RECONSTRUCTIVE

Classification of Mandible Defects and

Algorithm for Microvascular Reconstruction
Benjamin D. Schultz, B.A.
Background: Composite mandibular tissue loss results in significant functional
Michael Sosin, M.D.
impairment and cosmetic deformity. This study classifies patterns of mandibu-
Arthur Nam, M.D., M.S.
lar composite tissue loss and describes a microvascular treatment algorithm.
Raja Mohan, M.D. Methods: A retrospective review of microvascular composite mandibular recon-
Peter Zhang, B.S. struction from July of 2005 to April of 2013 by the senior surgeon at the
Saami Khalifian, B.A. R Adams Cowley Shock Trauma Center and at The Johns Hopkins Hospital
Neil Vranis, B.S. yielded 24 patients with a mean follow-up of 17.9 months. Causes of compos-
Paul N. Manson, M.D. ite mandibular defects included tumors, osteoradionecrosis, trauma, infection,
Branko Bojovic, M.D. and congenital deformity. Patients with composite tissue loss were classified
Eduardo D. Rodriguez, according to missing subunits.
M.D., D.D.S. Results: A treatment algorithm based on composite mandibular defects and
Baltimore, Md.; and New York, N.Y. microvascular reconstruction was developed and used to treat 24 patients. A
type 1 defect is a unilateral dentoalveolar defect not crossing the midline and
not extending into the angle of the mandible. A type 2 defect is a unilateral
defect extending beyond the angle. A type 3 defect is a bilateral defect not
involving the angles. A type 4 defect is a bilateral defect with extension into
at least one angle. Type 2 defects were the predominant group. Patients had
microvascular reconstruction using either fibula flaps (n = 19) or iliac crest
flaps (n = 5). Complications included infection, partial necrosis, plate fracture,
dehiscence, and microvascular thrombosis.
Conclusion: This novel classification system and treatment algorithm allows for
a consistent and reliable method of addressing composite mandibular defects
and focuses on recipient vasculature and donor free flap characteristics.  (Plast.
Reconstr. Surg. 135: 743e, 2015.)
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

M
andibular defects following tumor resection an ideal approach with which to achieve consistent
or trauma can be disabling both function- and optimal outcomes. Restoration of mandibular
ally and aesthetically. Multiple approaches defects with associated composite tissue loss compli-
exist in reconstructing complex, critically sized man- cates flap selection, which makes management chal-
dibular defects to restore form and function. The lenging.1 Composite mandibular tissue loss from
difficulty of successful reconstruction is selecting trauma and oncologic resection results in significant
functional and cosmetic deformities.2,3 Intact con-
tralateral muscles can result in malocclusion, which
From the Division of Plastic, Reconstructive and Maxil- limits range of motion and impairs lateral and pro-
lofacial Surgery, R Adams Cowley Shock Trauma Center; trusive movements on opening or closing.4
the Department of Plastic and Reconstructive Surgery, The
Johns Hopkins University School of Medicine; the Univer-
sity of Maryland School of Medicine; and the Department Disclosure: None of the authors has a financial interest
of Plastic Surgery, New York University Langone Medical in any of the products or devices mentioned in this article.
Center, Institute of Reconstructive Plastic Surgery.
Received for publication May 20, 2014; accepted October
14, 2014.
Presented at the American Society for Reconstructive Micro- Supplemental digital content is available for this
surgery Annual Meeting, in Kauai, Hawaii, on January article. Direct URL citations appear in the text;
11 through 14, 2014; and poster presentation at the D.C. simply type the URL address into any Web brows-
American College of Surgeons All Surgeons Day, in Wash- er to access this content. Clickable links to the ma-
ington, D.C., on March 8, 2014. terial are provided in the HTML text of this article
Copyright © 2015 by the American Society of Plastic Surgeons on the Journal’s Web site (www.PRSJournal.com).
DOI: 10.1097/PRS.0000000000001106

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 Plastic and Reconstructive Surgery • April 2015

