SURGICAL ONCOLOGY AND RECONSTRUCTION
Mandibular Reconstruction With Iliac Crest Free Flap, Nasolabial Flap, and Osseointegrated Implants Carlos Navarro Cuellar, MD, DMD, PhD,* Santiago Jose Ochandiano Caicoya, MD, DMD,y Julio Jes us Acero Sanz, MD, DMD, PhD,z Ignacio Navarro Cuellar, MD, DMD,x Cristina Maza Muela, MD,k and Carlos Navarro Vila, MD, DMD, PhD{ Purpose:
Oncologic patients undergoing segmental mandibulectomy with soft tissue resection develop several esthetic and functional sequelae; therefore, the defect must be reconstructed immediately. The iliac crest flap is the only flap that allows reconstruction of the previous dimensions of the mandible. However, the excessive soft tissue of this flap prevents optimal reconstruction of intraoral soft tissue defects.
Materials and Methods:
This report describes a reconstructive technique used in 12 patients who underwent segmental mandibulectomy because of soft tissue defects resulting from tumor resection. The technique involves reconstruction of the mandible using an iliac crest flap combined with a nasolabial flap to enable subsequent reconstruction of the intraoral soft tissue and immediate placement of osseointegrated implants.
Results:
The osseointegration success rate was 95.2% with a failure rate of 4.8%. Failure particularly affected the irradiated patients. Excellent functional and aesthetic results were obtained with the iliac crest free flap, nasolabial flap and osseointegrated dental implants.
Conclusions: This technique has several advantages. On the one hand, it enables reconstruction of the original dimensions of the mandible, thus allowing immediate placement of implants in an ideal position for subsequent rehabilitation with a dental prosthesis. On the other hand, the nasolabial flap provides a thin layer of tissue that can be used to reconstruct the anatomy of the oromandibular soft tissue. Ó 2014 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 72:1226.e1-1226.e15, 2014
Reconstructive surgery is a technique that has been used for many years, although it remains challenging for the head and neck surgeon. Most clinical experience in mandibular reconstruction has been gained from the treatment of the devastating injuries received during the World Wars I and II.1 Currently, segmental
mandibular reconstruction is used mainly to treat defects produced by tumor resection. Extensive resection of tumor tissue often creates major bone and soft tissue defects, which have functional and esthetic consequences. It also leads to retrusion of the lower third of the face and severe ptosis of
Complutense
n General Hospital, Maxillofacial Department, Gregorio Mara~ no
University Medical School, Madrid, Spain; Staff Member, Oral and n General Hospital, Maxillofacial Department, Gregorio Mara~ no
Madrid, Spain. Address correspondence and reprint requests to Dr C. Navarro n GenCuellar: Oral and Maxillofacial Department, Gregorio Mara~ no
*Associate
Professor,
Maxillofacial
Surgery,
Madrid, Spain. yStaff Member, Oral and Maxillofacial Department, Gregorio n General Hospital, Madrid, Spain. Mara~ no
eral Hospital, Calle Doctor Esquerdo 46, 28007, Madrid, Spain; e-mail: [email protected]
zHead, Oral and Maxillofacial Department, Ram on y Cajal Hospital, Madrid, Spain.
Received November 5 2013 Accepted February 17 2014
xStaff Member, Oral and Maxillofacial Department, Virgen de la Salud Hospital, Toledo, Spain. kStaff Member, Oral and Maxillofacial Department, Gregorio n General Hospital, Madrid, Spain. Mara~ no
Ó 2014 American Association of Oral and Maxillofacial Surgeons 0278-2391/14/00242-0$36.00/0 http://dx.doi.org/10.1016/j.joms.2014.02.031
{Full Professor, Maxillofacial Surgery, Complutense University Medical School, Madrid, Spain; Head and Chair, Oral and
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Table 1. SEGMENTAL MANDIBULECTOMY IN PATIENTS WITH ASSOCIATED SOFT TISSUE DEFECTS
Age (yr)
Gender
Diagnosis
Mandibular Defect
41
M
43
M
66
F
68
M
52
M
59
F
73
F
45
M
left angle to right angle left angle to right angle left parasymphysis to right angle left angle to left parasymphysis right ramus to right parasymphysis left body to right body right angle to left angle right angle to left angle
60
M
53
M
squamous cell carcinoma of floor of mouth squamous cell carcinoma mandibular gum squamous cell carcinoma of floor of mouth squamous cell carcinoma of floor of mouth oncologic sequelae: osteoradionecrosis squamous cell carcinoma mandibular gum squamous cell carcinoma anterior floor of mouth squamous cell carcinoma of anterior floor of mouth squamous cell carcinoma right retromolar area squamous cell carcinoma right floor of mouth
48
M
squamous cell carcinoma left parasymphysis
52
M
basaloid squamous cell carcinoma
Length of Flap (cm)
right ramus to right body right mandibular angle to right parasymphysis left mandibular body to right mandibular body left body to right body
Radiotherapy (Gy)
Implants, n
Prosthesis
10
70
6
fixed
12
60
7
fixed
9
50
4
removable
5.5
no
3
fixed
7.5
60
2
fixed
11
60
3
fixed
10
50
8
fixed
11
50
4
removable
8
60
4
fixed
8
60
4
fixed
10
60
6
fixed
8
no
5
fixed
Abbreviations: F, female; M, male. Navarro Cuellar et al. Mandibular Reconstruction. J Oral Maxillofac Surg 2014.
the lower lip. Resection involving the body of the mandible leads to facial asymmetry with sinking of the affected side. This asymmetry is more noticeable when resection includes the condyle.2 The major functional sequelae are lower lip incompetence, salivary incontinence, extreme difficulty chewing and swallowing, and phonation disorders.3 Very often, the patient is unable to perform these functions, and social interaction and professional quality of life are clearly diminished.4,5 From an anatomic point of view, it is important to reconstruct not only the mandibular continuity defect, but also the associated soft tissue defect. Several surgical techniques can be used, depending on the bone and soft tissue defects to be reconstructed. The fibula flap is the only flap that enables reconstruction of segmental mandibular defects longer than 14 cm. In addition, this flap can be harvested with a reliable skin paddle for reconstruction of soft tissue.6 However, the height of the bone is less than that of the native mandible. The scapular flap also is insufficient in terms of height7 and cannot be used to reconstruct
defects longer than 12 to 14 cm.8,9 The iliac crest flap is the only free flap that enables reconstruction of the initial width and height of the mandible, immediate placement of implants in a position that does not interfere with osteosynthesis material, and, therefore, appropriate rehabilitation with a dental prosthesis. Its disadvantages are that it cannot be used to reconstruct defects longer than 14 cm10 and that its excessive soft tissue bulk renders it unsuitable for reconstruction of intraoral defects.4 The nasolabial flap is a pedicled flap supplied by the angular artery. It is straightforward and safe and enables moderate intraoral defects to be reconstructed with minimal esthetic consequences.11 Therefore, it is used as a complementary technique for reconstruction of complex orofacial defects. n General Hospital (Madrid, At Gregorio Mara~ no Spain) and in their private practice at Clinica Navarro Vila, the authors performed segmental mandibulectomy in 12 patients with an associated soft tissue defect. Reconstruction was performed with an iliac crest free flap, nasolabial flap, and immediate
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vessels was performed. The patient underwent surgery under general anesthesia. Before performing the ablative surgery, a reconstruction plate was modeled and placed at the level of the mandibulectomy and remnant mandible to maintain the intermaxillary relations. Then, the plate was removed and surgical resection was performed, including segmental mandibulectomy at the level of the right mandibular body and floor of the mouth and right functional neck dissection (Figs 3, 4). Immediate reconstruction was performed with an iliac crest free flap. The flap was modeled and adapted to the plate to reconstruct the segmental defect (Fig 5). The vascular pedicle was anastomosed to the facial artery and vein. During the same surgical procedure, 4 MG-OSSEOUS implants were placed on the iliac crest free flap (Fig 6). Then, the soft tissue defect was reconstructed with a right nasolabial flap tunneled into the mouth (Figs 7, 8). The study of the specimen showed free margins and a positive neck dissection. The patient received postoperative radiotherapy (Figs 912). Therefore, the osseointegration period (8 months) was duplicated and the patient underwent rehabilitation with an implant-fixed prosthesis. PATIENT 2
FIGURE 1. A 53-year-old man diagnosed with squamous cell carcinoma involving the mandibular gum and the right side of the floor of the mouth. Navarro Cuellar et al. Mandibular Reconstruction. J Oral Maxillofac Surg 2014.
osseointegrated implants. Ethical approval was obtained from the institution (Table 1).
