Mandibular Reconstruction after Head and Neck Tumor Treatment, a Systematic Review

Jonas Emanuelsson Jonathan Viblom Master thesis 30 ECTS MSc. Dental Surgery Dept. Oral and Maxillofacial Surgery Tutor: Mats Sjöström, Linda Pettersson

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ABSTRACT

Objectives

This systematic literature review examined the literature about mandibular

reconstruction after cancer treatment with segmental resection, with focus on

success rate for the reconstruction, patient survival rate, dental rehabilitation

and how this effect the patients QOL, oral function and aesthetics.

Material and methods

A search was performed in Pubmed, a database of scientific articles, based on

four keywords (Mandibular, Reconstruction, Cancer, Segmental). After

screening using our inclusion and exclusion criteria’s, 89 articles were chosen.

A data base in excel was established to sort the information we needed for our

study.

Results

Sixty out of the 89 included articles were in full text and 29 were abstracts. The

median year of publication was 2006 (range 1977 to 2013). A total of 5629

patients were included in the literature review. Of these, 3783 patients were

included in articles that had categorized by gender and we found that 65.4%

were males and 34.6% were females.

The total success rate for reconstruction therapies including plate, vascularized-

and non-vascularized bone transplant was 86.4% in 3219 patients (range from

70.4% in the plate group to 92.3% in the non-vascular group). The mean follow

up time were 46.9 mounts (range 0.2 – 216 months).

Conclusion

This literature review indicates a focus on success rates for different kinds of

reconstruction techniques. The overall success rate for non- and vascularized

bone reconstruction techniques were very high compared to plate

reconstruction only. To evaluate patient-related factors such as function,

aesthetics and quality of life, further prospective randomized studies is required.

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INTRODUCTION

Primary tumors

The mandible is primarily made of bone which is a highly specialized form of

connective tissue. Tumors that originate from connective tissue are called

sarcomas (Mosby’s Dental Dictionary, 2nd edition (2008)). Several variants of

sarcoma exist but the most common variants are osteosarcoma which

constitutes about 35% of sarcoma cases followed by chondrosarcoma (25.8%),

Ewing´s sarcoma (16%) and chordoma (8.4%). (Dorfman et al., 1995; Coleman

et al., 2012).

The incidence and ratio between these four variants of sarcomas varies in

different age groups. Chondrosarcoma is the most common variant in adults

over the age of 30 years while Ewing’s sarcoma and Osteosarcoma accounts

for more than 90% of the cases in the age group of 0-9 years, and

Osteosarcoma is the most common variant in the age group of 10-19 years.

The primary site for sarcoma differs between the age groups. The proportion of

sarcomas originating in the skull and face is highest in patients between 30-59

years of age. Most cases of osteosarcoma affecting the face and skull area is

seen in persons between 30-39 years of age (Francis et al., 2012).

Benignant bone tumors affecting the mandible does not spread to other tissues

and usually have a relatively good prognosis. Among the benign tumors

affecting the mandible is mainly odontomas and ameloblastomas. (Regezi et al.,

1978).

Secondary tumors

The most common secondary tumors affecting the mandibular bone originate

from epidermoid cells which form the tissue types in the floor of the mouth and

gingiva. Cancer originated from this tissue is for example squamous cell

carcinoma. The most common secondary tumors caused by malignancies

originating outside the head and neck area are spread by metastasis from

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primary tumors in the breast (women) and lung tissue (men) (Weber et al.

2003). Other primary malignancies that can cause metastasis in the mandible

are adrenal gland, colon, genital, thyroid tissues for women and prostate,

kidney, bone and adrenal gland for men. Most common site for secondary tumor

of the mandible is posteriorly to the wedge starting in the molar region. The

mean age for patients with metastasis in the mandible is 50 to 60 years (N.

Zachariades., 1989; Hirshberg et al., 1994; Jham et al., 2011).

Treatment alternatives

When a patient is afflicted by malignancies in the mandible, you have to plan

the treatment in order to cure the patient. The normal treatment alternatives are

irradiation, chemotherapy and/or resection. This review will focus on the

resection therapy but it will also include the irradiation therapy as these

treatments often are given together (Bak et al., 2010). There are two kinds of

resections of the mandible. The first type is called a “rim resection” a technique

where you leave a base of the mandible meaning that you don’t split the

mandible in sections. The other type of resection is based on a technique where

you split the mandible in to sections during cancer removal, called segmental

resection (Rogers et al., 2004).

One decision is if the treatment should include irradiation therapy and if the

irradiation therapy should be performed before or after resection of the

mandible. However, the literature is inconclusive according the result if the

radiation is given before or after surgery (Choi et al., 2004).

A major side effect of irradiation therapy is the risk for osteoradionecrosis

(ORN). Research on ORN has recently undergone a “shift” from the thought

that the tissue is hypo-cellular, hypo-vascular and hypo-oxygen. Today it is

considered that ORN is caused by the cell damage in the bone due to an acute

inflammation, free radicals and a chronic activation of fibroblasts triggered by a

series of growth hormones. This side effects results in a tissue more vulnerable

to trauma with reduced capacity for healing. For example, dental extractions

performed after irradiation results in higher risk for complications (Koga et al

2008). Previously ORN was treated by a hyperbaric chamber where the high

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pressure and the high oxygen content of the air would re-oxygenate the tissue

and improve the conditions for healing (Teng and Futran, 2005). Today, the

treatment of ORN with hyperbaric oxygen is questioned. Clayman (1997) have

shown low incidence (5%) of ORN following careful dental extraction on patients

post radiation therapy, without the use of hyperbaric oxygen treatment. New

articles describe the pathogenesis of ORN as radiation-induced fibrosis (Lyons

et al., 2008).

The main goal with mandibular reconstruction is to restore the patient’s function

with focus on speech, range of motion, aesthetics, chewing, swallowing, and

Quality of life (QOL). With today’s techniques the surgeons can restore this to

an acceptable level but there is room for improvement (Hidalgo and Pusic,

2002).

Previous, the main goal of the resection and reconstruction were made in order

to make the patient survive the malignancy, resulting in a suboptimal esthetic

result. Reconstruction was generally made with two methods. The first method

was based on a reconstructing rail or mesh, made of metal (titanium or stainless

steel) filled with bone grafts taken from the hip, or hydroxyapatite (Dumbach et

al., 1994). The second method included endogenous non vascular bone grafts.

The deciding factor in choosing between treatments was mainly patient’s life

expectancy (Kanchanarak et al., 1999). These methods have different treatment

outcomes according to graft survival.

Today’s surgical techniques have progressed further partly in the planning of the

operation with MRI, 3D models, titanium plates and better instruments resulting

in an improving treatment outcome. Today the surgeons uses free bone grafts

taken from the fibula, iliac crest or scapula and transplants it with both the skin,

muscles and bones with its own vascular supply and anastomose it into the

reception site. The selection of donor site is based on access, surgery

technicalities, height in the restored mandible, how much bone and soft tissue

that is needed and so on (Bak et al., 2010).

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Occlusal rehabilitation is based on factors such as facial height, lip support and

aesthetics. One important factor for the choice of reconstruction is if the

occlusion should be with removable prosthesis or dental implants (Schrag et al.,

2006).

The most common postoperative occlusal rehabilitation for patients undergoing

mandibular reconstruction is dental implants. This technique is fairly new and its

technology have improved over the years and today the success rate is around

85-90% in terms of survival of the implants (Jacobsen et al., 2012).

