76 y)
No
Yes
No
100% was
Full
irradiated preop 6
post op 25
Aydin , et al. (2004) 21
7 patients free osseous flap and
14 patients free osteocutaneous
flap.
Fibula
X
5y
20/21 95,2% 5 y
post op.
95,2% (20/21) success
rate
X
mean 41 y (range
22-58 y)
No
No
No
100% was
irradiated post op
Full
Barnard , et al.
(1991)
30
free flap
radial forearm
X
4y
X
X
X
X
No
No
No
X
Ab
Baumann , et al.
(2011)
63
43/63 (68,3%) of the patients was fibula 37
recontstructed with bone flap
iliac 4
Segmental defect with intact condyle mean 18,2 month
27.
Posterior or hemi (range 3-72 month)
resection with resection of condyle
36
52/63 (82,5%) 32
month post op.
11/63 (17,5%)
died after, mean
8 month post op
(range 3-32
month).
1/27 (3,7%) segmental
X
bony defect lost the
implant
3/36
(8,3%) posterior or hemi
resection lost the
implant
mean 61 y (range
29-88 y)
No
Yes
No
5-year survival:
84%
X
X
X
No
No
Survival rate;
X
10/13 (76,9%)
32,8 mån post op.
Mean time alive
post op of those
who died; 47,6
X
mean 8 y (range 5
month - 18 y
No
No
Table 3: The database.
radial 2
Beecroft , et al.
(1982)
34
marginal mandibula resection
X
X
15 y
Benoit , et al.
(2013)
13
free tissue transfer
7/13 (53,8%): combined
musculocutaneous flap
and plate,
1/13 (7,7%): regional
tissue + plate
5/13 (38,5%):
Hemi mandibula ectomy: 9/13
mean 32,8 month
(69,2%)
Marginal/segmental (range 0,2-124 month)
mandibula ectomy 3/13 (23,1%)
Total mandibula ectomy 1/13 (7,7%)
35
X
Full
Full
5X
No
53,8% was
irradiated
Full
Full
Authors (year)
Number of
Patients
Techunique
Site (Bone)
osteocutaneous free
tissue transfer.
Size and position of resection (with Follow up
or wthout temporomandibular joint) mean + range
Survival rate
month
36
Success rate (loss of
plate and/or fractures)
Dental
Mean age
rehabilitation
Implants/protheses
Aesthetics
Function
(included or (included
not)
or not)
Quality of Irradiation
life
(included or
not)
Abstract/ Full
text
Authors (year)
Number of
Patients
Techunique
Site (Bone)
Size and position of resection (with Follow up
or wthout temporomandibular joint) mean + range
Bianchi , et al.
(2013)
31
free flap
14/31 (45,2%) Iliac
17/31 (54,8%) Fibula
mean 5,6 cm (range 3,5-12,5 cm)
Bilodeau , et al.
(2011)
27
Segmental mandibula ectomy
Blackwell , et al.
(1996)
15
soft-tissue free flaps + plate
(titanium (14/15) or stainless
steel (1/15)
11/15 (73,3%): Radialis X
2/15 (13,3%): rectus
abdominis 1/15 (6,7%):
scapular and
parascapular 1/15
(6,7%): lateral arm flap
X
X
success rate; 15/15
(100%) for microvascular free tissue
transfer.
Overall success rate for
plate 11/15 (73,3%) 1 y
post op.
Blackwell , et al.
(1999)
27
free flap + plate
radialis free flap: 21/27 x
(77,8%)
rectus free flap: 6/27
(22,2%)
mean 19,5 month
survival rate;
23/27 (85,2%)
18,7 month post
op.
Mean time alive
of those who died
17,3 month post
op
Boffano , et al.