Report of Cases This report describes 2 patients with segmental mandibular defects and associated soft tissue defects who underwent reconstruction using an iliac crest free flap, nasolabial flap, and immediate MG-OSSEOUS implants (Mozo-Grau, Valladolid, Spain). It also describes the patients’ subsequent rehabilitation with dental prostheses. PATIENT 1
A 53-year-old man developed a lesion in the right side of the floor of the mouth involving the mandibular gingiva and lingual cortical bone of the mandible (Fig 1). Biopsy of the tumor showed squamous cell carcinoma. Orthopantomography (OPT) and computed tomographic (CT) scans displayed the affected lingual cortical bone and there was no evidence of distant metastases (Fig 2). A vascular study of the cervical
A 48-year-old man was diagnosed with squamous cell carcinoma affecting the left parasymphysis of the mandible (Figs 13, 14). OPT and CT scans showed the tumor involving the left parasymphysis of the mandible with bone destruction at the external cortical bone without distant metastases (Figs 15, 16). Similar to patient 1, a plate for rigid fixation was modeled before the segmental mandibulectomy (Fig 17). The ablative surgery was carried out, including segmental mandibulectomy of the left body of the mandible with soft tissue margins and a left functional neck dissection. The defect was immediately reconstructed with an iliac crest free flap, which allowed reconstruction of the previous height and width of the mandible (Fig 18). The vascular pedicle was anastomosed to the superior thyroid artery and internal jugular vein. At the same time, 6 MG-OSSEOUS implants were placed on the iliac crest free flap (Fig 19). The soft tissue defect was reconstructed with a left nasolabial flap tunneled into the mouth (Fig 20). The study showed free margins and negative neck dissection. Four months later, at the time of the second phase of the dental implants, there was a lack of bone consolidation at the left side of the union between the iliac crest bone and remnant mandible (Fig 21). Therefore, a left mandibular osteoplasty was performed and rehabilitation of the dental implants was delayed 6 months (Fig 22). An implant-fixed prosthesis was developed for dental rehabilitation, achieving optimal esthetic and functional results (Figs 23-25).
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FIGURE 2. Preoperative orthopantomography. Navarro Cuellar et al. Mandibular Reconstruction. J Oral Maxillofac Surg 2014.
Discussion Reconstructive surgery has developed considerably during the past 30 to 40 years. Head and neck defects that require surgical reconstruction result from injury, deformity, and mainly oncologic resection. Although the main objective is cure, esthetic and functional rehabilitation has become a priority in the treatment of these patients.
From an esthetic point of view, segmental mandibulectomy can result in retrusion of the lower third of the face, especially when it involves the symphysis and parasymphysis and severe ptosis of the lower lip. Resection involving the body of the mandible leads to clear facial asymmetry with collapse of the affected side. This asymmetry is more evident when the resection includes the condyle.3 The main functional sequelae are lower lip incompetence, salivary incontinence, severe difficulty chewing and swallowing, and phonation disorders.2
FIGURE 3. Surgical resection including segmental mandibulectomy at the level of the right mandibular body and floor of the mouth and right functional neck dissection.
FIGURE 4. Resulting defect after ablative surgery.
Navarro Cuellar et al. Mandibular Reconstruction. J Oral Maxillofac Surg 2014.
Navarro Cuellar et al. Mandibular Reconstruction. J Oral Maxillofac Surg 2014.
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FIGURE 5. Iliac crest free flap for immediate reconstruction of the right mandibular body defect. Navarro Cuellar et al. Mandibular Reconstruction. J Oral Maxillofac Surg 2014.
The unreconstructed mandible tends to be retruded and deviates to the affected side. In addition, previous vertical movements are replaced by oblique or diagonal movements enabled by a single temporomandibular joint. Tongue mobility and strength are limited, and proprioceptive disorders lead to loss of coordination of mandibular movements.3 Given the many factors involved, reconstruction of the mandible should be meticulously planned and tailored to the patient. Therefore, to achieve the best possible esthetic and functional outcomes, complete mandibular reconstruction is comprised of 3 distinct phases: 1) bone reconstruction, 2) reconstruction of intraoral soft tissue, and 3) functional rehabilitation with osseointegrated implants. BONE RECONSTRUCTION
The primary objective of reconstruction is to ensure that the new mandible is as similar as possible in
FIGURE 7. Right nasolabial flap for reconstruction of the intraoral soft tissue defect resulting from ablative surgery. Navarro Cuellar et al. Mandibular Reconstruction. J Oral Maxillofac Surg 2014.
appearance to the native mandible in length, height, and width. Consequently, the scapular flap and the fibular flap do not re-create the previous height and width of the mandible. The iliac crest free flap allows reconstruction of the height, length, and width when the length to be reconstructed does not exceed 14 cm.
FIGURE 6. Immediate placement of 4 MG-OSSEOUS implants on the iliac crest flap.
FIGURE 8. Nasolabial flap tunneled into the mouth. Reconstruction of soft tissue defect.
Navarro Cuellar et al. Mandibular Reconstruction. J Oral Maxillofac Surg 2014.
Navarro Cuellar et al. Mandibular Reconstruction. J Oral Maxillofac Surg 2014.
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FIGURE 9. Postoperative orthopantomography showing reconstruction of the mandible with an iliac crest flap and immediate implants. Navarro Cuellar et al. Mandibular Reconstruction. J Oral Maxillofac Surg 2014.
In 1979, Taylor et al12 and Sanders and Mayou13 described the iliac crest free flap, which is supplied by the deep circumflex iliac artery (DCIA). In 1984, Ramasastry et al14 identified the ascending branch of the DCIA as the main blood supply to the internal oblique muscle. In 1989, Urken et al15,16 used this vascular pedicle in cases in which soft tissue was necessary for intraoral reconstruction. They grafted skin over the muscle to achieve a thinner, more pliable flap for oromandibular reconstruction. In 1988, Riediger17 was the first to place osseointegrated implants for esthetic and functional rehabilitation. The main characteristics of this flap are a bone length of 14 to 16 cm, a vascular pedicle that is 5 to 7 cm in length,18 and a vascular pedicle with a caliber of 2 to 3 mm for the artery and a caliber of 3 to 5 mm for the vein.19 Advantages 1. Bone measuring approximately 14 to 16 cm in length can be used to extend the dissection to the posterior superior iliac spine and sacroiliac joint.10 Nevertheless, Boyd20 does not recommend
2.
3.
4.
