Independent risk factors for long-term skeletal relapse after mandibular advancement with bilateral sagittal split osteotomy

The purpose of this retrospective cohort study was to identify the independent risk factors for long-term skeletal relapse following mandibular advancement with bilateral sagittal split osteotomy. Univariate and multivariate linear regression analyses were performed including nine common risk factors for relapse as independent variables and horizontal/vertical long-term (≥2 years) skeletal relapse as dependent variables. Ninety-six patients were analyzed; 66 were female (68.8%) and the average age of the patients was 29.7 ± 10.5 years. Over an average follow-up of 3.8 ± 1.8 years after an initial mandibular advancement of 8.8 ± 2.4 mm, long-term skeletal relapse of 1.6 ± 1.0 mm horizontal and 0.9 ± 0.7 mm vertical was found. Multivariate analysis identified age, preoperative mandibular plane angle (MPA), bimaxillary surgery, counterclockwise mandibular rotation, and the magnitude of mandibular advancement to be significantly associated with horizontal long-term skeletal relapse. Preoperative MPA, counterclockwise mandibular rotation, and the magnitude of mandibular advancement were significantly associated with vertical long-term skeletal relapse. Thus preoperative MPA, the magnitude of mandibular advancement, and counterclockwise mandibular rotation of the mandible were found to be independent risk factors for both horizontal and vertical long-term skeletal relapse. Although long-term skeletal relapse cannot be avoided entirely, understanding the independent risk factors and their contributions will optimize treatment planning and long-term stability.     

Three-dimensional analysis of condylar changes in surgical correction for open bite patients with skeletal class II and class III malocclusions

The aim of this study was to quantify three-dimensional condylar displacements as a result of two-jaw surgery for open bite correction in patients with skeletal class II and class III malocclusion. Pre-surgical (T1) and post-surgical (T2) cone beam computed tomography scans were taken for 16 patients with skeletal class II (mean age 22.3 ± 9.47 years) and 14 patients with skeletal class III (mean age 25.6 ± 6.27 years). T2 scans were registered to T1 scans at the cranial base. Translational and rotational condylar changes were calculated by x,y,z coordinates of corresponding landmarks. The directions and amounts of condylar displacement were assessed by intra- and inter-class Mann–Whitney U-test or t-test. Class II patients presented significantly greater amounts of lateral (P = 0.002) and inferior (P = 0.038) translation than class III patients. The magnitudes of condylar translational displacements were small for both groups. Skeletal class III patients had predominantly medial (P = 0.024) and superior (P = 0.047) condylar translation. Skeletal class II patients presented greater condylar counterclockwise pitch (P = 0.007) than class III patients. Two-jaw surgery for the correction of open bite led to different directions and amounts of condylar rotational displacement in patients with skeletal class II compared to class III malocclusion, with greater rotational than translational displacements.     

Effect of self-setting α-tricalcium phosphate between segments for bone healing and hypoaesthesia in lower lip after sagittal split ramus osteotomy

AimsThe aim of this study was to evaluate hypoaesthesia of the lower lip and bone formation using self-setting α-tricalcium phosphate (Biopex^®) between the proximal and distal segments following sagittal split ramus osteotomy (SSRO) with bent absorbable plate fixation.Subjects and methodsThe subjects were 40 patients (80 sides) who underwent bilateral SSRO setback surgery. They were divided into a Biopex^® group (40 sides) and a control group (40 sides). The Biopex^® was inserted into the anterior part of the gap between the segments in the Biopex^® group. Trigeminal nerve hypoaesthesia in the region of the lower lip was assessed bilaterally using the trigeminal somatosensory-evoked potential (TSEP) method. Ramus square, ramus length, and ramus width, the square of the Biopex^® at the horizontal plane under the mandibular foramen were assessed preoperatively, immediately after surgery, and 1 year postoperatively by computed tomography (CT).ResultsThe mean measurable period and standard deviation were 9.3 ± 15.7 weeks in the control group, 5.3 ± 8.3 weeks in the Biopex^® group, and there was no significant difference. Ramus square after 1 year was significantly larger than that prior to surgery and new bone formation was found between the segments in both groups (P < 0.05). In the Biopex^® group, the square of the Biopex^® after 1 year was significantly smaller than that immediately after surgery (P < 0.05).ConclusionThis study suggested that inserting Biopex^® in the gap between the proximal and distal segments was useful for new bone formation and it did not prevent the recovery of lower lip hypoaesthesia after SSRO with bent absorbable plate fixation.     

