Bone Management in Free Fibula Flap for Functional Jaw Reconstruction: Experiences and Technical Innovations

Dento-facial rehabilitation is a multi-step procedure that requires skeletal reconstruction, implant insertion, peri-implant soft tissue management, and prosthetic restoration. These different steps require the surgeon to face complications often related to incorrect surgical planning. The authors proposed a review of their experience with the use of fibula free flaps for mandibular and maxillary reconstruction. More specifically, they analyzed all the phases of correct bone management, beginning with flap harvesting up to the final implant-based prosthetic restoration, including implant stability evaluation at long-term follow-up.

From December 1989 to May 2005, 165 patients were treated for jaw reconstruction with a vascularized fibular flap. One hundred six of them underwent reconstruction after tumor resection, 57 were treated for correction of severe alveolar crest atrophies (Cawood's class V and VI), and two after gunshot. Of the 165 patients, 156 had a single jawbone reconstruction (98 mandibles and 53 maxillas) and 9 had both mandible and maxilla reconstruction. The total number of fibula transplants was 174; the length of transplanted fibula bone ranged from 10 to 25 cm. Two hundred eighty implants were inserted into the fibular bone, and 67 implant-supported prostheses were manufactured. The long-term follow-up ranged between 2 months and 15 years. A retrospective analysis was attempted to detect the main complications related to bone management immediately and in long-term follow-up.

One hundred sixty-seven of the 174 fibular flaps healed primarily, with a success rate of 96%. Seven failures were observed, and they were related to vascular problems. Late complications were observed under different circumstances. Sixteen implants were lost, 5 because of instability, 6 because of infection, and 5 because of incorrect masticatory loading. The implant success rate was 94.4%. An incorrect fixation was responsible for a microplate rupture in 6 of 160 patients; this caused delayed healing of the osteotomic site. Ten cases of vertical discrepancy between the fibula and the mandibular dentate stump were treated with iliac bone grafting and vertical distraction osteogenesis, respectively.

Correct bone management begins with an accurate evaluation of flap perfusion. The authors recommended implant insertion not prior to 5 to 6 months from the transplant, at the time of plate removal. Late complications are related to incorrect surgical bone orientation, incorrect implant surgery (as to type, number, and spatial position of fixtures), and incorrect management of peri-implant soft tissue. These problems may be avoided with accurate preoperative planning and follow-up.