5.
using excessive bone, because the DCIA runs along the crest only for the first 6 cm before separating from the bone. Therefore, the more bone that is used in the corresponding osteotomies, the greater the risk of compromising the distal blood supply. The iliac crest flap provides bone of excellent quality for reconstruction of the mandible. It is the only flap that can be used to reconstruct the height and width of the native mandible. The iliac crest is basically cancellous bone and therefore has a rich blood supply that enables it to better tolerate infection. It also improves osseointegration of the implants.20 Multiple remodeling osteotomies can be performed to shape the new mandible. Osteotomy is performed on the outer cortical layer, leaving the periosteum intact on the inner aspect.18 The width and height of the iliac crest flap make it possible to place immediate implants during mandibular reconstruction without interfering with osteosynthesis material. Thus, dental implants can be placed in an ideal position for rehabilitation with a prosthesis. In this respect, the iliac crest flap differs considerably from the fibula flap, in which the decreased height of the
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FIGURE 10. Intraoral reconstruction 1 month after surgery. Navarro Cuellar et al. Mandibular Reconstruction. J Oral Maxillofac Surg 2014.
FIGURE 11. Left, Results 3 weeks after surgery. Note mandibular symmetry. Right, Results 3 months after surgery. Note the harmonious facial profile and favorable esthetic outcome for the jaw and nasolabial area. Frontal view. Navarro Cuellar et al. Mandibular Reconstruction. J Oral Maxillofac Surg 2014.
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Disadvantages 1. There is a risk of inguinal hernia.18 Alternative flaps should be considered in women of childbearing age. 2. In patients who have undergone surgery (appendectomy, herniorrhaphy, iliac crest free grafts), the vascular pedicle and its musculocutaneous perforators could have been damaged.21 In this case and to ensure greater safety, the authors prefer a contralateral crest or other flap. 3. There may be gait disorders owing to dissection of the tensor fascia lata and gluteus medius. 4. Impossibility of sensory reinnervation of the flap.22 Therefore, the authors’ indications for using the iliac crest flap for bone reconstruction are as follows: 1. Reconstruction of mandibular defects of up to 12 to 14 cm.23 2. Reconstruction of isolated mandibular bone defects in dentate patients (ameloblastoma, osteoradionecrosis, injury) with the possibility of placing immediate implants. 3. Reconstruction of the mandible and soft tissue defects with simultaneous placement of a nasolabial flap. FIGURE 12. Results 3 months after surgery. Lateral view. Navarro Cuellar et al. Mandibular Reconstruction. J Oral Maxillofac Surg 2014.
bone and the presence of osteosynthesis material can lead to poor positioning of the implants. 6. Two teams can work simultaneously.10 7. There are minimal esthetic sequelae.20
INTRAORAL SOFT TISSUE RECONSTRUCTION
Many oncologic patients must undergo resection of intraoral soft tissue to leave safety margins. On most occasions, these defects cannot be closed without reconstruction based on bone flaps with soft tissue. The ideal flap should have relatively thin and pliable soft tissue that can be used to reconstruct
FIGURE 13. A 48-year-old man diagnosed with squamous cell carcinoma affecting the left parasymphysis of the mandible. Frontal view.
FIGURE 14. Patient at lateral view.
Navarro Cuellar et al. Mandibular Reconstruction. J Oral Maxillofac Surg 2014.
Navarro Cuellar et al. Mandibular Reconstruction. J Oral Maxillofac Surg 2014.
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FIGURE 15. Preoperative orthopantomography. Navarro Cuellar et al. Mandibular Reconstruction. J Oral Maxillofac Surg 2014.
the anatomy of the mouth and mandible. It should ensure a constant blood supply through cutaneous perforators. The iliac crest flap requires a muscle cuff comprised of the internal oblique muscle, the external oblique
muscle, and the transversus abdominis muscle to ensure that the perforators to the skin paddle are included in the flap. This configuration is necessary, because the musculocutaneous perforators cross this triple muscle layer on their path to the
FIGURE 16. Preoperative computed tomogram shows a tumor involving the left parasymphysis of the mandible. Navarro Cuellar et al. Mandibular Reconstruction. J Oral Maxillofac Surg 2014.
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FIGURE 17. Modeled plate for rigid fixation before the segmental mandibulectomy.
FIGURE 19. Immediate placement of 6 MG-OSSEOUS implants on the iliac crest free flap.
Navarro Cuellar et al. Mandibular Reconstruction. J Oral Maxillofac Surg 2014.
Navarro Cuellar et al. Mandibular Reconstruction. J Oral Maxillofac Surg 2014.
skin.24 Consequently, the excessive bulk of the osteomusculocutaneous iliac crest flap renders it unsuitable for intraoral reconstruction. Nevertheless, it is occasionally used to reconstruct large defects resulting from ablative surgery.4 Alternatively, intraoral soft tissue can be reconstructed using the internal oblique muscle.15 In this case, neither the skin nor the subcutaneous cellular tissue is used; therefore, the volume of the soft tissue is smaller. This technique is problematic because the internal oblique muscle must cover the new mandible and the intraoral tissue, thus potentially compressing the vascular pedicle and leading to loss of the flap. Consequently, the soft tissue obtained from this flap is not ideal for reconstruction of intraoral soft tissue. The nasolabial flap is a pedicled skin flap that has been widely used for reconstruction of oronasal defects and defects of the lips, tongue, buccal mucosa, alveolar ridge (upper and lower), maxilla, and floor of the mouth.25-27 This flap is an axial flap supplied by
the angular artery. The skin of the nasolabial flap is doubly vascularized (upper and lower), thus enabling a flap to be raised based on the upper or lower pedicle. The facial artery is responsible for the blood supply of the lower flap. At the level of the fold, the blood supply comes from the lateral nasal and upper labial branches. As the facial artery courses over the dorsum of the nose, it becomes the angular artery. These branches supply the lower nasolabial flap. The lower pedicle nasolabial flap is the most widely used flap for the reconstruction of intraoral soft tissue. Defects of the lip, commissure, buccal mucosa, and floor of the mouth can be reconstructed using a nasolabial flap inside the oral cavity. This flap also is an excellent source of local tissue for immediate reconstruction of post-traumatic full-thickness defects. The main application of this flap in head and neck surgery is for reconstruction of defects in the anterior floor of the mouth. To cover defects of up to 5 cm, the nasolabial flap can be harvested bilaterally.28 The flaps should be cut in the shape of a triangle and superficial to the facial muscles. They are tunneled through the cheek and sutured to the floor of the mouth. Primary closure is performed in the donor area. The advantages of this flap for the reconstruction of the floor of the mouth include the contribution of a large amount of soft tissue for repair and the favorable appearance of the donor area after closure. The disadvantages of this flap are the presence of hair in the donor area, especially in men, and the potential compression of the vascular pedicle in dentate patients. Therefore, the nasolabial flap should be used in edentulous patients in the area to be repaired to avoid damage to the pedicle. In the reconstruction of segmental mandibular defects with soft tissue defects, the combination of the iliac crest flap for bone reconstruction with the
FIGURE 18. Iliac crest free flap. Navarro Cuellar et al. Mandibular Reconstruction. J Oral Maxillofac Surg 2014.
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FIGURE 20. Left, Left nasolabial flap used to reconstruct the associated soft tissue defect. Right, Appearance of the left nasolabial flap 1 month after surgery. Navarro Cuellar et al. Mandibular Reconstruction. J Oral Maxillofac Surg 2014.
nasolabial flap for intraoral reconstruction is an excellent option that allows restoration of the width and height of the mandible with adequate soft tissue volume.
OSSEOINTEGRATED IMPLANTS
Before the development of techniques for the reconstruction of the head and neck with microsurgical free flaps and pedicled flaps, patients who had
FIGURE 21. Orthopantomography after reconstructive surgery. An iliac crest flap was used to reconstruct the mandibular height and immediate implant placement. Note the lack of bone consolidation at the left side of the union between the iliac crest bone and the remnant mandible. Navarro Cuellar et al. Mandibular Reconstruction. J Oral Maxillofac Surg 2014.
