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Introduction:
Tumor, malignancy, radionecrosis, cystic lesion, trauma,
infection or congenital anomalies may be reasons for
mandibular defects. Among them the benign lesion affect
most commonly.1-3 The management of mandibular
continuity defect has changed in the last decade. The most
frequently used technique for reconstruction of extended
defect is the transfer of vascularized osseous free graft. The
fibula, scapula, rib and the illiac crest are the preferred
donor-sites for reconstruction.4, 5 It is essential to establish
bone viability after revascularization of the graft . Lack of
vitality as a result of vascular occlusion either arterial or
venous can result in graft necrosis, bone resorption and poor
healing.

Reconstruction of Mandibular Defect by Free Re-Vascularized Fibula Graft:
A Case Report
Quazi Billur Rahman1, Mahmudur Rahman1, Showkat Mamun1, Munjur Iqbal2, Binay Kumar Das3
1Associate Professor, Department of Oral & Maxillofacial Surgery, Faculty of Dentistry, BSMMU, 2 MPH (Student),  NIPSOM, 3Medical Officer,
Department of Oral & Maxillofacial Surgery, Dhaka Dental College

Abstract:
Background: In maxillofacial surgery tumor ablation often causes continuity defect of mandible which results anatomical
and functional morbidity of the patient. The reconstruction of the mandibular defect is mandatory to restore the oral
function and speech. Various methods of immediate reconstruction are implemented by different authors time to time
including autogenous non vascularized bone graft, allogenic bone graft , auto frozen mandible or reconstruction plates
and others.  Each has its own advantages and disadvantages including donor site morbidity, failure and others. The
purpose of the present case report is to establish micorvascular free fiblula is as a better option to other methods in
immediate reconstruction of mandibular continuity defect. Objective: Anatomical, functional and esthetic rehabilitation
of patients after mandibular resection Method: Revascularization of free fibula graft by microvascular  anastomosis of
paroneal artery with facial artery at the segmental defect site of mandible. Result: Remarkable contour, cosmesis and
early functional rehabilatation of the patient.  Conclusion: Microvascular reconstruction with fibula is the better option
for defect correction and early rehabilitation in patients with mandibular continuity defect.

Key word: Mandible, defect, reconstruction, microvascular technique, fibula graft

[BSMMU J 2008; 1(1): 35-38]

Address of correspondence to: Dr. Quazi Billur Rahman, Department of Oral & Maxillofacial Surgery, Faculty of Dentistry, Bangabandhu Sheikh
Mujib Medical University (BSMMU), Dhaka

Incidence of ameloblastoma in mandible is one of the most
common causes of mandibular defect. Goal of the surgery,
include resection of mandible and immediate reconstruction
to maintain the function- speech, mastication & deglutation,
facial contour and oral competence.6   However, the best
option to reconstruct mandibular continuity defect  has not
yet been satisfactorily resolved and represents a challenge
for oral and maxillofacial surgeons.

Case History:
A 18 years old Bangladeshi woman came to the OPD of
oral & maxillofacial surgery Dept. of Bangabandhu Sheikh
Mujib Medical University with 2 years history of slowly
growing lesion at the left side of the lower face.

Fig.1: Preoperative  view  of the patient with close (a) & open (b) (c)  mouth.



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The lesion was non-tender and there was no regional
lymphadenopathy with no motor or sensory functional
deficit. She was otherwise fit and was not medically
compromised. On examination the size of the   lesion was
7.5cm X 4cm, extended from left lateral incisor to 3rd
molar of mandible. Cortical expansion was marked on the
buccal side but lingual expansion of the cortex was
minimal. There was no intra oral or extra oral persistent
sinus or discharge. The remainder of the oral cavity was
unremarkable.

Two teams were involved in the surgery. One team
extirpated the tumor and the other team simultenously
harvested the fibula. A left submandibular approach was
used to expose the lesion. Subperiosteal dissection was
carried out to expose the tumor and it was resected with 1
cm healthy bone on each side. The facial artery and the
vein were secured with vascular clips for future vascular
anastomosis. On the donor site the other team
simultaneously exposed the fibula utilizing lateral
approach.

A line was drawn from the fibular head to the lateral
malleolus indicating the submascular and subcutenous
course of fibula. Two markings were made on the line.
First was 7 cm distal from the fibular head which indicate
approximate insertion of peroneal vessels within the
intermascular septum. Second marking was 14 cm distal
from the fibular head indicating the approximate location
of nutrient vessels. A curvilinear incision is then make
along the lateral border of the peroneal muscles. The
posterior intermuscular septum was identified separating
the peroneal muscle from soleus muscle. The septum is
separated from its attachments to the fibula along its
posterior border. Dissection next proceeds anteriorly
toward the anterior intermuscular septum which seperates
the peroneal muscle from the extensor muscle.
Extraperiosteal dissection proceeds and about 1cm cuff
of flexor hallucis muscle with associated peroneal vessels
was left attached to the fibula. The paroneal vessels were
identified at the distal osteotomy site and were ligated.
The paroneal vessel was identified to their origin from
posterior tibial artery. The first osteotomy cut was done
4cm distal to the nutrient vessel by gigli saw with 1 cm
excess periosteum. The second osteotomy cut was done
4cm proximal to the nutrient vessels with 1cm excess
periosteum also. The osseous tissue attached only by its

Fig.-2: Preoperative Orthopantamogram

Orthopantamograph revealed a multilocular radiolucent
lesion involving the body of the madible from left lateral
incisor to third molar. Clinically, radiologically and
histologically  it was diagnosed as a case of
ameloblastoma.

Methods:
She underwent surgery as a case of ameloblastoma with
the treatment plan of a wide excision of the lesion followed
by immediate reconstruction with revascularized fibula
graft for the first time in our country.

