MICROSURGERY
Aesthetic and Functional Mandibular Reconstruction With Immediate Dental Implants in a Free Fibular Flap and a Low-Profile Reconstruction Plate Five-Year Follow-up Yu-Fu Shen, DDS,* Eduardo D. Rodriguez, MD, DDS,Þ Fu-Chan Wei, MD,Þ Chi-Ying Tsai, DDS,þ and Yang-Ming Chang, DDSþ Background: Aesthetic and functional mandibular reconstruction can be achieved in 1-stage. It involves simultaneous dental implant placement in a free vascularized fibula transfer with a low-profile reconstruction plate. The aim of this study was to assess the postoperative aesthetic profile and oral functional result. Material and Methods: Ten patients with a mean age of 31.6 years and an average follow-up time of 83.7 months underwent 1-staged mandibular reconstructions after segmental mandibulectomies. Simultaneous dental implantation was placed at the fibular segment according to the maxillary dentition. The fibula-implant construct was stabilized superiorly with miniplates and an additional low-profile reconstruction plate recreated the inferior mandibular contour. Any remaining vascularized soft tissue was used for augmentation. Palatal mucosa grafts were placed around the dental implant healing abutment at the uncovering stage surface. Aesthetic profile and oral function were evaluated postoperatively for 5 years. Results: All microsurgical transplantations were successful. None of the patients required subsequent revisions. All patients completed prosthodontic rehabilitation. All patients had palatal mucosal grafts placed around the dental implants. The mean probing pocket depths were shallower around the implants, 3.09 T 0.82 mm at mesial, 3.33 T 1.05 mm at distal, 3.02 T 1.13 mm at buccal, and 3.23 T 1.17 mm at lingual surfaces. Radiographs revealed no statistical differences in mean of the mesial [0.27 T 0.26 mm] and distal [0.33 T 0.25 mm] of peri-implant bone loss. The prosthetic load mean follow-up time was 71.7 months with a satisfactory implant-supported prosthesis. Two slender female patients palpated the reconstruction plate beneath the soft tissue envelope. Conclusions: This approach is selectively fashioned for patients with benign disease when the overlying soft tissue drape is adequate. The technique described results in improved appearance and function through definition of the lower third of the face and simultaneous dental implant replacement. Key Words: mandibular reconstruction, fibula, osteointegration teeth, implant (Ann Plast Surg 2015;74: 442Y446)
M
icrosurgical vascularized bone transfers have revolutionized mandibular reconstruction. It allows the performance of 1-staged restoration of the bony defect, facial contour, and dentition. The fibular osteoseptocutaneous f lap has been widely used for maxillary and mandibular reconstruction. The fibula has good bone
Received April 1, 2013, and accepted for publication, after revision, June 17, 2013. From the Departments of *Prosthodontics, †Plastic and Reconstructive Surgery, and ‡Oral and Maxillofacial Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taipei, Taiwan. This article has not been submitted to any other journal. Conflicts of interest and sources of funding: none declared. Reprints: Yang-Ming Chang, DDS, Department of Oral and Maxillofacial Surgery, Chang Gung Memorial Hospital, 199 Tun Hwa North Rd, Taipei 105, Taiwan. E-mail: [email protected]. Copyright * 2013 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043/15/7404-0442 DOI: 10.1097/SAP.0b013e3182a0dedf
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stock and sufficient bone length to be easily osteotomized to match the mandibular contour. It also has a long vascular pedicle combined with a reliable skin f lap that enables the simultaneous reconstruction of intraoral and/or external face defect. The fibula bone also has an adequately wide diameter for dental implantation and subsequent implant-supported prosthesis.1Y9 Despite its numerous advantages, 1 limitation is its inherent height discrepancy when compared to the native mandible. This deficiency makes it less than ideal for simultaneous restoration of the alveolar height to the level of the occlusal plane and the mandibular contour. The fibula f lap placement at the inferior border of the mandible yields excellent skeletal and soft-tissue contour but results in implant overloading, compromising long-term success. We sought to overcome this dilemma by shifting the fibula f lap superiorly toward the upper mandibular border with simultaneous dental implant insertion, placing an additional low-profile reconstruction plate at the inferior border of the native mandible and correcting the residual soft-tissue deficiency with deepithelialized skin island from the fibula osteoseptocutaneous f lap.
