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Reconstructive
Oral and
Maxillofacial Surgery

Carlos Navarro Vila

Editor

123
Reconstructive Oral and Maxillofacial
Surgery
Carlos Navarro Vila
Editor

Reconstructive Oral
and Maxillofacial Surgery
Editor
Carlos Navarro Vila
Hospital General Universitario Gregorio Marañón
Madrid
Spain

ISBN 978-3-319-20486-4 ISBN 978-3-319-20487-1 (eBook)

DOI 10.1007/978-3-319-20487-1

Library of Congress Control Number: 2015947347

Springer Cham Heidelberg New York Dordrecht London

© Springer International Publishing Switzerland 2015
This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of
the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recita-
tion, broadcasting, reproduction on microfilms or in any other physical way, and transmission or infor-
mation storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar
methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this publica-
tion does not imply, even in the absence of a specific statement, that such names are exempt from the
relevant protective laws and regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and information in this book
are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the
editors give a warranty, express or implied, with respect to the material contained herein or for any errors
or omissions that may have been made.

Printed on acid-free paper

Springer International Publishing AG Switzerland is part of Springer Science+Business Media

(www.springer.com)
Preface

Reconstruction of head and neck defects after tumor resection is one of the main
challenges facing the maxillofacial surgeon.
Such complex defects require not only cosmetic reconstruction but also func-
tional reconstruction that enables patients to return to their family, social, and pro-
fessional life under optimal conditions and as quickly as possible.
While resection surgery has developed little in recent years—with the exception
of new techniques, such as navigation, that enable safer and more adapted proce-
dures—reconstruction has advanced considerably, with the incorporation of free
flaps and virtual planning, which makes it possible to model flaps and customize
prostheses to the defect.
These advances are evident in reconstruction of the mandible.
Various pedicle flaps have been used to provide bone. The outcome has generally
been unsatisfactory, except for Demergasso’s trapezius osteomyocutaneous flap, which
proved to be a very acceptable option for cosmetic and functional reconstruction.
The advent of free fibula flaps and scapula flaps revolutionized reconstruction
and enabled defects to be repaired with high-quality bone and abundant soft tissue.
The placement of dental implants in transferred bone makes it possible to insert
prostheses that restore chewing and phonation and considerably improve labial
competence.
Software-based virtual surgery enables more accurate anatomical reconstruction
using customized plates and cutting guides for the flap bone, which can be adapted
exactly to the defect left by resection and to the patient’s original facial structure.
Similarly, pedicle flaps and microsurgical flaps have transformed the reconstruc-
tion of defects of the maxilla and the middle third.
Each chapter of this book covers a specific area on the spectrum of head and neck
reconstruction: mandibular reconstruction, reconstruction of the middle third, reconstruc-
tion of the cranio-orbital region, reconstruction of soft tissue defects, treatment of facial
paralysis, dental implants, and regional flaps, which continue to be extremely useful.
We present our experience in the Maxillofacial Surgery Department of Hospital
General Universitario Gregorio Marañón, Madrid, Spain, where these techniques
have been taught to numerous specialists from Spain, Europe, and South America.

Madrid, Spain Carlos Navarro Vila

v
Contents

1 Mandibular Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Carlos Navarro Cuellar, Cristina Maza Muela,
Santiago José Ochandiano Caicoya, and Carlos Navarro Vila
2 Maxillary and Middle Face Reconstruction . . . . . . . . . . . . . . . . . . . . . . 39
Carlos Navarro Vila, Ana María López López,
Cristina Maza Muela, and Carlos Navarro Cuellar
3 Reconstruction of the Cranio-Orbital Region . . . . . . . . . . . . . . . . . . . . 77
Julio Acero Sanz, Cristina Maza Muela,
José Ignacio Salmerón Escobar,
and Santiago José Ochanciano Caicoya
4 Reconstruction of Soft Tissue Defects Using
Microsurgical Flaps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
Ignacio Navarro Cuellar, Teresa González Otero,
José Alfonso Ruiz Cruz, and Carlos Navarro Vila
5 Reconstruction of Soft Tissue Defects with Regional Flaps . . . . . . . . 129
José Ignacio Salmerón Escobar, José Alfonso Ruiz Cruz,
Ana María López López, and Carlos Navarro Vila
6 Functional Implant-Supported Dental Rehabilitation
in Oncologic Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
Santiago Jose Ochandiano Caicoya, Carlos Navarro Cuellar,
Julio Acero Sanz, and Carlos Navarro Vila
7 Reconstruction in Facial Paralysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203
Teresa González Otero and Ignacio Navarro Cuellar

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221

vii
Contributors

Julio Acero Sanz, MD, DDS, PhD, FEBOMS Head of Oral and Maxillofacial
Surgery Department, Ramón y Cajal University Hospital, Madrid, Spain
Associate Professor of Alcalá University, Madrid, Spain
Teresa González Otero, MD, PhD, FEBOMS Consultant at Oral and
Maxillofacial Surgery Department, La Paz University Hospital, Madrid, Spain
Ana María López López, MD, DDS, FEBOMS Consultant at Oral and
Maxillofacial Surgery Department, Miguel Servet University Hospital,
Zaragoza, Spain
Cristina Maza Muela, MD, DDS, FEBOMS Consultant at Oral and
Maxillofacial Surgery Department, Gregorio Marañón General University
Hospital, Madrid, Spain
Carlos Navarro Cuellar, MD, DDS, PhD, FEBOMS Associate Professor
Medical Faculty, Complutense University of Madrid, Madrid, Spain
Consultant at Oral and Maxillofacial Surgery Department, Gregorio Marañón
General University Hospital, Madrid, Spain
Ignacio Navarro Cuellar, MD, DDS, FEBOMS Consultant at Oral and
Maxillofacial Surgery Department, Virgen de la Salud Hospital, Toledo, Spain
Carlos Navarro Vila, MD, DMD, PhD, FEBOMS Full Professor
Medical Faculty, Complutense University of Madrid, Madrid, Spain
Head of Oral and Maxillofacial Department Surgery, Gregorio Marañón General
University Hospital, Madrid, Spain
Académico Correspondiente of the Royal National Academy of Medicine of
Spain, Madrid, Spain
Santiago José Ochandiano Caicoya, MD, DDS, FEBOMS Consultant at Oral
and Maxillofacial Surgery Department, Gregorio Marañón General University
Hospital, Madrid, Spain

ix
x Contributors

José Alfonso Ruiz Cruz, MD, DDS, FEBOMS Consultant at Oral and
Maxillofacial Surgery Department, University Hospital del Sur, Madrid, Spain
José Ignacio Salmerón Escobar, MD, PhD, FEBOMS Associate Professor
Medical Faculty, Complutense University, Madrid, Spain
Consultant at Oral and Maxillofacial Surgery Department, Gregorio Marañón
General University Hospital, Madrid, Spain
Mandibular Reconstruction
1
Carlos Navarro Cuellar, Cristina Maza Muela,
Santiago José Ochandiano Caicoya,
and Carlos Navarro Vila

Abstract
Mandibular reconstruction involves restoration of the functions of chewing,
swallowing, phonation, and facial expression. Until relatively recently, the only
reconstruction options available were pedicle flaps, bone grafts, and reconstruc-
tion plates. Microsurgery has provided us with better options for reconstruction.
Pedicle flaps and microsurgical flaps can provide sufficient bone and soft tissue
to resolve these problems.
Reconstruction of the mandible and associated soft tissue can be performed
during the ablation procedure (primary reconstruction) or during a subsequent
procedure (secondary reconstruction).
The optimal approach is one that attempts to reconstruct the original contour
as much as possible using bone and soft tissue for extraoral and intraoral tissue
defects where applicable.

C. Navarro Cuellar, MD, DDS, PhD, FEBOMS (*)

Associate Professor Medical Faculty, Complutense University of Madrid, Madrid, Spain
Consultant at Oral and Maxillofacial Surgery Department, Gregorio Marañón General
University Hospital, Madrid, Spain
e-mail: [email protected]
C. Maza Muela, MD, DDS, FEBOMS • S.J. Ochandiano Caicoya, MD, DDS, FEBOMS
Consultant at Oral and Maxillofacial Surgery Department, Gregorio Marañón General
University Hospital, Madrid, Spain
e-mail: [email protected]; [email protected]
C. Navarro Vila, MD, DMD, PhD, FEBOMS
Full Professor Medical Faculty, Complutense University of Madrid, Madrid, Spain
Head of Oral and Maxillofacial Department Surgery, Gregorio Marañón General
University Hospital, Madrid, Spain
Académico Correspondiente of the Royal National Academy of Medicine of Spain,
Madrid, Spain
e-mail: [email protected]

© Springer International Publishing Switzerland 2015 1

C. Navarro Vila (ed.), Reconstructive Oral and Maxillofacial Surgery,
DOI 10.1007/978-3-319-20487-1_1
2 C. Navarro Cuellar et al.