(2011)
10
free flap
iliac: 5/10 (50%)
non 3/10 (30%) (lesions
<3cm),
other: 2/10 (20%)
(maxilla)
X
Success rate (loss of
plate and/or fractures)
Dental
Mean age
rehabilitation
Implants/protheses
Aesthetics
Function
(included or (included
not)
or not)
Quality of Irradiation
life
(included or
not)
Abstract/ Full
text
X
25/31 (80,6%)
endosteal dental
implants. 100%
success rate
No
No
No
X
Ab
No
No
No
X
Full
X
No
No
No
100% was
irradiated
Full
success rate 25/27
X
(92,6%) 19,5 month post
op. With new type of
low-profile MRP (plate)
in comparison with the
MRP used by Blackwell
1996 when the success
rate was 73,3%)
mean 65 y (range
32-88 y)
No
No
No
23/27 was
Full
irradiated Preop
(n=5)
Post
op (n=17) Pre+post
op (n=1) No
irrradiation (n=4)
Pre-molar region: 2
Molar mean 67,3 month
100% 165 month
region: 7
Paramedian
(range 12-165 month) post op
region: 1
mean size 3,85 cm
(range 2-5 cm)
X
mean 40,1 y (range No
20-55 y)
No
Yes
X
Full
mean 8,5 cm (range 5,3-11 cm)
Survival rate
mean 53,6 month
31/31
(range 18-120 month)
X
X
X
X
X
X
X
mean
men/women:
55/66 y
Boyd , et al. (1995) 71
free flap: 31
100% radialis
radial forearm osteocutaneous
flap 15, radial fasciocutaneous
flap 16
free
flap + Plate: 40 Plate 40
X
X
X
success rate
X
total; 78,9% mandibular
defects anterior
positioned 65% lateral
positioned 95%
X
No
No
No
X
Ab
Brown , et al.
(2002)
65
X
X
X
X
X
X
X
X
No
No
No
X
Full
Burkey , et al.
(1990)
14
X
X
X
X
survival rate; 70% X
3,5 y post op
X
X
No
No
No
X
Full
Canadian Society of 35
OtolaryngologyHead and Neck
Surgery Oncology
Study Group (2004)
X
X
X
X
survival rate 79% X
2 y post op and
57% 5 y post op
X
mean 40 y (range
14-76 y)
No
No
No
X
Full
37
Authors (year)
Number of
Patients
Cantu , et al. (2009) 72
Techunique
Site (Bone)
Size and position of resection (with Follow up
or wthout temporomandibular joint) mean + range
Survival rate
Success rate (loss of
plate and/or fractures)
Dental
Mean age
rehabilitation
Implants/protheses
Aesthetics
Function
(included or (included
not)
or not)
Quality of Irradiation
life
(included or
not)
Abstract/ Full
text
X
Autologous freezetreated mandibular
bone
Anterior or Anterior-Lateral: 35/72
(48,6%)
lateral: 37/72 (51,4%)
14 y
survuval rate
success rate total; 41/72 X
32/72 (44,4%) 5 y (56,9%) 1-10 month post
post op.
op. laterala resections
75,7%
anteriora
resections 37,1%
mean 58 y (range 4 Yes
77)
No
No
26/72 was
irradiated
Full
8y
survival rate
14/16 (87,5%)
success rate 15/16
(93,8%)
X
X
Yes
Yes
No
X
Full
Carlson , et al.
(2002)
16
bone graft (7/16=43,8%) plate +
condylar prosthesis
X
15/16 (93,8%): Disarticulation
resection of mandible
Chaine , et al.
(2009)
44
segmental mandibulectomy +
Free osteocutaneous flap
Fibula
mean 12 cm (range 7-16 cm) 55,6% mean 53 month
hemimandible
22,2% total (range 26-73 month)
mandibulectomy 22,2%
lateral+frontal mandible
survival rate
100% 73 month
post op
success rate: 88,9%
22,2% got dental
implants
mean 35 y (range
18-70 y)
No
No
No
X
Full
Chana , et al. (2004) 13
free fibula flap + osseointegrated X
implants
mean 8,8 cm (range 4,5-13 cm)
mean 40,1 month
(range 18-70 month)
survival rate
100% 70 month
post op
success rate 13/13
(100%)
100% 40 month
post op (range 1870 month)
mean 32 y (range
17-50 y)
No
No
No
X
Ab
Chang , et al. (1998) 12
Fibula osteoseptocutaneous flap
mean 8,1 cm
mean 25 month
X
success rate 12/12
success rate 12/12
mean 36,3 y (range No
No
No
X
Full
(100%) 25 month post
op
(100%) 25 mån post 17-65 y)
op
Fibula
+ osseointegrated implants
(range 1-47 month)
Chang , et al. (2010) 114
free fibula flap
Fibula
mean 8,9 cm (range 3-26 cm)
25 month
X
Cordeiro , et al.