MATERIALS AND METHODS Between January 2003 and June 2004, 10 patients underwent simultaneous dental implant placement and fibula osteoseptocutaneous flap transfer along the superior mandibular border and a low-profile reconstruction plate at the inferior mandibular border for segmental mandibulectomy after ameloblastoma excision. Table 1 provides a summary of the patients’ data. Five patients were men and 5 patients were women, with an average age of 31.6 years (range, 15Y50 years) and the average bone defect was 7.75 cm (3.5Y12 cm). Facial aesthetic contour was evaluated by medical personnel during follow-up visits. En bloc ameloblastoma resection was performed with 1-cm tumor margins. Patients were placed in maxillomandibular fixation, allowing for restoration of the premorbid occlusion. First, a low-profile reconstruction plate was contoured and stabilized to the inferior border of the mandible. After completion of the fibula flap harvest and ostectomies, dental implant placement was performed on the back table as previously described.1 After accurately positioning the superior border of the fibula-implant construct approximately 10 to 12 mm inferior to the occlusal plane, the bony construct was stabilized with miniplates, the skin flap was inset, and microvascular anastamosis was performed. The remaining vascularized soft tissue from the fibula flap was used to provide soft-tissue augmentation when indicated. Approximately 6 to12 months later, the implant uncovering surgery was performed and palatal mucosa grafts placed around the implants.10 All patients were dentally rehabilitated with implantsupported fixed prosthesis and functional loading began approximately 3 months after implant uncovering. The following parameters were evaluated: (1) aesthetic facial contour, and (2) implant survival rate after functional loading. Annals of Plastic Surgery
& Volume 74, Number 4, April 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Annals of Plastic Surgery
& Volume 74, Number 4, April 2015
Aesthetic & Functional Mandibular Reconstruction
TABLE 1. Patient Summary Sex
Age, y
Osteotomies
Implants
Prosthetic Type
1
F
15
1/03
1
3
83 Fixed
2
M
18
7/03
0
3
78 Fixed
3
M
37
10/03
1
4
74 Fixed
4
M
32
10/03
0
2
74 Fixed
5
M
50
12/03
2
5
72 Fixed
6
F
21
12/03
0
3
72 Fixed
7
F
45
1/04
0
3
71 Fixed
8
F
19
3/04
1
4
59 Fixed
9
F
39
4/04
1
3
68 Fixed
10
M
22
6/04
1
2
66 Fixed
Patient
Diagram (Defect Size, cm)
Prosthetic Loading Follow-up, mo (Dec/10)
Date of Surgery
Cases 7 and 9, ameloblastoma recurrence; cases 1Y6, 8, and 10, ameloblastoma.
Implant survival and success rate was based on the following Albrektsson criteria: (a) painless, (b) no in question, (c) no mobility, and (d) no peri-implant radiolucency and peri-implant resorption less than 1.5 mm at the first year of function and 0.2 mm in the subsequent years.11 Peri-implant health was assessed for redness, hyperplasia, swelling, presence of plaque, and probing depth. Bone resorption was recorded by measuring the peri-implant marginal bone loss at the mesial and distal surfaces via panoramic or periapical x-ray. Vertical bone loss around the implant-abutment was gauged by * 2013 Wolters Kluwer Health, Inc. All rights reserved.
measuring the relation of the first thread of the implant fixture to the implant-crest bone junction. To correct the dimension distortion, the apparent dimension of the implant was measured on the radiographs and divided by the actual implant size.12,13
RESULTS All microsurgical transplantations were successful. None of the patients in our series required subsequent operations for either recurrence or additional recontouring. All patients achieved satisfactory www.annalsplasticsurgery.com
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
443
Annals of Plastic Surgery
Shen et al
to good facial aesthetics. A total of 32 pieces of dental implants were inserted; 25 pieces of implants were placed in simultaneous and the remaining 7 pieces of implants were placed at the second stage, when bone union between the fibula and native mandible junction was achieved. Panoramic and periapical radiographs revealed no statistical differences in mean peri-implant bone loss between the mesial [0.27 T 0.26 mm; range, 0.1Y1.2 mm] and distal [0.33 T 0.25 mm; range, 0.1Y1.2 mm] surfaces (Table 2). All 10 cases had palatal grafts placed around the dental implants during the uncovering surgery, The mean probing pocket depths were shallower around the implants, 3.09 T 0.82 mm at mesial, 3.33 T 1.05 mm at distal, 3.02 T 1.13 mm at buccal, and 3.23 T 1.17 mm at lingual surfaces (Table 3). Average follow-up was 71.7 months (range, 59Y83 months). The implant and prosthesis survival rate was 100% (Table 4). All patients were fully satisfied with the function of the prosthetic restoration. Eight patients were fully satisfied and 2 were partially satisfied with the aesthetic facial contour.