1.1 Introduction

Reconstructive surgery dates back to the sixth century, when Sushruta Samhita [1,
2] performed the first reconstructions of the nose and ears in India. However, it was
not until the time of the Romans that Celsus recorded the use of advancement flaps
for the reconstruction of the head and neck. Mandibular reconstruction has a shorter
history, since most clinical experience and research dates from the treatment of
injuries from the First and Second World Wars. In the United States, two hospitals
were built to care for patients with these injuries, and emphasis was placed on the
development of head and neck units, where specialists in maxillofacial surgery were
trained. Laboratories were also established for the manufacture of devices such as
arch bars, ferrules, and wires, all of which are necessary for the treatment of trau-
matic and oncologic lesions of the face.
The angiosome is a key concept in mandibular reconstruction that was intro-
duced in 1987 by the plastic surgeons Taylor and Palmer [3, 4]. An angiosome is a
three-dimensional block of tissue that involves the muscular, cutaneous, and subcu-
taneous territories that are supplied by an artery and a vein. This discovery made it
possible to apply both free and pedicle osteomyocutaneous flaps for mandibular
reconstruction.
Mandibular reconstruction involves not only restoration of continuity with cos-
metic objectives in mind but also restoration of the functions of chewing, swallow-
ing, phonation, and facial expression. Thus, maxillofacial surgery has evolved over
time with the introduction of muscle transfer techniques, nerve anastomosis, and
osseointegrated implants, all of which help to restore mandibular function.
When part of the mandible is missing, generally as a result of ablative surgery for
the treatment of tumors, the major sequelae in bone and soft tissue have both a cos-
metic and a functional effect. In cosmetic terms, we can observe retrusion of the
lower third, which is more remarkable when the part of the mandible affected is the
parasymphysis or symphysis, and eversion of the lower lip. When resection affects
the body of the mandible, we observe asymmetry with sinking of the affected side
and retraction of the soft tissue that leads to deviation of the remnant mandible to
the missing area. In functional terms, missing structure in the anterior area leads to
labial and salivary incontinence and phonation disorders. When the body of the
mandible is affected toward the condyle, we observe the occlusal plane canted with
crossbite, which hinders mouth opening, chewing, and swallowing. The absence of
some areas of the mandible generates overload on the remnant mandible and other
structures of the oral cavity with altered proprioception leading to incoordination of
mandibular movement.
Analysis of the possible sequelae arising from partial or total mandibular bone
loss clearly illustrates the serious difficulties faced by patients in leading a normal
social and working life.
As Wong et al. [5] reported, there is no ideal biomechanical solution for man-
dibular reconstruction. The mechanical resistance and forces acting on the recon-
structed mandible are complex and not fully understood. Excessive pressure on
traditional bone grafts and metal plates can lead to fracture of the plate, loosening
1 Mandibular Reconstruction 3

of the screws, and bone resorption, which could in turn lead to potential fracture of
the mandible. New approaches in mandibular reconstruction attempt to distribute
forces evenly in the remnant mandible.
The aim of mandibular reconstruction is to return cosmetic and functional integ-
rity and thus ensure quality of life. Until relatively recently, the only reconstruction
options available were pedicle flaps, bone grafts, and reconstruction plates.
Microsurgery has provided us with better options for reconstruction.

1.2 Bone Grafts

Publications on mandibular reconstruction with free bone grafts date from as early
as the end of the eighteenth century and beginning of the nineteenth century.
Bardenheuer [6] and Skyoff [7] reported the first cases of mandibular reconstruction
with autologous bone grafts harvested from the iliac crest, tibia, and rib.
Considerable experience treating traumatic mandibular defects was gained dur-
ing the First World War. Ivy and Epes [8] followed a delayed approach to recon-
struction of the mandible using solid blocks of tibial bone or mandibular bone
pedicle grafts. The authors reported mandibular continuity in 76 % of cases and a
long period of intermaxillary fixation.
The Second World War saw the advent of new approaches in this type of recon-
structive surgery. These included internal blocks for stabilizing the graft, use of the
iliac crest as the donor site, and administration of antibiotics. Studies from this period
by Blocker and Stout [9] reported the use of bone grafts for mandibular reconstruction
harvested from the tibia, ribs, and iliac crest. Graft survival was 90 % in approxi-
mately 1000 grafts. These successes made autologous bone grafts the main option for
reconstruction of both traumatic and oncologic defects during the 1950s and 1960s.
Despite these promising beginnings, problems with bone grafts began to appear,
mainly when contouring the symphysis. Brown et al. [10] and Millard et al. [11]
reported difficulties shaping the symphysis with iliac crest grafts.
In other series, the rate of complications and graft loss was greater. Wersal et al.
[12] performed 23 mandibular reconstructions with rib grafts, and although the
author indicated that the grafts were for lateral and anterior defects, 22 % of the
grafts failed. Hamaker [13, 14] used delayed reconstruction with bone grafts in 15
patients who had undergone mandibulectomy and radiation therapy. The graft failed
in 33 % of cases because of radionecrosis and superinfection.
Cummings and Leipzig [15] reported the use of a cryogenically devitalized auto-
graft for mandibular reconstruction. DeFries et al. [16] used cadaver mandible grafts
with autologous bone from the iliac crest and reported 10 failures in 14 patients who
had undergone radiation therapy. The main problem of bone grafts is their low toler-
ance of infection, particularly in cancer patients. This problem did not affect trau-
matic defects, since surgery was delayed and based on an extraoral approach, thus
preventing contamination of the oral cavity. Therefore, most surgeons recommended
delaying reconstructive surgery and, if the graft survived locoregional recurrence,
using an extraoral approach.
4 C. Navarro Cuellar et al.

Bone grafts continue to be the subject of debate. Although the maximum length
indicated to ensure viability is 3 cm, recent publications [17] report the vasculariza-
tion of free bone grafts in 11 patients measuring up to 7 cm in length in a single
block and 14 cm when blocks are combined.

1.3 Alloplastic Materials

Alloplastic materials are inert (nonorganic) materials normally implanted inside the
body to remodel and create volume or replace a given anatomic area. They have the
advantage that no donor site is necessary and no antigen response to foreign pro-
teins occurs. The main alloplastic materials used are iron, titanium, hydroxyapatite,
chrome-cobalt, methyl methacrylate, and other polymers.
Titanium was first used in 1983 by Luckey and Kubli [18] for implants and pros-
theses. It is the material of choice for medical devices because it is light in weight,
resistant, and biocompatible. In addition, it does not interfere with diagnostic tech-
niques such as nuclear magnetic resonance or computed tomography.
Several materials have been described in the literature. Castermans et al. [19]
reported a failure rate of 70 % in a series of patients undergoing mandibular recon-
struction with Kirschner wires. Joyce and McQuarrie [20] reported a 25 % failure
rate in their series of patients undergoing reconstruction with a silicone and metal
prosthesis. Bowerman [21] used titanium plates in patients who had not undergone
radiation therapy to reconstruct the symphysis, with losses of 35 %, and Conley [22]
and Cook [23] used vitallium plates, with losses of 33 % at 5 years. A-O plates have
also been used to reconstruct the mandible [24], with failure rates of 4 % in the first
year, increasing exponentially with time and radiation therapy.
As these authors show, alloplastic materials have high rates of exposure and
superinfection, especially in patients undergoing radiation therapy.
Prostheses are currently being made from polyether ether ketone, hydroxyapa-
tite, and polyethylene, which can be prepared using computer-assisted design
(CAD)/computer-assisted manufacture (CAM) systems [25] before surgery to pro-
vide a more adapted approach to defects. However, the number of patients neces-
sary to perform feasibility studies is insufficient, and not enough time has passed to
determine long-term survival and resistance to radiation.

1.4 Combination of Bone Grafts and Alloplastic Material

During the 1960s, surgeons began to think that the reasons for graft failure were
incorrect fixation and poor vascularization. Supporting trays made of metal or
Dacron were used to improve fixation by filling them with cancellous bone, thus
enhancing neovascularization. In 1944, Moulem [26] first demonstrated the osteo-
genic capacity of cancellous bone chip grafts. Boyne and Zarem [27] were the first
to use a wire mesh tray with cancellous bone chips for mandibular reconstruction.
The mesh had to be removed in 11 % of 53 cases.
1 Mandibular Reconstruction 5