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FIGURE 22. Left mandibular osteoplasty at the union with the iliac crest in the second phase of implant surgery. Rehabilitation was performed with an implant-fixed prosthesis. Navarro Cuellar et al. Mandibular Reconstruction. J Oral Maxillofac Surg 2014.
undergone segmental mandibulectomy had a moderate or severe esthetic defect, and restoration of function to presurgical levels was minimal.29 The use of conventional prostheses in such patients provides little improvement owing to the lack of mandibular bone support and anatomic and physiologic impairment of the soft tissue. The anatomic impairment resulting from reconstruction of the mandible includes increased flap thickness, loss of sensation in the flap, changes in the muscles of mastication, loss of the labial vestibule, and an irregular bone contour. In addition, patients who have undergone radiation therapy will present xerostomia and mucosal atrophy, which makes it even more difficult to support removable prostheses and can lead to local irritation, ulceration, and exposure of the bone.30 Consequently, in most cases, these prostheses are not even suitable for improving the appearance of the lips. Patients feel greatly frustrated and, in most cases, social or occupational interaction is diminished. The degree of impairment of mastication depends on the amount of mandible resected, tongue function, and lip competence. The tongue should be able to
place the food bolus over the occlusive surfaces of the teeth so that it can be chewed. Often limited in strength and mobility, the tongue plays a key role in balancing the position of movable (removable) prostheses. An unreconstructed mandible tends to retract and deviate to the operated side. When the mandible opens and closes, the original vertical movements are replaced by oblique or diagonal movements enabled by only 1 temporomandibular joint. The loss of the proprioceptive sense of occlusion induces lack of coordination and less accurate mandibular movements. The loss of the muscles of mastication on the operated side also forces the mandible to rotate upward during closure in the frontal plane. The severity and duration of the deviation are variable and unpredictable and depend on many factors. The loss of soft tissue and primary closure of the unreconstructed defect with flaps contribute to this impaired function.29 Esthetic and functional rehabilitation of these patients has advanced considerably with the clinical application of osseointegrated implants in edentulous mandibles and the subsequent studies by Br anemark et al31 and Lindstr€ om et al32 who used titanium screws
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FIGURE 23. Final appearance of the implant-fixed prosthesis in the mouth. A nasolabial flap was used to reconstruct the anterior floor of the mouth. Navarro Cuellar et al. Mandibular Reconstruction. J Oral Maxillofac Surg 2014.
in bone grafts, thus showing that suitable osseointegration could be achieved and that bone implants could be used to support a prosthesis. Riediger17 was the first surgeon to place implants in the iliac crest flap, and Urken et al33 placed them immediately during reconstruction of the bone. One of the main advantages of the iliac crest flap is its rich blood supply. The better a flap is vascularized, the easier and faster osseointegration of the implants is. The size of the blood supply is closely associated with the quantity of cancellous bone in the flaps. Thus, the iliac crest is well irrigated because it contains a large amount of cancellous bone. Another advantage of this flap is its size: using the iliac crest makes it possible to recreate the width and height of the native mandible; therefore, it is suitable for long and thick implants to ensure functional rehabilitation. Similarly, the height of this flap allows immediate placement of implants, without the interference of osteosynthesis material in the ideal positioning of the implants for appropriate rehabilitation with dental prosthesis. The role of radiation therapy in bone and implants is of paramount importance when planning functional rehabilitation. The negative effects of radiation ther-
apy on bone include destruction of capillaries, proliferative endarteritis, decrease in bone cell population, and decreased neovascularization.34 Radiation therapy impairs scarring in the irradiated tissue. The authors usually try to place the implants immediately for several reasons: 1. Faster rehabilitation of the prosthesis. 2. Fewer surgical interventions. 3. It is mandatory in patients who are to receive radiation therapy. Urken et al33 found that reconstructive surgery and initiation of radiation therapy are usually separated by a 4- to 6-week interval. The initiation of radiation therapy and the onset of its effects on bone and implants are separated by an additional 6 to 8 weeks. Therefore, a 3-month window period is available. After this period, the osteophyllic and osteoconductive phases of osseointegration are complete, and the implants are osseointegrated. To real with have
conclude, the authors have highlighted the possibility of offering dental rehabilitation an implant-fixed prosthesis to patients who undergone segmental mandibulectomy and
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FIGURE 24. Lateral view 1 year after surgery and after dental rehabilitation.
FIGURE 25. Final frontal view. Note the mandibular and facial symmetry. The cosmetic outcome of the left nasolabial area was optimal.
Navarro Cuellar et al. Mandibular Reconstruction. J Oral Maxillofac Surg 2014.
Navarro Cuellar et al. Mandibular Reconstruction. J Oral Maxillofac Surg 2014.
reconstruction with an iliac crest free flap and nasolabial flap. This technique ensures a favorable esthetic and functional outcome and improves facial harmony and quality of life.
References 1. Navarro Cu ellar C: [Mandibular reconstruction. Free flaps versus pediculated flaps]. Doctoral thesis. Madrid, Spain, Universidad Complutense de Madrid, 2005 (in Spanish) 2. Cuesta M, Ochandiano S, Riba F, et al: Oral rehabilitation with osseointegrated implants in oncological patients. J Oral Maxillofac Surg 67:2485, 2009 3. Cuesta Gil M, Ochandiano S, Barrios JM, Navarro Vila C: Rehabilitacio´n oral con implantes osteointegrados en pacientes oncologicos. Rev Esp Cirugı´a Oral y Maxillofacial 23:171, 2001 4. Navarro Vila C, L opez de Atalaya FJ, Cuesta Gil M, et al: [Our reconstructive experience in advanced head and neck cancer]. Rev Esp Cir Oral Maxilofac 17:1, 1995 5. L opez de Atalaya FJ: [Use of microsurgical flaps in maxillofacial surgery]. Doctoral thesis. Madrid, Spain, Universidad Complutense de Madrid, 1996 6. Swartz WM, Banis JC: Head and Neck Microsurgery. Fibula. Section II1. Baltimore, MD, Williams and Wilkins, 1992, pp 75–82 7. Frodel JL, Funk GF, Capper DT, et al: Osseointegrated implants: A comparative study of bone thickness in four vascularized bone flaps. Plast Reconstr Surg 92:449, 1993
8. Swartz W, Banis J, Newton D, et al: The osteocutaneous scapular flap for mandibular and maxillary reconstruction. Plast Reconstr Surg 77:530, 1986 9. Sullivan MJ, Baker SR, Crompton R, et al: Free scapular osteocutaneous flap for mandibular reconstruction. Arch Otolaryngol Head Neck Surg 115:1334, 1989 10. Urken ML: Composite free flaps in oromandibular reconstruction. Arch Otolaryngol Head Neck Surg 117:724, 1991 11. Hofstraa EI, Hoferb SOP, Nautac JM, et al: Oral functional outcome after intraoral reconstruction with nasolabial flaps. Br Assoc Plast Surg 57:150, 2004 12. Taylor GI, Townsend P, Corlett R: Superiority of the deep circumflex iliac vessels as the supply for free groin flaps: Experimental work. Plast Reconstr Surg 64:595, 1979 13. Sanders R, Mayou B: A new vascularized bone graft transferred by microvascular anastomosis as a free flap. Br J Surg 66:787, 1979 14. Ramasastry SS, Granick MS, Futrell J: Clinical anatomy of the internal oblique muscle. J Reconstr Microsurg 2:117, 1986 15. Urken ML, Vickery C, Weinberg H, et al: The internal obliqueiliac crest osseomyocutaneous free flap in head and neck reconstruction. J Reconstr Microsurg 5:203, 1989 16. Urken ML, Vickery C, Weinberg H, et al: The internal obliqueiliac crest osseomyocutaneous free flap in oromandibular reconstruction: Report of 20 cases. Arch Otolaryngol Head Neck Surg 115:339, 1989 17. Riediger D: Restoration of masticatory function by microsurgically revascularized iliac crest bone grafts using endosseous implants. Plast Reconstr Surg 81:861, 1988
