Int. J. Oral Maxillofac. Surg.

2008; 37: 597605

doi:10.1016/j.ijom.2008.03.002, available online at http://www.sciencedirect.com

Review Paper
Reconstructive Surgery

Mandibular reconstruction in
adults: a review

Bee Tin Goh1, Shermin Lee1,

Henk Tideman1,
Paul J. W. Stoelinga2
1
Department of Oral & Maxillofacial Surgery,
National Dental Centre, Singapore;
2
Departments of Oral and Maxillofacial
Surgery, University of Nijmegen and
University of Maastricht, the Netherlands

Bee TinGoh, SherminLee, HenkTideman, Paul J. W. Stoelinga: Mandibular

reconstruction in adults: a review. Int. J. Oral Maxillofac. Surg. 2008; 37: 597605.
# 2008 International Association of Oral and Maxillofacial Surgeons. Published by
Elsevier Ltd. All rights reserved.
Abstract. Mandibular defects may result from trauma, inflammatory disease and
benign or malignant tumours. Mastication, speech and facial aesthetics are often
severely compromised without reconstruction. The goal of mandibular
reconstruction is to restore facial form and function, implying repair of mandibular
continuity and muscle attachments. There should also be room for implant insertion
so as to allow for rehabilitation of occlusion and articulation, whereas the function
of the inferior alveolar nerve should be restored to assure adequate sensitivity of the
lips. Mandibular reconstruction principles and techniques have evolved
dramatically over the years. Refinements in techniques continue to improve patient
quality of life. This paper reviews current techniques of mandibular reconstruction
in adults and discusses the strengths and weaknesses of each.

Surgeons have been trying to reconstruct

mandibles for more than a century.
Despite the enormous progress made over
particularly the last 40 years, the ideal
solution implying an anatomical reconstruction with sufficient height of the
mandible and adequate muscle attachments to allow for normal function
has not yet been achieved. There should
be the possibility for implant insertion to
allow for rehabilitation of occlusion and
articulation, and the function of the inferior alveolar nerve should be restored.
None of the presently available techniques
can meet all these needs, and so the search
for a better means of reconstruction should
continue.
The need for mandibular reconstruction
is dictated by the loss of mandibular bone
due to trauma, inflammatory disease, and
benign or malignant tumours. In the latter
case particularly concomitant loss of soft
0901-5027/070597 + 09 $30.00/0

tissues complicates attempts at reconstruction. These challenges are compounded by

radiation therapy, which often is necessary
in cases of malignant tumour.
It is the aim of the present review to
evaluate the existing techniques of mandibular reconstruction and to discuss their
advantages and disadvantages.
Free bone grafts

The first attempts to bridge defects of the

mandible stem from German pioneers at
the turn of the 19th century. Sykoff100 is
thought to be the first surgeon to have done
a free bone transplant. He used a graft
from the horizontal part of the contralateral mandible of 4 cm length to bridge a
defect. Several surgeons followed using
the tibia or rib as a donor site. The real
thrust to use free bone grafts came in
World War I. The German surgeons Klapp

Keywords: mandible; reconstruction.

Accepted for publication 3 March 2008
Available online 1 May 2008

and Schroder49 described in detail various

ways to bridge mandibular defects in their
book on Gun shot wounds of the mandible. Since that time this technique has
been used by many surgeons worldwide
and, particularly with the advent of antimicrobial prophylaxis, the success rate
must have improved. Up until the end of
the 1970s, these grafts were fixed with
wire osteosyntheses, often combined with
long periods of intermaxillary fixation.
At present, many surgeons will opt for a
cortico-cancellous block graft taken from
the anterior or posterior iliac crest. The
success of these grafts is probably much
dependent on the way the transplants are
fixed because their survival depends largely on revascularization from the recipient site. This revascularization is of
paramount importance for the process of
resorption and deposition of new bone,
also called creeping substitution. Any

# 2008 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

598

Goh et al.

micro-movement, because of non-rigid

fixation, would jeopardize the viability
of the graft. There is surprisingly little
literature about the success rate of free
bone grafts fixed with plates and screws as
compared to wire fixation. Kruger and
Krumholz51 in 1982 reported on 62
patients who underwent a secondary bone
grafting procedure using rigid fixation.
One of these grafts was completely lost
and one partially lost, but in 15% of the
cases a pseudoarthrosis was present. In the
same report they gave the results of 10
primary grafted patients. They lost two
grafts in these patients, whereas in 30%
a pseudoarthrosis occurred.
Free bone grafts are still a good option
for defects that are not bigger than
approximately 5 cm, provided the soft
tissues are in good condition. Current textbooks also recommend free bone grafts for
bridging relatively small defects of the
mandible.41,82,125
The advantages of these block grafts are
obvious. When they take, they serve their
purpose in that the continuity of the mandible is assured. The width of these grafts is
usually sufficient to receive implants,
which would allow for occlusal rehabilitation. A serious drawback is their limited
use. Gaps greater than 5cm are not really
suitable for this means of bridging a
defect, while in most cases of malignancy,
when a large part of the surrounding soft
tissues is lacking, healing cannot be
assured. Previous radiation therapy would
also preclude the use of free block bone
grafts. Morbidity associated with the
donor site is usually mild. Studies comparing the anterior to the posterior iliac crest
as a donor site reveal less morbidity when
the posterior site is used1,45.
Pedicled bone grafts

The use of pedicled bone grafts goes even

further back in history36. Again, German
surgeons were the first to apply this technique. According to the information provided by Klapp and Schroder49,
Bardenheuer (1891) was the first to transplant a frontal bone graft, pedicled to the
soft tissues, to the mandible. The details of
this operation are lacking, but apparently
the graft took. Rydygier and Woffler
(1892) transplanted a pedicled clavicle
to restore continuity of a mandible. The
success of this operation is not known.
Wildt (1896) and Diakonow (1896) used
the mandible of the same side and took a
partial thickness graft that was pedicled to
probably the platysma and the skin. This
composite graft was then transposed to
the defect and fixed with wires. According

to Klapp and Schroder both operations

were successful.
A major breakthrough came with the
introduction of the pectoralis major flap in
1968 by Hueston & McConchie40. Cuono
& Ariyan15 reported the first rib graft
pedicled to this muscle flap. This was
followed by reports of several clinicians
on the feasibility of this technique. Green
et al.29 and Robertson73 reported on the
same flap but using the sternum as a bone
graft. Modifications of this technique,
including the pleura, have been described.
Another muscle flap used to carry a
bone graft included the sternocleidomastoid muscle. It was Conley12 who introduced this principle, using the medial
fragment of the clavicle. Many surgeons
reported on modifications of this principle
to improve the suitability of this technique111. The feasibility of the sternocleidomastoid muscle flap depended largely
on the way the neck dissection was carried
out, i.e. with or without inclusion of the
muscle.
There are some obvious drawbacks
associated with the above-mentioned
methods. The grafted bone, particularly
rib, is too thin and thus not suitable for
an implant-supported prosthesis. The sternocleidomastoid muscle is not always
available or not sufficiently vascularized
to be used as a pedicle. The aesthetic
results of these techniques were not
always acceptable when compared with
currently used free flaps. The introduction
of microvascular free flaps has largely
replaced the techniques described.
Particulate bone cancellous marrow
(PBCM) grafts