Lawson et al. [28] reported a series of 54 cases of mandibular reconstruction per-

formed using metal trays and cancellous bone in which the failure rate was 54 % for
immediate reconstructions compared with 19 % in delayed procedures. Infection of the
intraoral wound was the factor that most contributed to the failure of the reconstruction.
Albert et al. [29] used Dacron trays with cancellous bone and reported a 24 % failure rate.
Branemark et al. [30] used titanium mesh with and without cancellous bone in
mandibular reconstruction procedures. In patients whose graft was with mesh only,
the failure rate was 40 %, and the graft was reabsorbed in 60 %.
In 1987, Klotch and Prein [31] performed reconstruction in 60 patients with A-O
reconstruction plates. Regional pedicle grafts were used to cover the plates and thus
fully seal the soft tissue. The authors reported a success rate of 86 % with exposure
of the plate in 25 % of patients who received radiation therapy, multiple salivary
fistulas, and late fractures in 8 %.
In 1990, Komisar [32] studied series with plates used for primary and deferred
reconstruction, whether combined or not with bone, and found that 82 % of primary
reconstructions were complicated by infection and that, when a bone graft was used,
the reabsorption rate was more than 50 %.
In 1990, Saunders et al. [33] presented a series of 27 patients who underwent
primary reconstruction with titanium plates not combined with bone graft. The suc-
cess rate was 78 %, although none of the patients who underwent reconstruction of
the symphysis could wear dentures after surgery. The results reported by Gullane
[34] were similar, with a 78 % success rate during the first year.
Almost 40 years later, the combination of bone grafts with alloplastic material
remains controversial. Studies continue to show integration and corticalization of
iliac crest grafts packed in titanium mesh [35].
No multicenter studies have analyzed reconstruction of mandibular defects in
cancer patients who undergo radiation therapy. Yagihara et al. [36] recently pub-
lished the results of a study in which they combined poly-L-lactide mesh with can-
cellous bone grafts. As this material descomposes after 6 months to 2 years in the
body, the authors reported a success rate of 84 % and concluded that the frequency
of excellent or good regeneration tended to be better in primary reconstruction,
benign lesions, and marginal resections, in patients not undergoing radiation ther-
apy, and in procedures that do not involve reconstruction of associated soft tissue. A
separate analysis of patients receiving radiation therapy showed that classic con-
cepts remained unchanged, with poor bone regeneration in 27.4 % of cases com-
pared with 13.3 % in those who did not receive radiation therapy.
Therefore, mandibular reconstruction would not be the technique of choice for
defects resulting from cancer, although such techniques are associated with low mor-
bidity and could be considered in patients who cannot undergo other procedures.

1.5 Distraction Osteogenesis

Techniques for the reconstruction of the lower third (both soft tissue and bone) are
very varied. Each has its indications and risks.
6 C. Navarro Cuellar et al.

Distraction osteogenesis was first described in 1957 by Ilizarov and involves a

process in which bone is formed between two segments that are gradually separated
by progressive traction using a device known as a distractor. This separation gener-
ates both bone and the surrounding tissue. The technique has been used by orthope-
dic surgeons for more than 40 years. Distraction osteogenesis of the mandible was
first described in 1998 by McCarthy et al. [37].
We can distinguish between two types of distraction osteogenesis. The first is
performed without bone transport and is used to treat bone malformations in maxil-
lofacial and orthopedic surgery. This technique makes it possible to lengthen the
bone and adjacent soft tissue. The second type involves bone transfer and is used to
treat bone defects by filling the defect without altering the original length of the
bone.
Mandibular bone is distracted by means of bone resection and placement of the
distractor. This is followed by the latency period, which is the time necessary for the
bone to lengthen, generally between 5 and 7 days. The distraction period then
begins, with growth of 0.8–1 cm per day. When the planned length is reached, the
distractor must be kept in place for the so-called consolidation period, which usu-
ally lasts about 3 months.
The associated mortality of this technique is low and results are good. However,
it is not the technique of choice in mandibular reconstruction after tumor resection,
because the application time is too long, thus preventing coadjuvant radiation ther-
apy from being administered within the effective window period (4–6 weeks). In
addition, the likelihood of osteoradionecrosis is increased. If possible, the technique
should be applied after other bone reconstructions, for example, using microsurgi-
cal fibular flaps, for vertical lengthening in order to gain sufficient height and fit
implants.

1.6 Primary Reconstruction vs Secondary Reconstruction

Reconstruction of the mandible and associated soft tissue can be performed during
the ablation procedure (primary reconstruction) or during a subsequent procedure
(secondary reconstruction).
We favor primary reconstruction for several reasons. It is technically easier than
secondary reconstruction, there is no fibrosis or retraction, and anatomic relation-
ships can be maintained (e.g., with intermaxillary fixation or by molding and fixing
before resection of mandibular reconstruction plates to maintain the mandibular
arch). Furthermore, a second procedure is obviated, the cost is lower, and the patient
can return more quickly to his/her social and working life. Since the patient does not
have to face the functional and cosmetic sequelae of ablative surgery, psychological
recovery is much quicker and complete after oncologic surgery.
We do not agree with the reasons against primary reconstruction, mainly poor
control of subsequent relapses. Today, imaging techniques such as computed tomog-
raphy or magnetic resonance enable relapses—even those involving only a few mil-
limeters—to be detected very quickly.
1 Mandibular Reconstruction 7

Similarly, we do not agree with the other reason against primary reconstruction,
namely, the recommendation to avoid exertion, because 50 % of patients were lost
to follow-up during the first year. We believe that the quality of life patients gain
during the remainder of their lives is more than sufficient reason to perform imme-
diate reconstruction.
In our department, we limit secondary reconstruction to those cases where pri-
mary reconstruction was not successful and for patients who underwent procedures
at other centers, where, for whatever reason, no reconstruction was performed dur-
ing the first intervention.

1.7 Type of Reconstruction: Pedicle Flaps

and Microvascular Flaps

The optimal approach is one that attempts to reconstruct the original contour as
much as possible using bone and soft tissue for extraoral and intraoral tissue defects
where applicable. Pedicle flaps and microsurgical flaps can provide sufficient bone
and soft tissue to resolve these problems. Several factors must be taken into consid-
eration when deciding which technique to choose.
Many factors come into play when deciding on reconstruction and selecting a
specific flap. The most important are the following:

1. Type, size, and position of the defect

2. Quantity and quality of the remnant bone
3. Size and defect of the soft tissue
4. Intraoral and extraoral defects
5. Quality of local vascularization (compromised by previous radiotherapy, diabe-
tes mellitus, arteriosclerosis)
6. State of the maxilla, tongue, and floor of the mouth, as well as lip competence
7. Previous surgery: functional or radical neck dissection, failed reconstructions
8. Previous local surgery: functional or radical neck dissection
9. General status of the patient

1.7.1 Pedicle Flaps

In the 1980s, myocutaneous flaps began to be used for soft tissue defects. Bone
was later included in these flaps for mandibular reconstruction. The flaps were
taken from the pectoralis major with the fifth or sixth rib, as described by Cuono
and Ariyan [38] in 1980, the trapezius muscle with the spine of the scapula, the
sternocleidomastoid muscle with the clavicle, and the latissimus dorsi with the
iliac crest.
In 1979, Demergasso and Piazza [39] reported for the first time the use of the
trapezius osteomyocutaneous flap for mandibular reconstruction. Panje and Cutting
[40, 41] used this flap in 24 patients, and the flap failed in 13 %. Little et al. [42]
8 C. Navarro Cuellar et al.

used a pectoralis major flap with the fifth rib for mandibular reconstruction and
reported complications in two cases, although the rib was viable in a further three
patients.
Kudo et al. [43] reconstructed the mandible of five patients using a pectoralis
major flap with rib and sternum. Two patients experienced pneumothorax, and the
rib had to be withdrawn in a further two cases.
The results of our experience with this reconstruction have not been good, since
the rib is largely reabsorbed after radiation therapy.

1.7.2 Microvascular Flaps

The first microsurgery-based mandibular reconstruction was reported in 1971 by

Strauch et al. [44]. The subsequent studies by Ostrup and Fredrickson [45], Daniel
[46], and Taylor [47] show that both the rib and the iliac crest can be transferred to
the mandible using microsurgery. Thanks to these techniques, flap failure is much
reduced, although surgical time and morbidity increase.
Franklin et al. [48] performed six mandibular reconstructions with the iliac crest
flap of which one failed (16 %). The author reported problems such as the large size
of the flap, the lack of sensitivity of the skin paddle, and surgical time.
MacLeod and Robinson [49] published a series of 12 reconstructions of the ante-
rior mandible. The flap used was the second metatarsal based on the dorsalis pedis
vein and artery. They reported only one case of flap loss.
In 1986, Soutar and Widdowson [50] reported on the use of the radius as a radial
osteofasciocutaneous flap for mandibular defects associated with a soft tissue
defect. The flap failed in only 1 of the 14 patients who underwent surgery.
Cordeiro and Hidalgo [51] compared mandibular reconstructions performed
with free flaps and those performed with reconstruction plates combined with pedi-
cle flaps to seal soft tissue. The authors reported a greater number of complications,
longer hospital stay, and greater number of reoperations in the series that underwent
reconstruction with plates and pedicle flaps.
Schusterman et al. [52] also compared reconstruction with plates and free flaps.
The free flaps survived in most cases and could be used to reconstruct any segment,
whereas plates were exposed and superinfected in the symphysis in 66 % of cases.
Hoffmeister et al. [53] combined an iliac crest free flap and a jejunal free flap to
reconstruct the mandible and mucosa in a series of 22 patients.