(1999)
150
free flap + plate and titanium
screws (98% of cases)
Fibula: 135/150 (90%)
Radius 6/150 (4%)
Scapula 6/150 (4%)
Ilium 3/150 (2%)
43% hemi mandibular defek t
25% 10 y
lateral and
32%
frontal
Dholam , et al.
(2011)
12
free fibular graft
Fibula
Disa , et al. (1997)
27
free fibula flap
Fibula
16/27 (59,3%) anterior
(40,7%) lateral.
11/27 mean 54 month
(range 24-104)
X
free flap success rate:
93%
6/27 (22,2%) got
osseointegrated
dental implants
mean 43 y (range
14-65)
Disa , et al. (1999)
48
Free osseous flap
fibula 35/48 (72,9%)
radius 6/48 (12,5%)
scapula 4/48 (8,3%)
ilium 3/48 (6,3%)
24/48 (50%) anterior
(50%) lateral
24/48 mean 47 month
X
(range 24-104 month)
free flap success rate:
97%
Dor , et al. (1980)
126
X
X
X
X
X
success rate 98,3%
free flap success rate:
100%
survival rate
11/12 (91,7%).
X
X
38
X
20/150 (13,3%)
osseo-integrated
dental implants
mean 49,5 y (range No
12-85 y)
No
No
X
Full
mean 50 y (range 3 Yes
79 y)
Yes
Yes
X
Full
Yes
Yes
Yes
8/12 was
irradiated
Full
No
No
No
10/27 (37%) was
irradiated
6/10 (60%) Preop
4/10 (40%) Post
op.
Full
17/48 (35,4%) got
osseointegrated
dental implants
mean 45 y (range 5 No
75 y)
No
No
10/48 (20,8%) was Ab
irradiated
6/10 (60%) pre op
4/10 (40%) post op
X
X
No
No
X
success rate 63%.
18 month post op
No
Full
Authors (year)
Number of
Patients
Techunique
Site (Bone)
Size and position of resection (with Follow up
or wthout temporomandibular joint) mean + range
Etti , et al. (2010)
334
Titanium bridging plates
X
30/334 (9,0%) lateral + Condyle
mean 5,1 y (range 0,3- survival rate
success rate;
2/334 (0,6%) anterior
177 18,0 y)
81,6% 2 y post op (191/334) of
(53,0%) lateral
1/334
Success rate (loss of
plate and/or fractures)
Dental
Mean age
rehabilitation
Implants/protheses
57,2% X
Aesthetics
Function
(included or (included
not)
or not)
mean 53,2 y (range No
29-79 y)
No
Quality of Irradiation
life
(included or
not)
No
71,8% 5 y post op reconstruction plates
(0,3%) anterolateral+Condyl 53
(15,9%) Anterolateral
71
(21,3%) Total mandible ectomy
Abstract/ Full
text
282/334 (84,4%)
Full
was irradiated pre
op
62% 10 y post op
143/334 of plates was
removed due to
complications. 7/143
due to fractures.
mean 75 month
(range 2-75 month)
X
free flap success rate:
147/155 (94,8%)
9/155 (5,8%) got
implants
mean 56 y (range
22-80 y)
No
No
No
109/155 was
irradiated
57/155 pre op
52/155 post op
Ab
X
X
titanium plate success
rate: 147/184 (79,9%)
X
mean 60,9 y (range No
19,7-85,1 y)
No
No
147/184 was
irradiated
79/184 pre op
64/184 post op
Full
X
free fibula flap success X
rate: 36/38 (94,7%) free
scapula flap success
rate: 18/18 (100%)
mean 63 y (range
24-80 y)
No
No
No
8/56 (14,3) was
irradiated
Ab
45/46 (97,8%)
33/46 (71,7%) (CP) and
48,5% (16/33) IP
X
mean 60 y
No
No
No
success rate 66%
X
X
No
No
No
X
Evans , et al. (1994) 155
free flap
Radialis
Farwell , et al.
(2006)
free flap + titanium
reconstruction plates
Fibula 145/184 (78%). X
Iliac crest 27/185
(14,6%). Radialis
12/185 (6,5%). Scapula
1/185 (0,5%)
Fujiki , et al. (2013) 56
free flap
38/56 (67,9%): Fibula
lateral 29/56 (51,8%) anterolateral 7 y
18/56 (32,1%): Scapula 19/56 (33,9%)
total
mandibulectomy 13/56 (23,2%)
Garrett , et al.