Skeletal and dental stability of segmental distraction of the anterior mandibular alveolar process. A 5.5-year follow-up

17 patients (14 female; 3 male) were analysed retrospectively for skeletal and dental relapse before distraction osteogenesis (DO) of the mandibular anterior alveolar process at T1 (17.0 days), after DO at T2 (mean 6.5 days), at T3 (mean 24.4 days), at T4 (mean 2.0 years), and at T5 (mean 5.5 years). Lateral cephalograms were traced by hand, digitized, superimposed, and evaluated. Skeletal correction (T5–T1) was mainly achieved through the distraction of the anterior alveolar segment in a rotational manner where the incisors were more proclined. The horizontal backward relapse (T5–T3) measured ?0.3 mm or 8.3% at point B (non-significant) and ?1.8 mm or 29.0% at incision inferior (p < 0.01). Age, gender, amount and type (rotational vs. translational) of advancement were not correlated with the amount of relapse. High angle patients (NL/ML′; p < 0.01) showed significant smaller relapse rates at point B. Overcorrection of the overjet achieved by the distraction could be a reason for dental relapse. Considering the amount of long-term skeletal relapse the DO could be an alternative to bilateral sagittal split osteotomy for mandibular advancement in selected cases.     

Variables associated with stability after Le Fort I osteotomy for skeletal class III malocclusion

The purpose of this study was to assess skeletal stability and predictors of relapse in patients undergoing an isolated Le Fort I osteotomy. A retrospective cohort study of 92 subjects undergoing Le Fort I osteotomy for Class III malocclusion was implemented. Predictor variables were demographic and perioperative factors. The primary outcome variable was postoperative skeletal position with relapse defined as >2 mm sagittal and/or vertical change at A-point on serial lateral cephalograms at immediate postoperative, 1 year, and latest follow-up time points. Mean advancement at A-point was 6.28 ± 2.63 mm and mean lengthening was 0.92 ± 1.76 mm. Eight subjects (8.70%) had relapse (>2 mm) in the sagittal plane, and two subjects (2.17%) in the vertical plane. No subjects required reoperation for relapse as overbite and overjet remained in an acceptable range due to dental compensation. In regression analysis, magnitude of maxillary advancement was an independent predictor of relapse in the sagittal plane (P = 0.008). There were no significant predictors of relapse in the vertical plane. This study suggests that isolated Le Fort I osteotomy for correction of skeletal Class III malocclusion is a stable procedure and that greater advancement is an independent risk factor for sagittal relapse.     

Interaction analysis of risk factors for long-term skeletal relapse following mandibular advancement with bilateral sagittal split osteotomy

The aim of this study was to identify interaction effects among risk factors for long-term skeletal relapse. The study sample consisted of 96 patients who underwent mandibular advancement with bilateral sagittal split osteotomy. Ten predictor variables were analyzed for an interaction effect: sex, age, preoperative temporomandibular joint symptoms, mandibular plane angle (MPA), single or double jaw surgery, clockwise or counterclockwise mandibular rotation, magnitude of mandibular advancement, concomitant genioplasty, type of fixation, and follow-up duration. Modeling interactions between pairs of covariates were applied to detect a significant interaction among these risk factors on horizontal and vertical long-term skeletal relapse, respectively. Stratification analyses and two-way full factorial interaction analyses were performed to demonstrate how the interaction influenced the associations between covariates and relapse. The interactions between sex and mandibular rotation (P = 0.006) and between MPA and mandibular rotation (P = 0.002) were statistically significant for horizontal long-term skeletal relapse. No significant interaction was identified for vertical relapse. This study showed that female patients and those with an MPA ≥30° undergoing counterclockwise mandibular rotation are predisposed to greater horizontal long-term skeletal relapse. Therefore, the judicious use of counterclockwise rotation is recommended in order to minimize the relapse, especially in female patients and those with a high MPA.     