In 1944, Mowlem64 demonstrated the

superior osteogenic potential of cancellous bone grafts. The physiology of the
PBCM graft was explained by the Axhausen theory of osteogenesis2 which states
that surviving transplanted cells proliferate and form new random osteoid, which is
dependent on the spatial orientation of the
grafted tissue. Thus, the eventual quantity
of bone is determined in phase I. This
process takes place during the first 4
post-transplantation weeks. The second
phase of osteogenesis results from induction of the host connective tissue bed and
host bone, a process partially mediated by
bone morphogenic proteins. Phase II of
osteogenesis results in resorption and
remodeling of the random osteoid into
mature osteons with organized structures.
The quality of bone is thus determined in
phase II. Rappaport71 showed that the use
of PBCM grafts afforded a higher rate of

osteogenesis and lower rate of surgical

complications as compared to cortical
grafts.
Due to the inherent lack of cohesion, the
PBCM graft is required to be placed in a
frame or crib to maintain its physical
dimensions and to provide the mechanical
stability essential for graft healing. Alloplastic, allogeneic and autogenous cribs as
well as bone plates have been used for this
purpose.
In 1969, Boyne4 demonstrated the success of PBCM grafts using metal cribs.
Cribs of titanium, vitallium, tantalum,
chrome cobalt and stainless steel have
since been used. Metal trays are available
as custom-made or off-the-shelf products.
The main advantage of metal trays is the
ability to maintain the spatial relationship
of the mandibular segments without the
need for additional fixation. Patients can
be allowed to resume normal functions
early. With a rigid metal tray gradual
resorption of the graft may occur because
of stress shielding112. This is due to the
higher modulus of elasticity of the tray
compared to bone resulting in the tray
absorbing much of the functional stress.
In 1972, Leake and Rappoport53
described the use of Dacron-coated polyurethane trays in dogs for mandibular
reconstruction and good healing was
demonstrated. In another animal study,
histological examination showed a normal
trabecular pattern with good osteoblastic
activity and bone in the periphery resembling bony cortex at 6- and 12-month
intervals89. The rigidity of this material,
to immobilize the proximal and distal
mandibular segments in the proper spatial
relationship, is questionable. Intermaxillary fixation, internal reinforced metal
rods or external devices may have to be
used in conjunction with the Dacron tray.
Cheung et al.8 showed in a clinical study
that the bone height at both ends and the
middle of the reconstructed segment
underwent even resorption, and 80% of
the bone height was retained over a 3-year
period.
The Dacron-coated polyurethane tray,
also available as an off-the-shelf product,
has several advantages. It is light weight,
biologically inert and has low thermal
conductivity. The tray is easy to trim
and adapt to the mandible during operation without the need for specialized
instruments. Its pore size is small but large
enough to allow capillary ingrowth. The
material has a low modulus of elasticity,
much less than cortical bone. This allows
functional stress to be transmitted to the
grafted bone. The crib is radiolucent,
which allows postoperative assessment

Mandibular reconstruction in adults: a review

of bone graft healing8. In cases requiring
postoperative radiotherapy, the absorbed
radiation dose to the surrounding tissues
was enhanced in vitro by 29% to 36% with
various types of metallic trays in contrast
to only 1% dose enhancement by the
Dacron tray90.
In 1996, Tideman and colleagues108,110
and Samman et al.80 described a modified
titanium mesh system, utilizing a tray with
a removable lid, which was custom made
to achieve good positioning of the reconstructed alveolar process in relation to the
upper arch for correct placement of dental
implants. A commercial titanium mesh
sheeting was used which was less stiff
and minimized stress shielding. The use
of a lid over the superior aspect created a
closed system, which permitted more
effective condensation of the PCBM graft,
thus increasing cellular volume and bone
density9.
Complications reported with the use of
metal or Dacron trays are wound dehiscence, tray exposure and postoperative
infection that can lead to partial or total
loss of the graft. Interference of the tray
with subsequent prosthetic or implant
rehabilitation may require removal of
the tray.
Poly (L-Lactide) (PLLA) or Poly (D,LLactide) (PDLLA) trays have the advantage of being biodegradable. Kinoshita
et al.48 showed good results in an animal
study using PBCM grafts with PLLA trays
for mandibular reconstruction. Louis
et al.54 reported the use of a PDLLA mesh
tray as a containment system for PBCM
grafts in 3 patients for reconstruction of
fractured atrophic edentulous mandibles
with satisfactory results.
Apart from alloplastic cribs, allogeneic
or autogenous bone cribs have also been
used for containment of PBCM grafts. In
1971, DeFries et al.18 introduced lyophilized freeze-dried allogeneic mandibular
cribs combined with autogenous iliac
PBCM for mandibular reconstruction. In
1973 a case series, involving surface-decalcified allogeneic mandible, iliac PBCM
and postoperative hyperbaric oxygen therapy, was presented by Mainous et al.57 and
this technique was further refined by Marx
et al.60 in 1983. The use of allogeneic cribs
has the advantages of low immunogenicity
due to the freeze-drying process and bioresorbability of the non-viable mineral
matrix. The cortical crib has an osteoinductive effect on the resting mesenchymal
cells and stem cells of the recipient bed. It
acts as a scaffold on which osteocompetent cells can proliferate and eventually
support and maintain the remodeled graft.
Using a mandibular crib gives good ana-

tomic contouring. This method of reconstruction has been shown to be successful

in restoring form and function in more
than 80% of cases55,70. The major disadvantage is the lack of availability of allogeneic mandibles. Due to the short supply,
allogeneic ribs7,50 have been used instead
of mandible.
The use of allogeneic bone may also be a
problem due to medical, ethical, religious,
cultural or political issues. Reimplantation
of a resected mandible to be used as a crib
for PBCM grafts is an alternative. Reimplanting the resected part of the mandible
has been performed using various techniques. In 1957, Harding32,33 reported a
method in which resected mandibular segments were reimplanted, based on research
done by Orell69 20 years earlier. The invasive cancer was removed from the bone
after which the bone crib was autoclaved
prior to re-implantation, but bone regeneration was poor. Fibrous tissue surrounded
the autoclaved grafts, which the author
described as a foreign body reaction. This
conclusion could not be confirmed in animal and human studies by Ewers and Wangerin and colleagues21,118 and they
attributed the better results to a more stable
form of osteosynthesis. Instead of autoclaving, Hamaker30 and Hamaker and Singer31
irradiated the resected mandible with
100Gy before reimplantation and reported
50% success in a 5-year follow-up study.
The method was later modified by Jisander
et al.44 who resected the mandible and
hollowed it out, after which it was defatted
and sterilized with ethylene oxide, irradiated and stored for 710 months before
reimplantation. They reported successful
reconstruction in 3 patients. Simon
et al.95 reported less favourable results with
fracture of the irradiated bone crib in 2
patients and wound dehiscence in 1 patient
out of a total of 6 patients following reimplantation.
The use of autogenous PBCM and autologous fibrin glue in mandibular reconstruction was proposed by Tayapongsak
et al.101 in 1994, stating a 50% reduction in
maturation time. In 1998, Marx et al.59
published a case series on the use of
platelet-rich plasma (PRP) gel in combination with PBCM grafts. Acceleration of
the bone maturation rate by a factor of two
was reported. Whitman et al.124, Thorn
et al.107 and Merkx et al.63 have presented
excellent results on secondary reconstruction using autogenous PBCM grafts with
autologous PRP. Fennis et al.22,23 published animal studies using an autogenous
bone crib and PBCM graft with or without
PRP for primary reconstruction of the
mandible. Histological and histomorpho-