(2006)
46
free fibula flap + conventional
(CP) and/or implant-supported
(IP) prostheses
Hamaker , et al.
(1983)
15
Resection + postoperative
radiation
X
X
He , et al. (2010)
17
free fibula flap and/or
postoperative radiotherapy
Fibula
lateroposterior 5/17 (29,4%)
mean 25 month
anterolateroposterior 3/17 (17,6%)
(range 3-57 month)
lateral 2/17 (11,8%) anteriolateral
5/17 (29,4%)
total
mandibulectomy + condyle 1/17
(5,9%)
bilateral+anterior 1/17
(5,9%)
survival rate
free flap success rate:
15/17 (88,2%)
100%
life time of those
who died 8 mån
post op (range 313 month)
X
mean 51,5 y (range No
35-63 y)
No
No
11/17 (64,7%) was Ab
irradiated post op
153/210 (72,9%) lateral
57/210 mean 21,5 month
(27,1%) Anterior or anterolateral
(range 1-70 month)
survival rate
98,1% (206/210)
70 month post
op. Life time of
those who died
mean 16,3 days
post op (range 724 days)
X
range 19-88 y
No
No
165/210 (78,6%)
was irradiated
184
Head , et al. (2003) 210
X
Survival rate
lateral 2/46 (4,4%)
anterolateral
20/46 (43,5%) anterior 1/46 (2,2%)
posterior 13/46 (38,3%)
hemi
6/46 (13%)
total
mandibulektomi 3/46 (6,5%) total +
Condyle 1/46 (2,17%)
free microvascular flap + titanium 134/210 (63,8%) Fibula
platta
11/210 (5,2%) Scapula
5/210 (2,4%) Iliac
1/210 (0,5%) Radialis
4 y and 3 month
39
success rate: 93,3%
(196/210)
No
Ab
Full
Ab
Authors (year)
Number of
Patients
Heller , et al. (1995) 47
Techunique
Site (Bone)
Size and position of resection (with Follow up
or wthout temporomandibular joint) mean + range
free osseous flap or soft tissue +
plate
18/47 (38,3%) iliac
11/47 (23,4%) anterior
5/47 (10,6%) fibula
(57,4%) lateral
2/47 (4,3%) scapula
(19,2%) posterior
1/47 (2,1%) rib.
8/47 plate + soft tissue
transfer
8/47 pectoralis
5/47 forearm
27/47
9/47
Success rate (loss of
plate and/or fractures)
Dental
Mean age
rehabilitation
Implants/protheses
Aesthetics
Function
(included or (included
not)
or not)
Quality of Irradiation
life
(included or
not)
Abstract/ Full
text
survival rate 74%
1 y post op 67%
2 y post op 40% 5
y post op (mean
39 month alive
post op of those
who died)
free flap success rate:
21/23 (91,3%)
success rate for plate
14/21 (66,6%)
X
mean 67 y (range
13-82 y)
No
Yes
No
35/47 (74,5%) was Ab
irradiated
6/35 (17,1%) pre
op 29/35 (82,9%)
post op
X
free flap success rate:
100%
X
X
No
No
No
6/12 (50%) was
irradiated post op
Hidalgo , et al.
(1989)
12
free fibula flap el free fibula flap
+ miniplates (11/12)
fibula
mean 13,5 cm
Hundepool , et al.
(2008)
70
OFFF
fibula
20/70 (28,6%) anterior
31/70 mean 39,5 month
(44,3%) lateral
1/70 (1,4%) (range 6-89 month)
posterior
16/70 (22,9%)
anterolateral
2/70 (2,9%)
lateroposterior
survuval rate
X
64,3% (45/70) 18
month post op
total implant
success rate: 97%.
mean 53 y (range 6 Yes
82 y)
Yes
Yes
Iino , et al. (2009)
15
Cancellous bone and marrow +
titanium reconstruction plate
Iliac
1/15 (6,7%) anterior
(66,7%) Lateroposterior
(26,7%) lateral
X
Success rate 90,1% mean 58,3 y (range No
(10/11)
23-74 y)
11/15 (73,3%) got
dental
implants/prosthesi
s
No
No
6/15 (40%) was
irradiated
Full
Irjala , et al. (2012) 10
free osseous flap
9/10 (90%) fibula in
which 1 of these also
included radialis
1/10 (10%) iliac.
