Vertical Ridge Augmentation of Fibula Flap in Mandibular Reconstruction: A Comparison between Vertical Distraction, Double-Barrel Flap and Iliac Crest Graft

Abstract

Double-barrel flap, vertical distraction and iliac crest graft are used to reconstruct the vertical height of the fibula. Twenty-four patients with fibula flap were reconstructed comparing these techniques (eight patients in each group) in terms of height of bone, bone resorption, implant success rate and the effects of radiotherapy. The increase in vertical bone with vertical distraction, double-barrel flap and iliac crest was 12.5 ± 0.78 mm, 18.5 ± 0.5 mm, and 17.75 ± 0.6 mm, (p < 0.001). The perimplant bone resorption was 2.31 ± 0.12 mm, 1.23 ± 0.09 mm and 1.43 ± 0.042 mm (p < 0.001), respectively. There were significant differences in vertical bone reconstruction and bone resorption between double-barrel flap and vertical distraction and between iliac crest and vertical distraction (p < 0.001). The study did not show significant differences in implant failure (p = 0.346). Radiotherapy did not affect vertical bone reconstruction (p = 0.125) or bone resorption (p = 0.237) but it showed higher implant failure in radiated patients (p = 0.015). The double-barrel flap and iliac crest graft showed better stability in the height of bone and less bone resorption and higher implant success rates compared with vertical distraction. Radiation therapy did not affect the vertical bone reconstruction but resulted in a higher implant failure.

Virtual Surgical Planning, Stereolitographic Models and CAD/CAM Titanium Mesh for Three-Dimensional Reconstruction of Fibula Flap with Iliac Crest Graft and Dental Implants

“…Mandibular segmental defects lead to significant aesthetic and functional sequelae, and primary reconstruction is mandatory. Although the fibula free flap is the most versatile technique for reconstruction, its main disadvantage is the low height of bone to reconstruct the height of the previous mandible [ 2 , 4 ]. In cases of mandibular segmental defects with a remaining mandible and occlusion on one or both sides of the defect, there is a vertical discrepancy between the fibula and the remnant mandible, which makes the correct prosthetic rehabilitation with implants impossible because the prosthesis would be extremely high and occlusally inadvisable [ 4 ].…”

“…Although the fibula free flap is the most versatile technique for reconstruction, its main disadvantage is the low height of bone to reconstruct the height of the previous mandible [ 2 , 4 ]. In cases of mandibular segmental defects with a remaining mandible and occlusion on one or both sides of the defect, there is a vertical discrepancy between the fibula and the remnant mandible, which makes the correct prosthetic rehabilitation with implants impossible because the prosthesis would be extremely high and occlusally inadvisable [ 4 ]. The purpose of this study was to evaluate the outcomes of the three-dimensional reconstruction of the fibula flap with iliac crest graft and dental implants through virtual surgical planning (VSP) and CAD/CAM titanium mesh.…”

“…This technique is indicated in patients who are not going to receive radiotherapy and in patients with extensive defects at the level of the symphysis and mandibular body. When this technique is accomplished, it is important to perform a cervical approach for the placement of the graft and avoid communication with the oral cavity [ 4 ]. In this way, we avoid mesh exposure, graft infection and bone resorption.…”

“…One point of discussion would be whether it is better to perform a double-barrel fibula flap, as the 3D reconstruction is primarily performed, and no delayed surgery is needed compared with the vertical distraction or cortico-cancellous iliac crest grafts that require multiple stages to reach the final outcomes [ 4 ]. The double-barrel fibula flap is the ideal technique to reconstruct the mandibular height and to solve the problem of vertical discrepancy.…”

“…Although the fibula flap has become the flap of choice for the reconstruction of composite mandibular defects, it does not provide sufficient height of bone to restore the native height of the mandible. The vertical discrepancy between the fibula flap and the native mandible results in (1) shortening of the vertical dimension of the lower third of the face with the consequent aesthetic defects and (2) difficulty in implant placement and prosthetic rehabilitation, which may cause implant overloading and endanger both the functional and aesthetic long-term results [3,4]. Therefore, vertical augmentation remains a challenge for oromandibular reconstruction.…”