599

metric evaluation revealed that the use of

PRP enhanced bone healing considerably.
Simon et al.95 reported fewer complications in patients who had primary mandibular reconstruction with autogenous
PBCM, autologous PRP and customized
titanium plates as compared to those who
had reconstruction with PBCM and PRP
gel in combination with reimplanted irradiated mandibular cribs.
The advantages of PBCM grafts are the
potential to create an anatomic mandibular
reconstruction of adequate height, symmetrical arch form and width, and the ability
to adequately support dental implants. The
graft may be used to bridge mandibular
defects of any length, and even the entire
mandible, when used together with costochondral grafts for reconstruction of condyles. The disadvantages include
remodeling resorption, and wound dehiscence and infection may still occur leading
to loss of the graft. The latter is the main
reason why PBCM grafts are not frequently used in patients with malignant
tumors where the soft tissues are compromised or where radiation therapy has been
or will be used. Complications may also
arise from the containment system, such as
tray exposure or foreign-body reactions to
bone cribs, leading to subsequent infection.
Reconstruction plates

According to Luhr56, probably the first

surgeon to apply plates and screws for
mandibular fractures was Hansmann in
1886. Due to a high failure rate because
of infection and other complications this
application was soon abandoned. The
interest in plate fixation appeared again
after the Belgium surgeon Danis introduced the principle of axial compression
of the fracture stumps. This idea was
further developed by the Austrian and
Swiss working group on osteosyntheses
(ASIF). Luhr, in 1967, introduced this
principle in the maxillofacial area. From
this the reconstruction plates evolved and
it was Spiessl, in 1976, who first reported
on the use of metal plates to bridge a
mandibular defect after ablative surgery.
Reconstruction plates are rigid plates
that are applied along the lower border
of the mandible. They were made with the
intention of bridging a defect, stabilizing
remaining segments, and maintaining
occlusion and facial contour. They are
presently frequently used to fix corticocancellous blocks or vascularized bone
grafts to the remaining mandible.
Reconstruction plates were originally
made of stainless steel, but currently tita-

600

Goh et al.

nium plates are more popular mainly due

to their biocompatibility. There are several
types of these plates on the market, but the
overriding principle is to have one single
plate of sufficient thickness and width to
hold the fragments in place. This implies
plates approximately 3 mm thick and
5 mm wide. A special feature of the modern types is the locking screw. This is
supposed to minimize compression
between the plate and the underlying bone,
thereby optimizing the vascularity surrounding the graft19. A study conducted
by Kim et al.47 has shown that locking
plates are associated with significantly
fewer complications than non-locking
plates when used in the symphyseal
region.
Several studies have reported on the
various complications associated with
the use of reconstruction plates such as
wound dehiscence with plate exposure,
infection from loosening and breakage
of screws, plate fracture and unsatisfactory facial contour. Variables such as the
combined use of reconstruction plates
with bone grafts, immediate or delayed
reconstruction, radiotherapy and the location of the resection have been evaluated
to determine if they affect the results and
frequency of complications. It has been
shown that radiation and reconstruction of
the anterior mandible crossing the midline
significantly increases the incidence of
complications and the need for revision
or plate removal46.
Several studies have reported an incidence of 2.9%10.7% of plate fractures94.
Reconstruction plates should match closely the three-dimensional shape of the
mandible to avoid preoperative bending
as much as possible58. When part of the
ascending ramus is involved in the resection, a plate should be applied that has a
contour that more or less follows this
anatomic structure. In general, plates need
to be adapted to the underlying bone of the
stumps, which is done using special bending forceps. This causes weak spots in the
plate, which are prone to fracture when the
plate is loaded. This was also demonstrated in an animal study using sheep58.
The surface quality and notches in the
edge of the plate, where stress is concentrated, both contribute to the tendency to
break. It is thus obvious that the predilection areas for fracture will be those areas
where the mandible is curved, i.e. the
symphysis and the mandibular angle.
Plate exposure is a special problem
which occurs in 20%48% of cases, especially when the patient has undergone
irradiation therapy which has been shown
to have a significant effect on wound

dehiscence46. An associated problem with

the use of mandibular reconstruction
plates is related to imaging and postoperative irradiation therapy. Radiography and
computed tomography scans in particular
show backscattering which causes diagnostic problems. Irradiation therapy is
equally hampered by the plates. It has
been shown that titanium causes the least
amount of artefacts in magnetic resonance
imaging compared to stainless steel and
vitallium24.
Despite the inherent disadvantages and
possible complications there are still indications for the use of these plates as a
single means to maintain three-dimensional stability of the stumps. An example
might be a patient whose medical condition precludes a prolonged operation time
to carry out a microsurgically anastomosed flap, or in whom the vascular system does not allow for a microvascular
anastomosis. Some surgeons prefer plate
fixation as a first means to stabilize the
mandible and will carry out a secondary
reconstruction a year later26.
Microvascular free flaps

The introduction of microvascular surgery

and its subsequent application in the transposition of bone grafts has brought about a
revolution in mandibular reconstructive
surgery. In contrast to previously
described methods, a free tissue graft
can be transferred with an intact blood
supply, due to microvascular anastomosis.
Provided the graft is properly fixed, it will
heal primarily at the site of the ostectomies. In principle, healing time will be
short and complications like resorption
and infection are greatly reduced as compared to all other methods. Microvascular
surgery has made possible reconstructions
that hitherto could not be carried out.
McKee62 was the first to describe the
use of a microvascular free rib graft, for
mandibular reconstruction in 1971. This
was subsequently adopted by several surgeons17,92. In the late 1970s, a vascularized
metatarsus
graft,
originally
developed from the free dorsalis pedis
flap, was first applied by OBrien
et al.68, Bell and Barron3 and Salibian
et al.79 for mandibular reconstruction.
The use of the rib and metatarsus free
flaps was associated with significant donor
site morbidity. The bone was thin and
unsuitable for reshaping and, has little
use in modern-day mandibular reconstruction. At present, the donor sites used most
commonly for mandibular reconstruction
are the radial forearm, scapula, iliac crest
and fibula. Each donor site differs in the

quality and quantity of available bone and

soft tissue, quality of the vascular pedicle,
and suitability for reshaping and placement of implants.
The radial forearm flap was introduced
in the English literature by Song et al.97 in
1982, but was originally developed by
Yang et al.128 in China. The flap is based
on the radial artery and its concomitant
veins or subcutaneous forearm veins. In
1983, Soutar et al.98 reported the use of the
radial forearm flap, including radial bone,
to replace segments of the mandible.
Approximately 1012 cm of bone can be
harvested. The advantages of this flap for
mandibular reconstruction are its pedicle,
with excellent length and diameter, as well
as the reliable skin paddle which is large,
thin and pliable, ideal for intraoral lining.
Fracture of the radius at the donor site
remains a complication that has caused the
greatest criticism. The use of a keelshaped osteotomy121 or pre-plating67 has
been described to prevent this. The transplanted bone is thin and may not allow for
multiple osteotomies to adapt to the shape
of the mandible, and the height does not
favour the insertion of implants.
Gilbert and Teot27 introduced the use of
a free scapular flap, based on the circumflex scapular artery and vein, in 1982. Teot
et al.104 further described the osteocutaneous scapular flap and used this for mandibular reconstruction in 1 patient. Up to
14cm of bone could be harvested. Swartz
et al.99 and Granick et al.28 reported the
use of this flap for reconstruction of massive facial composite defects. It has been
described as a versatile flap for mandibular
reconstruction because a single vascular
pedicle can supply a large quantity of soft
tissue with bone. It is a good choice for
through-and-through defects involving
facial skin, bone and mucosa. There is
good flexibility of the soft tissue in relation to the bone. One disadvantage is the
location of the donor site which prohibits
simultaneous harvest of the flap at the time
of tumour resection.
The iliac crest was the main free flap
used for mandibular reconstruction in the
1980s. Although the superficial circumflex
iliac vessels were first used as the vascular
pedicle for combining a groin skin flap
with iliac bone, Taylor et al.103 subsequently reported the superiority of using
the deep circumflex system. The skin
paddle of this flap is thick, immobile
and relatively unreliable which limits its
use for intraoral reconstruction. To overcome this problem, Urken et al.115 in 1989
introduced the internal oblique-iliac crest
osseomyocutaneous flap, whereby the
muscle was used to resurface intraoral