X
mean 51,5 month
(range 4-142 month)
survival rate 6/10 free flap success rate:
(60%) was alive
90% (9/10)
142 month post
op. Of those who
died, lived for
15,3 month
(range 4-26
month)
Success rate 100%
4/10 (40%) got
dental implants.
mean 60 y (range
48-75 y)
No
No
No
10/10 (100%) was
irradiated
Full
Jeng , et al. (2005)
10
Double Free Flaps and
Fascia Lata Grafts for Oral
Sphincters
10 fibula
mean (9.4cm(6-14cm))
24m
9 of 10
100%
x
51.7y (44-64y)
Yes
Yes
No
x
Ab
Ji , et al. (2006)
541
The reconstruction methods
x
included soft flap, reconstruction
plate and bone grafts.
x
x
x
x
x
40-70y
No
No
No
x
Ab
Julieron , et al.
(1996)
38
free bone grafts
25 fibula
7 scapular
3 iliac
3 forearm free flaps
24 anterior
laterala
anterio-laterala
x
x
36/38
x
x
Yes
Yes
No
x
Full
Kadota , et al.
(2008)
23 (12)
2 iliac
2 scapula
x
x
x
x
x
65.6y (47-74y)
No
Yes
No
x
Full
2 metal plate
2 iliac crest free flap
2 scapula osteocutaneous free
flap
6 without reconstrcution
X
Survival rate
4/15
9
10/15 62,7 month (29-108
month)
success rate 86,7%
(13/15)
Ab
Full
5
40
Authors (year)
Number of
Patients
Techunique
Site (Bone)
Survival rate
Success rate (loss of
plate and/or fractures)
Dental
Mean age
rehabilitation
Implants/protheses
Aesthetics
Function
(included or (included
not)
or not)
Quality of Irradiation
life
(included or
not)
Abstract/ Full
text
Kim , et al. (2007)
29
latissimus-serratus-rib free flap
27 latissimus-serratus- 15 anterio-laterala
rib free flap
2 anteriora
2 serratus-rib
osteomuscular free flap
21m
x
28/29
x
68y (21-82y)
No
No
No
22 was irradiated
preop 13
post op 9
Ab
Knott , et al. (2007) 101
locking mandibular
reconstruction plate and
vascularized bone grafts
93 fibula flaps
x (8.1cm (4-23cm))
8 latissimus-serratus rib
flaps
14.6m (6-46m)
x
86/101
x
x
No
No
No
87 was irradiated
29 preop and 56
postop
Ab
Koch , et al. (1994)
40
Thorp vs. Metal plate
x
x
72m
x
THORP 11/12
Metal plate 14/28
x
x
No
No
No
x
Ab
Kovács , et al.
(1994)
30
Free radial forearm flap
Radial 30
x
x
x
100%
x
x
No
No
No
x
Full
Kroll , et al. (1992)
69
A:15 soft tissue
B:20 immediate reconstruction
with vascularized bone
C:15 metal plate
D:9 plate (bone later)
E:10 no reconstruction (bone
later)
x
x
x
x
A: 77%
50%
C: 27%
D: 22%
E: 30%
B: x
x
No
No
Yes
x
Ab
Kudo , et al. (1992) 32
27 seg. Resection
hemiresection
A:8 autogenous bone
x
graft
B:7 pedicled
myocutaneous flap+
bone graft
C: 6 metalic plate
D: 11 Pedicled
myocutaneous flap and
metallic plate
x
30/32 levde vid
sista
uppföljningen
A:6 of 8
4 of 7
2 of 6
D: 7 of 11
B: x
C:
x
No
No
No
x
Ab
Li , et al. (2007)
112
fibular grafts
Group A (7):
microvascular bone
graft
Group B (61):
microvascular
reconstruction of
Seg.Defects.
Group C (41):Avascular
onlay grafts
Group D (7):avascular
reconstruction
x
12-140m
x
x
239 implantat
sattes på 115
patienter
Group A : 56y
Group B: 55y
Group C: 50y
Group D:54y
No
Yes
No
19 patients was
irradiated
Full
Lindqvist , et al.
