Outcomes of osseous free flap reconstruction in stage III bisphosphonate-related osteonecrosis of the jaw: Systematic review and a new case series

IntroductionThere is currently no gold standard for the treatment of Stage III bisphosphonate-related osteonecrosis of the jaw (BRONJ). The question remains whether osseous reconstruction can offer an additional gain in outcome given the theoretical risk of non-union at the resection margins and recurrence in the osseous free flap. The objective was to conduct a systematic review of articles describing outcomes of osseous microsurgical reconstruction in cases of BRONJ with a minimum follow-up of 12 months, and to present the long-term outcomes of a new case series of three patients.Material and methodsA multi-database QUORUM-based single-reviewer systematic review identified eight papers that fulfilled the selection criteria. There are only case series and case reports available (Level 4 of the Oxford Evidence-based medicine scale). A total of 31 patients were analysed including the cases described in this article.ConclusionThe limited overall rate of non-union at the resection margins and the 6.5% recurrence rate of BRONJ in the transplant counters the theoretical objections and advocates for considering osseous free flap reconstruction in the treatment of refractory BRONJ Stage III lesions. However, additional data derived from larger case series or case-control studies are imperative to support this hypothesis.     

血管化复合组织瓣修复全上颌骨缺损的临床进展

上颌骨、软腭、颊等组成的面中份结构不仅支撑面部外形、决定个人的面容,同时参与完成咀嚼、吞咽、语音和维持正常视觉等重要功能。因此,上颌骨重建是头颈部缺损修复中最复杂、最有争议的临床课题之一,其中以保留眶内容物的全上颌骨缺损（James Brown Ⅲb类）重建尤为困难。本文对保留眶内容物全上颌骨缺损的血管化复合组织瓣的修复重建目标、方法选择以及相关问题作一综述。     

Patient-specific alloplastic endoprosthesis for reconstruction of the mandible following segmental resection: A case series

Reconstruction of mandibular discontinuity defects remains a challenge for maxillofacial surgeons. Despite vascularized free flaps representing the current gold standard for managing such defects, the search continues for other less morbid yet predictable interventions. This study aimed at reviving the idea of alloplastic mandibular endoprosthesis as a treatment modality for reconstruction of segmental mandibular defects following eradication of benign tumors.To reconstruct their segmental mandibular defects, this case series compiled seven patients who received patient-specific titanium implant (PSI) with osseointegrated components and were designed to receive a restoration for dental rehabilitation. The recruited patient population was followed-up for a period of 3–5 years. Three of the seven PSIs failed due to extensive intraoral mucosal dehiscence or persistent extraoral fistulae. Patients with the 4 surviving PSIs enjoyed good results in terms of occlusion, masticatory function, mouth opening as well as pleasing facial esthetics.The described technique represents a viable less morbid alternative to the standard bone grafting techniques for mandibular reconstruction in carefully selected patients. Further studies are needed to modify the PSI design and surface treatment for better outcomes.     

腓骨瓣及CAD/CAM技术在重建下颌骨缺损中的应用

目的　探讨应用腓骨瓣及CAD/CAM技术修复大面积下颌骨缺损的经验。方法　根据16例患者下颌骨缺损的部位和特征,通过螺旋CT扫描获取缺损区的数据,在软件中应用CAD/CAM技术模拟下颌骨切除及重建手术,利用快速成型机加工制作出实物模型,依据模型对腓骨进行塑形、钛板重建,恢复下颌骨的形态和功能。结果　CAD/CAM技术的应用使术中截骨、腓骨塑形、定位速度明显加快;术后患者面部外形基本对称,影像学检查显示下颌骨缺损区的重建形态及固位良好;无严重并发症。结论　腓骨瓣联合CAD/CAM技术重建下颌骨缺损,能够明显缩短手术时间,提高手术质量,保证手术效果,是值得推广的重建下颌骨缺损的理想方法。     

Computer-assisted surgery for reconstruction of complex mandibular defects using osteomyocutaneous microvascular fibular free flaps: Use of a skin paddle-outlining guide for soft-tissue reconstruction. A technical report

Introduction

We present our pre-operative virtual planning of complex mandibular reconstruction with a microvascular fibular composite free flap and its harvesting using our novel cutaneous positioning guide based on the perforator vessels for our soft tissue reconstructive surgery.