Mandibular reconstruction in adults: a review

mucosal defects. They reported few failures and low donor site morbidity in their
series. The natural contour of the ipsilateral iliac crest bears a resemblance to the
hemi-mandible. No other donor site can
supply as much bone that is suitable for
implants. Riediger72 in 1988 reported the
successful integration of implants in preirradiated vascularised iliac crest bone
graft over a follow-up period of up to
30 months. A disadvantage of the iliac
crest free flap is its short vascular pedicle
and the lack of segmental perforating vessels which limits its use for osteotomies.
Patients may be slow to ambulate after
surgery and permanent gait disturbance
may occasionally occur. Removal of
bicortical bone produces significant donor
site deformity and herniation of the abdomen is a risk factor34.
In 1975, Taylor et al.102 described the
use of a free fibula flap for reconstruction
of the lower extremity. This flap was
adapted for mandibular reconstruction
by Hidalgo37 in 1989. The fibula is currently the most popular free flap for mandibular reconstruction and has the widest
application. The flap is based on the peroneal artery and associated veins. The
pedicle is of adequate length and diameter.
Blood supply to the fibula is both intraosseous and segmental and therefore multiple
osteotomies can be made. It can provide
up to 30cm of bone length which is sufficient for reconstructing any length of the
mandible. The height of bone is inadequate relative to a dentate mandible which
can be a problem when dental implants are
planned for occlusal rehabilitation. To
overcome this problem, the use of a double barrel flap39 and vertical distraction of
the fibular flap66 have been described.
Donor site morbidity is relatively mild
but pre-existing peripheral vascular disease will preclude use of this flap.
No single type of free flap is capable of
coping with the wide variety of mandibular defects. The choice of flap depends on
several factors including the type of bone
and soft tissue (skin and/or oral) defect,
vessel geometry of the donor and recipient
sites, donor site morbidity, whether the
patient is dentate or edentulous, need for
dental implant rehabilitation, and often the
type of training and individual preference
of the surgical team. Brown et al.5 recommended the iliac crest free flap as the flap
of choice in dentate patients because of the
superior bone height which allows good
support for implants. The fibula free flap
remains the first choice for the edentulous
mandible or for extensive mandibular
resections. The scapular flap is suitable
in cases of large composite defects, while

the radial forearm flap is mostly used to

cover intra- to extraoral soft-tissue
defects.
Foster et al.25 reported an implant success rate of 99% in vascularized bone flaps
versus 82% in non-vascularized bone
grafts over a mean follow-up period of 3
years. There is no significant difference in
implant loss rates in irradiated versus nonirradiated free bone flaps20,85,93,122,123.
Implants may be placed either at the time
of ablative and reconstructive surgery (primary implants)91,113 or at a later date
(secondary implants). The application of
primary implants prior to radiotherapy has
been advocated by Schoen et al.88 and
Schepers et al.81. Advantages include
implant healing before radiation, reducing
the risk of radiation-induced complications such as osteoradionecrosis and
avoidance of adjuctive hyperbaric oxygen
therapy. Rohner et al.77 in 2003 described
a technique using prefabricated osseous
free tissue transfer. In the first stage,
implants are placed in the donor bone in
a preplanned position and lined with a
split-thickness skin graft. After 6 weeks,
a second-stage procedure is carried out for
flap transfer and reconstruction of the
mandible using an implant-mounted dental prosthesis as a template for occlusion.
Immediate functional loading can be
achieved with this technique.
The main advantage of using free flaps
for mandibular reconstruction is the feasibility to reliably combine bone and softtissue repair in one session using only one
donor site. High success rates of over 90%
have been reported, even in irradiated
patients38. At present, mandibular reconstruction using microvascular free flaps is
the gold standard in that it provides in
most cases a functional reconstruction.
Rogers et al.75 in 2002 explored the
relationship between an 11-point clinical
examination and health-related quality of
life (HRQOL) in 130 patients after primary surgery for oral cancer. The results
of the study suggested that patients with
better clinical function had better
HRQOL. Increased tumour size11, loss
of oral soft-tissue function, particularly
tongue mobility83 and the sequelae of
radiotherapy6,116 all have a detrimental
effect on function. Wilson et al.126
reported better HRQOL after mandibulectomy in patients with bony reconstruction as compared to only soft-tissue
reconstruction. Reconstruction of the
mandible resulted in better facial appearance and masticatory functions. The introduction of microvascular free flaps has
helped to alleviate many functional deficits resulting from mandibular resec-

601

tions. Studies have shown that patients

who underwent reconstruction with
microvascular free flaps achieved better
function than those with myocutaneous
flaps16,114,117. No difference in HRQOL
scores was found between either fibula or
deep circumflex iliac crest reconstruction
for oral cancer, although those patients
with significant donor site morbidity had
poorer HRQOL74. Occlusal rehabilitation
is an important part of reconstruction.
Implants are able to provide a stable support for dentures, improving mastication
which is important for the psychological
well being and HRQOL of the patient76,87.
Despite the many advantages of microvascular free flap reconstruction, it is time
consuming and associated with varying
degrees of donor site morbidity. These
may not be acceptable in elderly patients
whose health may already be compromised by the primary disease and other
medical conditions. The procedures
require specialized surgical expertise
and hospital infrastructure which may
not be available everywhere in the world.
New developments

In recent years, new techniques for mandibular reconstruction have been tested,
with the common aim of eliminating the
need for harvesting bone from a donor site.
These include transport disc distraction
osteogenesis (TDDO), tissue engineering
and modular endoprosthesis.
TDDO

Distraction osteogenesis is a technique

originally developed for lengthening of
long bones, but it has evolved over the
past decade from exclusive application in
the extremities to the craniofacial skeleton. Distraction osteogenesis is a process
in which new bone formation is gradually
induced by an opening (distraction) device
between two bony surfaces. It was first
described by Codivilla in 190410. The
technique was later popularized by Ilizarov who created a device for surgical
lengthening of long bones in 1951. He
later published his landmark studies on
the tensionstress effect on the genesis
and growth of tissues42,43.
With regard to the craniofacial skeleton,
Snyder et al.96 reported the first experimental study of distraction osteogenesis in
the canine mandible in 1973. The first
clinical cases of mandibular lengthening
by distraction osteogenesis were reported
almost two decades later by McCarthy in
199261. Distraction osteogenesis is mostly
applied in craniofacial surgery for bone

602

Goh et al.

lengthening in the treatment of congenital

deformities.
For mandibular reconstruction, a technique known as transport disc distraction
osteogenesis (TDDO) is used. A segment
of bone is cut adjacent to the defect and
moved gradually across the defect by a
mechanical device. New bone fills in
between the two bone segments. The piece
of bone being moved or transported is
referred to as the transport disc78. In
1990, Costantino et al.14 used an extraoral
device to distract a 1.5-cm transport disc
of bone across a 2.5-cm segmental defect
of the mandibular body in dogs. The
regenerated bone had a similar diameter
to the pre-existing mandible, and the inferior alveolar artery and vein were found to
recannulate through the regenerated bone
in 5 of 6 animals. Since then, several
clinical reports have described the use
of TDDO for mandibular reconstruction
in patients13,52. External devices were
employed in early cases but these caused
problems of facial scarring along the pin
tracks. To overcome this problem, an
internal plate-guided distraction device
was described by Herford in 200435.
TDDO is an attractive option for mandibular reconstruction as it obviates the
need for harvesting bone from a donor site.
It offers the potential of growing bone and
soft tissue from the native site and placement of dental implants is possible. This is
still a developing technology with few
published data. Problems with TDDO
include the difficulty in regenerating a
curved bone in mandibular symphyseal
defects, unreliability in cases receiving
radiotherapy, the need for expensive hardware and patient compliance.
Tissue-engineered transplants