Maxillo-mandibular counter-clockwise rotation and mandibular advancement with TMJ Concepts® total joint prostheses: Part II – Airway changes and stability

The purpose of this study was to evaluate the anatomical changes and stability of the oropharyngeal airway and head posture following TMJ reconstruction and mandibular advancement with TMJ Concepts custom-made total joint prostheses and maxillary osteotomies with counter-clockwise rotation of the maxillo-mandibular complex. All patients were operated at Baylor University Medical Center, Dallas TX, USA, by one surgeon (Wolford). The lateral cephalograms of 47 patients were analyzed to determine surgical and post-surgical changes of the oropharyngeal airway, hyoid bone and head posture. Surgery increased the narrowest retroglossal airway space 4.9 mm. Head posture showed flexure immediately after surgery (?5.6 ± 6.7°) and extension long-term post surgery (1.8 ± 6.7°); cervical curvature showed no significant change. Surgery increased the distances between the third cervical vertebrae and the menton 11.7 ± 9.1 mm and the third cervical vertebrae and hyoid 3.2 ± 3.9 mm, and remained stable. The distance from the hyoid to the mandibular plane decreased during surgery (?3.8 ± 5.8 mm) and after surgery (?2.5 ± 5.2 mm). Maxillo-mandibular advancement with counter-clockwise rotation and TMJ reconstruction with total joint prostheses produced immediate increase in oropharyngeal airway dimension, which was influenced by long-term changes in head posture but remained stable over the follow-up period.     

Maxillo-mandibular counter-clockwise rotation and mandibular advancement with TMJ Concepts® total joint prostheses: Part I - Skeletal and dental stability

The purpose of this study was to evaluate skeletal and dental stability in patients who had temporomandibular joint (TMJ) reconstruction and mandibular counterclockwise advancement using TMJ Concepts total joint prostheses (TMJ Concepts Inc. Ventura, CA) with maxillary osteotomies being performed at the same operation. All patients were operated at Baylor University Medical Center, Dallas TX, USA, by one surgeon (Wolford). Forty-seven females were studied; the average post-surgical follow-up was 40.6 months. Lateral cephalograms were analyzed to estimate surgical and post-surgical changes. During surgery, the occlusal plane angle decreased 14.9 ± 8.0°. The maxilla moved forward and upward. The posterior nasal spine moved downward and forward. The mandible advanced 7.9 ± 3.5 mm at the lower incisor tips, 12.4 ± 5.4 mm at Point B, 17.3 ± 7.0 mm at menton, 18.4 ± 8.5 mm at pogonion, and 11.0 ± 5.3 mm at gonion. Vertically, the lower incisors moved upward ?2.9 ± 4.0 mm. At the longest follow-up post surgery, the maxilla showed minor horizontal changes while all mandibular measurements remained stable. TMJ reconstruction and mandibular advancement with TMJ Concepts total joint prosthesis in conjunction with maxillary osteotomies for counter-clockwise rotation of the maxillo-mandibular complex was a stable procedure for these patients at the longest follow-up.     

Comprehensive analysis of soft tissue changes in response to orthognathic surgery: mandibular versus bimaxillary advancement

This study was performed to compare soft tissue changes in response to mandibular and bimaxillary advancement osteotomy. Preoperative and postoperative cone beam computed tomography scans of 24 cases were analysed: 12 underwent bimaxillary advancement and 12 underwent mandibular advancement. The skeletal surgical movements were measured and soft tissue changes were displayed on a three-dimensional colour map. The intensity and shade of the colour indicated the magnitude and direction of the changes. In the bimaxillary advancement group, maxillary advancement was 5.5 ± 2.7 mm with anterior vertical impaction of 2.7 ± 2.5 mm; mandibular advancement was 4.6 ± 3.2 mm. Most of the mediolateral soft tissue changes were limited to the anatomical boundaries of the paranasal region – the columella together with the alar bases of the nose; these showed clear forward movement, which extended to involve most of the cheeks. In the mandibular surgery group, the mean advancement was 3.5 ± 2.6 mm. The chin region, lower lip, and inferior parts of the cheek showed forward shift with minimal changes at the vermilion border, which was only displaced in an upward direction. In conclusion, dense anatomical correspondence is a clinically meaningful method of producing a visual comprehensive analysis of the changes in response to orthognathic surgery.     