Complications

The mandible is a very important part in the facial structure. It is not only the

aesthetics that is suffering from the resection and reconstruction, but also the

function. The patient can have functional problems with swallowing, speech and

chewing after the resection and reconstruction (Hidalgo and Pusic, 2002). The

reconstruction itself can be affected with graft detachment, clots and hematoma.

An inevitable complication is numbness, because of the removal of n. alveolaris

inferior during the resection. To improve the sensory function, transplanting

nerve in to the resected area, can regain function of the nerve (Shibahara et al.,

1999; Gennaro et al., 2013).

The literature about the prognosis of mandible reconstruction is comprehensive

but definitive prognosis is difficult to predict (Boyd et al., 1995; Hidalgo and

Pusic, 2002; Virgin et al., 2010). The literature reports about different

techniques, different diagnosis of the malignancy and different measurements

for success. The main focus in the literature is success rate of flap survival

while factors descriebing function, estetic and QOL are neglected.

The aim of this study is to investigate and evaluate the literature which

discusses mandibular reconstruction after cancer treatment including segmental

resection of the mandible.

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MATERIALS AND METHODS

Objectives for literature review

The aim of this study is to investigate and evaluate the literature describing

mandibular reconstruction after cancer treatment including segmental resection

of the mandible.

Search strategy

A systematic literature review based on four keywords (Mandibular,

Reconstruction, Cancer, Segmental) was performed in PubMed, a database of

scientific articles, October 21, 2013 (See Table 1: Search strategy)

The articles were then entered into Endnote in order to get an easy overview.

After manual review of the abstracts we sorted out the articles meeting our

exclusion/inclusion criteria. (See Figure 1: Process of selection)

Inclusion criteria

Published and reviewed examined human studies on patients who have

undergone segmental resection of the mandible as part of treatment of cancer

in the head and neck area. The studies needed to be published in scientific

journals with a review system to be included. Articles (at least the abstracts)

must be published in English.

Exclusion criteria

Case reports and articles with less than 10 patients, patients with known

comorbidity, ex. HIV and Diabetes and Rim resections.

Data extraction

One hundred and eight of the 208 articles did not fulfill the inclusion criteria and

were excluded. The 100 remaining articles were reviewed by the two reviewers

independently. During the review, data extraction was performed and data was

placed in a database created in Excel. Data about function, aesthetics and

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quality of life was excluded in table 2, due to a very large amount of information

that was not suitable to present in that format.

We extracted information out of the articles using the following variables:

Author, article type (full text or abstract), publication year, number of patients,

average age, sex, type of operation, reconstruction technique (Plate,

Vascularized bone graft or non-vascularized bone graft), origin of bone grafts,

size of the resection, success rate of reconstruction, postop follow-up, survival

rate, dental rehabilitation, aesthetics, function, QOL, and radiation or not. If

information could not be contained in an article it was not included in the

summation of the current variable. Along with the data extraction and full text

review, a second exclusion was done and additionally, 11 articles were excluded

as these did not meet the criteria. All variables where later summarized.

Ethical consideration

Since this is a literature study, all data will be reported anonymously. There is no

possibility for personal identification which excludes ethical problems.

RESULTS

Literature review

Out of the 89 included articles, 60 were in full text and 29 were abstracts. The

large numbers of abstracts were the result of articles without full text in English

or articles published back in time before the start of publications on the internet.

The median year of publication was 2006 (range 1977 – 2013).

A total of 5629 patients were included in the study. Of these, 3783 patients were

included in articles that had categorized by gender and we found that 65.4%

were males and 34.6% were females (mean age 52.6 years, range 5 month’s –

88 years of age).

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The overall success rate (the number of reconstructions with no or minor

complications, that did not need further surgery or to be redesigned) for

reconstruction in the groups; vascular, non-vascular and plate were extracted

from 62 unique articles. The success rate was 86.4% in 3219 patients, with a

range from 70.4% in the plate group to 92.3% in the non-vascular group. Of the

articles included; 59 articles published data about follow up time. The mean

follow up time were 46.9 months (range 0.2 – 216 months).

Size and position of the segmental resection of the mandible

Of the included articles; 51 published data about mandibular resection. Two

perspectives on this subject can be recognized. While some of the included

articles report the size of the resection, other articles talk about the location of

the resection. Twenty articles published data about the size and 31 articles

published data about the site of the resection. Three of the included articles

published data of both the size and location of the resection.

The size of resection ranged from 2 to 26 cm with a mean value of

approximately 8.1 cm. The mean values ranged from 6.7 cm in the first quartile

to 8.9 cm in the last quartile, ie half of the participants had a reconstruction size

comprising between these two values.

The site of the resection varies depending on the location of the cancer, but is

also related to the extent of the tumour. The extent of the resection is dependent

on type and size of the malignancy and the approach of the surgeon. Based on

data extracted from the 31 articles (2029 patients), the most commonly found

mandibular site of resection is the lateral part of the mandible with 43.1% of the

cases. Next comes the anterior-lateral part (16.1%) followed by the anterior-

lateral-posterior (11.4%) site of removal. The fourth most common site of

resection is the removal of the anterior part of the mandible which was carried

out in 9.3% of the cases. A resection of the mandibular condyle was performed

in 7.2% of cases. A very small proportion (0.1%) was reported to have the

resection localized lateral-posterior.

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Reconstruction

After segmental resection of the mandible, a reconstruction of the resected area

is usually performed. Our statistics about the three different reconstruction

methods can be viewed in Tabel 2: Results of reconstruction.

Vascular reconstruction

Of the articles included; 15 unique articles explored the outcome of vascular

reconstruction (some articles investigate 2 or more techniques).

A total of 641 patients were reconstructed with a success rate of 90.6%, with a

range from 83.3% to 94.3%. The most common graft site were Fibula, used in

393 reconstructions. Fibula was also the most publicized graft site with 11

articles. The most successful graft site were Scapula with a success rate of

94.3%.

Non vascular reconstruction

Of the articles included; 31 unique articles explored the outcome of non-

vascular reconstruction (some articles investigate two or more techniques).

A total of 1764 patients were reconstructed with a success rate of 92.3%, with a

range from 89.5% to 100%. The most common graft site in non-vascular

reconstruction was fibula, used in 1195 reconstructions. Fibula was also the

most publicized graft site with 28 articles. The most successful graft site was

Ilium with 100%.

Plate

Of the articles included; 16 unique articles explored the outcome of plate

reconstruction. All plates that did not include a graft of bone were included in the

group plate. A total of 814 patients were reconstructed with a success rate of

70.4%.

Dental rehabilitation

Of the articles included; 29 articles reported about dental rehabilitation.

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A total of 1425 patients were included. Of these patients, 467 received dental

rehabilitation with removable prosthesis or implants. Implants were the most

common treatment option with 87.6% of the 467 patients.

Irradiation

Of the articles included; 38 articles discussed radiation as an adjuvant therapy

to surgery in the treatment of cancer of the mandible. 62.4%, or 1605 of a total

of 2573 patients received radiotherapy as adjuvant therapy to surgery. Of these

1605, 500 (31%) patients received radiotherapy preoperatively, while 415 (26%)

received radiation therapy postoperatively. For the other 690 (42.9%) patients

who received radiotherapy the time was not specified including a very small

proportion (n = 12, ie, 0.8%) who received radiotherapy, both preoperatively and

postoperatively.

Patient survival rate

We sorted the material from the articles and created three groups. First group; 1

year survival or less; five articles reported a total of 566 patients with a survival

rate of 86.0% (range 74-95%). The patient´s cancer types were: 519 malign

tumors, 0 benign tumors and 47 were undefined.