Tissue engineering builds on the interface

between materials science and biocompatibility, and integrates the application of
principles and methods of engineering and
life sciences toward the fundamental
understanding of structurefunction relationships in normal and pathological
mammalian tissues and the development
of biological substitutes to restore, maintain or improve tissue functions65.
To date, there is only one published case
of successful reconstruction of the mandible, using the principle of tissue engineering, in a human being as reported by
Warnke et al.119,120 It concerned a patient
who underwent a secondary reconstruction after tumour resection. The engineered graft was allowed to heal in the
trapezius muscle and subsequently transplanted to the recipient side, using micro-

vascular anastomosis. This clinical

application was largely based on research
carried out on minipigs by Terheyden
et al.105,106
This means of reconstruction, clever as
it may seem, still requires a microsurgical
transplantation apart from the implantation of the scaffold in the muscle that will
serve as a vehicle to carry the graft. In
principle, engineering a graft at the site of
the defect would be more of an advantage
to other methods, but would require a
period of healing in which the mandible
should be immobilized. It would also
require adequate soft-tissue conditions to
protect the engineered bone in its healing
phase. Although there is definitely a future
for engineered grafts their routine clinical
application is still a long way off. Apart
from the technical problems there is the
question of unknown effects on various
tissue cells and even plain oncogenic
effects. This is one of the main reasons
why morphogenetic growth factors are not
freely available yet. Autogenous growth
factors, like those present in platelets, are
mainly mitogenetic and are not known to
be oncogenetic, at least not for epithelial
cells. Another factor relates to economics:
the costs involved in using currently available bone morphogenetic proteins preclude their use on a large scale.
Modular endoprosthesis

Tideman and Lee109 recently introduced

the concept of a modular endoprosthesis
for mandibular reconstruction in a study
on Macaca monkeys. The principle has
been is known in the orthopaedic community for almost 10 years127. An endoprosthesis is a metallic device that
replaces diseased bone in long bones
and is fixed internally with bone cement
within the medullary space of the remaining healthy bone. There is no need for
screw fixation. The variable length of the
bone gap can be bridged by using modules
that allow for accurate three-dimensional
reconstructions. The modules are connected by a locking system.
In principle, the mandible would qualify
for such an endoprosthesis because of the
existing medullary space. Occlusal rehabilitation could be achieved on implants
that are screwed into existing holes of the
endoprosthesis. Whether this system will
also work in patients with compromised
soft tissues remains to be seen, but the
principle is worthy of further research.
This review confirms that the ideal system for reconstruction of the mandible has
yet to be found. Each of the methods
discussed has its shortcomings and limita-

tions. Mandibular reconstruction cannot

be considered without taking into account
the soft-tissue conditions that are often
compromised. Another important issue
is the sensory problems that are often seen
when patients have undergone ablative
surgery. Be it the inferior alveolar nerve
or the lingual and glossopharyngeal
nerves, they all are important for the most
basic functions in a human life, i.e. chewing and swallowing. Quality-of-life studies have unequivocally pointed to the
importance patients attach to these fundamental functions75,83,84,86. Unfortunately,
a reconstructed mandible with implants
and occlusal rehabilitation on implants
is not enough to restore these functions
completely. Adequate nerve reconstruction is equally important.
References
1. AHLMAN E, PATZAKIS M, ROIDIS N, SHEPERD L, HOLTOM P. Comparison of anterior and posterior iliac crest bone grafts
in terms of harvest-site morbidity and
functional outcomes. J Bone Joint Surg
Am 2002:84:71620.
2. Axhausen W. The osteogenic phases of
regeneration of bone: A historical and
experimental study. J Bone Joint Surg
1956: 38-A: 593600.
3. Bell MS, Barron PT. A new method
of oral reconstruction using a free composite foot flap. Ann Plast Surg 1980: 5:
281287.
4. Boyne PJ. Restoration of osseous
defects in maxillofacial casualties. J
Am Dent Assoc 1969: 78: 767776.
5. Brown JS, Magennis P, Rogers SN,
Cawood JI, Howell R, Vaughan ED.
Trends in head and neck microvascular
reconstructive surgery in Liverpool
(19922001). Br J Oral Maxillofac Surg
2006: 44: 364370.
6. Bundgaard T, Tandrup O, Elbrond
O. A functional evaluation of patients
treated for oral cancer. A prospective
study. Int J Oral Maxillofac Surg 1993:
22: 2834.
7. Chen Z, Wu T. Reconstruction of mandibular defects with composite autologous iliac bone and freeze-treated
allogeneic rib grafts. J Oral Maxillofac
Surg 1982: 40: 2933.
8. Cheung LK, Samman N, Tong CK,
Tideman H. Mandibular reconstruction
with dacron urethane tray: A radiologic
assessment of bone remodeling. J Oral
Maxillofac Surg 1994: 52: 373380.
9. Cheung LK, Samman N, Chow TW,
Clark RKF, Tideman H. A bone graft
condensing syringe system for maxillofacial reconstructive surgery. Br J Oral
Maxillofac Surg 1997: 35: 267270.
10. Codivilla A. On the means of lengthening, in lower limbs, the muscles and
tissues which are shortened through

Mandibular reconstruction in adults: a review

11.

12.

13.

14.

15.

16.

17.
18.

19.

20.

21.

22.

23.

24.

deformity. Am J Orthop Surg 1904: 2:

353369.
Colangelo LA, Logemann JA, Pauloski BR, Pelzer JR, Rademaker
AW. T stage and functional outcome
in oral and oropharyngeal cancer
patients. Head Neck 1996: 18: 259268.
Conley J. Use of composite flaps containing bone for major repair in head and
neck. Plast Reconstr Surg 1972: 49:
522526.
Costantino PD, Johnson CS, Friedman CD, Sissons Sr GA. Bone regeneration within a segmental human
mandible defect: a preliminary report.
Am J Otolaryngol 1995: 16: 5665.
Costantino PD, Shybut G, Friedman
CD, Pelzer HL, Masini M, Shindo
ML, Sisson Sr GA. Segmental mandibular regeneration by distraction osteogenesis: an experimental study. Arch
Otolaryngol Head Neck Surg 1990:
116: 535545.
Cuono BC, Ariyan S. Immediate
reconstruction of a composite mandibular defect with a regional osteomyocutaneous flap. Plast Reconstr Surg 1980:
65: 477483.
Curtis DA, Plesh O, Miller AJ. A
comparison of masticatory function in
patients with or without reconstruction
of the mandible. Head Neck Surg 1997:
19: 287296.
Daniel RK. Free rib transfer by microvascular anastomoses. Plast Reconstr
Surg 1977: 59: 737738.
DeFries Ho. Marble HB, Sell KW.
Reconstruction of the mandible: Use of a
homograft combined with autogenous
bone and marrow. Arch Otolaryngol
1971: 93: 426432.
Dimitroulis G. Mandibular reconstruction following ablative tumour surgery:
an overview of treatment planning. Aust
N Z J Surg 2000: 70: 120.
Esser E, Wagner W. Dental implants
following radical oral cancer surgery
and adjuvant radiotherapy. Int J Oral
Maxillofac Implants 1997: 12: 552557.
Ewers R, Wangerin K. The autoclaved
autogenous reimplant, an immediately
replaced, mineral frame. J Maxillofac
Surg 1986: 14: 138142.
Fennis JPM, Stoelinga PJW, Jansen
JA. Mandibular reconstruction: a clinical and radiographic animal study on the
use of autogenous scaffolds and plateletrich plasma. Int J Oral Maxillofac Surg
2001: 31: 281286.
Fennis JPM, Stoelinga PJW, Jansen
JA. Mandibular reconstruction: a histological and histomorphometric study on
the use of autogenous scaffolds, particulate cortico-cancellous bone grafts
and platelet rich plasma in goats. Int J
Oral Maxillofac Surg 2004: 33: 4855.
Fiala TG, Paige KT, Davis TL, Campbell TA, Rosen BR, Yaremchuk MJ.
Comparison of artifact from craniomaxillofacial internal fixation devices: mag-

25.