1.8 Microvascular Flaps

1.8.1 Fibula Flap

The microsurgical fibula flap was first described by Taylor et al. [47] in 1975.
Hidalgo [54] was the first to use this flap for mandibular reconstruction in 1988. The
fibula is a long thin non-weight-bearing bone. It has a constant tubular cross section
along its length, with a thick cortex (66 % of the section [55]), thus making it one of
1 Mandibular Reconstruction 9

the strongest bones for transfer. The fibula provides approximately 25 cm of bone,
which is sufficient to reconstruct any mandibular defect [56]. Both a bone flap and
an osteocutaneous flap can be obtained.
The main advantages of this flap are that it is very long and enables two teams to
work simultaneously. Furthermore, its rich periosteal vascularization makes it pos-
sible to perform several osteotomies for remodeling. The skin paddle can be rein-
nervated to provide sensation, and morbidity in the donor area is minimal. We prefer
the fibula flap to the iliac crest flap in obese patients, because the bone is easy to
harvest. According to Moscoso et al. [55], the main disadvantage of this flap is that
15 % of men and a somewhat higher percentage of women cannot receive implants
owing to the size of the bone. In addition, multiple osteotomies are necessary for
remodeling, thus necessitating a large quantity of osteosynthesis material and pre-
venting immediate fitting of implants. The fibula lacks sufficient height in segmental
defects in dentulous patients; therefore, there is some discrepancy between the height
of the flap and the remnant mandible, which leads to a poor crown-implant ratio.
Horiuchi et al. [57] and Siciliano et al. [58] resolved this issue with a double-strut
fibula or secondary vertical distraction of the fibula. The main disadvantage of this
flap is the very variable number of septocutaneous perforators that irrigate the skin
paddle. Wei et al. [59] provided the clearest explanations of the vascularization of the
skin paddle, which is supplied by 4–7 branches, of which between 1 and 4 are septo-
cutaneous (inconstant, may be missing) and the remainder musculocutaneous. Two
septocutaneous branches feed an area of skin measuring 20 × 25 cm. Futran et al. [60,
61] proposed Doppler imaging to locate the perforators and prepare the preoperative
sketch of the skin paddle based on these perforators and achieved excellent results;
in our opinion, this technique is the approach of choice when attempting to ensure
maximum viability of the skin paddle. In 1994, Hidalgo [62] proposed obtaining a
very broad skin paddle by de-epithelializing any surplus skin. Thus, we can ensure
vascularization of the skin paddle, whose viability ranges between 95.5 % and
100 %. In order to ensure this viability, it is a good idea to design a skin paddle based
on the intermuscular septum and the distal third of the bone and to include a wedge
of muscle (soleus and flexor hallucis longus) to ensure that the musculocutaneous
perforators are included. The last main disadvantage of the fibula flap is that it
requires preoperative confirmation by arteriography or Doppler imaging that there is
sufficient circulation to supply the skin once the fibular artery has been resected,
because some arterial disorders can lead to ischemic necrosis.
The main characteristics of the fibula flap are its maximum length (25 cm, mean
length of 17–18 cm), pedicle length (2–3 cm at the origin, increasing via subperios-
teal dissection to 12 cm), artery caliber (1.8–3 mm), and vein caliber (2–4 mm).
The fibula flap is indicated in the following situations:

• Reconstruction of total or subtotal mandibular defects: when the defect is greater

than 14 cm, only the fibula provides sufficient bone.
• The main application of the fibula is reconstruction of mandibular segment
defects: the strength of the bone can resist the forces of mastication, and implants
can be placed. In defects measuring less than 14 cm, the iliac crest has lost ground
in favor of the fibula, which is today the main flap in mandibular reconstruction.
10 C. Navarro Cuellar et al.

• Secondary reconstructions that affect the ramus and condyle. The thin bone of
the fibula flap is easy to insert in the tunnel created by the fibrous soft tissue
without damaging the facial nerve.
• Reconstruction of mandibular defects accompanied by major defects of intra-
oral soft tissue, which advise against using the iliac crest and in which we
cannot use the trapezius osteomyocutaneous flap for the reasons specified
above.
• Microsurgical reconstruction of the mandible in children [63].

As for functional recovery of the teeth, the fibula accepts small-to-medium

implants. Given the number of miniplates and screws necessary to fix osteotomies
and ensure a good cosmetic outcome, we place implants in this flap during a second-
ary procedure.
If the patient undergoes radiation therapy after surgery, we wait until 9–12 months
have passed. The screws and miniplates are removed and the implants inserted. The
percentage of osteointegration of the implants in the patients we treat was 96.6 %,
which decreases to 92 % in the long term (more than 3 years) [64] (Figs. 1.1, 1.2,
1.3, 1.4, 1.5, 1.6, 1.7, 1.8, 1.9, 1.10, 1.11, and 1.12).

Fig. 1.1 Mandibular

tumor (ameloblastoma)

Fig. 1.2 Preoperative

OPT
1 Mandibular Reconstruction 11

Fig. 1.3 Fibula flap

dissection

Fig. 1.4 Postoperative

OPT with dental implants

Fig. 1.5 Dental prosthesis and occlusion

12 C. Navarro Cuellar et al.

Fig. 1.6 Postoperative view

Fig. 1.7 Ablative

resection
1 Mandibular Reconstruction 13

Fig. 1.8 Fibula flap

intraoperative design

Fig. 1.9 Immediate

postoperative
reconstruction

Fig. 1.10 Postoperative

OPT
14 C. Navarro Cuellar et al.

Fig. 1.11 Definitive

occlusion

Fig. 1.12 Postoperative

view

1.8.2 Iliac Crest Flap

The iliac crest flap is based on the deep circumflex iliac artery, which arises from the
external iliac artery 1–2 cm cranially to the inguinal ligament. It runs toward the
anterosuperior iliac spine, internal face of the iliac bone, and between the iliacus
and transversus abdominis muscles. It gives off an ascending branch, which sup-
plies the lesser oblique muscle, periosteal and endosteal branches that supply the
bone, and musculocutaneous perforating branches toward the skin.
1 Mandibular Reconstruction 15

Venous drainage is from the deep circumflex iliac vein, which is usually a double
vein, into the external iliac vein.
Skin is obtained via the perforators along the internal part of the crest that cross
the three muscles of the abdominal wall. Therefore, a considerable part of the major
and minor oblique muscles and the transversus abdominis must remain attached to
the internal portion to carry the perforators. It is also necessary to design a wide skin
flap to incorporate as large a number as possible of perforators (between three and
nine in a field that extends longitudinally 9 cm posterior to the anterosuperior iliac
spine and 2.5 cm medial to the crest). The wide mesentery of the skin flap limits the
relative mobility of the skin.
The anatomical characteristics of this flap are as follows: short vascular pedicle
(5–7 cm); 1.5–3 mm diameter at its origin; bone length, 14–16 cm; lesser oblique
muscle of 10 × 15 cm; and skin surface of 15 × 25 cm.
Its main indications are as follows:

• Mandibular bone defects. We think that the iliac crest has the best quality, height, and
thickness for mandibular reconstruction of all the bone flaps; however, as it is only
10–12 cm long, larger defects require a fibular flap. It takes the thickest and longest
osseointegrated implants, which can be inserted during the same procedure.
• In defects of the symphysis, the flap can be molded to the form of the defect using
osteotomies and preserving the periosteum of the internal surface to maintain the
supply to the bone. When the defect includes the body and ascending ramus of the
mandible, the ramus can be contoured by designing an “L”-shaped flap.
• Bone defects associated with extraoral soft tissue defects. In this case, the cutane-
ous part of the flap is used to reconstruct the defect, although inguinal skin is con-
siderably paler in color. The cutaneous part can also be used to monitor the flap
• Bone defects associated with intraoral soft tissue defects. In these cases, the flap is
only feasible if it contains internal oblique muscle. The large volume of soft tissue
renders it inadequate for this type of reconstruction. We prefer other types of osteo-
cutaneous flap, such as the fibula, scapula, and trapezius osteocutaneous flaps.

The excellent quality of the bone in an iliac crest flap makes it possible to fit a
sufficient number of implants for the rehabilitation of most patients with an implant-
supported prosthesis. Since the height of the flap is similar to that of the remnant
mandible, for dentulous patients the crown-implant ratio obtained is optimal (1:3;
the crown accounts for 33 % of the total length of the crown-pillar-implant com-
plex). Implants can be fitted during mandibular reconstruction with a balanced
occlusal relationship. We obtained a 94 % osseointegration success rate with Mozo
Grau implants (MG osseous) and, in the long term, a 12 % failure rate [64].
In our opinion, the iliac crest flap is the best flap for mandibular bone reconstruc-
tion when we do not need to reconstruct soft tissue and for the reconstruction of the
symphysis and mandibular body up to 10 cm (Figs. 1.13, 1.14, 1.15, 1.16, 1.17,
1.18, and 1.19).
16 C. Navarro Cuellar et al.