(1992)
34
alloplastic reconstructions
x
x
x
19 of 34 lived at
last follow up
22 of 34 (64.7%)
x
x
No
Yes
No
x
Ab
revascularized free scapular flap
93 scapula
x
10-144m
Louis , et al. (2010) 93
5
Size and position of resection (with Follow up
or wthout temporomandibular joint) mean + range
12 laterala
x
41
88/93 (94.6%)
x
x
No
No
No
x
Full
Authors (year)
Number of
Patients
Techunique
Site (Bone)
Size and position of resection (with Follow up
or wthout temporomandibular joint) mean + range
Survival rate
Success rate (loss of
plate and/or fractures)
Dental
Mean age
rehabilitation
Implants/protheses
Aesthetics
Function
(included or (included
not)
or not)
Quality of Irradiation
life
(included or
not)
Malata , et al.
(1997)
100
Würzburg noncompression
titanium miniplate system
92% with vascularised
bone grafts. (Fibula,
scapula, radius)
4 patients having
nonvascularised iliac
bone grafts.
x(10cm (3-19cm))
47m (12-96m)
x
92/100 (92%)
x
60y (10-86y)
No
Yes
No
11 was irradiated Ab
preop
53 was
irradiated postop
11 was irradiated
both pre and post
Maurer , et al.
(2006)
20
reconstruction plate 16
Iliac 3
miniplate 1
Iliac 3
x
x
x
x
x
59y
No
Yes
No
x
Millsopp , et al.
(2006)
278
No flap 56
Soft tissue 147
Bone flap 63
Bone + soft tissue 7
x (not defined)
x
24m
Group1 (114pat): x
95% 1 year, 89% 2
year, 81% 3 year.
Gruop 2
(164pat): 75%
1year, 64% 2year,
60% 3year.
x
Grupp 65-: 158
Grupp 65+: 120
Yes
No
No
110 was irradiated Ab
Miyamoto , et al.
(2012)
23
clinical results were compared
between mandibular
reconstruction plate (MRP)
procedures and double flap
transfers.
Double flap :
10 Fibula
scapula
MRP: anterio-lateral 8,
lateral 4
(1 included the joint)
Double flap: 11 anterio-laterala
22m (1-108m)
5 of 23 lived with MRP: 12 of 12
out disease after Double flap 11 of 11
108m
x
58.4y +- 12y
Yes
Yes
Yes
MRP: 1 was
Full
irradiated
Double Flap: 2 was
irradiated
Obiechina , et al.
(2003)
20
free nonvascularised iliac crest.
20 iliac
5 anterio-lateral
Okoturo , et al.
(2011)
13
immediate plate reconstruction
x
1 anterior
7 anterio-laterala
Patel , et al. (1996) 83
Grupp 1: 47 rekonstruerades ej.
8 pectoralis. M. omc.
Grupp 1:47 anteriolateralt (47
1
Grupp 2: 21 fick siliastic implants. 7 iliac
8 fick PM-OMC. 7 fick Iliac flap
involved the joint)
Grupp 2: 36 laterla
Pellini , et al. (2012) 41
x
x
x
Politi , et al. (2012) 24
Iliac flap vs. Fibula flap
13 iliac
fibula
Puxeddu , et al.
(2004)
vascularized
bone-containing free flap
12 iliac
12
15 laterala
5 lateral
11 x (6-15 cm)
8 laterala
laterala
4 anterio6.9cm(5.2-9cm)
x
x
19/20
x
x
Yes
Yes
No
x
Abstract/ Full
text
Full
Full
15m (6-23m)
x
11 of 13 plate 2
11 patients had
removed due to fracture implants
24y (10-36y)
Yes
Yes
Yes
x
Ab
x
x
x
32-76y
Yes
Yes
No
25 was irradiated
Full
12/36 got
prosthesis
after surgery
x
x
x
x
x
No
No
No
x
Ab
12m
x
Iliac 13 of 13
fibula 10 of 11
Every one had
implants
56y (17-62y)
Yes
Yes
Yes
x
Ab
21m (6-64m)
6 of 12 survived
50%
11 of 12
no one had
implants
62.5y (57-77y)
No
No
Yes
9 patients was
irradiated after
suregery
Full
42
Authors (year)
Number of
Patients
Techunique
Site (Bone)
Size and position of resection (with Follow up
or wthout temporomandibular joint) mean + range
Survival rate
Success rate (loss of
plate and/or fractures)
Dental
Mean age
rehabilitation
Implants/protheses
Aesthetics
Function
(included or (included
not)
or not)
Quality of Irradiation
life
(included or
not)
Abstract/ Full
text
Rivas , et al. (2000) 15
vascularized bone grafts
11 fibula
3 iliac
1 radial
10 laterala
3 anterio-laterala
the joint)
x
13/15
x
x
No
No
No
x
Full
Robey ,et al. (2008) 117
free fibular flaps. Miniplates Vs.