TABLE 3. Probing Implant Depth, mm Case
Mesial
Distal
Buccal
Lingual
1
3 3 3 2 2 3 3 3 2 3 2 3 3 3 3 4 3 4 3 3 5 5 5 3 3 2 2 2 3 4 3 3
2.5 3.5 2 3 2 3 3 4 2 3 2 3 5 3 3 4 5 4 3 4 5 5 6 4 3 2 2 2 3 4 3 3
3 3 2 3 2 2.5 2 2 2 3 2 3 5 3 3 4 4 3 3 3 5 6 6 3 3 2 2 2 2 3 2 2
3 3 2 3 2 3 3 3 2 3 2 3 3 3 3 3 4 5 3 2 6 6 6 3 3 2 2 2 3 5 4 4
2
3
4 5
CASE REPORTS Case 1 of This Series A 15-year-old adolescent girl diagnosed with a right mandibular ameloblastoma from the body to subcondyle area underwent en
Case
Mesial
Distal
1
0.1 0.1 0.1 0.1 0.1 0.1 0.3 0.3 0.1 0.1 0.1 0.1 0.6 0.3 0.3 0.3 0.6 0.1 0.1 0.1 0.6 0.6 1.2 0.3 0.6 0.6 0.1 0.1 0.1 0.3 0.1 0.1
0.1 0.3 0.1 0.3 0.1 0.3 0.6 0.6 0.1 0.1 0.1 0.1 0.6 0.3 0.3 0.3 0.6 0.1 0.1 0.3 0.6 0.6 1.2 0.3 0.6 0.6 0.1 0.1 0.1 0.3 0.3 0.3
2
3
4 5
6
7
8
9
10
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6
7
TABLE 2. Marginal Bone Loss, mm (Postocclusal Loading)
& Volume 74, Number 4, April 2015
8
9
10
bloc resection from the right mandible from the canine teeth to the condyle and reconstructed with a reconstruction plate with condylar prosthesis 2 years prior (Fig. 1). The patient and her family requested denture restoration for functional and aesthetic improvements. The original reconstruction plate at the inferior border of the native mandible was maintained and a vascularized fibula contained 1 osteotomy, 2 segments (7 and 4 cm), and 3 pieces of dental implants were used for mandibular continuity restoration and dental rehabilitation. The implant-fibula construct was fixed to the superior border of the native mandible with miniplates (Fig. 1BYD). A portion of the skin paddle (3 6 cm) of the fibula osteoseptocutaneous f lap was used to reconstruct the intraoral lining. The remaining portion of the cutaneous f lap (3 7 cm) was deepithelialized and used to augment the submandibular hollow. Follow-up at 83 months revealed good bone union, functional and aesthetic results (Fig. 1EYG).
DISCUSSION The fibula f lap has been contoured to the inferior border of the native mandible, yielding good aesthetic results.7,8 However, the fibula bone (approximately 14 mm thick) cannot provide adequate bone height to match that of the native alveolar ridge, making prosthodontic rehabilitation challenging.9 Placement of the fibula f lap at the inferior border of the mandible results in a significant height * 2013 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Annals of Plastic Surgery
& Volume 74, Number 4, April 2015
Aesthetic & Functional Mandibular Reconstruction
TABLE 4. Cumulative Survival and Success Rate of Implants Placement to loading Loading to 1 y 1Y2 y 2Y3 y 3Y4 y 4Y5 y 95 y
Implant No.
Drop-out Implants
Failing Implants
Remade Implants
Cumulative Survival Rate, %
32 32 32 32 32 28 28
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
100 100 100 100 100 100 100
Failing implant, bone resorption greater than 1.5 mm in the first year postloading and greater than 0.2 mm the after years.
discrepancy between the reconstructed segment and the occlusal plane. The step-off at the mandibular interface creates a problem for patients with adjacent normal dentition. Endosteal implants would require long prosthetic suprastructures to approximate the occlusal plane. This discrepancy generates significant occlusal leverage forces, overloads the implant-borne prosthesis, and compromises its
long-term success.14 Additionally, using implants with long crowns produces less than ideal aesthetic results. Although a double-barrel fibula f lap is a worthwhile method of circumventing this problem, manipulation of the skin paddle and simultaneous placement of endosteal implants for large mandibular defects remains taxing.15,16 We have modified our practice by shifting the fibula f lap superiorly
FIGURE 1. A, Preoperative panoramic x-ray of case 1. B, Waxing screw connected to dental implants in implant-fibular construct. C, Stabilization of fibular-implant construct superiorly with miniplate fixation. D, Panoramic x-ray after reconstruction of mandible. E, Panoramic x-ray after complete prosthesis fabrication. 83 month F/u. F, Appearance of implant-supported prosthesis. G, Facial appearance 5 years after surgery. * 2013 Wolters Kluwer Health, Inc. All rights reserved.