Second group; 2-4 years of survival; 19 articles reported a total of 1524 patients

with a survival rate of 70.4% (range 50-100%). The patient’s cancer types were:

1033 malign tumors, 138 benign tumors and 283 were undefined.

Third group: 5 years of survival or more; 14 articles reported a total of 1089

patients with a survival rate of 71.8% (range 40-100%). The patient´s cancer

types were: 674 malign tumors, 119 benign tumors and 366 were undefined.

Aesthetics

Of the articles included; 22 articles investigated the aesthetic outcome of

restorations after the treatment of cancer. Thirteen articles featured useful

statistical data with quite varying results regarding the perceived aesthetic level

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of the patients. This is exemplified by Young et al. (2007) reporting less than

30% of patients have gained an acceptable appearance compared with other

studies in which over 95% were considered to have gained an acceptable

appearance (Patel et al., 1996; Politi et al., 2012).

Function

Of the articles included; 30 articles investigated the functional outcome of

restorations after treatment. Fourteen of these articles presented statistics

about the subject.

The oral function can include many areas, such as the ability to speak and eat.

Three of the 14 articles examined the proportion of patients who had received a

normalized speaking ability. These articles showed that approximately 75% of

patients regained normal speech ability (range 36%-100%).

Nine of the 14 articles examined the proportion of patients who had received a

normalized eating ability, which includes the ability to chew and swallow.

Only seven of these articles presented statistics on both of these functions. Two

of the articles presented statistics only about the ability to chew. The studies

show that half of the patients regained the ability to swallow (58.8%, range 25.8

-81%) and chew (53.1% 25.4 – 81%).

Limitations in the ability to eat mean that the food must be modified in order to

be eaten. Seven of articles have looked at the type of food that patients can eat.

In these studies it can be seen that the patients were divided into four different

groups, those who can eat solid / regular food, those who tolerate soft foods,

those who can only eat liquid food, and those who are dependent on tube

feeding. These studies showed that almost half of the patients (48.6%) regained

the ability to eat a regular diet (Range 25.8 – 65%) and slightly fewer than half

of the patients tolerated soft food (42.9%, range 22.7 – 94%). Ten percent of the

patients could only ingestion liquid food (range 0.9 -27.3%) and 9.8% were

dependent on tube feeding (range 5 -15.9%).

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Quality of life

Of the articles included; four articles investigated the quality of life (QOL) after

cancer treatment. Factors examined included the extent to which the mental

and physical well-being had been affected by the cancer treatment. Young et al.

(2007) came to the following; of their patient population (26 patients), 58%

stated that their wellbeing was good. Sixty five percent reported that their mood

was positive and 77% stated that they did not feel physical pain. Boffano et al.

(2011) indicated that 70% of their patients (total 10 patients) had retained the

sensory function of the nervus alveolaris inferior. Dholam et al. (2011) did a

statistical analysis of speech, swallowing parameters and quality of life and

found no significant difference because of the paucity of numbers. Garrett, et al.

(2006) looked at how facial appearance affected the social life and came up

with the following conclusions; the patients satisfaction with facial appearance

was approximately 65% both prior to and after surgery. On the question about if

appearance affect social life, approx. 85% said this was a fact prior to resection.

Postoperatively approximately 75% stated this as a fact.

DISCUSSION

This review examined the literature about mandibular reconstruction after

cancer treatment with segmental resection. Main focus has been to examine

success rate for the reconstructions, patient survival rate, dental rehabilitation

and how this effects the patients QOL, oral function and aesthetics.

Of the 89 articles, 60 articles were in full text. In the remaining 29 articles, only

the abstract could be reviewed due to difficulties in interpreting these on their

original language. Though we cannot evaluate the scientific level of evidence in

these articles, all of the articles have been published in scientific journals and

therefore they have been controlled by a review group. We have chosen to trust

the validity of these review groups, due to the fact that their function is to

evaluate the validity of articles before publication in reputable scientific journals.

We found that there is no major difference in success rate between vascularized

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bone vs. non- vascularized bone transplants for method of reconstruction. Our

findings with a success rate of 90-92% for bone transplants lies roughly in line

with other research done on the subject. However, recent studies have shown

success rates up to 96% on mandibular reconstructions (Virgin et al., 2010). We

found that the reconstruction method using only plate had a lower frequency of

success than the other two methods using bone transplant. Why plate have a

lower success rate could be explained by the risk of penetration through soft

tissue due to high friction between plate and the mucosa. If radiation is given, it

creates fibrosis making the soft tissue even more sensible. Another known

reason for failure is plate fracture during heavy loading. The plate technique

was more common back in time. Today it is mostly used in patients with spread

cancer with bad prognosis and who have a lateral defect of the mandible. The

plate reconstruction is less invasive for the patient (less blood loss, shorter time

in surgery), why it´s still used in this patient group (Miyamoto et al., 2012).

Some of the patients don’t get any reconstructive therapy at all, mostly due to

bad tumor prognosis.

Fibula is the most common donor site in both the vascularized and non-

vascularized groups. The use of fibula over other bone transplants can be

explained by; easy access and the possibility to reconstruct major resections

due to its length, although the use of Iliac and other donor sites is increasing.

The disadvantage of fibula against Iliac, which is the second most common

donor site, is that Iliac have a more suitable height that can better facilitates

implant placement.

Although we have a large patient material, interpretation of the success rate

should be done with caution because the follow up time varies widely between

the studies, from one week to 216 months.

The average age of the 5629 patients included in our study is 52.6 years. The

age variation is however very great. In some studies exists individuals younger

than a year old, while in other studies exists individuals who are nearly ninety

15

years old. This large variation in age is explained by; the fact that the material

studied is extensive and includes many different types of tumors, which is age

related. As an example, we have studies on children (Benoit et al., 2013) where

the mean age was eight years.

Another study, Boffano et al. (2011) with low average age of the patients, had

odontogenic myxoma as diagnose and this tumor mostly affects young adults

(Barros et al., 1969). Another study (Puxedduet et al., 2004) had a much higher

average age of the participants with a mean age of 62.5 years. All participants

in this study had been diagnosed with squamous cell carcinoma, a form of

tumor that usually affects people over the age of 50 (Chen et al., 1999).

In our study we concluded that 65.4% were males and 34.6% were females.

The fact that the gender distribution looks like this in our study can be supported

by the fact that oral cancer affects more men than women. Rosenquist et al.

(2005) showed that men were over-represented when a total of 91 men,

compared with 41 women were subjected to oral and oropharyngeal squamous

cell carcinoma. This corresponds to 68.9% men and 31.1% women, which is

close to the gender distribution we have seen in our study.

In our study, we have chosen not to include articles in which co-morbidity, such

as Diabetes Mellitus noted to occur in the population studied. We have chosen

to do so because this can be assumed to affect the statistics relating the

survival of patients or the success rate of free flaps and implants. We can,

however not, ignore that there are probably individuals in the studies we have

selected, who have other diseases as well, such as Diabetes Mellitus. This is a

relatively common disease that also appears to increase the risk of oral cancer.

Diabetes can cause inflammatory lesions in the oral mucosa. A correlation

between oral lesions in diabetic patients and a higher risk for premalignant

status is supported by studies, for example, a study of Ujpál et al. (2004) and

Goutzanis et al. (2007). The probability that Diabetes Mellitus is represented

among the individuals in our study is therefore quite high.

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The degree of malignancy of the tumors shows great diversity in our review.

This is shown in studies discussing the use of radiation therapy as part of

treatment and the size of the mandibular resection performed.