Restoration of mandibular continuity and from July of 2005 to April of 2013 of patients who
functionality, and attempting to return patients underwent microvascular reconstruction for man-
to their premorbid state, is the ultimate goal dibular defects 5 cm or larger following compos-
of reconstruction. Reestablishing jaw function, ite tissue loss was performed. A total of 24 patients
including chewing, swallowing, oral competence, were included for review, 15 male and nine female
and speech, is essential to providing successful patients, with a mean age of 52.2 years (range, 15
execution of microvascular reconstruction.4 To to 64 years). Causes of the defects included osteora-
achieve these goals, the reconstructive surgeon dionecrosis (n = 11), benign and malignant tumors
must address bony continuity, tongue mobility, (n = 5), trauma (n = 4), infection (n = 2), and con-
and restoration of sensation to denervated areas. genital deformities (n = 2). The mean follow-up
The majority of complex defects result from time was 17.9 months (range, 12 days to 84 months).
oncologic ablation and resection of the orophar-
ynx and oral cavity.4 However, causes such as Classification
trauma, congenital deformities, and osteoradione- The choice of an osseous flap for mandibular
crosis contribute to the pool of patients requiring reconstruction depends on pedicle length require-
reconstruction. These patients are often left with ment and the availability of donor tissue. A clas-
a complex, large defect that necessitates restora- sification of mandibular defects has been created
tion of form to achieve successful rehabilitation.5,6 that focuses on mandibular functional subunits
The mainstay of composite mandibular recon- that require reconstruction. Iliac crest or fibular
struction consists of bony stabilization with autog- free flaps are ideal choices for reconstruction of
enous, nonvascularized bone grafts or vascularized the aforementioned defects. Our classification
bone grafts and soft-tissue coverage.7 Defects of system is based on the ascending order of recon-
critical size that require a large volume of bone structive complexity (Fig. 1): a type 1 defect con-
necessitate harvesting bone from distant donor sists of a unilateral dentoalveolar defect that does
sites. The evolution of microsurgery has improved not cross the midline; a type 2 defect includes a
the complex, functional, and aesthetic outcomes unilateral dentoalveolar defect extending beyond
of oromandibular reconstruction with the use of the angle; a type 3 defect involves bilateral defects
radial forearm, scapula, iliac crest, and fibula free of the dentoalveolar regions without extending
flaps.8 The use of osseous vascularized free flaps has beyond either angle; and a type 4 defect consists of
allowed for a consistent method of reconstruction, bilateral dentoalveolar defects extending beyond
with success rates of greater than 90 percent.4,8,9 either one or both angles. Each type is further
Creating a simple, practical classification and subdivided based on whether or not the ipsilateral
management algorithm with universal acceptance vasculature is available (A) or not available (B) for
has proven to be difficult. A commonly known sys- anastomosis, with the latter being a situation that
tem from Boyd et al.10 was designed to account for would require use of the contralateral neck vascu-
the various possible combinations of mandibular lature. Subsequently, the proposed free flap in our
subunit defects. However, it does not adequately algorithm is based on the required pedicle length.
address surgical treatment. Other classification sys- For type 2 defects, it should be noted whether
tems have been developed for the classification and or not the associated condyles are intact, as this
treatment of complex mandible defects that focus helps determine which free flap should be used
on different aspects of the recipient site for pri- for reconstruction. If unilateral condylar involve-
mary consideration.8,9,11 However, our experience ment exists, the deficit would be labeled a type
has found these algorithms to be cumbersome and 2Ac/Bc; however, if the condyles are not involved,
unable to adequately address the complex nature of the deficit would be classified as a type 2A/B. The
large mandible defects. Therefore, the purpose of algorithm for classifying and managing type 3 defi-
this article is to report the use of a novel classifica- cits is similar to that of type 1 because the deficit
tion system that simplifies the patterns of mandibu- is limited to the dentoalveolus; as such, condylar
lar composite tissue loss, and provides an algorithm involvement does not need to be addressed. Type
for microvascular reconstruction. 4 deficits require multiple approaches because of
the almost complete mandibular involvement.
PATIENTS AND METHODS
A retrospective review of the senior surgeon’s RESULTS
(E.D.R.) experience at the R Adams Cowley Shock Based on composite tissue microvascular flaps,
Trauma Center and The Johns Hopkins Hospital an algorithm was developed and used to treat

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Fig. 1. Flow chart of algorithm for mandibular defect classification and microsurgical repair. A, viable ipsilateral vasculature; B,
nonviable ipsilateral vasculature; c, condylar involvement; DCIA, deep circumflex iliac artery (iliac flap); FOSC, fibula osteoseptocu-
taneous flap; VG, vein graft.