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Shen et al
Annals of Plastic Surgery
and leaving approximately 10 to 12 mm of space between the upper margin of the implant-fibular construct and occlusal plane with the upper jaw.1 However, this modification would result in a significant facial contour deformity without the placement of a reconstruction plate in the inferior border of the newly reconstructed mandible. Fabrication of a well-contoured reconstruction plate during surgery can be a difficult and time-consuming task. Use of stereolithographic or wax models in segmental mandibular reconstructions allows for easier preoperative reconstruction plate contouring and shorter operative times.17 However, this type of costly technology has limited acceptance at our institution. Achieving good aesthetic results after tumor excision is invaluable to a patient’s quality of life. Patients who undergo segmental mandibulectomy require rigid fixation to ensure proper long-term mandibular function and alignment. Evaluation of bigonial widths and chin projections before resection is a useful aid for achieving appropriate facial contours.18 The fibular construct is fixed superiorly with miniplates and a low-profile reconstruction plate is precisely contoured to define the inferior mandibular border. This additional hardware preserves the skeletal integrity of the mandible and provides external soft tissues support. Soft tissue defects compromise the final aesthetic result, and therefore, mandates augmentation with vascularized deepithelialized cutaneous tissue. The addition of a reconstruction plate to the inferior mandibular border is selectively fashioned for patients diagnosed with benign disease when the overlying soft tissue drape is adequate. This modification may not be suitable for patients diagnosed with malignant disease. Most of the patients who undergo segmental mandibulectomy malignancy ablation also require adjuvant radiotherapy and are therefore not candidates for this type of reconstruction. They have a high risk for plate exposure after radiotherapy.19 The most remarkable functional benefits have been gained by placing the dental implants in the initial reconstructive phase. In addition, placement at the normal dentoalveolar position avoids damage to the implant suprastructure due to occlusal forces and mastication. This practice affords patients a hasty functional recovery with an implant-supported prosthesis. The palatal mucosal graft provides a good seal around the implant-borne prosthesis confirmed by diminished bone loss after functional loading and good oral hygiene care. This approach has contributed to the 100% implant survival rate. In conclusion, the technique described results in improved definition of the lower third of the face through simultaneous replacement of the supportive architecture and early functional recovery by placing the dental implants in the fibula construct at the appropriate height for a truly restorative occlusion in 1-stage.
1. Chana JS, Chang YM, Wei FC, et al. Segmental mandibulectomy and immediate free fibula osteoseptocutaneous flap reconstruction with endosteal implants: an ideal treatment method for mandibular ameloblastoma. Plast Reconstr Surg. 2004;113:80Y87. 2. Chang YM, Santamaria E, Wei FC, et al. Primary insertion of osseointegrated dental implants into fibula osteoseptocutaneous free flap for mandible reconstruction. Plast Reconstr Surg. 1998;102:680Y688. 3. Wei FC, Seah CS, Tsai YC, et al. Fibula osteocutaneous flap for reconstruction of composite mandibular defects. Plast Reconstruct Surg. 1994;93:294Y304. 4. Yim KK, Wei FC. Fibula osteoseptocutaneous flap for mandible reconstruction. Microsurgery. 1994;15:245Y249. 5. Taylor GI. A review of 60 consecutive fibula free flap mandible reconstruction (discussion). Plast Reconstr Surg. 1995;96:597Y602. 6. Jones NF, Monstrey S, Gambier BA. Reliability of the fibular osteocutaneous flap for mandibular reconstruction. Anatomical and surgical confirmation. Plast Reconstr Surg. 1996;97:707Y716. 7. Hidalgo DA. Fibula free flap: a new method of mandible reconstruction. Plast Reconstr Surg. 1989;84:71Y79. 8. Hidalgo DA. Aesthetic improvements in free-flap mandible reconstruction. Plast Reconstr Surg. 1991;88:574Y585. 9. Wells MD. Mandibular reconstruction using vascularized bone grafts. J Oral Maxillofac Surg. 1996;54:883Y888. 10. Chang YM, Chan CP, Shen YF, et al. Soft tissue management using palatal mucosa around endosteal implants in vascularized composite graft in the mandible. Int J Oral Maxillofac Surg. 1999;28:341Y343. 11. Albrektsson T, Zarb G, Worthington P, et al. The long-term efficacy of currently used dental implants. A renew and proposed criteria of success. Int J Oral Maxillofac Implants. 1986;1:11Y25. 12. Chiapasco M, Colletti G, Romeo E, et al. Long term result of mandible reconstruction with autogenous bone grafts and oral implants after tumor resection. Clin Oral Implants Res. 2008;19:1074Y1080. 13. Watzak G, Zechner W, Busenlechner D, et al. Radiological and clinical follow up of mechanical and anodized surface implants after mean functional loading for 33 months. Clin Oral Implants Res. 2006;17:651Y657. 14. Saadoun AP, LeGall ML. Clinical results and guidelines on Steri-Oss endosseous implants. Int J Periodontics Restorative Dent. 1992;12:486Y499. 15. Bahr W, Stoll P, Wachter R. Use of the ‘‘double barrel’’ free vascularized fibula in mandibular reconstruction. J Oral Maxillofac Surg. 1998;56:38Y44. 16. Chang YM, Tsai CY, Wei FC. One stage double barrel fibula osteoseptocutaneous flap and immediate dental implants for functional and esthetic reconstruction of segmental mandibular defects. Plast Reconstr Surg. 2008;122:143Y145. 17. Hannen EJM. Recreating the original contour in tumor deformed mandibles for plate adapting. Int J Oral Maxillofac Surg. 2006;35:183Y185. 18. King TW, Gallas MT, Robb GL, et al. Aesthetic and functional outcomes using osseous or soft-tissue free flaps. J Reconstr Microsurg. 2002;18:365Y368. 19. Wei FC, Celik N, Yang WG, et al. Complications after reconstruction by plate and soft-tissue free flap in composite mandibular defects and secondary salvage reconstruction with osteocutaneous flap. Plast Reconstr Surg. 2003; 112:37Y42.