Puxeddu et al. (2004) reported that all participants had squamous cell

carcinoma, the size of the resection was 6.9 cm (range 5.2 to 9 cm), and the

survival rate of the patients was 50% at study end. The proportion that received

adjuvant radiation therapy in this study was 75%. On the other hand, Chaine et

al. (2009) reported a study where all participants had giant mandibular

ameloblastoma. The size of the resection was 12 cm (range 7-16 cm) and the

survival rate was 100% at study end. If radiotherapy was a part of the therapy

was not specified by Chaine et al. However, the patients were probably not

given radiotherapy, as this treatment normally is not used for this type of cancer

(Rosenstein et al., 2001).

The results we found on survival rate were better then we expected but we have

a sprawling patient materiel with various tumors. For example Lindqvist et al.

(1992) reported that patient survival was 20% at five year follow up for patients

with malign cancers stage III or IV. We found that studies with longer follow up

tended to have a higher proportion of patients with benign tumors, which could

explain the good survival rates in these groups. The range between the studies

that presented the best vs. the worst survival rates varied greatly in the groups.

In our data, some studies have been included although their main objective was

to check on implant survival. We believe that these articles probably have

chosen “healthy patients” for their study which results in a much higher survival

rate compared to a article that have a “random” group of reconstructed patients.

Our findings show that dental rehabilitation is not common. The articles that

brought up the subject included a total of 1425 patients. Only one third of these

patients received dental rehabilitation. The reason that so few individuals chose,

for example dental implant treatment can be explained by the fact, it´s a very

expensive treatment that is not state-subsidized in those parts of the world

where these studies where made (Zitzmann et al., 2005). Oral cancer is also

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more common in people with low socioeconomic status (Warnakulasuriya,

2009). In these patients, it can be assumed that the ability to pay for expensive

dental restorations are lower than average for other patient categories which

explains why so few chose this treatment option. Another explanation for the

low percentage of patients who received implants may be to the fact that

implant treatment is invasive and time consuming.

Regarding QOL and aesthetics we found that more research needs to be done.

These topics are hard to evaluate because of its nature. There should also be

some kind of standardized question formulas and/or indexes so that comparison

between studies can be done. This kind of data should originate from the

patient and not be evaluated by the surgeon. Function is easier to measure in

some cases for example when you measure the ability eating solid food vs. tube

feeding dependent. It is harder to measure the ability to be understood through

speech, because it depends on the ability of the receiver to understand the

conversation. In our study we found that most of the patients regained their

ability to speech but the ability to chew and swallow was more affected, the

latter could be explained by the loss of teeth and loss of masticatory muscles

after segmental resection of the mandible. To strengthen this thesis more

studies needs to be done.

A small number of articles included in this review investigated the opinion about

aesthetic results after mandibular reconstruction. Our study indicates that the

vast majority of patients are satisfied with the aesthetic results after mandibular

reconstruction. However, the numbers of patients are too small to draw any

general conclusions regarding this subject.

ACKNOWLEDGEMENTS

We would like to express our gratitude’s to the following people. A special

thanks to our tutors Mats Sjöström and Linda Pettersson for their help and

guidance during the process of this study. We would also like to thank Lina

Holmström for helping us retrieving full-text studies not available on the internet.

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Table 1: Search strategy.

Database Search details Hits Selected

articles

PubMed (“mandibular reconstruction”[MeSH Terms] OR

(“mandibular”[All Fields] AND “reconstruction”[All Fields]) OR

“mandibular reconstruction”[All Fields]) AND segmental[All

Fields] AND (“neoplasms”[MeSH Terms] OR “neoplasms”[All

Fields] OR “cancer”[All Fields])

208 208

34

Table 2: Results of reconstruction.

VASCULAR Patients Success Failure Success rate Number of articles

Fibula 393 355 38 90.33% 11

Radialis 60 50 10 83.33% 7

Iliac 71 66 5 92.95% 7

Scapula 106 100 6 94.33% 3

Rib 11 10 1 90.90% 2

TOTAL 641 581 60 90.63% 15 Unique

NON VASCULAR Patients Success Failure Success rate Number of articles

Fibula 1195 1101 94 92.13% 28

Radialis 315 293 22 93.01% 11

Iliac 172 154 18 89.53% 11

Scapula 46 45 1 97.82% 8

Rib 30 29 1 96.66% 2

Ilium 6 6 0 100,00% 2

TOTAL 1764 1628 136 92.29% 31 Unique

PLATE Patients Success Failure Success rate Number of articles

Plate 814 573 241 70.40% 16

TOTAL 814 573 241 70.40% 16 Unique

OVERALL TOTAL 3219 2782 437 86.42% 62

Authors (year) Number of

Patients

Techunique Site (Bone) Size and position of resection (with Follow up

or wthout temporomandibular joint) mean + range

Survival rate Success rate (loss of Dental

plate and/or fractures) rehabilitation

Implants/protheses

Mean age Aesthetics Function

(included or (included

Quality of Irradiation

life

(included or

not)

Abstract/ Full

text

not) or not)

35

Baumann , et al. 63 43/63 (68,3%) of the patients was fibula 37 radial 2 Segmental defect with intact condyle mean 18,2 month 52/63 (82,5%) 32 1/27 (3,7%) segmental X mean 61 y (range No Yes No

(2011)

recontstructed with bone flap iliac 4

27. Posterior or hemi (range 3-72 month) month post op. bony defect lost the

29-88 y) resection with resection of condyle

36

11/63 (17,5%) implant 3/36 died after, mean (8,3%) posterior or hemi

8 month post op resection lost the

(range 3-32 implant

month).

Table 3: The database.Abler , et al. (2005) 152 (112 had

segmental

resection)

Reconstruction plate X X x x x x No No No x Ab

Adekeye , et al. 109 autogenous bone grafts or a X X 8y 67,9% (74/109) 8y The bone transplants x X No No No X Full

(1980)

Bowerman-Conroy prosthesis

post op had 100% succesrate.

Anthony , et al. 17 free flap Fibula mean 6,3 cm (range 2,5-9 cm) 5,5 y 12/17 (70,6%) 21 82,4% (14/17) 3/17 71% dental mean age 54 y Yes Yes No 92% was irradiated Full

(1997) m post op (18%) fracture plate, rehabilitation (35% (range 29-76 y)

malocklusion in form of

osseointegrated

implants.)

Aramany , et al.

(1977)

17 immediate intermaxillary fixation X X X X X X X No No No X Full

Arden , et al. (1999) 31 30 patients; stainless steel plate mean 5,4 cm (range 3-10cm) 7 y X 83,9% (26/31) Success X mean 57 y (range No Yes No 100% was Full

and 1 patient; Vitallium plate

rates. 5/31 (16,1%)

41-76 y)

irradiated preop 6

Complications; fractured

post op 25

plate.

Aydin , et al. (2004) 21 7 patients free osseous flap and

14 patients free osteocutaneous

flap.

Fibula X 5 y 20/21 95,2% 5 y

post op.

95,2% (20/21) success

rate

X mean 41 y (range

22-58 y)

No No No 100% was

irradiated post op

Full

Barnard , et al.

(1991)

30 free flap radial forearm X 4 y X X X X No No No X Ab

Full

Beecroft , et al. 34 marginal mandibula resection X X 15 y 5-year survival: X X X No No 5 X Full

(1982)

84%

Benoit , et al. 13 free tissue transfer 7/13 (53,8%): combined Hemi mandibula ectomy: 9/13 mean 32,8 month Survival rate; X X mean 8 y (range 5 No No No 53,8% was Full

(2013)

musculocutaneous flap (69,2%) Marginal/segmental (range 0,2-124 month) 10/13 (76,9%)

month - 18 y

irradiated

and plate, mandibula ectomy 3/13 (23,1%) 32,8 mån post op.