24 patients with composite mandibular defects. thrombosis of microvascular anastomosis with sub-
Reconstructive details are listed in Table 1. Type sequent complete flap failure (n = 1). The mean
2 defects were predominant (n = 12), followed by number of reoperations per patient was 0.17.
type 3 (n = 6), type 1 (n = 5), and type 4 (n = 1)
defects in our series. Patients received either a free CASE REPORTS
fibula flap (n = 19) or an iliac crest flap (n = 5). The
recipient arterial vessels used were the facial artery Type 1 Defects
(n = 13), superior thyroid artery (n = 7), exter- Case 1
nal carotid artery (n = 2), lingual artery (n = 1), A 59-year-old man presented with osteoradionecrosis of the
and posterior auricular artery (n = 1). The venous right mandible with an orocutaneous fistula following radiation
treatment for tonsillar cancer (Fig. 2).12 After débridement, the
recipient vessels included the facial vein (n = 11), patient was left with a 7-cm defect in the right dentoalveolar region.
internal jugular vein (n = 11), and external jugular A 7 × 3-cm iliac crest free flap from the right hip was used for recon-
vein (n = 7). Nine of the 24 patients experienced struction. The ipsilateral facial artery and both external and inter-
minor complications, which included 12.5 percent nal jugular veins were used for vascular anastomosis (type 1A). By
5-month follow-up, there was complete resolution of the orocuta-
partial necrosis of the flap (n = 3), 8.3 percent
neous fistula and the patient exhibited good mandibular function
wound dehiscence (n = 2), 8.3 percent infection without complication. Donor-site morbidity was minimal, and the
not requiring débridement (n = 2), 4.2 percent patient went on to have successful implantation of prosthodontics.
hematoma (n = 1), and 4.2 percent malocclusion
Case 2
(n = 1). Three of the 24 patients experienced a A 60-year-old man underwent left radical neck dissection,
major complication, which included 8.3 percent left tonsillar resection, and external beam irradiation at an out-
hardware removal (n = 2) and 4.2 percent venous side hospital for squamous cell carcinoma of the left tonsil. He

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Table 1.  Patient Summary

Location of Ips or Type of
Mandibular Contra Mandibular Flap Recipient Follow-Up
Patient Sex Age (yr) MOI Defect Vasc Defect Type Vessels Complications (mo)
1 M 59 ORN Right Ips 1A Iliac Fa/EJV, IJV 0.5
2 M 60 SCC Left Ips 1A Fibula Fa/Fv Donor-site 65
infection
3 M 29 GSW Left Ips 1A Iliac STA/IJV Infection of 30
hardware/
fistula
4 M 23 Blunt Left Ips 1A Iliac STA/IJV Skin necrosis 5
trauma
5 M 64 SCC Right Contra 1B Fibula Fa/Fv Plate fracture 34
6 M 32 Odonto- Right Ips 2A Fibula Fa/EJV × 2 Malocclusion 2
genic
keratocyst
7 M 85 ORN Left Ips 2A Iliac STA/IJV 4
8 M 56 ORN Left Ips 2A Fibula Lingual 10
artery/IJV,
EJV
9 M 55 ORN Right Ips 2A Fibula Fa/Fv, IJV Wound dehis- 1
cence
10 M 46 ORN Left Ips 2Ac Fibula STA/EJV Plate fracture 24
11 F 15 Goldenhar Right Ips 2Ac Fibula Postauricular 12
syndrome artery/EJV,
IJV
12 M 21 GSW, OM Right Ips 2Ac Iliac STA/IJV Skin necrosis, 2.5
hematoma
13 F 54 Osteoma Right Contra 2B Fibula Fa/Fv Abscess/ 4
infection
14 F 81 ORN Left Contra 2B Fibula Fa/Fv 14
15 M 56 ORN Right Contra 2B Fibula STA/IJV Malocclusion, 38
exposed
hardware,
nonunion
16 M 48 ORN Right Contra 2B Fibula STA/EJV 2
17 F 53 Osteosar- Left Contra 2Bc Fibula Fa/Fv Wound 32
coma dehiscence
18 M 50 Ameloblas- Bilateral Ips 3A Fibula Fa/EJV, IJV 7
toma
19 F 52 OM Right Ips 3A Fibula Fa/Fv 84
20 M 63 SCC Bilateral Ips 3A Fibula ECA/Fv 18
21 F 52 ORN Bilateral Contra 3B Fibula ECA/IJV Infection 0.5
22 F 72 ORN Bilateral Contra 3B Fibula Fa/Fv Vessel 8
thrombosis
23 F 56 GSW Left Contra 3B Fibula Fa/Fv 17
24 F 18 McCune- Bilateral Contra 4 Fibula Fa/Fv 16
Albright
syndrome
MOI, mechanism of injury; M, male; F, female; GSW, gunshot wound; ORN, osteoradionecrosis; SCC, squamous cell carcinoma; OM, osteomy-
elitis; Fa, facial artery; Fv, facial vein; STA, superior thyroid artery; IJV, internal jugular vein; EJV, external jugular vein; ECA, external carotid
artery; Ips, ipsilateral; Contra, contralateral; Vasc, vasculature.