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REFERENCES
* 2013 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Aesthetic and Functional Mandibular Reconstruction With Immediate Dental Implants in a Free Fibular Flap and a Low-Profile Reconstruction Plate Five-Year Follow-up Yu-Fu Shen, DDS,* Eduardo D. Rodriguez, MD, DDS,Þ Fu-Chan Wei, MD,Þ Chi-Ying Tsai, DDS,þ and Yang-Ming Chang, DDSþ Background: Aesthetic and functional mandibular reconstruction can be achieved in 1-stage. It involves simultaneous dental implant placement in a free vascularized fibula transfer with a low-profile reconstruction plate. The aim of this study was to assess the postoperative aesthetic profile and oral functional result. Material and Methods: Ten patients with a mean age of 31.6 years and an average follow-up time of 83.7 months underwent 1-staged mandibular reconstructions after segmental mandibulectomies. Simultaneous dental implantation was placed at the fibular segment according to the maxillary dentition. The fibula-implant construct was stabilized superiorly with miniplates and an additional low-profile reconstruction plate recreated the inferior mandibular contour. Any remaining vascularized soft tissue was used for augmentation. Palatal mucosa grafts were placed around the dental implant healing abutment at the uncovering stage surface. Aesthetic profile and oral function were evaluated postoperatively for 5 years. Results: All microsurgical transplantations were successful. None of the patients required subsequent revisions. All patients completed prosthodontic rehabilitation. All patients had palatal mucosal grafts placed around the dental implants. The mean probing pocket depths were shallower around the implants, 3.09 T 0.82 mm at mesial, 3.33 T 1.05 mm at distal, 3.02 T 1.13 mm at buccal, and 3.23 T 1.17 mm at lingual surfaces. Radiographs revealed no statistical differences in mean of the mesial [0.27 T 0.26 mm] and distal [0.33 T 0.25 mm] of peri-implant bone loss. The prosthetic load mean follow-up time was 71.7 months with a satisfactory implant-supported prosthesis. Two slender female patients palpated the reconstruction plate beneath the soft tissue envelope. Conclusions: This approach is selectively fashioned for patients with benign disease when the overlying soft tissue drape is adequate. The technique described results in improved appearance and function through definition of the lower third of the face and simultaneous dental implant replacement. Key Words: mandibular reconstruction, fibula, osteointegration teeth, implant (Ann Plast Surg 2015;74: 442Y446)
M
icrosurgical vascularized bone transfers have revolutionized mandibular reconstruction. It allows the performance of 1-staged restoration of the bony defect, facial contour, and dentition. The fibular osteoseptocutaneous f lap has been widely used for maxillary and mandibular reconstruction. The fibula has good bone
Received April 1, 2013, and accepted for publication, after revision, June 17, 2013. From the Departments of *Prosthodontics, †Plastic and Reconstructive Surgery, and ‡Oral and Maxillofacial Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taipei, Taiwan. This article has not been submitted to any other journal. Conflicts of interest and sources of funding: none declared. Reprints: Yang-Ming Chang, DDS, Department of Oral and Maxillofacial Surgery, Chang Gung Memorial Hospital, 199 Tun Hwa North Rd, Taipei 105, Taiwan. E-mail: [email protected]. Copyright * 2013 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043/15/7404-0442 DOI: 10.1097/SAP.0b013e3182a0dedf
442
www.annalsplasticsurgery.com
stock and sufficient bone length to be easily osteotomized to match the mandibular contour. It also has a long vascular pedicle combined with a reliable skin f lap that enables the simultaneous reconstruction of intraoral and/or external face defect. The fibula bone also has an adequately wide diameter for dental implantation and subsequent implant-supported prosthesis.1Y9 Despite its numerous advantages, 1 limitation is its inherent height discrepancy when compared to the native mandible. This deficiency makes it less than ideal for simultaneous restoration of the alveolar height to the level of the occlusal plane and the mandibular contour. The fibula f lap placement at the inferior border of the mandible yields excellent skeletal and soft-tissue contour but results in implant overloading, compromising long-term success. We sought to overcome this dilemma by shifting the fibula f lap superiorly toward the upper mandibular border with simultaneous dental implant insertion, placing an additional low-profile reconstruction plate at the inferior border of the native mandible and correcting the residual soft-tissue deficiency with deepithelialized skin island from the fibula osteoseptocutaneous f lap.