Fig. 1.13 Preoperative

Fig. 1.14 Tumor resection

Fig. 1.15 Defect after

ablative surgery
1 Mandibular Reconstruction 17

Fig. 1.16 Intraoperative

reconstruction with iliac
crest free flap and MG
osseous implants

Fig. 1.17 Postoperative

CT

Fig. 1.18 Final occlusion

18 C. Navarro Cuellar et al.

Fig. 1.19 One year postoperative views

As shown in the indications (see above), reconstruction of soft tissue requires the
use of the internal oblique muscle, which is excessively bulky. Navarro Cuellar et al.
[65] present an alternative technique that enables mandibular reconstruction using
an iliac crest flap combined with one or two nasolabial flaps to reconstruct intraoral
soft tissues. This technique combines the advantages of mandibular reconstruction
and insertion of osseointegrated implants (MG osseous) using an iliac crest flap in
combination with reconstruction of anatomically adapted intraoral soft tissue
defects, avoiding the dissection of internal oblique muscle (Figs. 1.20, 1.21, 1.22,
1.23, 1.24, and 1.25).
1 Mandibular Reconstruction 19

Fig. 1.20 Preoperative CT

Fig 1.21 Squamous cell

carcinoma resection with
cervical dissection

Fig. 1.22 Iliac crest free

flap reconstruction with
MG osseous implants
20 C. Navarro Cuellar et al.

Fig. 1.23 Nasolabial flap

covering iliac crest flap

Fig. 1.24 Postoperative

OPT

Fig. 1.25 Final occlusion

1 Mandibular Reconstruction 21

1.8.3 Scapular Flap

In 1981, Teot et al. [66] described the scapular and parascapular osteomyocutaneous
flap. Swartz et al. [67], Baker and Sullivan [68], and Sullivan et al. [69] subse-
quently reported the use of the scapular osteocutaneous free flap for immediate
mandibular reconstruction.
The skin covering the posterior surface of the scapula and the periosteum of the
lateral border of the scapula are vascularized by the scapular circumflex artery, a
branch of the subscapular artery.
The circumflex artery exits the triangular space and divides into a horizontal
branch (scapular flap) and a vertical branch (parascapular flap), which supply the
skin field (14 × 21 cm) covering the scapula.
The specific anatomical distribution of the vessels means that the bony part of the
flap can be placed independently in three dimensions with respect to the skin flap.
The mobility of the soft tissue with respect to the bone makes it possible to recon-
struct complex orofacial defects in which soft tissue requirements are as important
as the bone defect itself.
Many options are available for reconstruction using this flap, since it can be
exclusively muscular, musculocutaneous, osteomyocutaneous, or combined with
the latissimus dorsi and serratus anterior (megaflap).
In addition, the skin covering the scapula is thin, hairless, pliable, and similar in
color to facial skin [70].
The flap provides well-vascularized corticocancellous bone (1.5–3 cm wide and
10–14 cm long). We can also obtain a further 3–4 cm from the angle of the scapula
if we include the angular branch of the thoracodorsal artery.
The disadvantages of this flap are the need to rotate the patient, thus preventing two
surgical teams from working simultaneously. It has been suggested that this disadvan-
tage could be avoided by placing the patient on his/her side, although it is still difficult
for two teams to work simultaneously. Furthermore, the amount of bone is limited,
thus hindering reconstruction of large defects and placement of implants. The result-
ing scar is usually unsightly, and sensory reinnervation of the flap is not possible.
The characteristics of the scapular flap are as follows: pedicle diameter, 3–4 mm;
length, according to Swartz et al. [67] and Neukam et al. [71], is 4–6 cm from the
scapular border to the axillary artery (6–9 cm if bone is not taken; if bone is included,
the pedicle is shortened); bone length, 14 cm in men and 10 cm in women (if we
include the tip, we gain a further 3–4 cm); bone thickness, 1.5 × 3 cm; and skin sur-
face, 14 × 21 cm (sizes greater than 12 cm hinder direct closing).
The scapular flap is our last option for mandibular reconstruction. We think it has
very specific indications, as follows:

• Three-dimensional orofacial defects with large defects of bone and soft tissue
(intraoral and extraoral), since the mobility between these parts is considerable
• If the patient has peripheral vascular disease involving the iliofemoral and tibio-
fibular system and the defect cannot be reconstructed using a trapezius osteo-
myocutaneous flap
22 C. Navarro Cuellar et al.

As reported by Deschler and Hayden [72], the contralateral scapula is usually

shaped to the defect for two reasons. First, removal of the scapular flap requires
disinsertion of several muscles from the upper edge (long part of the triceps, teres
major and minor, and subscapular muscle), thus weakening the arm. If we proceed
to radical dissection, the shoulder will be even more limited. Therefore, in order to
prevent weakening of the arm and of the shoulder, the contralateral scapula is shaped
to the defect and radical dissection performed. Second, by using the contralateral
scapula and moving the lateral border of the scapula downward in the neomandible,
we ensure that the pedicle emerges distally, in the area of the angle. Thus, the orien-
tation of the pedicle in the neck is optimal.
Weakness of the upper arm is minimized by immobilization for a few days after
surgery and rigorous physiotherapy [70] (Figs. 1.26, 1.27, 1.28, 1.29, and 1.30).

Fig. 1.26 Mandible tumor

[87]

Fig. 1.27 Scapular free

flap dissection
1 Mandibular Reconstruction 23

Fig. 1.28 Scapular free

flap adapted at the defect

Fig. 1.29 Immediately

postoperative view
24 C. Navarro Cuellar et al.

Fig. 1.30 Final

appearance

1.9 Pedicle Flaps

1.9.1 Trapezius Osteomyocutaneous Flap

The trapezius osteomyocutaneous flap was first described in 1977 by Demergasso

and Piazza [73]. It is formed by the upper and middle portion of the trapezius muscle,
a skin island from the shoulder and scapular spine, and the acromion of the scapula.
The flap is supplied by the superficial transverse cervical artery, its main pedicle,
and receives an accessory supply from the dorsal scapular artery, the occipital artery,
and the intercostal arteries.
This supply makes it possible to obtain three different myocutaneous flaps [74]:
the superior trapezius myocutaneous flap, which is based on the occipital artery and
the intercostal paraspinal perforators; the lateral trapezius osteomyocutaneous flap,
which is based on the superficial transverse cervical artery; and the inferior trape-
zius flap, which is based on the dorsal scapular artery and the deep branch of the
transverse cervical artery.
We only discuss the lateral trapezius osteomyocutaneous flap (trapezius island
flap), since it is the only one of the three that includes richly vascularized scapular
bone [75].
It is based on the superficial transverse cervical artery and vein. In 80 % of cases,
the superficial transverse cervical artery arises in the thyrocervical trunk; in the
1 Mandibular Reconstruction 25

remaining 20 %, it arises in the subclavian artery [76]. When the artery arises
directly from the subclavian artery, it can course deeply or via the brachial plexus,
thus seriously limiting the arc of rotation of the pedicle and necessitating the use of
another flap (10 % of cases) [74].
Venous anatomy is much more variable than arterial anatomy. The transverse
cervical vein drains into the medial subclavian system in two-thirds of cases and
into the external jugular vein (close to its union with the subclavian vein) in the
remaining third [77] (Fig. 1.31).
In our experience, the skin paddle and anatomical references must be drawn with
the patient seated and arms tight to the trunk. We center the paddle on the acromio-
clavicular joint. The paddle can be as long as 12–20 cm from the back and up to
10 cm from the shoulder [78].
Including the acromion, the scapular spine measures about 13.5 cm in length and
0.7 cm in height at its medial border and up to 4 cm at its lateral border. Its width
ranges between 1 and 2.4 cm.
Depending on the location of the mandibular defect, we use the acromion, spine,
or both, as follows:

1. Symphyseal defect: can be reconstructed exclusively with the acromion and

respecting the scapular spine
2. Lateral defect: can be reconstructed with the scapular spine respecting the acro-
mion at its anatomical site
3. Mixed anterior and lateral defect: requires both the acromion and the scapular
spine

Transverse cervical
artery

Suprascapular
artery

Fig. 1.31 Vascular pedicle

[88]
26 C. Navarro Cuellar et al.