1226.e15 18. Kuriloff DB, Sullivan MJ: Mandibular reconstruction using vascularized bone grafts. Otolaryngol Clin N Am 24:1391, 1991 19. Fredickson JM, Man SC, Hayden RE: Revascularized iliac bone graft for mandibular reconstruction. Acta Otolarynngol (Stockh) 99:214, 1985 20. Boyd JB: The place of the iliac crest vascularized flap in oromandibular reconstruction. Microsurgery 15:250, 1994 21. Baker SR: Microsurgical Reconstruction of the Head and Neck. New York, NY, Churchill Livingstone, 1989 22. Urken ML, Cheney ML, Sullivan MJ, et al: Atlas of Regional and Free Flaps for Head and Neck Reconstruction. New York, NY, Raven Press, 1995, p 274 23. Navarro Vila C, Acero Sanz J, Del Amo Fernandez de Velasco A, et al: Reconstrucci on Microquir urgica de los Defectos Oseos Oncol ogicos. Cirugıa Oral. Madrid, Spain, Aran Ediciones SL, 2008, pp 593–605 24. Omokawa S, Tamai S, Takayura Y, et al: A long term study of the donor ankle after vascularized fibula grafts in children. Microsurgery 17:162, 1996 25. Cormack G, Lamberty B: The Arterial Anatomy of Skin Flaps (ed 2). Edinburgh, UK, Churchill Livingston, 1994 26. Barthelemy I, Paoli J, Boutault F, et al: A superiorly pedicled nasobuccal flap: Its value in the reconstruction of posteriorsuperior loss of substance of the oral mucosa. Rev Stomatol Chir Maxillofac 97:217, 1996
MANDIBULAR RECONSTRUCTION 27. Varghese BT, Sebastian P, Cherian T, et al: Nasolabial flaps in oral reconstruction: An analysis of 224 cases. Br J Plast Surg 54:499, 2001 28. Lazaridis N, Zouloumis L, Venetis G, et al: The inferiorly and superiorly based nasolabial flap for the reconstruction of moderate-sized oronasal defects. J Oral Maxillofac Surg 56: 1255, 1998 29. Komisar A: The functional result of mandible reconstruction. Laryngoscope 100:364, 1990 30. Urken ML, Moscoso J, Lawson W, et al: A systematic approach to functional reconstruction of the oral cavity following partial and total glossectomy. Arch Otolaryngol Head Neck Surg 120:589, 1994 31. Br anemark PE, Hansson BO, Adell R: Osseointegrated implants in the treatment of the edentulous jaw. Scand J Plast Reconstr Surg 111:1, 1977 32. Lindstr€ om J, Br anemark PI, Albrektsson T: Mandibular reconstruction using performed autologous bone graft. Scand J Plast Reconstr Surg 15:29, 1981 33. Urken ML, Weinberg H, Vickery C, et al: Primary placement of osseointegrated implants in microvascular mandibular reconstruction. Otolaryngol Head Neck Surg 101:56, 1989 34. Barber HD, Seckinger RJ, Hayden RE, et al: Evaluation of osseointegration of endosseus implants in radiated, vascularized fibula flaps to the mandible: A pilot study. J Oral Maxillofac Surg 53:640, 1995
Mandibular Reconstruction With Iliac Crest Free Flap, Nasolabial Flap, and Osseointegrated Implants Carlos Navarro Cuellar, MD, DMD, PhD,* Santiago Jose Ochandiano Caicoya, MD, DMD,y Julio Jes us Acero Sanz, MD, DMD, PhD,z Ignacio Navarro Cuellar, MD, DMD,x Cristina Maza Muela, MD,k and Carlos Navarro Vila, MD, DMD, PhD{ Purpose:
Oncologic patients undergoing segmental mandibulectomy with soft tissue resection develop several esthetic and functional sequelae; therefore, the defect must be reconstructed immediately. The iliac crest flap is the only flap that allows reconstruction of the previous dimensions of the mandible. However, the excessive soft tissue of this flap prevents optimal reconstruction of intraoral soft tissue defects.
Materials and Methods:
This report describes a reconstructive technique used in 12 patients who underwent segmental mandibulectomy because of soft tissue defects resulting from tumor resection. The technique involves reconstruction of the mandible using an iliac crest flap combined with a nasolabial flap to enable subsequent reconstruction of the intraoral soft tissue and immediate placement of osseointegrated implants.
Results:
The osseointegration success rate was 95.2% with a failure rate of 4.8%. Failure particularly affected the irradiated patients. Excellent functional and aesthetic results were obtained with the iliac crest free flap, nasolabial flap and osseointegrated dental implants.
Conclusions: This technique has several advantages. On the one hand, it enables reconstruction of the original dimensions of the mandible, thus allowing immediate placement of implants in an ideal position for subsequent rehabilitation with a dental prosthesis. On the other hand, the nasolabial flap provides a thin layer of tissue that can be used to reconstruct the anatomy of the oromandibular soft tissue. Ó 2014 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 72:1226.e1-1226.e15, 2014
Reconstructive surgery is a technique that has been used for many years, although it remains challenging for the head and neck surgeon. Most clinical experience in mandibular reconstruction has been gained from the treatment of the devastating injuries received during the World Wars I and II.1 Currently, segmental
mandibular reconstruction is used mainly to treat defects produced by tumor resection. Extensive resection of tumor tissue often creates major bone and soft tissue defects, which have functional and esthetic consequences. It also leads to retrusion of the lower third of the face and severe ptosis of
Complutense
n General Hospital, Maxillofacial Department, Gregorio Mara~ no
University Medical School, Madrid, Spain; Staff Member, Oral and n General Hospital, Maxillofacial Department, Gregorio Mara~ no
Madrid, Spain. Address correspondence and reprint requests to Dr C. Navarro n GenCuellar: Oral and Maxillofacial Department, Gregorio Mara~ no
*Associate
Professor,
Maxillofacial
Surgery,
Madrid, Spain. yStaff Member, Oral and Maxillofacial Department, Gregorio n General Hospital, Madrid, Spain. Mara~ no
eral Hospital, Calle Doctor Esquerdo 46, 28007, Madrid, Spain; e-mail: [email protected]
zHead, Oral and Maxillofacial Department, Ram on y Cajal Hospital, Madrid, Spain.
Received November 5 2013 Accepted February 17 2014
xStaff Member, Oral and Maxillofacial Department, Virgen de la Salud Hospital, Toledo, Spain. kStaff Member, Oral and Maxillofacial Department, Gregorio n General Hospital, Madrid, Spain. Mara~ no
Ó 2014 American Association of Oral and Maxillofacial Surgeons 0278-2391/14/00242-0$36.00/0 http://dx.doi.org/10.1016/j.joms.2014.02.031
{Full Professor, Maxillofacial Surgery, Complutense University Medical School, Madrid, Spain; Head and Chair, Oral and
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Table 1. SEGMENTAL MANDIBULECTOMY IN PATIENTS WITH ASSOCIATED SOFT TISSUE DEFECTS
Age (yr)
Gender
Diagnosis
Mandibular Defect
41
M
43
M
66
F
68
M
52
M
59
F
73
F
45
M
left angle to right angle left angle to right angle left parasymphysis to right angle left angle to left parasymphysis right ramus to right parasymphysis left body to right body right angle to left angle right angle to left angle
60
M
53
M
squamous cell carcinoma of floor of mouth squamous cell carcinoma mandibular gum squamous cell carcinoma of floor of mouth squamous cell carcinoma of floor of mouth oncologic sequelae: osteoradionecrosis squamous cell carcinoma mandibular gum squamous cell carcinoma anterior floor of mouth squamous cell carcinoma of anterior floor of mouth squamous cell carcinoma right retromolar area squamous cell carcinoma right floor of mouth
48
M
squamous cell carcinoma left parasymphysis
52
M
basaloid squamous cell carcinoma
Length of Flap (cm)
right ramus to right body right mandibular angle to right parasymphysis left mandibular body to right mandibular body left body to right body
Radiotherapy (Gy)
Implants, n
Prosthesis
10
70
6
fixed
12
60
7
fixed
9
50
4
removable
5.5
no
3
fixed
7.5
60
2
fixed
11
60
3
fixed
10
50
8
fixed
11
50
4
removable
8
60
4
fixed
8
60
4
fixed
10
60
6
fixed
8
no
5
fixed
Abbreviations: F, female; M, male. Navarro Cuellar et al. Mandibular Reconstruction. J Oral Maxillofac Surg 2014.