MATERIALS AND METHODS Between January 2003 and June 2004, 10 patients underwent simultaneous dental implant placement and fibula osteoseptocutaneous flap transfer along the superior mandibular border and a low-profile reconstruction plate at the inferior mandibular border for segmental mandibulectomy after ameloblastoma excision. Table 1 provides a summary of the patients’ data. Five patients were men and 5 patients were women, with an average age of 31.6 years (range, 15Y50 years) and the average bone defect was 7.75 cm (3.5Y12 cm). Facial aesthetic contour was evaluated by medical personnel during follow-up visits. En bloc ameloblastoma resection was performed with 1-cm tumor margins. Patients were placed in maxillomandibular fixation, allowing for restoration of the premorbid occlusion. First, a low-profile reconstruction plate was contoured and stabilized to the inferior border of the mandible. After completion of the fibula flap harvest and ostectomies, dental implant placement was performed on the back table as previously described.1 After accurately positioning the superior border of the fibula-implant construct approximately 10 to 12 mm inferior to the occlusal plane, the bony construct was stabilized with miniplates, the skin flap was inset, and microvascular anastamosis was performed. The remaining vascularized soft tissue from the fibula flap was used to provide soft-tissue augmentation when indicated. Approximately 6 to12 months later, the implant uncovering surgery was performed and palatal mucosa grafts placed around the implants.10 All patients were dentally rehabilitated with implantsupported fixed prosthesis and functional loading began approximately 3 months after implant uncovering. The following parameters were evaluated: (1) aesthetic facial contour, and (2) implant survival rate after functional loading. Annals of Plastic Surgery
& Volume 74, Number 4, April 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Annals of Plastic Surgery
& Volume 74, Number 4, April 2015
Aesthetic & Functional Mandibular Reconstruction
TABLE 1. Patient Summary Sex
Age, y
Osteotomies
Implants
Prosthetic Type
1
F
15
1/03
1
3
83 Fixed
2
M
18
7/03
0
3
78 Fixed
3
M
37
10/03
1
4
74 Fixed
4
M
32
10/03
0
2
74 Fixed
5
M
50
12/03
2
5
72 Fixed
6
F
21
12/03
0
3
72 Fixed
7
F
45
1/04
0
3
71 Fixed
8
F
19
3/04
1
4
59 Fixed
9
F
39
4/04
1
3
68 Fixed
10
M
22
6/04
1
2
66 Fixed
Patient
Diagram (Defect Size, cm)
Prosthetic Loading Follow-up, mo (Dec/10)
Date of Surgery
Cases 7 and 9, ameloblastoma recurrence; cases 1Y6, 8, and 10, ameloblastoma.
Implant survival and success rate was based on the following Albrektsson criteria: (a) painless, (b) no in question, (c) no mobility, and (d) no peri-implant radiolucency and peri-implant resorption less than 1.5 mm at the first year of function and 0.2 mm in the subsequent years.11 Peri-implant health was assessed for redness, hyperplasia, swelling, presence of plaque, and probing depth. Bone resorption was recorded by measuring the peri-implant marginal bone loss at the mesial and distal surfaces via panoramic or periapical x-ray. Vertical bone loss around the implant-abutment was gauged by * 2013 Wolters Kluwer Health, Inc. All rights reserved.
measuring the relation of the first thread of the implant fixture to the implant-crest bone junction. To correct the dimension distortion, the apparent dimension of the implant was measured on the radiographs and divided by the actual implant size.12,13
RESULTS All microsurgical transplantations were successful. None of the patients in our series required subsequent operations for either recurrence or additional recontouring. All patients achieved satisfactory www.annalsplasticsurgery.com
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
443
Annals of Plastic Surgery
Shen et al
to good facial aesthetics. A total of 32 pieces of dental implants were inserted; 25 pieces of implants were placed in simultaneous and the remaining 7 pieces of implants were placed at the second stage, when bone union between the fibula and native mandible junction was achieved. Panoramic and periapical radiographs revealed no statistical differences in mean peri-implant bone loss between the mesial [0.27 T 0.26 mm; range, 0.1Y1.2 mm] and distal [0.33 T 0.25 mm; range, 0.1Y1.2 mm] surfaces (Table 2). All 10 cases had palatal grafts placed around the dental implants during the uncovering surgery, The mean probing pocket depths were shallower around the implants, 3.09 T 0.82 mm at mesial, 3.33 T 1.05 mm at distal, 3.02 T 1.13 mm at buccal, and 3.23 T 1.17 mm at lingual surfaces (Table 3). Average follow-up was 71.7 months (range, 59Y83 months). The implant and prosthesis survival rate was 100% (Table 4). All patients were fully satisfied with the function of the prosthetic restoration. Eight patients were fully satisfied and 2 were partially satisfied with the aesthetic facial contour.