血管化髂骨瓣重建下颌骨有牙区缺损时髂骨嵴不同朝向的优缺点比较

目的:通过比较髂骨嵴不同朝向重建下颌骨缺损后的对称性和是否符合种植牙治疗标准,分析血管化髂骨瓣重建下颌骨有牙区缺损时髂骨嵴不同朝向的优缺点.方法:回顾2017年1月—2019年12月于北京大学口腔医院行髂骨瓣重建下颌骨缺损的患者的基本信息和术后CT资料,根据髂骨嵴的朝向分为髂骨嵴朝向牙槽突组和髂骨嵴朝向下颌骨下缘组.C...     

Costs incurred by applying computer-aided design/computer-aided manufacturing techniques for the reconstruction of maxillofacial defects

This study aims to evaluate the additional costs incurred by using a computer-aided design/computer-aided manufacturing (CAD/CAM) technique for reconstructing maxillofacial defects by analyzing typical cases. The medical charts of 11 consecutive patients who were subjected to the CAD/CAM technique were considered, and invoices from the companies providing the CAD/CAM devices were reviewed for every case. The number of devices used was significantly correlated with cost (r = 0.880; p < 0.001). Significant differences in mean costs were found between cases in which prebent reconstruction plates were used (€3346.00 ± €29.00) and cases in which they were not (€2534.22 ± €264.48; p < 0.001). Significant differences were also obtained between the costs of two, three and four devices, even when ignoring the cost of reconstruction plates. Additional fees provided by statutory health insurance covered a mean of 171.5% ± 25.6% of the cost of the CAD/CAM devices. Since the additional fees provide financial compensation, we believe that the CAD/CAM technique is suited for wide application and not restricted to complex cases. Where additional fees/funds are not available, the CAD/CAM technique might be unprofitable, so the decision whether or not to use it remains a case-to-case decision with respect to cost versus benefit.     

Computed tomography-guided implant surgery for dental rehabilitation in mandible reconstructed with a fibular free flap: description of the technique

The fibular free flap, with or without a cutaneous component, is the gold standard for reconstructing mandibular defects. Dental prosthetic rehabilitation is possible this way, even if the prosthesis-based implant is still a challenge because of the many anatomical and prosthetic problems. We think that complications can be overcome or reduced by adopting the new methods of computed tomography (CT)-assisted implant surgery (NobelGuide, Nobel Biocare AB, Goteborg, Sweden). Here we describe the possibility of using CT-guided implant surgery with a flapless approach and immediate loading in mandibles reconstructed with fibular free flaps.     

Periosteal ossification of the vascular pedicle after reconstruction of continuity defects of the mandible and the maxilla with fibular free flaps: A retrospective study

Periosteal ossification of the vascular pedicle of a fibular free flap after reconstruction of mandibular and maxillary continuity defects has been thought to be rare. The purpose of this study was to evaluate its incidence and contributory factors to its development.     

A combined superficial inferior epigastric artery flap and vascularized iliac crest flap in the reconstruction of extended composite defects of the posterior mandible and adjacent soft tissue: first clinical results

The technique of posterior facial reconstruction using a combination of a superficial inferior epigastric artery (SIEA) flap and a microvascular iliac crest flap (deep circumflex iliac artery (DCIA) flap) is described. 12 cases are reported. The patients had unilateral squamous cell carcinoma of the posterior mandible affecting parts of the soft palate and tonsil region or the posterior cheek. In all patients unilateral neck dissection, resection of the posterior and lateral mandible, was performed. Reconstruction was carried out during primary surgical therapy, followed by postoperative radiotherapy. A flap combination of a SIEA and a DCIA flap was used. There were no problems with pedicle length or anastomoses. There was no flap loss or severe postoperative complications. All patients had good aesthetic and functional results. One patient had distant metastases 2 years postoperatively. All other patients were free of tumour relapse or metastases within 12-58 months of follow up. The SIEA flap and vascularized iliac bone flap combination is useful in reconstructing the posterior face. The iliac bone flap is well suited for posterior mandible reconstruction and the SIEA flap for reconstruction of the soft palate, lateral pharyngeal wall and cheek. Both flaps are harvested from the same donor site.     