Three-dimensional changes of proximal segments in facial asymmetry patients after bilateral vertical ramus osteotomy

The intraoral vertical ramus osteotomy (IVRO) is a useful technique for mandibular setback surgery. However, there is a tendency for lateral flaring of the proximal segments on the non-deviation side after the correction of mandibular asymmetry with this technique. The purpose of this retrospective study was to evaluate the positional changes of the proximal segments after IVRO setback in skeletal class III patients with asymmetry, using preoperative and postoperative computed tomography scan data, and to apply the results in clinical practice. A total of 28 skeletal class III patients with asymmetry who underwent bimaxillary orthognathic surgery were included. A three-dimensional cone beam computed tomography scan was obtained preoperative, at 1 month postoperative, and at 1 year postoperative. At 1 month after the surgery, the proximal segments showed an outward rotation, lateral flaring, and anterior rotation of the condylar head. All postsurgical directional changes had returned to the preoperative state at 1 year postoperative, and there was no statistically significant difference in postoperative angulation changes between the two sides. The results showed no statistical differences in the positional changes of the proximal segments between the deviation and non-deviation sides. This study reaffirms the benefits of the IVRO for a minimal bony interference between the proximal and distal segments in three dimensions, including mandibular asymmetry cases.     

Two-point nasomaxillary fixation of the Le Fort I osteotomy: assessment of stability at one year postoperative

The purpose was to assess maxillary position among patients undergoing Le Fort I maxillary advancement with internal fixation placed only at the nasomaxillary buttresses. This was a retrospective study of patients undergoing a Le Fort I osteotomy for maxillary advancement, with internal fixation placed only at the nasomaxillary buttresses. Demographic and cephalometric measures were recorded. The outcome of interest was the change in maxillary position between immediately postoperative (T1), 6 weeks postoperative (T2), and 1 year postoperative (T3). Fifty-eight patients were included as study subjects (32 male, 26 female; mean age 18.4 ± 1.8 years). Twenty-five subjects (43.1%) had a diagnosis of cleft lip and palate. Forty-three subjects (74.1%) had bimaxillary surgery, 16 (27.6%) had bone grafts, and 18 (31.0%) had segmental maxillary osteotomies. At T3, there were no subjects with non-union, malunion, malocclusion, or relapse requiring repeat surgery. Mean linear changes between T1 and T3 were ≤1 mm. Mean angular changes between T1 and T3 were <1°. There was no significant difference in stability in multi-segment maxillary osteotomies (P =  0.22) or with bone grafting (P =  0.31). In conclusion, anterior fixation alone in the Le Fort I osteotomy results in a stable maxillary position at 1 year postoperative.     

Effects of maxillary advancement and impaction on nasal airway function

The effects of Le Fort I osteotomy on the nasal airway are controversial. This study aimed to evaluate nasal airway changes after Le Fort I. 25 patients underwent conventional Le Fort I osteotomy and were separated into three groups depending on the type of surgery they underwent. 11 patients needed maxillary impaction, 9 underwent maxillary advancement, and 5 had both maxillary impaction and advancement. Rhinological examinations, anterior rhinomanometry and acoustic rhinometry were carried out 1 week before surgery and 3 months after that. Wilcoxon and χ² tests were used for data analysis. The samples included 19 females and 6 males with a mean age of 22.4 ± 3.32 years. Rhinomanometric assessment showed that total nasal airflow was increased from 406 ± 202 ml/s to 543 ± 268 ml/s in all three groups. Significant decrease in nasal airway resistance was seen in all three groups. Acoustic rhinometry revealed a significant decrease in total nasal volume but an increase in the cross-sectional areas of isthmus nasi (IN) and inferior concha. The rhinomanometric measurements showed improvements in the total nasal airflow after Le Fort I osteotomy with alar base cinch suture in cases where the impaction was not higher than 5.5 mm.     

Mandibular effects of maxillary distraction osteogenesis in cleft lip and palate

Maxillary distraction osteogenesis (DO) is a reliable treatment for severe maxillary deficiency in cleft lip and palate (CLP). The objective was to analyze its long-term effects on the mandible. A retrospective study of 24 CLP treated with maxillary DO using the Polley and Figueroa technique was done; patients were followed for more than 4 years. Preoperative (T0), 6–12 months postoperative (T1), and ≥4 years postoperative (T2) cephalometric radiographs were evaluated. A classical cephalometric analysis was used to assess treatment stability, and a Procrustes superimposition method was used to assess local changes in the shape of the mandible. The mean age of patients at T0 was 15.4 ± 4.1 years. SNA increased at T1 and T2 (P < 0.001), with no significant relapse between T1 and T2, indicating stability at 1 year after treatment (T0 = 72.4 ± 5.3°; T1 = 81.3 ± 6.2°; T2 = 79.9 ± 6.1°). SNB, facial angle, gonial angle, and symphyseal angle remained stable. Long-term analysis of the mandible demonstrated a minimal counter-clockwise rotation of the body (mandibular plane = −0.2 ± 3.2°) and ramus (−0.6 ± 4.3°). Maxillary DO in CLP had no significant effect on the shape or rotation of the mandible. The maxillary advancement remained stable after 1 year.     