TABLE 3. Probing Implant Depth, mm Case
Mesial
Distal
Buccal
Lingual
1
3 3 3 2 2 3 3 3 2 3 2 3 3 3 3 4 3 4 3 3 5 5 5 3 3 2 2 2 3 4 3 3
2.5 3.5 2 3 2 3 3 4 2 3 2 3 5 3 3 4 5 4 3 4 5 5 6 4 3 2 2 2 3 4 3 3
3 3 2 3 2 2.5 2 2 2 3 2 3 5 3 3 4 4 3 3 3 5 6 6 3 3 2 2 2 2 3 2 2
3 3 2 3 2 3 3 3 2 3 2 3 3 3 3 3 4 5 3 2 6 6 6 3 3 2 2 2 3 5 4 4
2
3
4 5
CASE REPORTS Case 1 of This Series A 15-year-old adolescent girl diagnosed with a right mandibular ameloblastoma from the body to subcondyle area underwent en
Case
Mesial
Distal
1
0.1 0.1 0.1 0.1 0.1 0.1 0.3 0.3 0.1 0.1 0.1 0.1 0.6 0.3 0.3 0.3 0.6 0.1 0.1 0.1 0.6 0.6 1.2 0.3 0.6 0.6 0.1 0.1 0.1 0.3 0.1 0.1
0.1 0.3 0.1 0.3 0.1 0.3 0.6 0.6 0.1 0.1 0.1 0.1 0.6 0.3 0.3 0.3 0.6 0.1 0.1 0.3 0.6 0.6 1.2 0.3 0.6 0.6 0.1 0.1 0.1 0.3 0.3 0.3
2
3
4 5
6
7
8
9
10
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6
7
TABLE 2. Marginal Bone Loss, mm (Postocclusal Loading)
& Volume 74, Number 4, April 2015
8
9
10
bloc resection from the right mandible from the canine teeth to the condyle and reconstructed with a reconstruction plate with condylar prosthesis 2 years prior (Fig. 1). The patient and her family requested denture restoration for functional and aesthetic improvements. The original reconstruction plate at the inferior border of the native mandible was maintained and a vascularized fibula contained 1 osteotomy, 2 segments (7 and 4 cm), and 3 pieces of dental implants were used for mandibular continuity restoration and dental rehabilitation. The implant-fibula construct was fixed to the superior border of the native mandible with miniplates (Fig. 1BYD). A portion of the skin paddle (3 6 cm) of the fibula osteoseptocutaneous f lap was used to reconstruct the intraoral lining. The remaining portion of the cutaneous f lap (3 7 cm) was deepithelialized and used to augment the submandibular hollow. Follow-up at 83 months revealed good bone union, functional and aesthetic results (Fig. 1EYG).
DISCUSSION The fibula f lap has been contoured to the inferior border of the native mandible, yielding good aesthetic results.7,8 However, the fibula bone (approximately 14 mm thick) cannot provide adequate bone height to match that of the native alveolar ridge, making prosthodontic rehabilitation challenging.9 Placement of the fibula f lap at the inferior border of the mandible results in a significant height * 2013 Wolters Kluwer Health, Inc. All rights reserved.
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Annals of Plastic Surgery
& Volume 74, Number 4, April 2015
Aesthetic & Functional Mandibular Reconstruction
TABLE 4. Cumulative Survival and Success Rate of Implants Placement to loading Loading to 1 y 1Y2 y 2Y3 y 3Y4 y 4Y5 y 95 y
Implant No.
Drop-out Implants
Failing Implants
Remade Implants
Cumulative Survival Rate, %
32 32 32 32 32 28 28
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
100 100 100 100 100 100 100
Failing implant, bone resorption greater than 1.5 mm in the first year postloading and greater than 0.2 mm the after years.
discrepancy between the reconstructed segment and the occlusal plane. The step-off at the mandibular interface creates a problem for patients with adjacent normal dentition. Endosteal implants would require long prosthetic suprastructures to approximate the occlusal plane. This discrepancy generates significant occlusal leverage forces, overloads the implant-borne prosthesis, and compromises its
long-term success.14 Additionally, using implants with long crowns produces less than ideal aesthetic results. Although a double-barrel fibula f lap is a worthwhile method of circumventing this problem, manipulation of the skin paddle and simultaneous placement of endosteal implants for large mandibular defects remains taxing.15,16 We have modified our practice by shifting the fibula f lap superiorly
FIGURE 1. A, Preoperative panoramic x-ray of case 1. B, Waxing screw connected to dental implants in implant-fibular construct. C, Stabilization of fibular-implant construct superiorly with miniplate fixation. D, Panoramic x-ray after reconstruction of mandible. E, Panoramic x-ray after complete prosthesis fabrication. 83 month F/u. F, Appearance of implant-supported prosthesis. G, Facial appearance 5 years after surgery. * 2013 Wolters Kluwer Health, Inc. All rights reserved.