Reconstruction plates
117 fibula
miniplates
x
Mp: 77/86
RP: 26/31
Mp: 7/86
Rp: 5/31
Mp: 60.4y (21-85y) Yes
Rp: 61.1y (21-88y)
No
No
Mp: 53% was
irradiated Rp:
Full
2 hel resection x
(tot. 9 involved
(86 x
31
29.6m
reconstruction plates)
Rogers , et al.
(2004)
224
123 no resection
44 rim
resection
57 segmental
resektion
26 fibula
7 DCIA
13 radial
6 scapula
5 compination
Sarukawa , et al.
(2012)
11
vascularised iliac crest
Iliac 11
Schliephake , et al.
(1999)
44
21 vascularized grafts
23 nonvascularized grafts
Shpitzer , et al.
(2000)
57
16% was irradiated
Of segmentresect. 16% in anterior
sites,
28% in
posterior, and 56% combined
x (4-12cm)
VG: iliac: 6
scapula: 4
fibula: 11
Non-VG: iliac 23
16m (12-36m)
6-44m
12m: 187/224
36m: 113/224
81%
x
81%
x
61y
Yes
Yes
Yes
51% of
segmentalresect.
Patients
Full
2 of 11
58.8y (32-78y)
No
No
No
6 was irradiated
before surgery
Full
x (6.7cm (2-12cm))
41.2m
41/44
x (100% on impants
after five years 60.3%
after 10years)
44
x
No
No
No
15/44 was
irradiated
Full
osteocutaneous free flaps,
plate + PMMF 27
plate + PMMF ,
plate + FRFF plate + FRFF 16
osteocutaneous free
flaps 14 (fibula)
Lateral defects (16 included the
joint)
PMMF: 45m(12126m)
FRFF:23m (12-53m)
OFF: 20m (13-38m)
x
PMMF 20/27
FRFF 14/16
OFF 14/14
x
PMMF 58y FRFF No
61y
OFF 55y
Yes
Yes
x
Full
Simon , et al. (2013) 32
reconstruction plates and an
autogenous particulate bone
graft
x (particulate bone
iliac)
x
27.9m (12-39m)
x
31/32 96.8%
x (13/32 got
prostehsis)
27.7y
No
No
Yes
x
Full
Suh , et al. (2010)
40
microvascular free flap
Fibula 36
Iliac 1
x
24cm))
17.4m
x
100%
x
62y (38-86y)
No
No
No
40 was irradiated
Full
Söderholm , et al.
(1988)
30
rigid internal fixation
x
x
x
x
29/30 96.6%
x
x
Yes
No
No
x
Full
Trignano , et al.
(2013)
34
fibular osteocutaneous flap vs
free fibular flap with periosteal
excess
Fibula 34
x (length 2-5.7cm)
1.5m
x
11/17 free flap
15/17 free flap PE
x
No
No
No
34 was irradiated
Ab
Tsuchiya , et al.
126 (114)
free flaps
Fibula 52
65m
x
101/114 88.6%
x
No
Yes
No
x
Full
rib 3
Scapla 7 x
(length 8cm(4-
43
42.9 (27-55y)
62.2
Authors (year)
(2013)
Number of
Patients
Techunique
Site (Bone)
Size and position of resection (with Follow up
or wthout temporomandibular joint) mean + range
Survival rate
Iliac 3
RAMC 43
ALT 5
RF 3
Success rate (loss of
plate and/or fractures)
Plate exposure 3
Plate infection 4
Fracture of plate 2
Total flap necrosis 4
44
Dental
Mean age
rehabilitation
Implants/protheses
Aesthetics
Function
(included or (included
not)
or not)
Quality of Irradiation
life
(included or
not)
Abstract/ Full
text
Authors (year)
Number of
Patients
Techunique
Ueyama , et al.