the lower lip. Resection involving the body of the mandible leads to facial asymmetry with sinking of the affected side. This asymmetry is more noticeable when resection includes the condyle.2 The major functional sequelae are lower lip incompetence, salivary incontinence, extreme difficulty chewing and swallowing, and phonation disorders.3 Very often, the patient is unable to perform these functions, and social interaction and professional quality of life are clearly diminished.4,5 From an anatomic point of view, it is important to reconstruct not only the mandibular continuity defect, but also the associated soft tissue defect. Several surgical techniques can be used, depending on the bone and soft tissue defects to be reconstructed. The fibula flap is the only flap that enables reconstruction of segmental mandibular defects longer than 14 cm. In addition, this flap can be harvested with a reliable skin paddle for reconstruction of soft tissue.6 However, the height of the bone is less than that of the native mandible. The scapular flap also is insufficient in terms of height7 and cannot be used to reconstruct
defects longer than 12 to 14 cm.8,9 The iliac crest flap is the only free flap that enables reconstruction of the initial width and height of the mandible, immediate placement of implants in a position that does not interfere with osteosynthesis material, and, therefore, appropriate rehabilitation with a dental prosthesis. Its disadvantages are that it cannot be used to reconstruct defects longer than 14 cm10 and that its excessive soft tissue bulk renders it unsuitable for reconstruction of intraoral defects.4 The nasolabial flap is a pedicled flap supplied by the angular artery. It is straightforward and safe and enables moderate intraoral defects to be reconstructed with minimal esthetic consequences.11 Therefore, it is used as a complementary technique for reconstruction of complex orofacial defects. n General Hospital (Madrid, At Gregorio Mara~ no Spain) and in their private practice at Clinica Navarro Vila, the authors performed segmental mandibulectomy in 12 patients with an associated soft tissue defect. Reconstruction was performed with an iliac crest free flap, nasolabial flap, and immediate
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vessels was performed. The patient underwent surgery under general anesthesia. Before performing the ablative surgery, a reconstruction plate was modeled and placed at the level of the mandibulectomy and remnant mandible to maintain the intermaxillary relations. Then, the plate was removed and surgical resection was performed, including segmental mandibulectomy at the level of the right mandibular body and floor of the mouth and right functional neck dissection (Figs 3, 4). Immediate reconstruction was performed with an iliac crest free flap. The flap was modeled and adapted to the plate to reconstruct the segmental defect (Fig 5). The vascular pedicle was anastomosed to the facial artery and vein. During the same surgical procedure, 4 MG-OSSEOUS implants were placed on the iliac crest free flap (Fig 6). Then, the soft tissue defect was reconstructed with a right nasolabial flap tunneled into the mouth (Figs 7, 8). The study of the specimen showed free margins and a positive neck dissection. The patient received postoperative radiotherapy (Figs 912). Therefore, the osseointegration period (8 months) was duplicated and the patient underwent rehabilitation with an implant-fixed prosthesis. PATIENT 2
FIGURE 1. A 53-year-old man diagnosed with squamous cell carcinoma involving the mandibular gum and the right side of the floor of the mouth. Navarro Cuellar et al. Mandibular Reconstruction. J Oral Maxillofac Surg 2014.
osseointegrated implants. Ethical approval was obtained from the institution (Table 1).
Report of Cases This report describes 2 patients with segmental mandibular defects and associated soft tissue defects who underwent reconstruction using an iliac crest free flap, nasolabial flap, and immediate MG-OSSEOUS implants (Mozo-Grau, Valladolid, Spain). It also describes the patients’ subsequent rehabilitation with dental prostheses. PATIENT 1
A 53-year-old man developed a lesion in the right side of the floor of the mouth involving the mandibular gingiva and lingual cortical bone of the mandible (Fig 1). Biopsy of the tumor showed squamous cell carcinoma. Orthopantomography (OPT) and computed tomographic (CT) scans displayed the affected lingual cortical bone and there was no evidence of distant metastases (Fig 2). A vascular study of the cervical
A 48-year-old man was diagnosed with squamous cell carcinoma affecting the left parasymphysis of the mandible (Figs 13, 14). OPT and CT scans showed the tumor involving the left parasymphysis of the mandible with bone destruction at the external cortical bone without distant metastases (Figs 15, 16). Similar to patient 1, a plate for rigid fixation was modeled before the segmental mandibulectomy (Fig 17). The ablative surgery was carried out, including segmental mandibulectomy of the left body of the mandible with soft tissue margins and a left functional neck dissection. The defect was immediately reconstructed with an iliac crest free flap, which allowed reconstruction of the previous height and width of the mandible (Fig 18). The vascular pedicle was anastomosed to the superior thyroid artery and internal jugular vein. At the same time, 6 MG-OSSEOUS implants were placed on the iliac crest free flap (Fig 19). The soft tissue defect was reconstructed with a left nasolabial flap tunneled into the mouth (Fig 20). The study showed free margins and negative neck dissection. Four months later, at the time of the second phase of the dental implants, there was a lack of bone consolidation at the left side of the union between the iliac crest bone and remnant mandible (Fig 21). Therefore, a left mandibular osteoplasty was performed and rehabilitation of the dental implants was delayed 6 months (Fig 22). An implant-fixed prosthesis was developed for dental rehabilitation, achieving optimal esthetic and functional results (Figs 23-25).
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FIGURE 2. Preoperative orthopantomography. Navarro Cuellar et al. Mandibular Reconstruction. J Oral Maxillofac Surg 2014.
Discussion Reconstructive surgery has developed considerably during the past 30 to 40 years. Head and neck defects that require surgical reconstruction result from injury, deformity, and mainly oncologic resection. Although the main objective is cure, esthetic and functional rehabilitation has become a priority in the treatment of these patients.
From an esthetic point of view, segmental mandibulectomy can result in retrusion of the lower third of the face, especially when it involves the symphysis and parasymphysis and severe ptosis of the lower lip. Resection involving the body of the mandible leads to clear facial asymmetry with collapse of the affected side. This asymmetry is more evident when the resection includes the condyle.3 The main functional sequelae are lower lip incompetence, salivary incontinence, severe difficulty chewing and swallowing, and phonation disorders.2
FIGURE 3. Surgical resection including segmental mandibulectomy at the level of the right mandibular body and floor of the mouth and right functional neck dissection.
FIGURE 4. Resulting defect after ablative surgery.
Navarro Cuellar et al. Mandibular Reconstruction. J Oral Maxillofac Surg 2014.
Navarro Cuellar et al. Mandibular Reconstruction. J Oral Maxillofac Surg 2014.
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FIGURE 5. Iliac crest free flap for immediate reconstruction of the right mandibular body defect. Navarro Cuellar et al. Mandibular Reconstruction. J Oral Maxillofac Surg 2014.