1/13 (7,7%): regional Total mandibula ectomy 1/13 (7,7%) Mean time alive

tissue + plate

post op of those

5/13 (38,5%):

who died; 47,6

Authors (year) Number of

Patients

Techunique Site (Bone) Size and position of resection (with Follow up

or wthout temporomandibular joint) mean + range

Survival rate Success rate (loss of Dental

plate and/or fractures) rehabilitation

Implants/protheses

Mean age Aesthetics Function

(included or (included

Quality of Irradiation

life

(included or

not)

Abstract/ Full

text

not) or not)

36

osteocutaneous free

month

tissue transfer.

Authors (year) Number of

Patients

Techunique Site (Bone) Size and position of resection (with Follow up

or wthout temporomandibular joint) mean + range

Survival rate Success rate (loss of Dental

plate and/or fractures) rehabilitation

Implants/protheses

Mean age Aesthetics Function

(included or (included

Quality of Irradiation

life

(included or

not)

Abstract/ Full

text

not) or not)

37

Bianchi , et al. 31 free flap 14/31 (45,2%) Iliac mean 5,6 cm (range 3,5-12,5 cm) mean 53,6 month 31/31 X 25/31 (80,6%) X No No No X Ab (2013)

17/31 (54,8%) Fibula

(range 18-120 month)

endosteal dental

implants. 100%

success rate

Bilodeau , et al.

(2011)

27 Segmental mandibula ectomy X mean 8,5 cm (range 5,3-11 cm) X X X X mean

men/women: 55/66 y

No No No X Full

Blackwell , et al. 15 soft-tissue free flaps + plate 11/15 (73,3%): Radialis X X X success rate; 15/15 X X No No No 100% was Full

(1996)

(titanium (14/15) or stainless 2/15 (13,3%): rectus

(100%) for micro-

irradiated

steel (1/15) abdominis 1/15 (6,7%):

vascular free tissue

scapular and

transfer.

parascapular 1/15

Overall success rate for

(6,7%): lateral arm flap

plate 11/15 (73,3%) 1 y

post op.

Blackwell , et al. 27 free flap + plate radialis free flap: 21/27 x mean 19,5 month survival rate; success rate 25/27 X mean 65 y (range No No No 23/27 was Full

(1999)

(77,8%)

23/27 (85,2%) (92,6%) 19,5 month post

32-88 y)

irradiated Preop

rectus free flap: 6/27

18,7 month post op. With new type of

(n=5) Post

(22,2%)

op. low-profile MRP (plate)

op (n=17) Pre+post

Mean time alive in comparison with the

op (n=1) No

of those who died MRP used by Blackwell

irrradiation (n=4)

17,3 month post 1996 when the success op rate was 73,3%)

Boffano , et al. 10 free flap iliac: 5/10 (50%) Pre-molar region: 2 Molar mean 67,3 month 100% 165 month X X mean 40,1 y (range No No Yes X Full

(2011)

non 3/10 (30%) (lesions region: 7 Paramedian (range 12-165 month) post op

20-55 y)

<3cm), region: 1 mean size 3,85 cm

other: 2/10 (20%) (range 2-5 cm)

(maxilla)

Boyd , et al. (1995) 71 free flap: 31 100% radialis X X X success rate X X No No No X Ab

radial forearm osteocutaneous

total; 78,9% mandibular

flap 15, radial fasciocutaneous

defects anterior

flap 16 free

positioned 65% lateral

flap + Plate: 40 Plate 40

positioned 95%

Brown , et al.

(2002)

65 X X X X X X X X No No No X Full

Burkey , et al. 14 X X X X survival rate; 70% X X X No No No X Full

(1990)

3,5 y post op

Canadian Society of 35 X X X X survival rate 79% X X mean 40 y (range No No No X Full

Otolaryngology-

2 y post op and

14-76 y) Head and Neck

57% 5 y post op

Surgery Oncology Study Group (2004)

Authors (year) Number of

Patients

Techunique Site (Bone) Size and position of resection (with Follow up

or wthout temporomandibular joint) mean + range

Survival rate Success rate (loss of Dental

plate and/or fractures) rehabilitation

Implants/protheses

Mean age Aesthetics Function

(included or (included

Quality of Irradiation

life

(included or

not)

Abstract/ Full

text

not) or not)

38

Cantu , et al. (2009) 72 X Autologous freeze- Anterior or Anterior-Lateral: 35/72 14 y survuval rate success rate total; 41/72 X mean 58 y (range 4 Yes No No 26/72 was Full

treated mandibular (48,6%)

32/72 (44,4%) 5 y (56,9%) 1-10 month post 77)

irradiated

bone lateral: 37/72 (51,4%)

post op. op. laterala resections 75,7% anteriora

resections 37,1%

Carlson , et al.

(2002)

16 bone graft (7/16=43,8%) plate +

condylar prosthesis

X 15/16 (93,8%): Disarticulation

resection of mandible

8 y survival rate

14/16 (87,5%)

success rate 15/16

(93,8%)

X X Yes Yes No X Full

Chaine , et al. 44 segmental mandibulectomy + Fibula mean 12 cm (range 7-16 cm) 55,6% mean 53 month survival rate success rate: 88,9% 22,2% got dental mean 35 y (range No No No X Full

(2009)

Free osteocutaneous flap

hemimandible 22,2% total (range 26-73 month) 100% 73 month

implants 18-70 y)

mandibulectomy 22,2%

post op

lateral+frontal mandible

Chana , et al. (2004) 13 free fibula flap + osseointegrated X mean 8,8 cm (range 4,5-13 cm) mean 40,1 month survival rate success rate 13/13 100% 40 month mean 32 y (range No No No X Ab

implants

(range 18-70 month) 100% 70 month (100%) post op (range 18- 17-50 y)

post op

70 month)

Chang , et al. (1998) 12 Fibula osteoseptocutaneous flap Fibula mean 8,1 cm mean 25 month X success rate 12/12 success rate 12/12 mean 36,3 y (range No No No X Full

+ osseointegrated implants (range 1-47 month) (100%) 25 month post

op

(100%) 25 mån post 17-65 y)

op

Chang , et al. (2010) 114 free fibula flap Fibula mean 8,9 cm (range 3-26 cm) 25 month X success rate 98,3% X mean 49,5 y (range No No No X Full

12-85 y)

Cordeiro , et al. 150 free flap + plate and titanium Fibula: 135/150 (90%) 43% hemi mandibular defek t 25% 10 y X free flap success rate: 20/150 (13,3%) mean 50 y (range 3 Yes Yes Yes X Full

(1999)

screws (98% of cases) Radius 6/150 (4%) lateral and 32%

100% osseo-integrated 79 y)

Scapula 6/150 (4%) frontal

dental implants

Ilium 3/150 (2%)

Dholam , et al. 12 free fibular graft Fibula survival rate success rate 63%. Yes Yes Yes 8/12 was Full

(2011)

11/12 (91,7%). 18 month post op

irradiated

Disa , et al. (1997) 27 free fibula flap Fibula 16/27 (59,3%) anterior 11/27 mean 54 month X free flap success rate: 6/27 (22,2%) got mean 43 y (range No No No 10/27 (37%) was Full

(40,7%) lateral. (range 24-104)

93% osseointegrated

dental implants

14-65)

irradiated

6/10 (60%) Preop

4/10 (40%) Post

op.