(1996)
34
single A-O plate
got ilactrans.
4st patients
Site (Bone)
Size and position of resection (with Follow up
or wthout temporomandibular joint) mean + range
Survival rate
Success rate (loss of
plate and/or fractures)
Dental
Mean age
rehabilitation
Implants/protheses
Aesthetics
Function
(included or (included
not)
or not)
Quality of Irradiation
life
(included or
not)
Abstract/ Full
text
x
x
47.4 m ( 6-115m)
69.7%
79%
4/34 plate exposure
1/34 screw loosening
2/34 TMJ pain
x
x
No
No
No
Ab
x
x
x
x
x
x
Yes
Yes
No
x
12-24m
61% after 2 y
100% Fibula
No
No
No
66/83 was
Urken , et al. (1991) 10
Vascularized bone flaps
x
van Gemert , et al.
free forearm flap and
Fibula 46
reconstruction plate and free
vascularized bone flaps
Free forearm + plate 15 laterala
NVBG
Iliac 74
83
(2012)
van Gemert ,et al.
74
iliac 22
68 (41) lateral
15 anterio-
Iliac
Radial
(After 1 year)
X (position)
(2009)
74 (32)
12m
x
94% 10/83 got implants 63 (25-85 y)
64%
76%
lateral
11
free deep circumflex iliac artery
or fibular flap
iliac 6
Villaret ,et al.
(2008)
92 (35
recsponded)
x
x
x
x
Virgin ,et al. (2010) 168
free flap reconstruction
Radial 51 Fibula 117
x
31m fibula
fibula
VU , et al. (2008)
vascularized fibular free flap and
nonvascularized iliac crest
Fibula 10 Iliac 8
X (position)
17 (10) lateral
1 anteriora
Young , et al. (2007) 26
Reconstruction plate
x
x (position)
18 (4) laterala
laterala
2 anteriora
6 (3) anterio-
Zender , et al.
(2012)
65
OCFF
Fibula 54 Radial 6
Iliac 5
x (position)
Lateral 50%
Anterio-Lateral 50%
30m
188m
Zenn , et al. (1997)
17
Free flap
Radial forearm
mean ~8cm (8.25)
13.5m
29 (18
responded)
fibula 5
x (position)
lateral
11 (2)
29,3m
38m)
Zhang , et al. (1999) 97 (68)
Reconstruction Plate
x
x
Full
11/74 got implants 54.3 (12-73 y)
No
Yes
No
27/74 was
Full
irradiated
100%
3/11 (due to cost)
25.4 (18-38 y)
Yes
Yes
Yes
x
Full
x
x
x
x
No
Yes
No
x
Full
75% after 5 year
96.6% Fibula
96.1% Radial
2.3% had implants
63.7 (radial)
(fibula)
No
No
No
x
Full
12m-40m from the
operation
x
x
x
42
Yes
Yes
Yes
33% were
irradiated
Full
12m-72m from the
operation
x
x
35% (7/20)
Implants
29,8
Yes
Yes
Yes
0%
Ab
90%
7/65 flap loss
x
62
No
No
No
83% irradiated
Full
3/17 x
55
No
No
No
>50% irradiated
Full
72m
(17m- x
Full
irradiated
33/74 got
prosthesis
Vayvada , et al.
(2006)
x
20m
1m- x
1m-
94.1% (16/17)
days post op
x
x
45
8 70%
59
fracture plate 2/17
fracture donor site
51%
x
x
No
No
No
x
Full
Authors (year)
Number of
Patients
Techunique
Site (Bone)
Size and position of resection (with Follow up
or wthout temporomandibular joint) mean + range
Survival rate
Success rate (loss of
plate and/or fractures)
22/68 detached
6/68 fracture plat
46
Dental
Mean age
rehabilitation
Implants/protheses
Aesthetics
Function
(included or (included
not)
or not)
Quality of Irradiation
life
(included or
not)
Abstract/ Full
text
Figure 1: Process of selection.
47
Figure 2: Definition of resection sites of the mandible.
Red box= Anterior part of mandible, Green box= Lateral part of mandible, Blue box= Posterior part of mandible and
Purple box= Condylar part of
48