The unreconstructed mandible tends to be retruded and deviates to the affected side. In addition, previous vertical movements are replaced by oblique or diagonal movements enabled by a single temporomandibular joint. Tongue mobility and strength are limited, and proprioceptive disorders lead to loss of coordination of mandibular movements.3 Given the many factors involved, reconstruction of the mandible should be meticulously planned and tailored to the patient. Therefore, to achieve the best possible esthetic and functional outcomes, complete mandibular reconstruction is comprised of 3 distinct phases: 1) bone reconstruction, 2) reconstruction of intraoral soft tissue, and 3) functional rehabilitation with osseointegrated implants. BONE RECONSTRUCTION
The primary objective of reconstruction is to ensure that the new mandible is as similar as possible in
FIGURE 7. Right nasolabial flap for reconstruction of the intraoral soft tissue defect resulting from ablative surgery. Navarro Cuellar et al. Mandibular Reconstruction. J Oral Maxillofac Surg 2014.
appearance to the native mandible in length, height, and width. Consequently, the scapular flap and the fibular flap do not re-create the previous height and width of the mandible. The iliac crest free flap allows reconstruction of the height, length, and width when the length to be reconstructed does not exceed 14 cm.
FIGURE 6. Immediate placement of 4 MG-OSSEOUS implants on the iliac crest flap.
FIGURE 8. Nasolabial flap tunneled into the mouth. Reconstruction of soft tissue defect.
Navarro Cuellar et al. Mandibular Reconstruction. J Oral Maxillofac Surg 2014.
Navarro Cuellar et al. Mandibular Reconstruction. J Oral Maxillofac Surg 2014.
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FIGURE 9. Postoperative orthopantomography showing reconstruction of the mandible with an iliac crest flap and immediate implants. Navarro Cuellar et al. Mandibular Reconstruction. J Oral Maxillofac Surg 2014.
In 1979, Taylor et al12 and Sanders and Mayou13 described the iliac crest free flap, which is supplied by the deep circumflex iliac artery (DCIA). In 1984, Ramasastry et al14 identified the ascending branch of the DCIA as the main blood supply to the internal oblique muscle. In 1989, Urken et al15,16 used this vascular pedicle in cases in which soft tissue was necessary for intraoral reconstruction. They grafted skin over the muscle to achieve a thinner, more pliable flap for oromandibular reconstruction. In 1988, Riediger17 was the first to place osseointegrated implants for esthetic and functional rehabilitation. The main characteristics of this flap are a bone length of 14 to 16 cm, a vascular pedicle that is 5 to 7 cm in length,18 and a vascular pedicle with a caliber of 2 to 3 mm for the artery and a caliber of 3 to 5 mm for the vein.19 Advantages 1. Bone measuring approximately 14 to 16 cm in length can be used to extend the dissection to the posterior superior iliac spine and sacroiliac joint.10 Nevertheless, Boyd20 does not recommend
2.
3.
4.
5.
using excessive bone, because the DCIA runs along the crest only for the first 6 cm before separating from the bone. Therefore, the more bone that is used in the corresponding osteotomies, the greater the risk of compromising the distal blood supply. The iliac crest flap provides bone of excellent quality for reconstruction of the mandible. It is the only flap that can be used to reconstruct the height and width of the native mandible. The iliac crest is basically cancellous bone and therefore has a rich blood supply that enables it to better tolerate infection. It also improves osseointegration of the implants.20 Multiple remodeling osteotomies can be performed to shape the new mandible. Osteotomy is performed on the outer cortical layer, leaving the periosteum intact on the inner aspect.18 The width and height of the iliac crest flap make it possible to place immediate implants during mandibular reconstruction without interfering with osteosynthesis material. Thus, dental implants can be placed in an ideal position for rehabilitation with a prosthesis. In this respect, the iliac crest flap differs considerably from the fibula flap, in which the decreased height of the
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FIGURE 10. Intraoral reconstruction 1 month after surgery. Navarro Cuellar et al. Mandibular Reconstruction. J Oral Maxillofac Surg 2014.
FIGURE 11. Left, Results 3 weeks after surgery. Note mandibular symmetry. Right, Results 3 months after surgery. Note the harmonious facial profile and favorable esthetic outcome for the jaw and nasolabial area. Frontal view. Navarro Cuellar et al. Mandibular Reconstruction. J Oral Maxillofac Surg 2014.
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Disadvantages 1. There is a risk of inguinal hernia.18 Alternative flaps should be considered in women of childbearing age. 2. In patients who have undergone surgery (appendectomy, herniorrhaphy, iliac crest free grafts), the vascular pedicle and its musculocutaneous perforators could have been damaged.21 In this case and to ensure greater safety, the authors prefer a contralateral crest or other flap. 3. There may be gait disorders owing to dissection of the tensor fascia lata and gluteus medius. 4. Impossibility of sensory reinnervation of the flap.22 Therefore, the authors’ indications for using the iliac crest flap for bone reconstruction are as follows: 1. Reconstruction of mandibular defects of up to 12 to 14 cm.23 2. Reconstruction of isolated mandibular bone defects in dentate patients (ameloblastoma, osteoradionecrosis, injury) with the possibility of placing immediate implants. 3. Reconstruction of the mandible and soft tissue defects with simultaneous placement of a nasolabial flap. FIGURE 12. Results 3 months after surgery. Lateral view. Navarro Cuellar et al. Mandibular Reconstruction. J Oral Maxillofac Surg 2014.
bone and the presence of osteosynthesis material can lead to poor positioning of the implants. 6. Two teams can work simultaneously.10 7. There are minimal esthetic sequelae.20
INTRAORAL SOFT TISSUE RECONSTRUCTION
Many oncologic patients must undergo resection of intraoral soft tissue to leave safety margins. On most occasions, these defects cannot be closed without reconstruction based on bone flaps with soft tissue. The ideal flap should have relatively thin and pliable soft tissue that can be used to reconstruct
FIGURE 13. A 48-year-old man diagnosed with squamous cell carcinoma affecting the left parasymphysis of the mandible. Frontal view.
FIGURE 14. Patient at lateral view.
Navarro Cuellar et al. Mandibular Reconstruction. J Oral Maxillofac Surg 2014.
Navarro Cuellar et al. Mandibular Reconstruction. J Oral Maxillofac Surg 2014.
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FIGURE 15. Preoperative orthopantomography. Navarro Cuellar et al. Mandibular Reconstruction. J Oral Maxillofac Surg 2014.
the anatomy of the mouth and mandible. It should ensure a constant blood supply through cutaneous perforators. The iliac crest flap requires a muscle cuff comprised of the internal oblique muscle, the external oblique
muscle, and the transversus abdominis muscle to ensure that the perforators to the skin paddle are included in the flap. This configuration is necessary, because the musculocutaneous perforators cross this triple muscle layer on their path to the
FIGURE 16. Preoperative computed tomogram shows a tumor involving the left parasymphysis of the mandible. Navarro Cuellar et al. Mandibular Reconstruction. J Oral Maxillofac Surg 2014.
NAVARRO CUELLAR ET AL
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FIGURE 17. Modeled plate for rigid fixation before the segmental mandibulectomy.
FIGURE 19. Immediate placement of 6 MG-OSSEOUS implants on the iliac crest free flap.
Navarro Cuellar et al. Mandibular Reconstruction. J Oral Maxillofac Surg 2014.