In order to prevent functional sequelae, the muscle at the donor site must be
reconstructed at closure: the supraspinatus muscle is sutured to the infraspinatus
muscle. Once joined, both muscles are sutured to the deltoid, and the anterior group
is anchored to the clavicle by nonabsorbable suture through purpose-made open-
ings. The skin island is closed with a posterior rotation flap.
One of the reasons this flap has fallen into disuse was the fact that it was
impossible to insert dental implants, without which only 10 % of patients could
wear stable prostheses. In their study of cadaver scapulas, Navarro Vila et al.
[74] showed that the acromion can take 13-mm implants in 100 % of cases,
whereas the lateral border of the spine can do so in 80 % and the medial border
in 20 %.
The trapezius island flap is indicated for mandibular reconstruction in patients
with intraoral bone and soft tissue defects who simultaneously undergo radical ipsi-
lateral dissection. The acromion and the scapular spine can be used to reconstruct
the mandibular bone defect, while the skin island is used to repair the intraoral soft
tissue defect. This flap makes it possible to repair bone defects of up to 10–12 cm.
In some cases, the skin paddle has been unfolded to repair intraoral and extraoral
tissue. The main contraindications are exclusively bone defects (iliac crest or fibula
free flaps are preferred) and situations where cervical dissection is functional rather
than radical. Using the trapezius muscle for the flap limits external rotation of the
scapula, which is necessary for raising the shoulder and elevation and separation of
the arm by 180°. It is also necessary to resect the sternocleidomastoid muscle to
leave space in the neck so that the flap can be passed through to the mouth. If the
dissection is radical, the nerves of the trapezius are always cut (XI pair) and the
sternocleidomastoid is resected; therefore, the trapezius flap does not involve added
morbidity. A final contraindication is secondary reconstruction after previous cervi-
cal dissection, because the pedicle could have been damaged during the first
procedure.
A clear advantage of the trapezius flap is that it is a regional flap; consequently,
morbidity is reduced, surgical time is shortened, and there is no need for two surgi-
cal teams.
Since this flap is more sensitive to the adverse effects of radiation therapy than
microsurgical flaps [79], implants must always be placed immediately.
Before microsurgical flaps began to be widely used, Navarro Vila et al. [74] used
the trapezius osteomyocutaneous flap to reconstruct the mandible in 78 cases, most
of which (52 %) involved squamous cell carcinoma of the floor of the mouth. The
cosmetic results were excellent, and the percentage of total/partial failures for this
flap at all sites was only 14 %.
Today, this flap is only used when severe arteriosclerosis prevents reconstruction
with microsurgical flaps, since the superficial transverse cervical vessels are not
usually involved. In addition, as the reconstruction is with a pedicle, there is no need
for anastomosis (Figs. 1.32, 1.33, 1.34, 1.35, and 1.36).
1 Mandibular Reconstruction 27

Fig. 1.32 Tumor

dissection

Fig. 1.33 Osteomy-

ocutaneous trapezius flap
isolated in its vascular
pedicle
28 C. Navarro Cuellar et al.

Fig. 1.34 Dental

rehabilitation

Fig. 1.35 Final occlusion

Fig. 1.36 Postoperative

anteroposterior view of the
patient
1 Mandibular Reconstruction 29

1.10 Reconstruction of the Condyle

The condyle is one of the main components of the temporomandibular joint (TMJ).
Condylar defects are usually caused by tumors and often involve severe facial defor-
mity and difficulty in mouth opening and mastication, thus significantly affecting
quality of life.
Any discussion on the reconstruction of the TMJ necessarily [80] shows a sig-
nificant difference between cases of a dysfunctional joint caused by a degenerative
disease or ankylosis and cases in which reconstruction of a section of the mandible
includes the TMJ. Advances in surgery to treat cancer of the head and neck have led
to the creation of subtotal defects on an irradiated bed or and are that could be irradi-
ated. These defects require a larger quantity of tissue and better vascularization;
therefore, microvascular flaps tend to be used.
Condylar reconstruction techniques include costochondral grafts, vertical sliding
osteotomy of the upper border of the ramus, sternoclavicular grafts, grafts of the
second metatarsal, and prosthesis.
The system used by Kaban et al. [81, 82] to describe condylar defects can be
applied to tumor resection, as follows:
• Class I defects, which only affect the condyle. The reconstruction articulates
with the intact joint surface.
• Class II defects, in which condyle and articular disc are absent. The reconstruc-
tion articulates with the fibrous cartilage of the glenoid fossa and eminence of the
temporal bone.
• Class III defects, in which the condyle, articular disc, and glenoid fossa are
absent. Reconstruction of the middle cranial fossa and the joint is necessary.
Therefore, depending on the resected area, reconstruction must be adapted to
anatomy and function. In unilateral openings, the objective is 35–40 mm; in bilat-
eral openings, it is 30 mm. Potter and Dierks [80] report their reconstruction sched-
ule according to the class of defect.
• Class I defects should have a good functional prognosis; therefore, the key to a
successful procedure is careful remodeling of the proximal end of the fibula flap
and its anatomical placement. A free condylar graft can also be added to the end
of the fibula.
• Class II defects can be better restored with a contoured fibula and interposition
of an auricular cartilage graft. This provides a stable bone reconstruction and the
formation of pseudoarthrosis in the joint. The second metatarsal can also be used
when only the structures of the TMJ are to be reconstructed.
• Class III defects that extend along the proximal mandible can be reconstructed
by combining the fibula and the second metatarsal, or the fossa can be recon-
structed with nonvascularized grafts, placement of an interposition flap, and
mandibular reconstruction with a fibula flap.

In addition to the classic techniques described, it is also possible to use 2-step

distraction osteogenesis for the reconstruction of the horizontal ramus and the
ascending ramus, as described by Wang et al. [83], and to apply new technology to
30 C. Navarro Cuellar et al.

design double-barrel fibula flaps in which one fragment slides along the other for
reconstruction of the condyle [84].
The promising results of Liu et al. [85] were based on three-dimensional porous
titanium scaffold or allogenic bone scaffold combined with osteogenic and chon-
drogenic material and bone marrow stromal stem cells for repair of condylar defects
in vivo using tissue engineering.

1.11 Application of Technology in Mandibular

Reconstruction

Current advances in reconstruction in oral and maxillofacial surgery include naviga-

tion systems, 3D imaging, virtual planning, stereolithographic models, and custom
prostheses.
Navigation systems enable the surgeon to know the position of surgical instru-
ments in the patient’s anatomy in real time. They were first described in the mid-
1990s for stereotactic brain surgery. Taylor subsequently began to use them in our
specialty this century.
Computer-assisted surgery is based on acquisition of preoperative images, which
are processed to create three-dimensional models, plan surgery, and perform the
intervention virtually.
Another important advantage of computer-assisted surgery is that it enables us to
create stereolithographic models, cutting guides, and custom prostheses. The main
benefit of this approach is that it can create mirror images of healthy areas for recon-
struction of resected areas.
CAD/CAM enables us to improve surgical accuracy, improve rehabilitation
prostheses, and reduce postoperative morbidity and surgical time.
When applying this technology in our practice, the necessary steps are as follows:

• Definition of the surgical problem.

• Analysis of all the options taking into account the diagnosis, prognosis, and
patient preferences.
• Selection of the surgical strategy.
• Acquisition and processing of images to create three-dimensional images.
• Performance of virtual surgery on the images using specific software that enables
us to make all three-dimensional movements.
• Creation of cutting guides, surgical models, and custom prostheses using CAD/
CAM.
• Use of the material obtained during virtual surgery to guide surgical incisions.
We can also use intraoperative surgery in order to perform guided resections and
place custom prostheses.

Mandibular reconstructions that were unthinkable only 10 years ago are now
being performed. Levine et al. [86] published a study of four complete mandibular
reconstructions with prosthesis fitted during the same procedure, as did Wang et al.
[84], who applied 3D technology for reconstruction of the mandible with the con-
dyle using microsurgical double-barrel fibular flaps.
1 Mandibular Reconstruction 31

Thanks to these advances, we can perform complex reconstructive surgery while

being sure of the outcome, since we know exactly where to make incisions in both
ablative and reconstructive surgeries [89]. We will also be able to use mandibular
reconstruction plates and previously modeled custom prostheses (Figs. 1.37, 1.38,
1.39, 1.40, 1.41, 1.42, 1.43, 1.44, 1.45, and 1.46).

Fig. 1.37 Preoperative

view

Fig. 1.38 Virtual planning

resection
32 C. Navarro Cuellar et al.

Fig. 1.39 Virtual planning

defect

Fig. 1.40 Virtual planning

reconstruction with fibula
free flap
1 Mandibular Reconstruction 33

Fig. 1.41 Stereo-

lithographic model with
adapted plate

Fig. 1.42 Surgical guided

resection at mandibular
tumor

Fig. 1.43 Surgical guided

resection of fibula flap
34 C. Navarro Cuellar et al.