presented to our institution 13 years later with an orocutaneous 11 months later with impaired mandibular function and a right
fistula in the left parasymphyseal region (Fig. 3).13 He was eden- type 2A defect (Fig. 4). He then underwent a free iliac osteocuta-
tulous and a smoker. The patient underwent free fibula osteosep- neous flap (7 × 2-cm bone, 10 × 2-cm skin paddle) reconstruction
tocutaneous flap surgery with a split-thickness skin graft. He to the right mandibular defect. Anastomosis was to the ipsilateral
underwent two revision operations, which consisted of debulking internal jugular vein and to the superior thyroid artery. The flap
of subcutaneous tissue and cervicofacial flap advancement for experienced venous congestion requiring partial débridement of
cosmetic enhancement, 6 months after the original operation. soft tissue; however, the bone and the majority of the remaining
soft tissue were viable. At 5-week follow-up, the patient was able to
Type 2 Defects achieve normal mandibular function and ultimately received suc-
cessful prosthetic dental implants.
Case 3
A 22-year-old man sustained a gunshot wound to the right Case 4
face. After multiple washouts and débridements, a right retromolar A 56-year-old man with a history of squamous cell carcinoma
mandibular fossa defect was present. Six days after the initial injury, of the right tonsil was treated with chemotherapy and radiation
he underwent reconstruction with a sternocleidomastoid rotational therapy. Three years later, the patient developed right osteoradio-
flap to cover the retromolar defect, but the mandibular defect of necrosis with a concomitant pathologic fracture. He underwent
the right dentoalveolus and ramus persisted. He presented to us partial mandibulectomy with application of a reconstruction bar,

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Fig. 2. Type 1 defect reconstructed with iliac crest free flap (case 1). (Above, left) Preoperative three-dimensional computed tomo-
graphic scan depicting a right mandibular defect. (Above, center) Clinical photograph of an orocutaneous fistula. (Right) An iliac
crest free flap (with internal oblique muscle) was anastomosed to the ipsilateral internal jugular vessels (arrow) to reconstruct the
7-cm composite mandibular defect (ellipse). (Below, left) Postoperative computed tomographic scan and (below, center) resolution
of orocutaneous fistula 1 year after reconstruction with an iliac crest free flap. (Reprinted with permission from Kelishadi SS, St-
Hilaire H, Rodriguez ED. Is simultaneous surgical management of advanced craniofacial osteoradionecrosis cost-effective? Plast
Reconstr Surg. 2009;123:1010–1017.)