不同表面处理方法对CAD/CAM氧化锆种植体表面显微形貌的影响研究

目的：：研究采用不同表面处理方法对CAD/CAM氧化锆种植体表面显微形貌特征及粗糙度的影响。方法：通过CAD/CAM技术加工氧化锆圆盘与一段式氧化锆种植体( Y-TZP, WIELAND),根据表面处理方式分为终烧结表面、喷砂表面及喷砂加热酸蚀处理表面;标准对照组选用BEGO钛种植体表面。各组圆盘试件及种植体用扫描电子显微镜及Keyence 3D激光显微形貌测量显微镜进行表面显微形貌观察与测量。采用单因素方差分析比较各组统计学差异。结果：各组CAD/CAM氧化锆试件表面显微形貌观察显示,喷砂后表面出现边缘锐利的凹坑及沟槽;喷砂加热酸蚀处理后,氧化锆表面可见纳米级的微小孔隙及沟纹。氧化锆种植体粗糙度测量结果显示：终烧结组的表面粗糙度值(Ra=0.69μm)显著低于其他3组(P<0.001),喷砂组Ra值(Ra=1.30μm)显著低于喷砂加热酸蚀组(Ra=1.49μm)及BEGO钛种植体组(Ra=1.57μm)(P<0.01),而喷砂加热酸蚀组与BEGO钛种植体组则无显著差异(P=0.196)。结论：CAD/CAM氧化锆试件终烧结后喷砂或喷砂加热酸蚀处理均可获得较为理想的表面粗糙度,热酸蚀处理能够改变氧化锆表面的纳米级微观结构。     

血管化腓骨重建下颌骨后用腓骨残端游离移植及牙种植的可行性研究

目的: 探讨利用残余腓骨增加下颌骨缺损腓骨重建患者垂直骨高度的临床效果。方法: 选择12例下颌骨缺损血管化腓骨重建后拟行种植牙修复的患者,利用腿部残余腓骨段进行垂直骨增量,同期或延期植入种植体并最终完成牙列修复,对术后骨吸收情况和种植体稳定性、存留率等数据采用SPSS 19.0软件包进行统计分析。结果: 术后6个月,近中骨块和远中骨块的吸收量分别为（0.94±0.18）mm和（0.89±0.15）mm;术后12个月,吸收量分别为（1.16±0.21）mm和（1.07±0.17）mm。种植体植入6个月和12个月后,ISQ值分别为（67.25±6.43）和（71.08±4.89）;边缘骨吸收量在植入术后6个月和12个月分别为（0.65±0.12）mm和（0.76±0.18）mm。术后1年种植体存留率为87.1%。结论: 非血管化腓骨具有可靠的抗吸收能力,在下颌骨缺损重建术后垂直骨高度不足的情况下,可为种植体植入提供充足骨量,并维持长期稳定性和存留率。     

Comparative clinicoanatomical study of ilium and fibula as two commonly used bony donor sites for maxillofacial reconstruction

We assessed the morphological characteristics and dimensions of the ilium and fibula to evaluate the suitability of particular areas of bone for use as donor sites for dental reconstructions that carry implants. We measured the dimensions of 130 bilaterally harvested ilium and fibula bones from 65 adult cadavers using osteometric methods, and analysed the effects of age, sex, and side. Dimensions at measuring points, overall suitability for implantation, and relations among age, sex, and side, were evaluated statistically. We report observations of bone morphology involving cross-sections, and clinical relevance. Although the mean dimensions of the fibula and iliac crest were adequate, some segments would not support an implant 10 mm long and 3.5 mm wide. The overall suitability of parts of the iliac block fell to 30%. Fibular morphology is characterised by constant height and width, and relation of cortical and cancellous bone. Bony dimensions on the iliac fossa and fibula were significantly greater in men than in women. Age had a negative impact in one area of the iliac fossa, but nowhere on the iliac crest. Side was not significant. We found differences in dimensions and morphology between measuring points on the same bone. Precise knowledge about which areas of the donor sites can reliably provide sufficient bone to carry implants after reconstructions will allow greater flexibility and safety when reconstructions are designed.     