Three-dimensional evaluation of long-term skeletal relapse following Le Fort I maxillary advancement surgery: a 2-year follow-up study

The aim of this study was to assess relapse following Le Fort I (LFI) maxillary advancement with superior or inferior repositioning at 2 years of follow-up. A total of 50 patients (26 female, 24 male; age range 15–56 years) with skeletal class II or III, who underwent bimaxillary surgery with LFI maxillary advancement in combination with either superior or inferior repositioning and also mandibular advancement/setback, were recruited. Preoperative (T0), immediate postoperative (T1), and 2-year postoperative (T2) cone beam computed tomography scans were acquired. Data were imported into a validated module to assess the skeletal movement (T0–T1) and relapse (T1–T2). Overall, the majority of the translational and rotational movements showed a relapse of <1 mm and <1°. Patients undergoing maxillary advancement with inferior repositioning in combination with mandibular advancement showed the highest amount of translational relapse in a superior (0.86 ± 0.85 mm, P < 0.0001) and posterior direction (?0.65 ± 1.11 mm, P < 0.0001). In relation to patients who received a bone graft, inferior repositioning with mandibular setback showed the highest maxillary relapse in a superior direction (1.20 ± 1.56 mm, P = 0.0719) with counterclockwise pitch rotation (2.15 ± 0.64°, P = 0.3759). Amongst the non-grafted procedures, superior repositioning with mandibular setback exhibited the highest relapse in a medial direction (1.38 ± 2.78 mm, P = 0.3981). Maxillary advancement was found to be a highly stable procedure with a lack of superoinferior stability in patients undergoing inferior repositioning.     

Evaluating the accuracy of resection planes in mandibular surgery using a preoperative,intraoperative, and postoperative approach

In mandibular surgery, three-dimensionally printed patient-specific cutting guides are used to translate the preoperative virtually planned resection planes to the operating room. This study was performed to determine whether cutting guides are positioned according to the virtual plan and to compare the intraoperative position of the cutting guide with the resection performed. Nine patients were included. The exact positions of the resection planes were planned virtually and a patient-specific cutting guide was designed and printed. After surgical placement of the cutting guide, intraoperative cone beam computed tomography (CBCT) was performed. Postoperative CT was used to obtain the final resection planes. Distances and yaw and pitch angles between the preoperative, intraoperative, and postoperative resection planes were calculated. Cutting guides were positioned on the mandible with millimetre accuracy. Anterior osteotomies were performed more accurately than posterior osteotomies (intraoperatively positioned and final resection planes differed by 1.2 ± 1.0 mm, 4.9 ± 6.6°, and 1.8 ± 1.5°, respectively, and by 2.2 ± 0.9 mm, 9.3 ± 9°, and 8.3 ± 6.5° respectively). Differences between intraoperatively planned and final resection planes imply a directional freedom of the saw through the saw slots. Since cutting guides are positioned with millimetre accuracy compared to the virtual plan, the design of the saw slots in the cutting guides needs improvement to allow more accurate resections.     

Splintless orthognathic surgery in edentulous patients—a pilot study

The aim of this pilot study was to evaluate the accuracy and predictability of a splintless treatment protocol for edentulous patients undergoing orthognathic surgery in four consecutive cases. All operations were virtually planned, followed by computer-aided design of individual osteotomy guides and patient-specific fixation implants, which were three-dimensionally printed in titanium. In order to evaluate the discrepancy between the planned and the achieved postoperative result, the postoperative outcome was compared to the virtual treatment plan. Rotational and translational movement and discrepancies with the planned movements were quantified for the maxilla; the advancement was quantified for the mandible. For the maxilla, there was a mean translation discrepancy of 0.6 mm. With regard to rotation, there was a mean discrepancy of 1.9°, 0.1°, and 0.4° for pitch, yaw, and roll, respectively. The mean discrepancy in translation of the mandible was 0.4 mm. The results of this pilot study indicate that the splintless treatment protocol for orthognathic surgery in edentulous patients presented here is accurate and predictable.     