26.

27.
28.

29.

30.

31.

32.
33.
34.

35.

36.

37.
38.

39.

netic resonance imaging. Plast Reconstr

Surg 1994: 93: 725.
Foster RD, Anthony JP, Sharma A,
Pogrel MA. Vascularized bone flaps
versus nonvascularized bone grafts for
mandibular reconstruction: an outcome
analysis of primary bony union and
endosseous implant success. Head Neck
1999: 21: 6671.
Gellrich N-C, Suarez-Cunqueiro
MM, Otero-Cepeda XL, Schon R,
Schmelzeisen R, Gutwald R. Comparative study of locking plates in mandibular reconstruction after ablative
tumour surgery: THORP versus UniLOCK system. J Oral Maxillofac Surg
2004: 62: 186193.
Gilbert A, Teot L. The free scapular
flap. Plast Reconstr Surg 1982: 69: 601
604.
Granick MS, Newton ED, Hanna
DC. Scapular free flap for repair of
massive lower facial composite defects.
Head Neck Surg 1986: 8: 436441.
Green MF, Gibson JR, Bryson JR,
Thomson E. A one-stage correction of
mandibular defects using a split sternum
pectoralis major myocutaneous transfer.
Br J Plast Surg 1981: 34: 1116.
Hamaker R. Irradiated autogenous
mandibular grafts in primary reconstructions. Laryngoscope 1981: 91: 1031
1051.
Hamaker R, Singer M. Irradiated mandibular autografts update. Arch Otolaryngol Head Neck Surg 1986: 112: 277
279.
Harding R. Follow-up clinic. Replantation of the mandible in cancer surgery.
Plast Reconstr Surg 1971: 48: 586587.
Harding R. Replantation of the mandible in cancer surgery. Plast Reconstr
Surg 1957: 19: 373383.
Hartman HM, Spauwen PHM, Jansen JA. Donor-site complications in
vascularized bone flap surgery. J Invest
Surg 2002: 15: 185197.
Herford AS. Use of a plate-guided
distraction device for transport distraction osteogenesis of the mandible. J Oral
Maxillofac Surg 2004: 62: 412420.
Herter NT, Godoy PR, Kroef RG.
Mandibular reconstruction with osteomyocutaneous flaps. In: Soutar DS,
Tiwari R, eds: Excision and Reconstruction in Head and Neck Cancer.
Edinburgh: Churchill Livingstone
1994 : 3778.
Hidalgo D. Fibular free flap: A new
method of mandible reconstruction.
Plast Reconstr Surg 1989: 84: 71.
Hidalgo DA, Pusic AL. Free-flap mandibular reconstruction: A 10-year follow-up study. Plast Reconstr Surg
2002: 110: 438449.
Horiuchi K, Hattori A, Inada I,
Kamibayashi T, Sugimura M, Yajima
H, Tamai S. Mandibular reconstruction
using the double barrel fibular graft.
Microsurgery 1995: 16: 450454.

603

40. Hueston JT, McConchie IH. A compound pectoral flap. Austr N Z J Surg
1968: 67: 143150.
41. Hutchison I. Reconstructive surgery
bone and cartilage harvesting. In: Langdon JD, Patel MF, eds: Operative
Maxillofacial Surgery. London: Chapman and Hall Medical 1998: 93110.
42. Ilizarov G. The tension-stress effect on
the genesis and growth of tissues: part I.
The influence of stability of fixation and
soft-tissue preservation. Clin Orthop
Relat Res 1989: 238: 249281.
43. Ilizarov G. The tension-stress effect on
the genesis and growth of tissues: part II.
The influence of the rate and frequency
of distraction. Clin Orthop Relat Res
1989: 239: 263285.
44. Jisander S, Aspenberg P, Salemark
L, Wennerberg J. Mandibular reconstruction by secondary reimplantation of
resected segments: a preliminary report.
Int J Oral Maxillofac Surg 1995: 24:
288292.
45. Kessler P, Thorwarth M, BlochBirkholz A, Nkenke E, Neukam
FW. Harvesting of bone from the iliac
crest - comparison of the anterior and
posterior sites. Br J Oral Maxillofac
Surg 2005: 43: 5156.
46. Kim MR, Donoff RB. Critical analysis
of mandibular reconstruction using AO
reconstruction plates. J Oral Maxillofac
Surg 1992: 50: 11521157.
47. Kim Y, Smith J, Sercarz JA, Head C,
Abemayor E, Blackwell KE. Fixation of mandibular osteotomies: comparison of locking and nonlocking
hardware. Head Neck 2007: 29: 453
457.
48. Kinoshita Y, Kobayashi M, Hidaka
T, Ikada Y. Reconstruction of mandibular continuity defects in dogs using
poly (L-lactide) mesh and autogenic
particulate cancellous bone and marrow:
Preliminary report. J Oral Maxillofac
Surg 1997: 55: 718723.
49. Klapp R, Schroder H. Die Unterkieferschussbruche und ihre Behandlung.
Berlin: Verlag von Hermann Meusser
1917.
50. Kline SN, Rimer SR. Reconstruction of
osseous defects with freeze-dried allogeneic and autogenous bone: Clinical
and histologic assessment. Am J Surg
1983: 146: 471473.
51. Kruger E, Krumholz K. Results of
bone grafting after rigid fixation. J Oral
Maxillofac Surg 1984: 42: 491496.
52. Kuriakose MA, Shnayder Y, Delacure MD. Reconstruction of segmental
mandibular defects by distraction osteogenesis for mandibular reconstruction.
Head Neck 2003: 25: 816824.
53. Leake DL, Rappoport M. Mandibular
reconstruction: Bone induction in an
alloplastic tray. Surgery 1972: 72:
332336.
54. Louis P, Holmes J, Fernandes R.
Resorbable mesh as a containment sys-

604

55.

56.
57.

58.

59.

60.

61.

62.
63.

64.
65.
66.

67.

68.