Virtual planning,simultaneous dental implantation and CAD/CAM plate fixation: a paradigm change in maxillofacial reconstruction

Prosthetic rehabilitation in patients undergoing reconstructive surgery using vascularized free flaps is challenging, and functional rehabilitation of the patient with a fixed prosthesis is rare. Virtually planned maxillofacial reconstruction including simultaneous dental implantation according to the prosthodontic ideal position of the implants could further enhance dental rehabilitation. The data of 21 patients undergoing fibula free flap reconstructive surgery with CAD/CAM patient-specific reconstruction plates during the years 2015–2018 were analysed, including the applicability of the virtual plan, flap survival, duration of surgery, ischemia time, simultaneous dental implantation, implant exposure, and postoperative complications. The virtual plan could be translated to surgery in all cases. In total, 76 dental implants were simultaneously placed during primary reconstruction in the 21 patients. For 38.1% of these patients, the implants could be uncovered in secondary surgery; the mean duration until exposure was 7.6 months. The implant survival rate was 97.4% (74/76). Wound infection requiring a secondary intervention occurred in 23.8% of patients during follow-up. Virtually planned reconstruction with a fibula free flap, simultaneous dental implantation, and CAD/CAM plates allows early and functional dental rehabilitation. A dental workflow should be integrated into the virtual planning, and prosthetically favourable implant positions should determine the position of the fibula segments.     

Head and neck reconstruction in the vessel depleted neck using robot-assisted harvesting of the internal mammary vessels

We report a novel technique of robot-assisted harvesting of the internal mammary vessels to provide effective recipient vessels in a patient with bilateral vessel depleted neck (VDN). A 44-year-old with a Notani grade III osteoradionecrosis (ORN) of the anterior mandible underwent robot-assisted (Da Vinci® Surgical System, Intuitive Surgical) harvesting of the left internal mammary vessels (LIMA, LIMV). Reconstruction of the mandibular defect was done with a virtually planned composite fibular free flap and microvascular anastomosis of the peroneal vessels to the LIMA and LIMV. Successful reconstruction of the anterior mandible was achieved with excellent recipient arterial diameter and length, devoid of any significant thoracic morbidities resulting from robot-assisted harvesting of the internal mammary vessels. Robot-assisted harvesting of internal mammary vessels is a viable alternative to an open approach. The advantages in tissue handling, vessel length, and favourable profile of complications may extend the indications for this otherwise ‘niche’ solution in the VDN.     

功能性颌骨重建61例临床分析

目的:评价采用多种骨瓣进行功能性颌骨重建的临床效果。方法:61例颌骨缺损患者,首先应用多种骨瓣重建颌骨的连续性,然后植入骨结合种植体,利用种植义齿重建患者的咀嚼和发音功能。61例患者中,男39例,女22例,平均年龄48岁(20～61岁)。游离髂骨瓣32例,血管化腓骨瓣21例,单纯牵引成骨重建颌骨7例,其他骨瓣1例。共植入种植体247颗。种植固定义齿修复29例,种植体支持的活动义齿修复32例。结果:种植义齿修复完成后平均追踪49个月(6～114个月),种植体脱落6颗。1例患者在修复完成2年后因肿瘤复发死亡(含4颗种植体,不计入存活种植体)。至最后复查,共237颗种植体仍在行使功能,累计5年存活率为95.95%。结论:应用游离髂骨瓣、血管化腓骨瓣重建颌骨的连续性后,植入骨结合种植体,能够有效地重建患者的咀嚼、发音功能,近期效果满意。     

Comparative study of the osseous healing process following three different techniques of bone augmentation in the mandible: an experimental study

The aim of this study was to evaluate the osseointegration of three different bone grafting techniques. Forty-eight mature New Zealand rabbits were divided randomly into three groups of 16 each. Horizontal augmentation was performed on the corpus of the mandible using three different techniques: free bone graft (FBG), free periosteal bone graft (PBG), pedicled bone flap (BF). The animals were sacrificed at postoperative weeks 1, 3, or 8. Specimens were decalcified for histological examination, and histomorphometric measurements were performed. The histological evaluation demonstrated bony fusion between the grafts and the augmented mandibular bone after 8 weeks in all groups. At week 8, the bone volume was significantly greater in the BF group than in the FBG (P < 0.001) and PBG (P = 0.001) groups, and also the trabecular thickness was significantly greater than in the FBG (P = 0.015) and PBG (P = 0.015) groups. Trabecular separation was significantly lower in the BF group than in the FBG group at week 8 (P = 0.015). BF demonstrated greater osseous healing capacity compared to FBG and PBG. The preserved vascularization in BF improves the bone quality in mandibular bone augmentations.     