Fig.3: a) Excised tumour b) Harvesting of Fibula with patent paroneal vessels c) Adapted fibula graft with plates

BSMMU J Vol. 1, Issue. 1, July 2008

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with good wound healing. She had an excellent recovery
both functionally & aesthetically. She was under in
regular follow up in the department of oral and
maxillofacial surgery. She was released after 10 days of
surgery and cameto the first follow-up after one month
of surgery. In first follow-up she was apparently better
with no donor and recipient site complication both
clinically and radiologically. In second follow-up three
months (Fig.4) after the surgery the oral opening, closing
and mastication was adequate. In radiological
observation the graft was in proper position and
significant amount of callous was formed with no
complication with the donor site. The final follow-up
(Fig.5) was given after one year which reveled excellent
functional and cosmetic result. Radiologically the bony
union was completed and no resorbtion of the graft was
observed except two miniplates on either side but the
medullary cavity of the graft was the isolating criteria
from the graft and mandible..

Fig.5: Follow up after One year a) Closed mouth b) Open mouth c) OPG after one year.

Fig.-4: Postoperative front view after 3 months.

vascular pedicle was observed for balanced perfusion after
deflating the torniquet. Then the proximal peroneal vessel
was ligated and cut. The graft was then trimmed and
adapted to the defect as per size and shape and stabilized
by miniplate with screws. The end to end anastomosis was
done in between paroneal and facial artery with 9/0 prolene
under aided vision of loop in a convetional way. The
clamps were released and patency of the anastomosed
vessel was observed for a little period. Then the wound
was closed in layers with water tight seal in the oral cavity.

Follow up:
 She received broad spectrum antibiotic, analgesics for
10 days and antiseptic mouth wash for 14 days following
surgery. The entire post operative period was uneventful

Discussion
Mandible plays an important role in airway protection,
support for the tongue, muscles of the floor of the mouth,
lower jaw dentition, articulation, deglutition, speech,
respiration and facial aesthesis. Vascularised osseous free
graft are used to good advantage in maxillofacial surgery
for the reconstruction of mandibular defect following
mandibular resection. The goal of the reconstruction are-
establishment of mandibular continuity with acceptable
cosmetic result, establishment of osseous alveolar base
for further dental rehabilitation, correction of soft tissue
defect.7 The surgeon has to balance his procedure to
achieve best cosmetic appearance with reliable function.
In order to achieve it one must restore bony continuity,
facial contour, tongue mobility and speech. For restoration

Reconstruction of Mandibular Defect by Free Re-Vascularized Fibula Graft: A Case Report Quazi Billur Rahman et al

37



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of the mandibular defect the use of autogenous bone is
the preferred option. The other options are solely
alloplastic materials or alloplast & bone graft together.
Alloplastic materials are in the form of stainless steel plates
(alloy of iron, chromium, nickel) or vittalium (alloy of
chromium, cobalt, molybdenum) 8. Facial deformity, poor
aesthetics, orocutaneous fistula was noted after mandibular
reconstruction by other convetional methods due to lack
of vascularity.10 But in our case these were not observed.
The fibula provides the longest segment of bone with 20-
30 cm available for harvest. In addition the segmental
blood supply of the bone permits multiple osteotomy. The
bone is also adequate width & height to allow placement
of osseointigrated dental implants. Donor site morbidity
with this graft is minimal unless the distal osteotomy site
is within 6cm of the ankle. In addition the location of the
graft will allow simultenous harvest by a second team at
the time of tumor resection.5,9 In our case 9 cm of fibular
graft was used to reconstruct the mandible. There is a risk
of peroneal nerve injury with resultant foot drop or
weakness in planter flexion of the great toe which can be
avoided with meticulous dissection. Advances in
anastomotic technique, monitoring devices  will add to its
success.In the follow up period,  orthopantamogram should
be done routinely to assess bone resorption and every time
compared with the immediate postoperative radiograph.

References:
1. Keszler A, Guliemotti MB, Dominguez F. Oral pathology in

children: frequency, distribution, and clinical significance. Acta
Odontal Latinoam. 1990; 5: 39-48.

2. Cordeiro PG. Disa JJ. Hidalgo DA. Hu OY. Reconstruction of the
mandible with osseous free flaps a 10-year experience with 10
consecutive patients. Plast Reconstr Surg 1999; 104: 1314-20.

3. 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: 66-71.

4. Urken ML. Weinberg H, Vickery C. Oromandibular reconstruction
using microvascular composite free flaps. Arch. Otolaryngol Head
Neck Surg. 1991; 117: 733-44.

5. Genden E, Haughey BH: Mandibular reconstruction by
vascularized free tissue transfer. Am J Otolaryngol. 1996; 17: 219-
27.

6. Ritvik P. Mehta and Daniel G. Deschler. Mandibular reconstruction
in 2004: an analysis of different techniques. Current Opinion in
Otolaryngology & Head and Neck Surgery 2004; 12: 288-293.

7. Urken ML. Buchbinder D. Chapter 86. In:  Cummings CC editor.
Oromandibular Reconstruction in otolaryngology-Head and Neck
Surgery. St Louis: Mosby Year Book. 1998 p.1654-68.

8. Koch WM, Yoo GH. Goodstein ML. Advantages of mandibular
reconstruction with the Titanium Hollow Screw Osseountegrating.
Reconstruction Plate (THORP). Laryngoscope 1994; 104: 545-52.

9. Horiuchi K, Hattori A, Inada I. Mandibular reconstruction using
the double barrel fibular graft. Microsurgery 1995; 16: 450-54.

10. Hidalgo DA, Pusic AL. Free-flap mandibular reconstruction: a
10-year follow-up study. Plast Reconstr Surg 2002; 110: 438-39

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