Goh et al.
tem in reconstruction of the atrophic
mandible fracture. J Oral Maxillofac
Surg 2004: 62: 719723.
Lowlicht RA, Delacure MD, Sasaki
CT. Allogeneic (homograft) reconstruction of the mandible. Laryngoscope
1990: 100: 837843.
Luhr H-G. Entwicklung der modernen
Osteosynthese.
Mund
Kiefer
GesichtsChir 2000: 4: S84.
MAINOUS EG, BOYNE PJ, HART GB,
TERRY BC. Restoration of resected
mandible by grafting with combination
of mandible homograft and autogenous
iliac marrow and postoperative treatment with hyperbaric oxygenation. Oral
Surg 1973; 35:1320.
Martola M, Lindqvist C, Hanninen
H, Al-Sukhun J. Fracture of titanium
plates used for mandibular reconstruction following ablative tumor surgery. J
Biomed Mater Res B Appl Biomater
2007: 80: 345352.
Marx RE, Carlson ER, Eichstaedr
RM, Schimmele SR, Strauss JE, Geogeff KR. Platelet-rich-plasma: growth
factor enhancement for bone grafts. Oral
Surg 1998: 85: 638646.
Marx RE, Kline SN, Johnson RP,
Malinin TI, Matthews 2nd JG, Gambill V. The use of freeze-dried allogeneic bone in oral and maxillofacial
surgery. J Oral Surg 1981: 39: 264274.
McCarthy JG, Schreiber J, Karp N,
Thorne CH, Grayson BH. Lengthening the human mandible by gradual
distraction. Plast Reconstr Surg 1992:
89: 18.
MCKEE DM. Microvascular bone transplantation. Clin Plast Surg 1978: 5: 283
292.
Merkx MAW, Fennis JPM, Verhagen
CM, Stoelinga PJW. Reconstruction
of the mandible using pre-shaped
2.4 mm titanium plates, autogenous particulate cortico-cancellous bone grafts
and platelet rich plasma: a report on
eight patients. Int J Oral Maxillofac Surg
2004: 33: 733739.
Mowlem R. Report of eighty-five cancellous chip grafts. Lancet 1944: 2: 746
748.
Nerem RM, Sambanis A. Tissue engineering: from biology to biological substitutes. Tissue Eng 1995: 1: 313.
Nocini PF, Wangerin K, Albanese M,
Kretschmer W, Cortelazzi R. Vertical distraction of a free vascularized
fibula flap in a reconstructed hemimandible: a case report. J Craniomaxillofac
Surg 2000: 28: 2024.
Nunez VA, Pike J, Avery C, Rosson
JW, Johnson P. Prophylactic plating of
the donor site of osteocutaneous radial
forearm flaps. Br J Oral Maxillofac Surg
1999: 37: 210212.
OBrien
BM, Morrison
WA,
MacLeod AM, Dooley BJ. Microvascular osteocutaneous transfer using the
groin flap and iliac crest and dorsalis

69.

70.

71.
72.

73.

74.

75.

76.

77.

78.

79.

80.

81.

82.

pedis flap and second metatarsal. Br J

Plast Surg 1979: 32: 188206.
Orell S. Surgical bone grafting with
os purum and os novum and
boiled bone. J Bone Joint Surg
1937: 19: 873885.
Plotnikov NA, Sysoljatin PG. Mandibular primary osteoplasty using orthotopic allografts. J Craniomaxillofac Surg
1993: 21: 4349.
Rappaport I. The particulate graft in
tumour surgery. Am J Surg 1971: 122:
748755.
Riediger D. Restoration of masticatory
function by microsurgically revascularized iliac crest bone grafts using enosseous implants. Plast Reconstr Surg
1988: 81: 861877.
Robertson GA. The role of sternum in
osteomyocutaneous reconstruction of
major mandibular defects. Am J Surg
1986: 152: 367370.
Rogers SN, Lakshmiah SR, Narayan
B, Lowe D, Brownson P, Brown JS,
Vaughan ED. A comparison of the
long term morbidity following deep circumflex iliac and fibula free flaps for
reconstruction following head and neck
cancer. Plast Reconstr Surg 2003: 112:
15171525.
Rogers SN, Lowe D, Fisher SE,
Brown JS, Vaughan ED. Healthrelated quality of life and clinical function after primary surgery for oral cancer. Br J Oral Maxillofac Surg 2002: 40:
1118.
Rogers SN, McNally D, Mahmood
M, Chan M, Humphris GM. The psychological response of the edentulous
patient following primary surgery for
oral cancer: a cross-sectional study. J
Prosthet Dent 1999: 82: 317321.
Rohner D, Jaquiery C, Kunz C,
Bucher P, Maas H, Hammer B. Maxillofacial reconstruction with prefabricated osseous free flaps: a 3-year
experience with 24 patients. Plast
Reconstr Surg 2003: 112: 748757.
Sacco AG, Chepeha DB. Current status of transport-disc-distraction osteogenesis for mandibular reconstruction.
Lancet Oncol 2007: 8: 323330.
Salibian AH, Rappaport I, Furnas
DW, Achauer BM. Microvascular
reconstruction of the mandible. Am J
Surg 1980: 140: 499502.
Samman N, Luk WK, Chow TW,
Cheung LK, Tideman H, Clark
RKF. Custom-made titanium mandibular reconstruction tray. Aust Dental J
1999: 44: 195199.
Schepers RH, Slagter AP, Kaanders
JHAM, van der Hoogen FJA, Merkx
MAW. Effect of postoperative radiotherapy on the functional result of
implants placed during ablative surgery
for oral cancer. Int J Oral Maxillofac
Surg 2006: 35: 803808.
Schliephake H, Hausamen JE. An
overview of the principles of reconstruc-

83.

84.

85.

86.

87.

88.

89.

90.

91.

92.

93.

tive surgery. In: Ward Booth P,

Schendel SA, Hausamen JE, eds:
Maxillofacial Surgery 2nd Edn St Louis:
Churchill Livingstone 2007: 535548.
Schliephake H, Jamil M. Impact of
intraoral soft-tissue reconstruction on
the development of quality of life after
ablative surgery in patients with oral
cancer. Plast Reconstr Surg 2002: 109:
421430.
Schliephake H, Neukam FW,
Schmelzeisen R, Varoga B, Schneller H. Long-term Quality of life
after ablative intraoral tumour surgery.
J Craniomaxillofac Surg 1995: 23: 243
249.
Schliephake H, Neukam FW,
Schmelzeisen R, Wichmann M.
Long-term results of endosteal implants
used for restoration of oral function after
oncologic surgery. Int J Oral Maxillofac
Surg 1999: 28: 260265.
Schliephake H, Ruffert K, Schneller T. Prospective study of the quality
of life of cancer patients after intraoral
tumor surgery. J Oral Maxillofac Surg
1996: 54: 664669.
Schoen PJ, Raghoebar GM, Bouma J,
Reintsema H, Burlage FR, Rooddenburg JLN, Vissink A. Prosthodontic
rehabilitation of oral function in headneck cancer patients with dental
implants placed simultaneously during
ablative tumour surgery: an assessment
of treatment outcomes and quality of
life. Int J Oral Maxillofac Surg 2008:
37: 816.
Schoen PJ, Reintsema H, Raghoebar
GM, Vissink A, Roodenburg JLN. The
use of implant retained mandibular prostheses in the oral rehabilitation of head
and neck cancer patients. A review and
rationale for treatment planning. Oral
Oncol 2004: 40: 862871.
Schwartz HC, Leake DL, Pizzofenato A. Evaluation of autologous cancellous bone grafting of mandibular
discontinuity defects in dogs using
dacron-urethane prosthesis. J Oral Maxillofac Surg 1987: 45: 143148.
Schwartz HC, Wollin M, Leake DL,
Kagan AR. Interface radiation dosimetry in mandibular reconstruction. Arch
Otolaryngol 1979: 105: 293295.
Sclaroff A, Haughey B, Gay WD,
Paniello R. Immediate mandibular
reconstruction and placement of dental
implants at the time of ablative surgery.
Oral Surg Oral Med Oral Pathol 1994:
78: 711717.
Serafin D, Villarreal-Rios A, Georgiade NG. A rib-containing free flap to
reconstruct mandibular defects. Br J
Plast Surg 1977: 30: 263266.
Shaw RJ, Sutton AF, Cawood JI,
Howell RA, Lowe D, Brown JS,
Rogers SN, Vaughan ED. Oral rehabilitation after treatment for head and
neck malignancy. Head Neck 2005: 27:
459470.