Disa , et al. (1999) 48 Free osseous flap fibula 35/48 (72,9%) 24/48 (50%) anterior 24/48 mean 47 month X free flap success rate: 17/48 (35,4%) got mean 45 y (range 5 No No No 10/48 (20,8%) was Ab

radius 6/48 (12,5%)

scapula 4/48 (8,3%)

ilium 3/48 (6,3%)

(50%) lateral (range 24-104 month)

97% osseointegrated

dental implants

75 y)

irradiated

6/10 (60%) pre op

4/10 (40%) post op

Dor , et al. (1980) 126 X X X X X X X X No No No X Full

Authors (year) Number of

Patients

Techunique Site (Bone) Size and position of resection (with Follow up

or wthout temporomandibular joint) mean + range

Survival rate Success rate (loss of Dental

plate and/or fractures) rehabilitation

Implants/protheses

Mean age Aesthetics Function

(included or (included

Quality of Irradiation

life

(included or

not)

Abstract/ Full

text

not) or not)

39

Etti , et al. (2010) 334 Titanium bridging plates X 30/334 (9,0%) lateral + Condyle mean 5,1 y (range 0,3- survival rate success rate; 57,2% X mean 53,2 y (range No No No 282/334 (84,4%) Full

2/334 (0,6%) anterior 177 18,0 y) 81,6% 2 y post op (191/334) of

29-79 y)

was irradiated pre

(53,0%) lateral 1/334 71,8% 5 y post op reconstruction plates op

(0,3%) anterolateral+Condyl 53

(15,9%) Anterolateral 71

(21,3%) Total mandible ectomy

62% 10 y post op 143/334 of plates was

removed due to

complications. 7/143

due to fractures.

Evans , et al. (1994) 155 free flap Radialis X mean 75 month X free flap success rate: 9/155 (5,8%) got mean 56 y (range No No No 109/155 was Ab

(range 2-75 month)

147/155 (94,8%) implants 22-80 y)

irradiated

57/155 pre op

52/155 post op

Farwell , et al. 184 free flap + titanium Fibula 145/184 (78%). X X X titanium plate success X mean 60,9 y (range No No No 147/184 was Full

(2006)

reconstruction plates Iliac crest 27/185

rate: 147/184 (79,9%)

19,7-85,1 y)

irradiated

(14,6%). Radialis

79/184 pre op

12/185 (6,5%). Scapula

64/184 post op

1/185 (0,5%)

Fujiki , et al. (2013) 56 free flap 38/56 (67,9%): Fibula lateral 29/56 (51,8%) anterolateral 7 y X free fibula flap success X mean 63 y (range No No No 8/56 (14,3) was Ab

18/56 (32,1%): Scapula 19/56 (33,9%) total

rate: 36/38 (94,7%) free

24-80 y)

irradiated

mandibulectomy 13/56 (23,2%)

scapula flap success

rate: 18/18 (100%)

Garrett , et al.

(2006)

46 free fibula flap + conventional

(CP) and/or implant-supported

(IP) prostheses

lateral 2/46 (4,4%) anterolateral

20/46 (43,5%) anterior 1/46 (2,2%)

posterior 13/46 (38,3%) hemi

6/46 (13%) total

mandibulektomi 3/46 (6,5%) total +

Condyle 1/46 (2,17%)

45/46 (97,8%) 33/46 (71,7%) (CP) and

48,5% (16/33) IP

X mean 60 y No No No Ab

Hamaker , et al. 15 Resection + postoperative X X 4 y and 3 month success rate 66% X X No No No X Full

(1983)

radiation

He , et al. (2010) 17 free fibula flap and/or Fibula lateroposterior 5/17 (29,4%) mean 25 month survival rate free flap success rate: X mean 51,5 y (range No No No 11/17 (64,7%) was Ab

postoperative radiotherapy

anterolateroposterior 3/17 (17,6%) (range 3-57 month) 15/17 (88,2%) 100%

35-63 y)

irradiated post op

lateral 2/17 (11,8%) anteriolateral

life time of those

5/17 (29,4%) total

who died 8 mån

mandibulectomy + condyle 1/17

post op (range 3-

(5,9%) bilateral+anterior 1/17

13 month)

(5,9%)

Head , et al. (2003) 210 free microvascular flap + titanium 134/210 (63,8%) Fibula 153/210 (72,9%) lateral 57/210 mean 21,5 month survival rate success rate: 93,3% X range 19-88 y No No No 165/210 (78,6%) Ab

platta 11/210 (5,2%) Scapula (27,1%) Anterior or anterolateral (range 1-70 month) 98,1% (206/210) (196/210) was irradiated

5/210 (2,4%) Iliac

70 month post

1/210 (0,5%) Radialis

op. Life time of

those who died

mean 16,3 days

post op (range 7-

24 days)

Authors (year) Number of

Patients

Techunique Site (Bone) Size and position of resection (with Follow up

or wthout temporomandibular joint) mean + range

Survival rate Success rate (loss of Dental

plate and/or fractures) rehabilitation

Implants/protheses

Mean age Aesthetics Function

(included or (included

Quality of Irradiation

life

(included or

not)

Abstract/ Full

text

not) or not)

40

Heller , et al. (1995) 47 free osseous flap or soft tissue + 18/47 (38,3%) iliac 11/47 (23,4%) anterior

27/47 survival rate 74% free flap success rate: X mean 67 y (range No Yes No 35/47 (74,5%) was Ab

plate 5/47 (10,6%) fibula (57,4%) lateral 9/47

1 y post op 67% 21/23 (91,3%)

13-82 y)

irradiated

2/47 (4,3%) scapula (19,2%) posterior

2 y post op 40% 5 success rate for plate

6/35 (17,1%) pre

1/47 (2,1%) rib.

y post op (mean 14/21 (66,6%)

op 29/35 (82,9%)

8/47 plate + soft tissue

39 month alive

post op

transfer

post op of those

8/47 pectoralis

who died)

5/47 forearm

Hidalgo , et al. 12 free fibula flap el free fibula flap fibula mean 13,5 cm X X free flap success rate: X X No No No 6/12 (50%) was Ab

(1989)

+ miniplates (11/12)

100%

irradiated post op

Hundepool , et al. 70 OFFF fibula 20/70 (28,6%) anterior 31/70 mean 39,5 month survuval rate X total implant mean 53 y (range 6 Yes Yes Yes Full

(2008)

(44,3%) lateral 1/70 (1,4%) (range 6-89 month) 64,3% (45/70) 18

success rate: 97%. 82 y) posterior 16/70 (22,9%) month post op

anterolateral 2/70 (2,9%) lateroposterior

Iino , et al. (2009) 15 Cancellous bone and marrow + Iliac 1/15 (6,7%) anterior 10/15 62,7 month (29-108 X success rate 86,7% Success rate 90,1% mean 58,3 y (range No No No 6/15 (40%) was Full

titanium reconstruction plate

(66,7%) Lateroposterior 4/15 month)

(13/15) (10/11) 23-74 y)

irradiated

(26,7%) lateral

11/15 (73,3%) got

dental

implants/prosthesi s

Irjala , et al. (2012) 10 free osseous flap 9/10 (90%) fibula in X mean 51,5 month survival rate 6/10 free flap success rate: Success rate 100% mean 60 y (range No No No 10/10 (100%) was Full

which 1 of these also

(range 4-142 month) (60%) was alive 90% (9/10) 4/10 (40%) got 48-75 y)

irradiated

included radialis

142 month post dental implants.