Variation between natural head orientation and Frankfort horizontal planes in orthognathic surgery patients: 187 consecutive cases

The purpose of this study was to assess the relationship between the Frankfort horizontal (FH) and natural head orientation (NHO), their correlation between patients’ malocclusion, and the impact of counterclockwise rotation (CCW) on the FH-NHO angle variation after orthognathic surgery. An evaluation of 187 consecutive patients was performed at the Maxillofacial Institute (Teknon Medical Center, Barcelona). FH-NHO° was measured pre- and postoperatively at 1 and 12 months, after three-dimensional (3D) superimposition using a software (Dolphin®). Patients were classified as follows: 3.2%, 48.7% and 48.1%, class I, II and III, respectively. Baseline FH-NHO° was significantly positive for patients with dentofacial deformities (2.73° ± 4.19 (2.12–3.33°, P < 0.001). The impact of orthognathic surgery in FH-NHO° was greater in class II when compared with class III patients, with a variation of 2.04° ± 4.79 (P < 0.001) and −1.20° ± 3.03 (P < 0.001), respectively. FH-NHO° increased when CCW rotational movements were performed (P = 0.006). The results of this study suggest that pre- and postoperative NHO differs from FH in orthognathic patients. The angle between FH and NHO is significantly larger in class III than in class II patients at baseline, which converges after orthognathic surgery when CCW rotation is performed. Therefore, NHO should be used as the real horizontal plane when planning for orthognathic surgery.     

In vitro evaluation of conventional and locking miniplate/screw systems for the treatment of mandibular angle fractures

This in vitro study evaluated the influence of the type of miniplate and the number of screws installed in the proximal and distal segments on the stability and resistance of Champy's osteosynthesis in mandibular angle fractures. Sixty polyurethane hemimandibles with bone-like consistency were randomly assigned to four groups (n = 15) and sectioned in the mandibular angle region to simulate fracture. The bone segments were fixed by different osteosynthesis methods using 2.0 mm miniplates and 2.0 mm × 6 mm monocortical screws. In groups 1 and 2, two conventional (G1) or locking (G2) screws were installed in each bone segment using a conventional (G1) or a locking (G2) straight miniplate; in groups 3 and 4, three conventional (G3) or locking (G4) screws were installed in the proximal segment and four conventional (G3) or locking (G4) screws were installed in the distal segment using a conventional (G3) or a locking (G4) seven-hole straight miniplate. The hemimandibles were loaded in compressive strength until a 4 mm displacement occurred between the segments, vertically or horizontally. Locking plate/screw systems provided significantly greater resistance to displacement than conventional ones (p < .01). Locking miniplates offered more resistance than conventional miniplates. Long locking miniplates provided greater stability than short ones.     

Utility of the lateral arm free flap in oral cavity reconstruction: a single-centre experience with Chinese patients

The lateral arm flap (LAF) may offer an alternative option for oral cavity repair. Twenty-five Chinese patients with oral cavity defects were reconstructed with a LAF. The anatomical characteristics of the flap, the donor site complications, and the functional and aesthetic assessments of recipient site were reviewed. The overall flap survival was 96.0% (24/25patients). The average pedicle length was 7.07 ± 1.09 cm when it was cut off at the insert of the deltoid, with an average arterial diameter of 1.30 ± 0.37 mm and vein diameter of 2.06 ± 0.48 mm. The average flap length was 7.06 ± 1.01 cm, and the average flap breadth was 5.28 ± 0.66 cm, with the average flap size ranging from 18 to 42 cm². One to three reliable perforators supplied the flap, with the proximal, middle, and distal perforators being located at 9.9 ± 1.1 cm, 8.6 ± 1.4 cm, and 5.7 ± 1.2 cm from the lateral epicondyle, respectively. The donor defect was closed primarily and healed uneventfully. A longitudinal scar was the most common morbidity of the donor site. The function and shape of the reconstructed tissues were well restored. The LAF provides a reliable choice for reconstructing medium-sized oral cavity defects, with minimal donor-site morbidity and ideally functional and aesthetic rehabilitation of the recipient site.