Mandibular reconstruction in adults: a review

94. Shibahara T, Noma H, Furuya Y,
Takaki R. Fracture of mandibular
reconstruction plates used after tumor
resection. J Oral Maxillofac Surg
2002: 60: 182185.
95. Simon ENM, Merkx MAW, Shubi FM,
Kalyanyama BM, Stoelinga PJW.
Reconstrcution of the mandible after
ablative surgery for the treatment of
aggressive, benign odontogenic tumours
in Tanzania: a preliminary study. Int J
Oral Maxillofac Surg 2006: 35: 421
426.
96. Snyder CC, Levine GA, Swanson
HM, Browne Jr EZ. Mandibular
lengthening by gradual distraction: preliminary report. Plast Reconstr Surg
1973: 51: 506508.
97. Song R, Gao Y, Song Y, Yu Y, Song
Y. The forearm flap. Clin Plast Surg
1982: 9: 2126.
98. Soutar DS, Scheker LR, Tanner NS,
McGregor IA. The radial forearm
flap: a versatile method for intra-oral
reconstruction. Br J Plast Surg 1983:
36: 18.
99. 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:
530545.
100. Sykoff W, Zur Frage der Knochenplastik
am
Unterkiefer.
Zentralbl
Chir1900:35
101. Tayapongsak P, OBrien DA, Monteiro CB, Arceo-Diaz LY. Autologous fibrin adhesive in mandibular
reconstruction with particulate cancellous bone and marrow. J Oral Maxillofac
Surg 1994: 52: 161165.
102. Taylor GI, Miller GDH, Ham FJ. The
free vascularized bone graft. Plast
Reconstr Surg 1975: 55: 533544.
103. Taylor GI, Townsend P, Corlett R.
Superiority of the deep circumflex iliac
vessels as the supply for free groin flaps.
Clinical work. Plast Reconstr Surg 1979:
64: 745759.
104. Teot L, Bosse JP, Mourfarrege R.
The scapular crest pedicled bone graft.
Int J Microsurg 1981: 3: 257262.
105. Terheyden H, Knak C, Jepsen S,
Palmie S, Rueger DR. Mandibular
reconstruction with a prefabricated vascularized bone graft using recombinant
human osteogenic protein-1: an experimental study in miniature pigs. Part I:
Prefabrication. Int J Oral Maxillofac
Surg 2001: 30: 373379.
106. Terheyden H, Menzel C, Wang H,
Springer IN, Rueger DR, Acil Y.
Prefabrication of vascularized bone
grafts using recombinant human osteogenic protein-1part 3: dosage of rhOP1, the use of external and internal scaf-

107.

108.

109.

110.

111.

112.

113.

114.

115.

116.

117.

118.

folds. Int J Oral Maxillofac Surg 2004:

33: 164172.
Thorn JJ, Sorensen H, Weis Fogh U,
Andersen M. Autologous fibrin glue
with growth factors in reconstructive
maxillofacial surgery. Int J Oral Maxillofac Surg 2004: 33: 95100.
Tideman H. Complete rehabilitation of
the lower jaw after segmental resection:
a new method. J Craniomaxillofac Surg
1996: 24(suppl 1):176.
Tideman H, Lee S. The TL endoprosthesis for mandibular reconstruction - a
metallic yet biological approach. Asian J
Oral Maxillofac Surg 2006: 18: 5.
Tideman H, Samman N, Cheung LK.
Functional reconstruction of the mandible: a modified titanium mesh system.
Int J Oral Maxillofac Surg 1998: 27:
339345.
Tiwari R. Mandibular reconstruction
with conventional bone graft. In: Soutar DS, Tiwari R, eds: Excision and
Reconstruction in Head and Neck Cancer. Edinburgh: Churchill Livingstone
1994: 5985.
Tonino A, Davidson CL, Klopper PJ,
Linelau LA. Protection from stress in
bone and its effects. J Bone Joint Surg
Am 1976: 58: 107113.
Urken ML, Buchbinder D, Weinberg
H, Vickery C, Sheiner A, Biller HF.
Primary placement of osseointegrated
implants in microvascular mandible
reconstruction. Otolaryngol Head Neck
Surg 1989: 101: 5673.
Urken ML, Buchbinder D, Weinberg
H, Vickery C, Sheiner A, Parker R,
Schaefer J, Som P, Shapiro A, Lawson W et al. Functional evaluation following microvascular oromandibular
reconstruction of the oral cancer patient:
A comparative study of reconstructed
and nonreconstructed patients. Laryngoscope 1991: 101: 935950.
Urken ML, Vickery C, Weinberg H,
Buchbinder D, Lawson W, Biller
HF. The internal oblique-iliac crest
osseomyocutaneous free flap in oromandibular reconstruction. Report of 20
cases. Arch Otolaryngol Head Neck
Surg 1989: 115: 339349.
Van Cann EM, Dom M, Koole R,
Merkx MAW, Stoelinga PJW. Health
related quality of life after mandibular
resection for oral and oropharyngeal
sqamous cell carcinoma. Oral Oncol
2005: 41: 687693.
Vaughan ED, Bainton R, Martin IC.
Improvements in morbidity of mouth
cancer using microvascular free flap
reconstructions. J Craniomaxillofac
Surg 1992: 20: 132134.
Wangerin K, Ewers R, Wottge HU,
Randzio G. The autoclaved autogenous
bone graft as a reimplant: Results of

119.

120.

121.

122.

123.

124.

125.

126.

127.

128.

605

animal experiments. J Maxillofac Surg

1986: 14: 132137.
Warnke PH, Springer IN, Wiltfang
J, Acil Y, Eufinger H, Wehmoller
M, Russo PA, Bolte H, Sherry E,
Behrens E, Terheyden H. Growth
and transplantation of a custom vascularised bone graft in a man. Lancet 2004:
364: 766770.
Warnke PH, Wiltfang J, Springer I,
Acil Y, Bolte H, Kosmahl M, Russo
PA, Sherry E, Lutzen U, Wolfart S,
Terheyden H. Man as living bioreactor: fate of an exogenously prepared
customized tissue-engineered mandible.
Biomaterials 2006: 27: 31633167.
Weinzweig N, Jones NF, Shestak
KC, Moon HK, Davies BW. Oromandibular reconstruction using a keelshaped modification of the radial forearm osteocutaneous flap 1994: 33: 359
369.
Weischer T, Mohr C. Ten-year experience in oral implant rehabilitation of
cancer patients: treatment concept
and proposed criteria for success. Int J
Oral Maxillofac Implants 1999: 12:
521528.
Werkmeister R, Szulczewski D,
Walteros-Benz P, Joos U. Rehabilitation with dental implants of oral cancer
patients. J Craniomaxillofac Surg 1999:
27: 3841.
Whitman DH, Berry RI, Green DM.
Platelet gel: an autologous alternative to
fibrin glue with applications in oral and
maxillofacial surgery. J Oral Maxillofac
Surg 1997: 55: 12951299.
Wilk RM. Bony reconstruction of the
jaws. In: Miloro M, ed: Petersons
Principles of Oral and Maxillofacial
Surgery 2nd edn HamiltonLondon:
BC Decker 2004: 783801.
Wilson KM, Rizk NM, Armstrong
SL, Gluckman JL. Effects of hemimandibulectomy on quality of life. Laryngoscope 1998: 108: 15741577.
Wodajo FM, Bickels J, Wittig J,
Malawer M. Complex reconstruction
in the management of extremity sarcomas. Curr Opin Oncol 2003: 15: 304
312.
Yang G, Chen B, Gao Y. Forearm free
skin flap transplantation. Natl Med J
China 1981: 61: 139.

Address:
Bee Tin Goh
Department of Oral and Maxillofacial
Surgery
National Dental Centre
5 Second Hospital Avenue
Singapore 168938
Tel: +65 63248817
Fax: +65 63248899.
E-mail: gohbee@cyberway.com.sg