and a sternocleidomastoid muscle flap to close intraoral defects. was referred to our clinic for definitive mandibular reconstruc-
Unfortunately, he developed an orocutaneous fistula with pro- tion (Fig. 6). She underwent reconstruction with a free fibula
gression of osteoradionecrosis. At this point, the patient was osteocutaneous flap to the left mandible and cheek. The contra-
referred to our clinic, and his evaluation revealed a 9.5-cm right lateral facial vessels were used for recipient vascular anastomosis.
dentoalveolar and ramus defect without condylar involvement. Ten months after her free flap reconstruction, the mandibular
Based on our classification, this is defined as a type 2B defect. A hardware was removed secondary to pain. However, she dem-
free fibula osteoseptocutaneous flap consisting of 9.5 cm of bone onstrated excellent mandibular form and function 19 months
and a 14 × 12-cm skin flap was used for reconstruction (Fig. 5). postoperatively.
The peroneal vascular pedicles were anastomosed to the contra-
lateral superior thyroid artery and internal jugular vein. Eight Type 4 Defect
months later, the reconstruction bar was removed, and excess
skin, subcutaneous tissue, muscle, and bone were débrided to Case 6
enhanced cosmesis. Thereafter, the patient underwent further An 18-year-old female patient presented with McCune-
revision operations to repair an Angle class 2 malocclusion. Fol- Albright syndrome with sarcomatous transformation of fibrous
low-up at 38 months demonstrated full form and function with- dysplasia of the mandible. After hemimandible resection at
out further complication. an outside institution in 1999, she remained disease-free for 2
years. However, she subsequently developed a recurrence in the
remaining portion of the mandible. This required complete
Type 3 Defects mandibular resection with titanium plate reconstruction, which
Case 5 remained in place for 3 years. [See Figure, Supplemental Digital
A 56-year-old woman sustained injuries to the craniofacial Content 1, which is a preoperative three-dimensional computed
region from a self-inflicted shotgun wound. At an outside hos- tomographic scan depicting a type 4 mandibular defect in the
pital, multiple débridements and washouts were performed, patient in case 6, http://links.lww.com/PRS/B259. See Figure,
midface fractures were rigidly fixated, and a reconstruction plate Supplemental Digital Content 2, which is a preoperative clinical
was used to span a 12-cm bilateral dentoalveolar mandibular photograph. (Reprinted with permission from Rodriguez ED,
bony defect (type 3B). Seven weeks after the initial injury, she Bluebond-Langner R, Brazio P, Collins M. Near-total mandible

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 Plastic and Reconstructive Surgery • April 2015

Fig. 3. Reconstruction of a type 1 defect using a free fibula flap (case 2). (Above, left) Preoperative computed tomographic scan of
the left mandibular body showing osteoradionecrosis. (Above, center) Preoperative clinical photograph. (Above, right) Resection
of the necrotic segment of bone resulted in a 5-cm segmental defect on the left mandibular body. Ipsilateral vessels were not
available because of radiation-induced fibrosis. A free fibula flap with single-stage dental implant placement. Anastomoses were
performed to the contralateral facial vessels. (Below, left) A postoperative computed tomographic scan is shown. (Below, center)
Six-month follow-up clinical photograph with (below, right) dental implants in place. (Reprinted with permission from Fisher M,
Dorafshar A, Bojovic B, Manson PN, Rodriguez ED. The evolution of critical concepts in aesthetic craniofacial microsurgical recon-
struction. Plast Reconstr Surg. 2012;130:389–398.)

reconstruction with a single fibula flap containing fibrous dyspla- [See Figure, Supplemental Digital Content 4, which shows a post-
sia in McCune Albright syndrome. J Craniofac Surg. 2007;18:1479– operative three-dimensional computed tomographic scan 1 year
148214), http://links.lww.com/PRS/B260.] The patient sought after reconstruction with a clinical photograph. (Reprinted with
further reconstructive surgery and underwent a free iliac crest permission from Rodriguez ED, Bluebond-Langner R, Brazio
bone graft to the symphyseal region, which left the patient dis- P, Collins M. Near-total mandible reconstruction with a single
satisfied with cosmesis and function, at which point she was fibula flap containing fibrous dysplasia in McCune Albright syn-
referred to our clinic for evaluation. Her defect measured 21 cm drome. J Craniofac Surg. 2007;18:1479–148214), http://links.lww.
bilaterally, extending into the condyles bilaterally. Microvascular com/PRS/B262.] Her recovery continued without complication.
reconstruction was performed using a free fibula flap with five
osteotomies designed to integrate iliac bone graft to give greater
height to the neomandible. (See Figure, Supplemental Digital DISCUSSION
Content 3, which shows the fibula flap osteotomized and rig-
idly fixated to create the symphysis and angles of the mandible,
Surgeons have been searching for the ideal
http://links.lww.com/PRS/B261.) Her 16-month follow-up dem- solution to complex mandibular defects. Com-
onstrated enhanced mandibular form with improved function. plete restoration of the mandible requires