1/10 (10%) iliac.

op. Of those who

died, lived for 15,3 month (range 4-26 month)

Jeng , et al. (2005) 10 Double Free Flaps and 10 fibula mean (9.4cm(6-14cm)) 24m 9 of 10 100% x 51.7y (44-64y) Yes Yes No x Ab

Fascia Lata Grafts for Oral

Sphincters

Ji , et al. (2006) 541 The reconstruction methods x x x x x x 40-70y No No No x Ab

included soft flap, reconstruction

plate and bone grafts.

Julieron , et al. 38 free bone grafts 25 fibula 24 anterior 9 x x 36/38 x x Yes Yes No x Full

(1996)

7 scapular laterala 5

3 iliac anterio-laterala

3 forearm free flaps

Kadota , et al. 23 (12) 2 metal plate 2 iliac x x x x x 65.6y (47-74y) No Yes No x Full

(2008)

2 iliac crest free flap

2 scapula

2 scapula osteocutaneous free

flap

6 without reconstrcution

Authors (year) Number of

Patients

Techunique Site (Bone) Size and position of resection (with Follow up

or wthout temporomandibular joint) mean + range

Survival rate Success rate (loss of Dental

plate and/or fractures) rehabilitation

Implants/protheses

Mean age Aesthetics Function

(included or (included

Quality of Irradiation

life

(included or

not)

Abstract/ Full

text

not) or not)

41

Kim , et al. (2007) 29 latissimus-serratus-rib free flap 27 latissimus-serratus- 15 anterio-laterala 12 laterala 21m x 28/29 x 68y (21-82y) No No No 22 was irradiated Ab

rib free flap 2 anteriora

preop 13

2 serratus-rib

post op 9

osteomuscular free flap

Knott , et al. (2007) 101 locking mandibular

reconstruction plate and

vascularized bone grafts

93 fibula flaps

8 latissimus-serratus rib

flaps

x (8.1cm (4-23cm)) 14.6m (6-46m) x 86/101 x x No No No 87 was irradiated Ab

29 preop and 56

postop

Koch , et al. (1994) 40 Thorp vs. Metal plate x x 72m x THORP 11/12

Metal plate 14/28 x x No No No x Ab

Kovács , et al.

(1994)

30 Free radial forearm flap Radial 30 x x x 100% x x No No No x Full

Kroll , et al. (1992) 69 A:15 soft tissue x x x x A: 77% B: x x No No Yes x Ab

B:20 immediate reconstruction

50%

with vascularized bone

C: 27%

C:15 metal plate

D: 22%

D:9 plate (bone later)

E: 30%

E:10 no reconstruction (bone

later)

Kudo , et al. (1992) 32 27 seg. Resection 5 A:8 autogenous bone x x 30/32 levde vid A:6 of 8 B: x x No No No x Ab

hemiresection

graft

sista 4 of 7 C:

B:7 pedicled

uppföljningen 2 of 6

myocutaneous flap+

D: 7 of 11

bone graft

C: 6 metalic plate

D: 11 Pedicled

myocutaneous flap and

metallic plate

Li , et al. (2007) 112 fibular grafts Group A (7): x 12-140m x x 239 implantat Group A : 56y No Yes No 19 patients was Full

microvascular bone

sattes på 115 Group B: 55y

irradiated

graft

patienter Group C: 50y

Group B (61):

Group D:54y

microvascular

reconstruction of

Seg.Defects.

Group C (41):Avascular

onlay grafts

Group D (7):avascular

reconstruction

Lindqvist , et al. 34 alloplastic reconstructions x x x 19 of 34 lived at 22 of 34 (64.7%) x x No Yes No x Ab

(1992)

last follow up

Louis , et al. (2010) 93 revascularized free scapular flap 93 scapula x 10-144m x 88/93 (94.6%) x x No No No x Full

Authors (year) Number of

Patients

Techunique Site (Bone) Size and position of resection (with Follow up

or wthout temporomandibular joint) mean + range

Survival rate Success rate (loss of Dental

plate and/or fractures) rehabilitation

Implants/protheses

Mean age Aesthetics Function

(included or (included

Quality of Irradiation

life

(included or

not)

Abstract/ Full

text

not) or not)

42

Malata , et al. 100 Würzburg noncompression 92% with vascularised x(10cm (3-19cm)) 47m (12-96m) x 92/100 (92%) x 60y (10-86y) No Yes No 11 was irradiated Ab (1997)

titanium miniplate system bone grafts. (Fibula,

preop 53 was

scapula, radius)

irradiated postop

4 patients having

11 was irradiated

nonvascularised iliac

both pre and post

bone grafts.

Maurer , et al.

(2006)

20 reconstruction plate 16

Iliac 3

miniplate 1

Iliac 3 x x x x x 59y No Yes No x Full

Millsopp , et al. 278 No flap 56 x (not defined) x 24m Group1 (114pat): x x Grupp 65-: 158 Yes No No 110 was irradiated Ab

(2006)

Soft tissue 147

95% 1 year, 89% 2

Grupp 65+: 120

Bone flap 63

year, 81% 3 year.

Bone + soft tissue 7

Gruop 2

(164pat): 75%

1year, 64% 2year,

60% 3year.

Miyamoto , et al. 23 clinical results were compared Double flap : MRP: anterio-lateral 8, lateral 4 22m (1-108m) 5 of 23 lived with MRP: 12 of 12 x 58.4y +- 12y Yes Yes Yes MRP: 1 was Full

(2012)

between mandibular 10 Fibula 1 (1 included the joint)

out disease after Double flap 11 of 11

irradiated

reconstruction plate (MRP) scapula

Double flap: 11 anterio-laterala

108m

Double Flap: 2 was

procedures and double flap

irradiated

transfers.

Obiechina , et al.

(2003)

20 free nonvascularised iliac crest. 20 iliac 5 anterio-lateral 15 laterala x x 19/20 x x Yes Yes No x Full

Okoturo , et al. 13 immediate plate reconstruction x 1 anterior 5 lateral 15m (6-23m) x 11 of 13 plate 2 11 patients had 24y (10-36y) Yes Yes Yes x Ab

(2011)

7 anterio-laterala

removed due to fracture implants

Patel , et al. (1996) 83 Grupp 1: 47 rekonstruerades ej. 8 pectoralis. M. omc. Grupp 1:47 anteriolateralt (47 x x x 12/36 got 32-76y Yes Yes No 25 was irradiated Full

Grupp 2: 21 fick siliastic implants. 7 iliac

8 fick PM-OMC. 7 fick Iliac flap

involved the joint)

Grupp 2: 36 laterla

prosthesis after surgery

Pellini , et al. (2012) 41 x x x x x x x x No No No x Ab

Politi , et al. (2012) 24 Iliac flap vs. Fibula flap 13 iliac 11 x (6-15 cm) 12m x Iliac 13 of 13 Every one had 56y (17-62y) Yes Yes Yes x Ab

fibula

fibula 10 of 11 implants

Puxeddu , et al.

(2004)

12 vascularized

bone-containing free flap

12 iliac 8 laterala 4 anterio-

laterala 6.9cm(5.2-9cm)

21m (6-64m) 6 of 12 survived

50%

11 of 12 no one had

implants

62.5y (57-77y) No No Yes 9 patients was

irradiated after

suregery

Full

Authors (year) Number of

Patients

Techunique Site (Bone) Size and position of resection (with Follow up

or wthout temporomandibular joint) mean + range

Survival rate Success rate (loss of Dental

plate and/or fractures) rehabilitation

Implants/protheses

Mean age Aesthetics Function

(included or (included

Quality of Irradiation

life

(included or

not)

Abstract/ Full

text

not) or not)

43

Rivas , et al. (2000) 15 vascularized bone grafts 11 fibula

3 iliac

1 radial

10 laterala 2 hel resection x x 13/15 x x No No No x Full

3 anterio-laterala (tot. 9 involved

the joint)

Robey ,et al. (2008) 117 free fibular flaps. Miniplates Vs. 117 fibula (86 x 29.6m x Mp: 77/86 Mp: 7/86 Mp: 60.4y (21-85y) Yes No No Mp: 53% was Full

Reconstruction plates miniplates 31

RP: 26/31 Rp: 5/31 Rp: 61.1y (21-88y)

irradiated Rp:

reconstruction plates) 16% was irradiated

Rogers , et al.