Navarro Cuellar et al. Mandibular Reconstruction. J Oral Maxillofac Surg 2014.
skin.24 Consequently, the excessive bulk of the osteomusculocutaneous iliac crest flap renders it unsuitable for intraoral reconstruction. Nevertheless, it is occasionally used to reconstruct large defects resulting from ablative surgery.4 Alternatively, intraoral soft tissue can be reconstructed using the internal oblique muscle.15 In this case, neither the skin nor the subcutaneous cellular tissue is used; therefore, the volume of the soft tissue is smaller. This technique is problematic because the internal oblique muscle must cover the new mandible and the intraoral tissue, thus potentially compressing the vascular pedicle and leading to loss of the flap. Consequently, the soft tissue obtained from this flap is not ideal for reconstruction of intraoral soft tissue. The nasolabial flap is a pedicled skin flap that has been widely used for reconstruction of oronasal defects and defects of the lips, tongue, buccal mucosa, alveolar ridge (upper and lower), maxilla, and floor of the mouth.25-27 This flap is an axial flap supplied by
the angular artery. The skin of the nasolabial flap is doubly vascularized (upper and lower), thus enabling a flap to be raised based on the upper or lower pedicle. The facial artery is responsible for the blood supply of the lower flap. At the level of the fold, the blood supply comes from the lateral nasal and upper labial branches. As the facial artery courses over the dorsum of the nose, it becomes the angular artery. These branches supply the lower nasolabial flap. The lower pedicle nasolabial flap is the most widely used flap for the reconstruction of intraoral soft tissue. Defects of the lip, commissure, buccal mucosa, and floor of the mouth can be reconstructed using a nasolabial flap inside the oral cavity. This flap also is an excellent source of local tissue for immediate reconstruction of post-traumatic full-thickness defects. The main application of this flap in head and neck surgery is for reconstruction of defects in the anterior floor of the mouth. To cover defects of up to 5 cm, the nasolabial flap can be harvested bilaterally.28 The flaps should be cut in the shape of a triangle and superficial to the facial muscles. They are tunneled through the cheek and sutured to the floor of the mouth. Primary closure is performed in the donor area. The advantages of this flap for the reconstruction of the floor of the mouth include the contribution of a large amount of soft tissue for repair and the favorable appearance of the donor area after closure. The disadvantages of this flap are the presence of hair in the donor area, especially in men, and the potential compression of the vascular pedicle in dentate patients. Therefore, the nasolabial flap should be used in edentulous patients in the area to be repaired to avoid damage to the pedicle. In the reconstruction of segmental mandibular defects with soft tissue defects, the combination of the iliac crest flap for bone reconstruction with the
FIGURE 18. Iliac crest free flap. Navarro Cuellar et al. Mandibular Reconstruction. J Oral Maxillofac Surg 2014.
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FIGURE 20. Left, Left nasolabial flap used to reconstruct the associated soft tissue defect. Right, Appearance of the left nasolabial flap 1 month after surgery. Navarro Cuellar et al. Mandibular Reconstruction. J Oral Maxillofac Surg 2014.
nasolabial flap for intraoral reconstruction is an excellent option that allows restoration of the width and height of the mandible with adequate soft tissue volume.
OSSEOINTEGRATED IMPLANTS
Before the development of techniques for the reconstruction of the head and neck with microsurgical free flaps and pedicled flaps, patients who had
FIGURE 21. Orthopantomography after reconstructive surgery. An iliac crest flap was used to reconstruct the mandibular height and immediate implant placement. Note the lack of bone consolidation at the left side of the union between the iliac crest bone and the remnant mandible. Navarro Cuellar et al. Mandibular Reconstruction. J Oral Maxillofac Surg 2014.
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FIGURE 22. Left mandibular osteoplasty at the union with the iliac crest in the second phase of implant surgery. Rehabilitation was performed with an implant-fixed prosthesis. Navarro Cuellar et al. Mandibular Reconstruction. J Oral Maxillofac Surg 2014.
undergone segmental mandibulectomy had a moderate or severe esthetic defect, and restoration of function to presurgical levels was minimal.29 The use of conventional prostheses in such patients provides little improvement owing to the lack of mandibular bone support and anatomic and physiologic impairment of the soft tissue. The anatomic impairment resulting from reconstruction of the mandible includes increased flap thickness, loss of sensation in the flap, changes in the muscles of mastication, loss of the labial vestibule, and an irregular bone contour. In addition, patients who have undergone radiation therapy will present xerostomia and mucosal atrophy, which makes it even more difficult to support removable prostheses and can lead to local irritation, ulceration, and exposure of the bone.30 Consequently, in most cases, these prostheses are not even suitable for improving the appearance of the lips. Patients feel greatly frustrated and, in most cases, social or occupational interaction is diminished. The degree of impairment of mastication depends on the amount of mandible resected, tongue function, and lip competence. The tongue should be able to
place the food bolus over the occlusive surfaces of the teeth so that it can be chewed. Often limited in strength and mobility, the tongue plays a key role in balancing the position of movable (removable) prostheses. An unreconstructed mandible tends to retract and deviate to the operated side. When the mandible opens and closes, the original vertical movements are replaced by oblique or diagonal movements enabled by only 1 temporomandibular joint. The loss of the proprioceptive sense of occlusion induces lack of coordination and less accurate mandibular movements. The loss of the muscles of mastication on the operated side also forces the mandible to rotate upward during closure in the frontal plane. The severity and duration of the deviation are variable and unpredictable and depend on many factors. The loss of soft tissue and primary closure of the unreconstructed defect with flaps contribute to this impaired function.29 Esthetic and functional rehabilitation of these patients has advanced considerably with the clinical application of osseointegrated implants in edentulous mandibles and the subsequent studies by Br anemark et al31 and Lindstr€ om et al32 who used titanium screws
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FIGURE 23. Final appearance of the implant-fixed prosthesis in the mouth. A nasolabial flap was used to reconstruct the anterior floor of the mouth. Navarro Cuellar et al. Mandibular Reconstruction. J Oral Maxillofac Surg 2014.
in bone grafts, thus showing that suitable osseointegration could be achieved and that bone implants could be used to support a prosthesis. Riediger17 was the first surgeon to place implants in the iliac crest flap, and Urken et al33 placed them immediately during reconstruction of the bone. One of the main advantages of the iliac crest flap is its rich blood supply. The better a flap is vascularized, the easier and faster osseointegration of the implants is. The size of the blood supply is closely associated with the quantity of cancellous bone in the flaps. Thus, the iliac crest is well irrigated because it contains a large amount of cancellous bone. Another advantage of this flap is its size: using the iliac crest makes it possible to recreate the width and height of the native mandible; therefore, it is suitable for long and thick implants to ensure functional rehabilitation. Similarly, the height of this flap allows immediate placement of implants, without the interference of osteosynthesis material in the ideal positioning of the implants for appropriate rehabilitation with dental prosthesis. The role of radiation therapy in bone and implants is of paramount importance when planning functional rehabilitation. The negative effects of radiation ther-
apy on bone include destruction of capillaries, proliferative endarteritis, decrease in bone cell population, and decreased neovascularization.34 Radiation therapy impairs scarring in the irradiated tissue. The authors usually try to place the implants immediately for several reasons: 1. Faster rehabilitation of the prosthesis. 2. Fewer surgical interventions. 3. It is mandatory in patients who are to receive radiation therapy. Urken et al33 found that reconstructive surgery and initiation of radiation therapy are usually separated by a 4- to 6-week interval. The initiation of radiation therapy and the onset of its effects on bone and implants are separated by an additional 6 to 8 weeks. Therefore, a 3-month window period is available. After this period, the osteophyllic and osteoconductive phases of osseointegration are complete, and the implants are osseointegrated. To real with have
conclude, the authors have highlighted the possibility of offering dental rehabilitation an implant-fixed prosthesis to patients who undergone segmental mandibulectomy and
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FIGURE 24. Lateral view 1 year after surgery and after dental rehabilitation.
FIGURE 25. Final frontal view. Note the mandibular and facial symmetry. The cosmetic outcome of the left nasolabial area was optimal.
Navarro Cuellar et al. Mandibular Reconstruction. J Oral Maxillofac Surg 2014.
Navarro Cuellar et al. Mandibular Reconstruction. J Oral Maxillofac Surg 2014.
reconstruction with an iliac crest free flap and nasolabial flap. This technique ensures a favorable esthetic and functional outcome and improves facial harmony and quality of life.
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