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Fig. 4. Reconstruction of a type 2 defect with an iliac crest free flap (case 3). (Above, left) Intraoper-
ative photograph of the right mandibular defect (body and angle) and presence of the ipsilateral
recipient vessels (arrow). (Above, right) Preoperative computed tomographic scan of the patient
revealing the defect of the right mandibular body and angle. (Below, left) Inset of the iliac crest
free flap. (Below, right) Computed tomographic scan of the patient 1 year after reconstruction.

consideration of many factors, such as sufficient being cumbersome and overly complicated to
height of the mandible, adequate muscle attach- routinely be implemented clinically. For exam-
ment for form and function, and preservation of ple, Urken et al.8 have designed a detailed and
neurovascular anatomy. Restoring or improving encompassing algorithm for the reconstruction
swallowing, chewing, speech articulation, and oral of large composite mandibular defects. Nearly all
competence is critical for successful rehabilitation forms of recipient defects, including bone, soft-
of patients.4–6 The development of a systematic tissue, and neurologic deficits, are considered
method of assessing, classifying, and summariz- for selecting a flap. Their scheme for classifying
ing the severity and extent of mandibular injury and treating complex mandibular defects is intri-
coupled with surgical management is challenging cate and carefully designed. However, the use of
because of the complex reconstructive nature of numerous abbreviations for a large number of
mandible defects. possible defects fails to create a practical and eas-
Several classification schemes have been ily implementable algorithm. Another commonly
designed to address reconstructive scenarios used algorithm from Takushima et al.11 suggests
in which a complex mandibular deficit is pres- that the soft-tissue defect is the critical factor for
ent.10,11,15,16 Although these systems have been use- determining the appropriate flap for reconstruc-
ful for the classification of mandibular defects, tion. Although this is an important consideration,
many have not been coupled with treatment our single-surgeon experience found this to be a
modalities. Those that do provide algorithm- secondary factor for flap selection. Furthermore,
based treatment modalities are criticized for the algorithms described by both Urken et al. and

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Fig. 5. Reconstruction of a type 2 defect using a fibula free flap (case 4). (Above, left) Intraoperative pho-
tograph of the type 2 defect involving the right body and angle of the mandible. (Above, right) Procure-
ment of an osteomyocutaneous fibula free flap with creation of the mandibular angle with osteotomy
and rigid fixation. (Below, left) Fibula flap inset with donor vessels anastomosed to the contralateral
superior thyroid artery and internal jugular vein. (Below, right) Three-dimensional computed tomo-
graphic scan of the patient 1 year postoperatively.

Takushima et al. use scapular flaps, a flap choice were and are still commonly used. Experts recom-
that adds additional difficulty because of the need mend using bone grafts for defects that measure
to change patient positioning and ultimately was 5 cm or smaller, and only if the surrounding soft
able to be avoided in our experience. The pres- tissues have adequate vascularity.18–20 Pedicled
ent study demonstrates the successful application bone grafts have also been used, but they have
of a novel, simplified algorithm that focuses on fallen out of favor in light of the development of
recipient vascular integrity for the classification microvascular surgery because pedicled options
and microsurgical management of critically sized, are extremely limited. Furthermore, the donor
complex mandibular deficits. sites that are used for pedicled bone grafts may
The proposed algorithm for mandibular not be available and are subject to significant
defect reconstruction is based on a minimum complications.21
critical size of 5 cm of osseous deficit. Kademani Microvascular surgery has revolutionized
et al.17 describe the use of free tissue transfer as repair of the mandible, especially when a signifi-
the treatment modality of choice for large seg- cant bony defect is present.21 Currently, the use
mental defects of 5 cm or greater, especially those of autogenous bone grafting is the criterion stan-
that include the overlying mucosa. Not only does dard of osseous mandibular reconstruction, as it
free tissue transfer address significant mandibular is the most reliable and predicable modality for
defects, it is also less prone to fail in an irradiated complex deficits.4 The most advantageous aspect
surgical site.17 Before the introduction of micro- of mandibular reconstruction with free flaps is the
vascular free flaps, nonvascularized bone grafts reliability of combining soft tissue and bone in