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& Volume 74, Number 4, April 2015
Shen et al
Annals of Plastic Surgery
and leaving approximately 10 to 12 mm of space between the upper margin of the implant-fibular construct and occlusal plane with the upper jaw.1 However, this modification would result in a significant facial contour deformity without the placement of a reconstruction plate in the inferior border of the newly reconstructed mandible. Fabrication of a well-contoured reconstruction plate during surgery can be a difficult and time-consuming task. Use of stereolithographic or wax models in segmental mandibular reconstructions allows for easier preoperative reconstruction plate contouring and shorter operative times.17 However, this type of costly technology has limited acceptance at our institution. Achieving good aesthetic results after tumor excision is invaluable to a patient’s quality of life. Patients who undergo segmental mandibulectomy require rigid fixation to ensure proper long-term mandibular function and alignment. Evaluation of bigonial widths and chin projections before resection is a useful aid for achieving appropriate facial contours.18 The fibular construct is fixed superiorly with miniplates and a low-profile reconstruction plate is precisely contoured to define the inferior mandibular border. This additional hardware preserves the skeletal integrity of the mandible and provides external soft tissues support. Soft tissue defects compromise the final aesthetic result, and therefore, mandates augmentation with vascularized deepithelialized cutaneous tissue. The addition of a reconstruction plate to the inferior mandibular border is selectively fashioned for patients diagnosed with benign disease when the overlying soft tissue drape is adequate. This modification may not be suitable for patients diagnosed with malignant disease. Most of the patients who undergo segmental mandibulectomy malignancy ablation also require adjuvant radiotherapy and are therefore not candidates for this type of reconstruction. They have a high risk for plate exposure after radiotherapy.19 The most remarkable functional benefits have been gained by placing the dental implants in the initial reconstructive phase. In addition, placement at the normal dentoalveolar position avoids damage to the implant suprastructure due to occlusal forces and mastication. This practice affords patients a hasty functional recovery with an implant-supported prosthesis. The palatal mucosal graft provides a good seal around the implant-borne prosthesis confirmed by diminished bone loss after functional loading and good oral hygiene care. This approach has contributed to the 100% implant survival rate. In conclusion, the technique described results in improved definition of the lower third of the face through simultaneous replacement of the supportive architecture and early functional recovery by placing the dental implants in the fibula construct at the appropriate height for a truly restorative occlusion in 1-stage.
1. Chana JS, Chang YM, Wei FC, et al. Segmental mandibulectomy and immediate free fibula osteoseptocutaneous flap reconstruction with endosteal implants: an ideal treatment method for mandibular ameloblastoma. Plast Reconstr Surg. 2004;113:80Y87. 2. Chang YM, Santamaria E, Wei FC, et al. Primary insertion of osseointegrated dental implants into fibula osteoseptocutaneous free flap for mandible reconstruction. Plast Reconstr Surg. 1998;102:680Y688. 3. Wei FC, Seah CS, Tsai YC, et al. Fibula osteocutaneous flap for reconstruction of composite mandibular defects. Plast Reconstruct Surg. 1994;93:294Y304. 4. Yim KK, Wei FC. Fibula osteoseptocutaneous flap for mandible reconstruction. Microsurgery. 1994;15:245Y249. 5. Taylor GI. A review of 60 consecutive fibula free flap mandible reconstruction (discussion). Plast Reconstr Surg. 1995;96:597Y602. 6. Jones NF, Monstrey S, Gambier BA. Reliability of the fibular osteocutaneous flap for mandibular reconstruction. Anatomical and surgical confirmation. Plast Reconstr Surg. 1996;97:707Y716. 7. Hidalgo DA. Fibula free flap: a new method of mandible reconstruction. Plast Reconstr Surg. 1989;84:71Y79. 8. Hidalgo DA. Aesthetic improvements in free-flap mandible reconstruction. Plast Reconstr Surg. 1991;88:574Y585. 9. Wells MD. Mandibular reconstruction using vascularized bone grafts. J Oral Maxillofac Surg. 1996;54:883Y888. 10. Chang YM, Chan CP, Shen YF, et al. Soft tissue management using palatal mucosa around endosteal implants in vascularized composite graft in the mandible. Int J Oral Maxillofac Surg. 1999;28:341Y343. 11. Albrektsson T, Zarb G, Worthington P, et al. The long-term efficacy of currently used dental implants. A renew and proposed criteria of success. Int J Oral Maxillofac Implants. 1986;1:11Y25. 12. Chiapasco M, Colletti G, Romeo E, et al. Long term result of mandible reconstruction with autogenous bone grafts and oral implants after tumor resection. Clin Oral Implants Res. 2008;19:1074Y1080. 13. Watzak G, Zechner W, Busenlechner D, et al. Radiological and clinical follow up of mechanical and anodized surface implants after mean functional loading for 33 months. Clin Oral Implants Res. 2006;17:651Y657. 14. Saadoun AP, LeGall ML. Clinical results and guidelines on Steri-Oss endosseous implants. Int J Periodontics Restorative Dent. 1992;12:486Y499. 15. Bahr W, Stoll P, Wachter R. Use of the ‘‘double barrel’’ free vascularized fibula in mandibular reconstruction. J Oral Maxillofac Surg. 1998;56:38Y44. 16. Chang YM, Tsai CY, Wei FC. One stage double barrel fibula osteoseptocutaneous flap and immediate dental implants for functional and esthetic reconstruction of segmental mandibular defects. Plast Reconstr Surg. 2008;122:143Y145. 17. Hannen EJM. Recreating the original contour in tumor deformed mandibles for plate adapting. Int J Oral Maxillofac Surg. 2006;35:183Y185. 18. King TW, Gallas MT, Robb GL, et al. Aesthetic and functional outcomes using osseous or soft-tissue free flaps. J Reconstr Microsurg. 2002;18:365Y368. 19. Wei FC, Celik N, Yang WG, et al. Complications after reconstruction by plate and soft-tissue free flap in composite mandibular defects and secondary salvage reconstruction with osteocutaneous flap. Plast Reconstr Surg. 2003; 112:37Y42.
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REFERENCES
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