Fig. 1.44 Fibula free flap

with reconstructed plate

Fig. 1.45 Intraoperative

reconstruction

Fig. 1.46 Postoperative

view
1 Mandibular Reconstruction 35

References
1. Bhishagratna KK. An English translation of the Sushruta Samhita based on original Sanskrit
text. 3rd ed. Calcutta: Bose; 1916. p. 107.
2. Rogers BO. The historical evolution of plastic and reconstructive surgery. In: Wood-Smith D,
Porowski PC, editors. Nursing care of the plastic surgery patient. St. Louis: C.V. Mosby;
1967. p. 4.
3. Taylor GI, Palmer JH. The vascular territories (angiosomes) of the body: experimental study
and clinical applications. Br J Plast Surg. 1987;40(2):113.
4. Taylor GI, Palmer JH. Angiosome theory. Br J Plast Surg. 1992;45:327.
5. Wong RC, Tideman H, Kin L, Merkx MA. Biomechanics of mandibular reconstruction: a
review. Int J Oral Maxillofac Surg. 2010;39:313–9.
6. Bardenheuer F. Verhandlung der Deutsch Gesellschaft Zentralbibliothek. Chirurgie. 1892;21:68.
7. Skyoff W. Frage der Knocken-plastik am Unterkiefer Zentralbibliothek. Chirurgie. 1900;35:881.
8. Ivy R, Epes BM. Bone grafting for defects of the mandible. Mil Surg. 1927;60:286–300.
9. Blocker TC, Stout RA. Mandibular reconstruction,World War II. Plast Reconstr Surg. 1949;4:153.
10. Brown RG, Vasquez LO, Jurkiewicz MJ. Reconstruction of the central mandible with a single
block of iliac bone. Br J Plast Surg. 1976;29:191–5.
11. Millard RD, Deane M, Garst WP. Bending an iliac bone graft for anterior mandibular arch
repair. Plast Reconstr Surg. 1976;48:600–1.
12. Wersal J, Bergsted H, Korlof B, Lind MG. Split rib graft for reconstruction of the mandible.
Otolaryngol Head Neck Surg. 1984;92:270–5.
13. Hamaker R. Irradiated autogenous mandibular grafts in primary reconstruction. Laryngoscope.
1981;91:1031–51.
14. Hamaker R, Singer M, Schockley W. Irradiated mandibular autograft. Cancer. 1983;52:1017–21.
15. Cummings C, Leipzig B. Replacement of tumor involved mandible by cryosurgically devital-
ized autograft. Arch Otolaryngol. 1980;106:252–4.
16. DeFries HO, Marble HB, Sell KW. Reconstruction of the mandible: use of a homograft com-
bined with autogenous bone and marrow. Arch Otolaryngol. 1971;93(4):426–32.
17. Akbay E, Aydogan F. Reconstruction of isolated mandibular bone defects with non-vascularized
corticocancellous bone autograft and graft viability. Auris Nasus Larynx. 2014;41:56–62.
18. Luckey HA, Kubli F. Titanium alloys in surgical implants. ASTM ATP 796. Philadelphia:
American Society for Testing and Materials; 1983.
19. Castermans A, Van Garse R, Vanwick R. Primary reconstruction of the mandible after resec-
tion for oral cancer. Acta Chir Belg. 1977;2:205–8.
20. Joyce LD, McQuarrie DG. Application of contemporary reconstructive techniques in head and
neck for anterior oro-facial cancers. Surgery. 1976;80:373–8.
21. Bowerman JE. Noes on mandibular reconstruction. Proc R Soc Med. 1974;67:610–4.
22. Conley JJ. The use of vitallium prosthesis and implants in the reconstruction of the mandibular
arch. Plast Reconstr Surg. 1951;8:150.
23. Cook HP. Immediate reconstruction of the mandible by metallic implant following resection
for neoplasm. Ann R Coll Surg Engl. 1968;42:233–58.
24. Gullane PJ, Havas T, Holmes H. Mandibular reconstruction with metal plate and myocutane-
ous flap. Aust N Z J Surg. 1986;56:701–6.
25. Abbas AT. Reconstruction skeleton for the lower human jaw using CAD/CAM/CAE. J of King
Saud Univ-Eng Sci. 2012;2:159–64.
26. Moulem R. Cancellous chip bone grafts. Lancet. 1944;2:146–748.
27. Boyne PJ, Zarem H. Osseous reconstruction of the resected mandible. Am J Surg. 1976;132:
49–53.
28. Lawson W, Loscalzo L, Baek SM. Experience with immediate and delayed mandibular recon-
struction. Laryngoscope. 1982;92:5–10.
29. Albert TW, Smith JD, Everts E, Cook TA. Dacron mesh tray and cancellous bone in recon-
struction of mandibular defects. Arch Otolaryngol Head Neck Surg. 1986;112:53–9.
36 C. Navarro Cuellar et al.

30. Branemark PI, Lindstrom J, Hallen O. Reconstruction of the defective mandible. Scand J Plast
Reconstr Surg. 1975;9:116–28.
31. Klotch DW, Prein J. Mandibular reconstruction using A-O plates. Am J Surg. 1987;154:
384–8.
32. Komisar A, Warman S, Danzinger E. A critical analysis of immediate and delayed mandibular
reconstruction using A-O plates. Arch Otolaryngol Head Neck Surg. 1989;115(7):830–3.
33. Saunders JR, Hirata RM, Jaques DA. Definitive mandibular replacement using reconstruction
plates. Am J Surg. 1990;160:387–9.
34. Gullane PJ. Primary mandibular reconstruction: analysis of 64 patients and evaluation of inter-
face radiation dosimetry on bridging plates. Laryngoscope. 1991;101(54):1–24.
35. Zhou L, Zhao J, Shang H, Liu W, Feng Z, Liu G, Wang G, Liu Y. Reconstruction of mandibular
defects using a custom-made titanium tray in combination with autologous cancellous bone.
J Oral Maxillofac Surg. 2011;69:1508–18.
36. Yagihara K, Okabe S, Ishii J, Amagasa T, Yamashiro M, Yamaguchi S, Yokoya S, Yamazaki
T, Kinoshita Y. Mandibular reconstruction using a poly(L-lactide) mesh combined with autog-
enous particulate cancellous bone and marrow: a prospective clinical study. Int J Oral
Maxillofac Surg. 2013;42:962–9.
37. McCarthy JG, Williams JK, Grayson BH, Crombie JS. Controlled multiplanar distraction of the
mandible: device development and clinical application. J Craniofac Surg. 1998;9(4):322–9.
38. Cuono C, Ariyan S. Immediate reconstruction of a composite mandibular defect with a
regional osteomusculocutaneous flap. Plast Reconstr Surg. 1980;65:477.
39. Demergasso F, Piazza M. Trapezius myocutaneous flap in reconstructive surgery for head and
neck cancer: an original technique. Am J Surg. 1979;138:533.
40. Panje W, Cutting C. Trapezius osteomyocutaneous island flap for reconstruction of the anterior
floor of the mouth and the mandible. Head Neck Surg. 1980;3:66–71.
41. Panje WR. Mandible reconstruction with the trapezius osteomusculocutaneous flap. Arch
Otolaryngol. 1985;111:223–9.
42. Little JW, McCulloch DT, Lyons JR. The lateral pectoral composite flap in one-stage recon-
struction of the irradiated mandible. Plast Reconstr Surg. 1983;71:326–37.
43. Kudo K, Miyasawa M, Fujikoka Y, Sasaki J. Immediate repair of mandibular defects following
surgery for carcinoma of the lower alveolus and gingiva using a pectoralis major osteomyocu-
taneous flap. J Maxillofac Surg. 1985;13:116–20.
44. Strauch B, Bloomberg AE, Lewin ML. An experimental approach to mandibular replacement:
island vascular composite rib grafts. Br J Plast Surg. 1971;24:334–9.
45. Ostrup LT, Fredrickson JM. Reconstruction of mandibular defects after radiation using a free
living bone graft transferred by microvascular anastomosis. Plast Reconstr Surg. 1975;55:
563–672.
46. Daniel RK. Mandibular reconstruction with free tissue transfer. Ann Plast Surg. 1978;1:346.
47. Taylor GI, Miller DH, Ham FJ. The free vascularized bone graft. A clinical extension of micro-
vascular techniques. Plast Reconstr Surg. 1975;55:533–44.
48. Franklin JD, Shack BR, Stone J. Single stage reconstruction of mandible and soft tissue defects
using a free osteocutaneous groin flap. Am J Surg. 1980;140:494–8.
49. MacLeod AM, Robinson DW. Reconstruction of defects involving the mandible and floor of the
mouth by free osteocutaneous flaps derived from the foot. Br J Plast Surg. 1982;35:239–46.
50. Soutar DS, Widdowson WP. Immediate reconstruction of the mandible using a vascularized
segment of radius. Head Neck Surg. 1986;8:232–46.
51. Cordeiro PG, Hidalgo DA. Soft tissue coverage of mandibular reconstruction plates. Head
Neck. 1994;16(2):112–5.
52. Schusterman MA, Reece GP, Kroll SS, Weldon ME. Use of the A-O plate for immediate man-
dibular reconstruction in cancer patients. Plast Reconstr Surg. 1991;88(4):588–93.
53. Hoffmeister B, Fleiner B, Dunsche A. Significance of vascularization of jejunal transplants in
secondary reconstruction of the mandible. Fortschr Kiefer Gesichtschir. 1994;39:111–4.
54. Hidalgo D. Fibula free flap: a new method of mandible reconstruction. Plast Reconstr Surg.
1989;84:71807.
1 Mandibular Reconstruction 37