(2004)

224 123 no resection 44 rim

resection 57 segmental

resektion

26 fibula

7 DCIA

13 radial

6 scapula

5 compination

Of segmentresect. 16% in anterior

sites, 28% in

posterior, and 56% combined

16m (12-36m) 12m: 187/224

36m: 113/224

x x 61y Yes Yes Yes 51% of

segmentalresect.

Patients

Full

Sarukawa , et al.

(2012)

11 vascularised iliac crest Iliac 11 x (4-12cm) 6-44m 81% 81% 2 of 11 58.8y (32-78y) No No No 6 was irradiated

before surgery

Full

Schliephake , et al. 44 21 vascularized grafts VG: iliac: 6 x (6.7cm (2-12cm)) 41.2m 41/44 x (100% on impants 44 x No No No 15/44 was Full

(1999)

23 nonvascularized grafts scapula: 4

after five years 60.3%

irradiated

fibula: 11

after 10years)

Non-VG: iliac 23

Shpitzer , et al. 57 osteocutaneous free flaps, plate + PMMF 27 Lateral defects (16 included the PMMF: 45m(12- x PMMF 20/27 x PMMF 58y FRFF No Yes Yes x Full

(2000)

plate + PMMF , plate + FRFF plate + FRFF 16 joint) 126m)

FRFF 14/16

61y OFF 55y

osteocutaneous free

FRFF:23m (12-53m)

OFF 14/14

flaps 14 (fibula)

OFF: 20m (13-38m)

Simon , et al. (2013) 32 reconstruction plates and an

autogenous particulate bone

graft

x (particulate bone

iliac)

x 27.9m (12-39m) x 31/32 96.8% x (13/32 got

prostehsis)

27.7y No No Yes x Full

Suh , et al. (2010) 40 microvascular free flap Fibula 36 rib 3 x (length 8cm(4- 17.4m x 100% x 62y (38-86y) No No No 40 was irradiated Full

Iliac 1

24cm))

Söderholm , et al.

(1988)

30 rigid internal fixation x x x x 29/30 96.6% x x Yes No No x Full

Trignano , et al.

(2013)

34 fibular osteocutaneous flap vs

free fibular flap with periosteal

excess

Fibula 34 x (length 2-5.7cm) 1.5m x 11/17 free flap x

15/17 free flap PE

No No No 34 was irradiated Ab

Tsuchiya , et al.

126 (114) free flaps Fibula 52 Scapla 7 x 65m x 101/114 88.6%

42.9 (27-55y)

x 62.2 No Yes No x Full

Authors (year) Number of

Patients

Techunique Site (Bone) Size and position of resection (with Follow up

or wthout temporomandibular joint) mean + range

Survival rate Success rate (loss of Dental

plate and/or fractures) rehabilitation

Implants/protheses

Mean age Aesthetics Function

(included or (included

Quality of Irradiation

life

(included or

not)

Abstract/ Full

text

not) or not)

44

(2013) Iliac 3

RAMC 43

ALT 5

RF 3

Plate exposure 3

Plate infection 4

Fracture of plate 2

Total flap necrosis 4

Authors (year) Number of

Patients

Techunique Site (Bone) Size and position of resection (with Follow up

or wthout temporomandibular joint) mean + range

Survival rate Success rate (loss of Dental

plate and/or fractures) rehabilitation

Implants/protheses

Mean age Aesthetics Function

(included or (included

Quality of Irradiation

life

(included or

not)

Abstract/ Full

text

not) or not)

45

Ueyama , et al. 34 single A-O plate 4st patients x x 47.4 m ( 6-115m) 69.7% 79% x x No No No x Ab (1996)

got ilactrans.

4/34 plate exposure

1/34 screw loosening

2/34 TMJ pain

Urken , et al. (1991) 10 Vascularized bone flaps x x x x x x x Yes Yes No x Full

van Gemert , et al. 83 free forearm flap and Fibula 46 iliac 22 68 (41) lateral 15 anterio- 12-24m 61% after 2 y 100% Fibula 94% 10/83 got implants 63 (25-85 y) No No No 66/83 was Full

(2012) reconstruction plate and free

vascularized bone flaps

Free forearm + plate 15 laterala Iliac 64%

Radial

(After 1 year)

irradiated

van Gemert ,et al. 74 NVBG Iliac 74 X (position) 74 (32) 12m x 76% 11/74 got implants 54.3 (12-73 y) No Yes No 27/74 was Full

(2009) lateral 33/74 got

prosthesis

irradiated

Vayvada , et al. 11 free deep circumflex iliac artery iliac 6 fibula 5 x (position) 11 (2) 29,3m (17m- x 100% 3/11 (due to cost) 25.4 (18-38 y) Yes Yes Yes x Full

(2006)

or fibular flap

lateral

38m)

Villaret ,et al. 92 (35 x x x x x x x x No Yes No x Full

(2008) recsponded)

Virgin ,et al. (2010) 168 free flap reconstruction Radial 51 Fibula 117 x 31m fibula 20m 75% after 5 year 96.6% Fibula 2.3% had implants 63.7 (radial) 59 No No No x Full

fibula

96.1% Radial

(fibula)

VU , et al. (2008) 29 (18 vascularized fibular free flap and Fibula 10 Iliac 8 X (position) 1 anteriora 12m-40m from the x x x 42 Yes Yes Yes 33% were Full

responded) nonvascularized iliac crest

17 (10) lateral

operation

irradiated

Young , et al. (2007) 26 Reconstruction plate x x (position) 2 anteriora

18 (4) laterala 6 (3) anterio-

laterala

12m-72m from the

operation

x x 35% (7/20)

Implants

29,8 Yes Yes Yes 0% Ab

Zender , et al. 65 OCFF Fibula 54 Radial 6 x (position) Lateral 50% 30m 1m- x 90% x 62 No No No 83% irradiated Full

(2012)

Iliac 5 Anterio-Lateral 50% 188m

7/65 flap loss

Zenn , et al. (1997) 17 Free flap Radial forearm mean ~8cm (8.25) 13.5m 1m- 94.1% (16/17) 8 70% 3/17 x 55 No No No >50% irradiated Full

72m days post op fracture plate 2/17

fracture donor site

Zhang , et al. (1999) 97 (68) Reconstruction Plate x x x x 51% x x No No No x Full

Authors (year) Number of

Patients

Techunique Site (Bone) Size and position of resection (with Follow up

or wthout temporomandibular joint) mean + range

Survival rate Success rate (loss of Dental

plate and/or fractures) rehabilitation

Implants/protheses

Mean age Aesthetics Function

(included or (included

Quality of Irradiation

life

(included or

not)

Abstract/ Full

text

not) or not)

46

22/68 detached

6/68 fracture plat

47

Figure 1: Process of selection.

48

Figure 2: Definition of resection sites of the mandible.

Red box= Anterior part of mandible, Green box= Lateral part of mandible, Blue box= Posterior part of mandible and

Purple box= Condylar part of