Free fibula flap for reconstruction of the severely atrophic mandible: a retrospective study

The purpose of this retrospective study was to assess the feasibility of using a free fibula flap (FFF) for reconstruction of the alveolar region of the severely atrophic mandible, by determining bone stability after dental implant insertion and prosthetic rehabilitation in a series of eight female patients aged 36–65 years. Dental implant insertion was performed 3–4 months after reconstruction. Prosthetic loading was performed 3–4 months after implant insertion. The height of the reconstructed mandible after surgery was 21.20 ± 1.87 mm, with an increase of 8.80 ± 1.71 mm from the preoperative height. The height of the FFF immediately after reconstruction was 11.24 ± 1.10 mm; this showed a vertical loss of 0.99 ± 0.52 mm (8.79%) and maintenance of 91.21% of the initial height at a mean 14 months post-reconstruction. Applying the Wical and Swoope formula to estimate the original mandibular body height, it was found that the difference between this calculated height (21.17 ± 3.76 mm) and the reconstructed height (21.20 ± 1.87 mm) was only 0.03 ± 3.17 mm (0.14%). An overall insignificant decrease of 0.46 ± 1.14 cm³ in FFF volume had occurred at 3–4 months after dental implant functional loading, while in two cases an increase in volume was found (1.22 cm³ and 1.71 cm³). The good and stable results obtained show that the FFF may be used to reconstruct the whole mandibular alveolar region, with the best possible outcomes.     

流体力学分析说话瓣膜对下颌骨缺损重建患者气管切开后功能恢复的影响

目的运用流体力学的方法,研究佩戴说话瓣膜（SV）对围术期气管切开下颌骨缺损重建患者误吸、口腔分泌物、嗅觉及发音的影响。 方法根据纳入标准及排除标准入组的8例患者按随机数字表法随机分成瓣膜组及对照组。瓣膜组予术后第2天佩戴SV,对照组不予佩戴SV,观察患者误吸、口腔分泌物、嗅觉、发音情况。吞咽功能采用染色实验,口腔分泌物采用视觉模拟评分法（VAS）,患者能正确回答易挥发分子的气味即嗅觉功能阳性,能进行简单的言语交流即发音功能阳性。采用锥形束CT（CBCT）扫描,Mimics和Gambit、Fluent软件,三维重建两组患者气道模型和气道流场,应用SPSS 23.0软件对比分析两组间术前、术后咽腔及声门下腔压力的变化,数据结果以中位数（25%值,75%值）表示。 结果两组相比,瓣膜组4例均改善误吸、嗅觉及发音,口腔分泌物明显减少,差异有统计学意义（P<0.05）,对照组术前、术后声门下压分别为101 327.00 Pa（101 326.25,101 327.75）、101 270.00 Pa（101 269.25,101 270.75）;瓣膜组佩戴SV后恢复声门下气压,术前、术后声门下压均为101 327.00 Pa（101 326.25,101 327.75）,差异无统计学意义（P>0.05）。 结论围术期气管切开患者佩戴SV能够减少误吸风险,改善嗅觉功能,此外,恢复患者言语交流能力,缓解患者围术期焦虑,有利于患者顺利度过围术期。因此,下颌骨缺损血管化腓骨复合组织瓣修复重建患者气管切开后运用SV值得推广运用。     

Comparison of Single Photon Emission Computed Tomography (SPECT) and implantable Doppler in the monitoring of a vascularised fibular free flap for reconstruction of the mandible

Monitoring of microvascular free flaps is an influencing factor in the success or failure of the treatment. In this study, we aim to compare the accuracy of implantable Doppler and scintigraphy in the monitoring of a vascularised buried fibular graft for reconstruction of the mandible. In a prospective cohort study, an implantable Doppler was placed intraoperatively, and Single Photon Emission Computed Tomography (SPECT) was taken in patients when abnormal blood flow was detected via the implantable Doppler or 48 hours after operations in patients with normal signals on the Doppler. The flaps were explored if patients did not have regular signals via implantable Doppler or if SPECT revealed impaired perfusion. The number of true- and false-positive cases and true- and false-negative cases were documented. Positive predictive value (PPV) and negative predictive value (NPV) were calculated. Eighteen (29%) of 62 patients underwent explorative surgery. The sensitivity of SPECT was 38.88%, and specificity was 97.72%. In SPECT, PPV was 87.50% and NPV 79.62%. The sensitivity of the implantable Doppler was 72.22%, and specificity was 93.08%. In assessment with the implantable Doppler, PPV was 81.25% and NPV 93.18%. It seems that SPECT and the implantable Doppler had sufficient specificity in the monitoring of a buried fibular graft. However, SPECT had a lower sensitivity than the implantable Doppler.