55. Moscoso JF, Keller J, Geneden E, Weinberg H, Biller H, Buchbinder D, et al. Vascularized bone
flaps in oromandibular reconstruction. Arch Otolaryngol Head Neck Surg. 1994;120:36–43.
56. Urken ML. Composite free flaps in oromandibular reconstruction. Review of the literature.
Arch Otolaryngol Head Neck Surg. 1991;117:724–32.
57. Horiuchi K, Hattori A, Inada I, Kamibayashi T, Sagimura M, Yajima H, et al. Mandibular
reconstruction using the double barrel fibular graft. Microsurgery. 1995;16:450–4.
58. Siciliano S, Lengele B, Reychler H. Distraction osteogenesis of a fibula free flap used for
mandibular reconstruction: preliminary re- port. J Craniomaxillofac Surg. 1998;26:386–90.
59. Wei FC, Chen HC, Chuang CC, Noordhoff MS. Fibular osteosepto-cutaneous flap: anatomic
study and clinical application. Plast Reconstr Surg. 1986;78:191–9.
60. Futran N, Stack BC, Payne LP. Use of color Doppler flow imaging for preoperative assessment in
fibular osteoseptocutaneous free tissue transfer. Otolaryngol Head Neck Surg. 1997;117:660–3.
61. Futran N, Stack BC, Zaccardi MJ. Preoperative color flow Doppler imaging for fibula free tis-
sue transfers. Ann Vasc Surg. 1998;12:445–50.
62. Wei F, Seah C, Tsai Y, Liu S, Tseu M. Hidalgo D. discussion “Fibula osteoseptocutaneous flap
for reconstruction of composite mandibular defects”. Plast Reconstr Surg. 1994;93:294–304.
63. Genden E, Buchbinder D, Chaplin JM, Lueg E, Funk GF, Urken ML. Reconstruction of the
pediatric maxillae and mandible. Arch Otolaryngol Head Neck Surg. 2000;126:293–300.
64. Cuesta-Gil M, Ochandiano Caicoya S, Riba García F, Duarte Ruiz B, Navarro Cuéllar C,
Navarro Vila C. Oral rehabilitation with osseointegrated implants in oncologic patients. J Oral
Maxillofac Surg. 2009;67(11):2485–96.
65. Cuellar CN, Caicoya SJ, Sanz JJA, Cuéllar IN, Maza Muela C, Vila CN. Mandibular recon-
struction with iliac crest free flap, nasolabial flap and osseointegrated implants. J Oral
Maxillofac Surg. 2014;72(6):1226.e1–15.
66. Teot L, Bosse JP, Maffaregz R, et al. The scapular crest pedicled bone graft. Int J Micro surg.
1981;3:257–62.
67. Swartz WM, Banis JC, Newton ED, Ramasastry SS, Jones NF, Acland R. The osteocutaneous
scapular flap for mandibular and maxillary reconstruction. Plast Reconstr Surg. 1986;77:530–45.
68. Baker SR, Sullivan MJ. Osteocutaneous free scapular flap for one stage mandibular recon-
struction. Arch Otolaryngol Head Neck Surg. 1988;114:267.
69. Sullivan MJ, Carroll WR, Baker SR. The cutaneous scapular free flap in head and neck recon-
struction. Arch Otolaryngol Head Neck Surg. 1990;116:600–3.
70. Kuriloff D, Sullivan M. Mandibular reconstruction using vascularized bone grafts. Otolaryngol
Clin North Am. 1991;24:1391–418.
71. Neukam FW, Schmelzeisen R, Schliephake H. Oromandibular reconstruction with vascular-
ized bone grafts in combination with implants. Oral and Maxill of Surg Clin N Am.
1994;7:717–38.
72. Deschler DG, Hayden RE. The optimum method for reconstruction of complex lateral
oromandibular-cutaneous defects. Head Neck. 2000;22:674–9.
73. Demergasso F, Piazza M. Colgajo cutáneo aislado a pedículo muscular en cirugía reconstruc-
tiva por cáncer de cabeza y cuello. Téc-nica original. Actas de XLVII Congreso Argentino de
Cirugía. Fórum de investigación. Buenos Aires; 1976.
74. Navarro-Vila C, Borja-Morant A, Cuesta M, López de Atalaya F, Salmerón JI, Barrios
JM. Aesthetic and functional reconstruction with the trapezius osseomyocutaneous flap and
dental implants in oral cavity cancer patients. J Craniomaxillofac Surg. 1996;24:322–9.
75. Navarro Vila C, Zárate Salazar J, Molini Dezotti D, Martínez Alegría J, Izaguirre Espinozo H,
Suñer Machado M, et al. Reconstruction experience with myocutaneous and osteomyocutaneous
skin flaps in oncological surgery of the head and neck. J Maxillofac Surg. 1984;12:107–13.
76. Netterville JL, Panje WR, Maves MD. The trapezius myocutaneous flap. Dependability and
limitations. Arch Otolaryngol Head Neck Surg. 1987;113:271–81.
77. Cuesta Gil M, Navarro Vila C. Reconstrucción mandibular con el colgajo osteomiocutáneo
trapecial. Estudio de 42 casos. Rev Esp Cirug Oral Maxil of. 1995;17:63–81.
78. Panje W, Morris M. Trapezius osteomusculocutaneous flap. In: Komisar A, editor. Mandibular
reconstruction. New York: Thieme; 1997. p. 45–55.
38 C. Navarro Cuellar et al.

79. Cuesta M, Ochandiano S, Barrios JM, Navarro Vila C. Rehabilitación oral con implantes
osteointegrados en pacientes oncológicos. Rev Esp Cirug Oral Maxilof. 2001;23:171–82.
80. Potter JK, Dierks EJ. Vascularized options for reconstruction of the mandibular condyle.
Semin Plast Surg. 2008;22(3):156–60.
81. Kaban LB, Moses MH, Mulliken JB. Surgical correction of hemifacial microsomia in the
growing child. Plast Reconstr Surg. 1988;82:9–19.
82. Kaban LB, Moses MH, Mulliken JB. Correction of hemifacial microsomia in the growing
child: a follow up study. Cleft Palate J. 1986;23 Suppl 1:50–2.
83. Wang JJ, Chen J, Ping FY, Yan FG. Double-step transport distraction osteogenesis in the
reconstruction of unilateral large mandibular defects after tumour resection using internal dis-
traction devices. Int J Oral Maxillofac Surg. 2012;41:587–95.
84. Wang WH, Zhu J, Deng JY, Xia B, Xu B. Three-dimensional virtual technology in reconstruc-
tion of mandibular defect including condyle using double-barrel vascularized fibula flap.
J Craniomaxillofac Surg. 2013;41:417–22.
85. Liu CK, Jing CX, Tan XY, Xu J, Hu M. Using three-dimensional porous internal titanium scaf-
fold or allogenic bone scaffold for tissue-engineering condyle as a novel reconstruction of
mandibular condylar defects. J Med Hypotheses and Ideas. 2014;8:69–73.
86. Levine JP, Bae JS, Soares M, Brecht LE, Saadeh PB, Ceradini DJ, Hirsch DL. Jaw in a day:
total maxillofacial reconstruction using digital technology. Plast Reconstr Surg. 2013;131(6):
1386–91.
87. López de Atalaya FJ. Utilización de los colgajos microquirúrgicos en cirugía maxilofacial
[PhD thesis]. Madrid: Universidad Complutense; 1996.
88. Navarro-Vila C, Ochandiano S, López de Atalaya FJ, Cuesta M, Acero J, Barrios JM, et al.
Reconstrucción mandibular: colgajos pediculados y microquirúrgicos. Cir Esp. 2002;72(5):
287–96.
89. Kontio R. Update on mandibular reconstruction: computer-aided design, imaging, stem cells
and future applications. Curr Opin Otolaryngol Head Neck Surg. 2014;22(4):307–15.
Maxillary and Middle Face
Reconstruction 2
Carlos Navarro Vila, Ana María López López,
Cristina Maza Muela, and Carlos Navarro Cuellar

Abstract
Reconstruction of the maxilla is a challenge for the maxillofacial and oral
surgeon. Defects caused by injury or tumor resection alter the stomatognathic
system, leading to cosmetic and functional abnormalities.
Surgery for primary reconstruction of defects resulting from tumor resection
is less complicated because no radiation therapy has been administered and
fibrosis is not present. Consequently, the patient can return to work and regain a
normal social and personal life.
Since there is no ideal surgical technique for reconstruction of the middle
third, the type of defect, general status, and experience of the surgical team are
key factors.

C. Navarro Vila, MD, DMD, PhD, FEBOMS (*)

Full Professor Medical Faculty, Complutense University of Madrid, Madrid, Spain
Head of Oral and Maxillofacial Surgery Department, Gregorio Marañón General
University Hospital, Madrid, Spain
Académico Correspondiente of the Royal National Academy of Medicine of Spain, Madrid, Spain
e-mail: [email protected]
A.M. López López, MD, DDS, FEBOMS
Consultant at Oral and Maxillofacial Surgery Department, Miguel Servet
University Hospital, Zaragoza, Spain
e-mail: [email protected]
C. Maza Muela, MD, DDS, FEBOMS
Consultant at Oral and Maxillofacial Surgery Department, Gregorio Marañón General
University Hospital, Madrid, Spain
e-mail: [email protected]
C. Navarro Cuellar, MD, DDS, PhD, FEBOMS
Associate Professor Medical Faculty, Complutense University of Madrid, Madrid, Spain
Consultant at Oral and Maxillofacial Surgery Department, Gregorio Marañón General
University Hospital, Madrid, Spain
e-mail: [email protected]

© Springer International Publishing Switzerland 2015 39

C. Navarro Vila (ed.), Reconstructive Oral and Maxillofacial Surgery,
DOI 10.1007/978-3-319-20487-1_2
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