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Fig. 6. Reconstruction of a type 3 defect using an osteomyocutaneous fibula free flap (case 5). (Above, left) Pre-
operative computed tomographic scan depicting a left type 3 mandibular defect. (Above, center) Intraoperative
photograph demonstrating the mandibular defect. (Right) The fibula flap is osteotomized and rigidly fixated to
create the natural shape of the mandible. (Below, left) Postoperative computed tomographic scan 1 year after
reconstruction with a fibula free flap. (Below, center) Clinical photograph correlating with the 1-year computed
tomographic scan.

one operation using one donor site.21 Microvascu- local myocutaneous flaps. Furthermore, patients
lar surgery allows for the transfer of vascularized receiving free fibula versus iliac crest grafts have
bone flaps, which have a reported success rate of shown comparable health-related quality-of-life
99 percent compared with nonvascularized bone outcomes.28–30
grafts over a 3-year follow-up.6 Even in patients The flaps that are most commonly used for
with radiation exposure, success rates exceed 90 osseous reconstruction include the fibula, iliac
percent.9 In fact, loss of implant-mounted dental crest, radial forearm, and scapula.4,21 The iliac
prostheses in irradiated versus nonirradiated free crest free flap has been widely used since its incep-
bone flaps is without substantial difference.21–26 tion in the 1980s by Taylor et al.,31 and was later
Free tissue transfer before irradiation is associ- refined by Urken et al.,29 who proposed the use of
ated with a reduced risk of osteoradionecrosis and the internal oblique–iliac crest osteomyocutane-
adjunctive hyperbaric oxygen therapy.19,27 Studies ous flap. Based on our work, the wide bone stock
have shown that reconstructions with microvascu- of the iliac crest bone, which is unmatched in
lar free flaps have better outcomes than those with terms of available bone supply, makes it an ideal

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 Plastic and Reconstructive Surgery • April 2015

flap for mandibular defects, especially those of the The radial forearm flap was first applied for
dentoalveolar region.21 Successful use of dental mandibular reconstruction in 1983 by Soutar et
implants in preirradiated vascularized iliac crest al.37 The free flap is designed around its vascular
bone grafts of greater than 30 months makes this pedicle consisting of the radial artery, vein, and
a robust flap in the setting of oncologic resection the subcutaneous veins. Like the free fibula flap,
and osteoradionecrosis.32 Another major advan- the radial forearm flap has a long pedicle, and
tage is that the ipsilateral iliac crest has a natural approximately 10 to 12 cm of bone may be taken.
contour that resembles that of the hemimandi- Furthermore, the skin paddle is thin, large, and
ble.4 The height of the iliac crest is similar to that pliable, qualities that make it ideal for lining the
of the native dentate mandible, allowing for the intraoral defect. However, the bone harvested is
necessary lower lip support, which improves oral often thin and lacking in segmental perforators,
competence.7,33 However, one of the most signifi- limiting multiple osteotomies. Furthermore, a
cant disadvantages of the iliac crest free flap is that lack of height makes it problematic for applica-
it has a short vascular pedicle and an absence of tion of dental implants, and donor-site fractures
segmental perforating vessels, aspects that make remain the greatest and most criticized aspect of
incorporating osteotomies difficult.21 Although its use.21
rare, donor-site morbidity may cause significant Finally, the scapular flap is a versatile com-
gait disturbances and difficulty ambulating post- posite flap that allows for restoration of large
operatively. When bicortical bone is removed, the soft-tissue defects and replacement of bone.
donor site is subject to deformity and, although It has a single vascular pedicle that can supply
rare, has the potential to develop abdominal large amounts of bone with soft tissue. Its recom-
herniation.34 mended use is for through-and-through defects of
The fibula free flap is a popular choice for the mucosa, bone, and skin.21 However, it must be
mandibular reconstruction because of its mul- harvested in the lateral decubitus or prone posi-
tifaceted application. The peroneal artery and tion, which makes a two-team approach more
vein are used for the flap and are advantageous difficult.7 Also, use of the scapular flap leads to
because of their diameter and length. In our decreased range of motion of the shoulder, espe-
patients, the free fibula flap was used when there cially with arm abduction.7 None of our patients
was significant damage or irradiation to the ipsi- received this free flap.
lateral vasculature, or when a long segment of Even with the use of free flaps, reconstruc-
bone was needed. Like the free iliac crest flap, tion plates are essential to mandibular defect
the fibula flap can be harvested in the supine repair. Ideal plates are those of sufficient size and
position, which allows for a two-team approach strength that allow for the stabilization of recon-
and decreases operative time.7 The long pedicle struction while taking into account the discretion-
allows for anastomosis to be completed to the ary use of locking screws. These are particularly
contralateral vasculature of the neck, preclud- useful because they minimize compression of the
ing the use of vein grafts or arteriovenous loops. underlying bone by the plate, thereby protecting
Unlike the iliac crest flap, the fibula receives its the vascular supply of the graft.38 However, perma-
blood supply from segmental perforators, which nent use of reconstructive plates for bony man-
allows for the creation of multiple osteotomies. dibular stabilization has its disadvantages. Kim
The fibula can also provide 30 cm of bone length, and Donoff39 have shown that if the mandible has
making it versatile in its application for mandibu- been irradiated or if the defect crosses the mid-
lar reconstruction.21 Moreover, the vascularized line, there is a substantial increase in the incidence
free fibula flap is recommended for those with of complications requiring revision or removal of
large anterior or bony defects requiring multiple the plate. However, some surgeons advocate the
osteotomies because, compared with the iliac use of reconstruction plates as a primary means of
crest bone graft, it has a lower rate of resorp- stabilization before reconstruction 1 year later.40
tion and lower failure rate.5 In contrast, a major Our classification system focuses on critical-
disadvantage of the free fibula flap is the short size deficits, which we defined as greater than
bone height, making it less suitable for dentate 5 cm, based on their anatomical subunits. Ini-
patients who require dental implants. However, tially, the selection of an appropriate free flap
surgical techniques have been designed to over- for reconstruction begins with the viability of
come this problem.35,36 As such, it remains the the recipient vasculature. The subsequent divi-
first choice for edentulous mandibles and large sion of deficit types addresses the viability of
mandibular resections.21 the desired recipient vasculature and associated

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Volume 135, Number 4 • Classification of Mandible Defects

wound bed. This approach allows for the simul- CONCLUSIONS

taneous classification of the deficit, based on This novel classification system and treatment
the surrounding structural integrity, and aids algorithm is a consistent and reliable method of
the surgeon in selecting proper surgical treat- addressing composite mandibular defects and
ment. For example, case 5 (Fig. 5) would be focuses on recipient vasculature and donor free
considered a type 2B defect because recipient flap characteristics. The treatment algorithm pat-
vessels ipsilateral to the deficit are considered terns are useful for classifying and treating defects
compromised as a result of osteoradionecrosis. based on subunit reconstruction of any cause.
The decision to use a free fibula flap was based Iliac crest and fibula free flaps are effective for
on its long pedicle and its ability to reach the restoring mandibular function by providing a rich
contralateral vessels. After assessing the viability bone stock and long vascular pedicle, respectively.
of the vasculature for anastomosis, determining
whether to use an iliac crest free flap or a fib- Eduardo D. Rodriguez, M.D., D.D.S.
Department of Plastic Surgery
ula free flap is a matter of operator preference. New York University Langone Medical Center
Factors such as skin deficit, length of deficit, or Institute of Reconstructive Plastic Surgery
the possible need for dentures postoperatively 305 East 33rd Street
help guide the surgeon’s choice in free flap. It New York, N.Y. 10016
should be noted that certain scenarios necessi- [email protected]
tate the use of particular free flaps. For example,
if a type 2 defect has condylar involvement (type
PATIENT CONSENT
2Ac/Bc), free fibula flaps are recommended
because they provide sufficient length for con- Patients provided written consent for the use of their
dylar reconstruction. After the anatomical loca- images.
tion of bilaterality of the mandibular defect, our
classification system emphasizes the importance
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