RESUMEN

OBJECTIVES: This study analyzed the human maxilla to support the development of mean-value-based cutting guide systems for maxillary reconstruction, bridging the gap between freehand techniques and virtual surgical planning (VSP). MATERIALS AND METHODS: This retrospective cohort study used routine CT scans. DICOM data enabled 3D modelling and the maxilla was divided into four regions: paranasal (R1), facial maxillary sinus wall (R2), zygomatic bone (R3) and alveolar process (R4). Surface comparisons were made with a reference skull. Statistical analyses assessed anatomical variations, focusing on mean distance (Dmean), area of valid distance (AVD), integrated distance (ID) and integrated absolute distance (IAD). The study addressed hemimaxillectomy defects for two-segmental reconstructions using seven defined bilateral points to determine segmental distances and angles. RESULTS: Data from 50 patients showed R2 as the most homogeneous and R4 as the most heterogeneous region. Significant age and gender differences were found in R3 and R4, with younger patients and females having more outliers. Cluster analysis indicated that males had R1 and R3 positioned anterior to the reference skull. The mean angle for segmental reconstruction was 131.24° ± 1.29°, with anterior segment length of 30.71 ± 0.57 mm and posterior length of 28.15 ± 0.86 mm. CONCLUSIONS: Anatomical analysis supported the development of semistandardized segmental resection approaches. Although gender and anatomical differences were noted, they did not significantly impact the feasibility of mean-value-based cutting-guide systems. CLINICAL RELEVANCE: This study provides essential anatomical data for creating cost-effective and efficient reconstruction options for maxillary defects, potentially improving surgical outcomes and expanding reconstructive possibilities beyond current techniques.

Asunto(s)

RESUMEN

BACKGROUND: The microvascular free fibula (MFF) flap is a reliable treatment modality for mandibular reconstruction and is suitable for dental implant placement after oncologic surgery. The most common issue with the MFF flap is its limited bone height, which typically results in excessive interarch space and complicates prosthodontic therapy. Overcoming the physical limitations from tumor excision and reducing the treatment time for prosthodontic rehabilitation to improve quality of life are critical clinical challenges. CASE PRESENTATION: A 64-year-old male with lower left gum and bilateral buccal cancer received a single-layer microvascular MFF flap to reconstruct a mandibular defect post-tumor excision. He underwent a bilateral modiolus Z-plasty combined with a skin flap debulking procedure to relieve oral contracture, achieving adequate mouth opening for prosthodontic rehabilitation. Scar tissue bands on the bilateral cheeks significantly affected retention and stability, hampering dental impression performance. The patient sought prosthodontic rehabilitation to enhance his chewing function and quality of life promptly. Prosthodontic rehabilitation with all-on-4 implant therapy, utilizing computer-aided design and computer-assisted manufacturing (CAD/CAM), was completed within one month. CONCLUSION: This case utilized the all-on-4 implant system to address the insufficient fibular height for conventional dental implant placements. Dental CAD/CAM was employed to mill custom prosthetic abutments and a large titanium framework for the implant bar overdenture, compensating for the excessive interarch space between the grafted fibula and maxilla. This treatment approach successfully shortened the prosthodontic rehabilitation time and overcame anatomical limitations.

Asunto(s)

RESUMEN

Primary bone tumors are rare but more frequently seen during childhood and with predilection for the distal femur and proximal tibia. Therapy of benign tumors-if indicated-includes surgical resection in most cases, whereas malignant bone tumors such as osteo- and Ewing's sarcomas are treated with chemotherapy, wide resection and/or radiation therapy (Ewing's sarcoma). The reconstruction of emerging bone defects is significantly influenced by surgeon-related preferences and tumor-associated factors, respectively. Double-barrel vascularized fibula grafts or extracorporeally irradiated autografts in combination with a free fibula transplant are preferred biological reconstruction techniques around the knee joint. In cases in which the knee joint cannot be preserved, reconstruction is performed using tumor endoprostheses, but potentially emerging leg length discrepancies after resection of a potent physis must be taken into account. In considerably young patients, rotationplasty might represent a viable option with promising functional results.

Asunto(s)

RESUMEN

Objective:To investigate the clinical effect of a segmented perforator flap of free peroneal artery to repair a complex defect after oral cancer. Methods:Forty-eight patients with oral cancer admitted to the Department of Oral and Maxillofacial Surgery of the First Affiliated Hospital of Bengbu Medical College from January 2018 to January 2022, including 8 of buccal cancer, 7 of floor cancer, 14 of tongue cancer, 5 of retromolar cancet, 9 of maxillary gingival cancer and 5 of mandibular gingival cancer. After lesion resection, 24 patients in the experimental group used the partial perforator flap to repair the defect, and 24 patients in the control group used the single flap to repair the defect. Compared with the general data of the two groups, the difference was not statistically significant（P>0.05）, which was comparable. The flap cutting range of the experimental group was 38.5-74.5 cm², and tension-reduced suture for the donor area. In the control group, the myocutaneous flap incision range was 61.0-76.5 cm², and skin graft suture for the donor area. Flap survival and patient survival were recorded and compared. The patients were followed up at 6 and 12 months after surgery, and their swallowing function and speech function, including the drinking water test, functional oral food intake scale and the Chinese language clarity test word table, were evaluated respectively, and their subjective satisfaction with the repair appearance was recorded. Patients in both groups were followed up for 12 to 60 months. Kaplan-Meier method was used to calculate the cumulative survival rate of patients, and survival curves were plotted. log-rank test was used to compare the survival curves between groups. Results:The survival rate of the two groups was 100%. The 5-year survival rate was 62.5% in the experimental group and 54.2% in the control group. There was no significant difference between the two groups （P>0.05）. According to the results of the functional recovery evaluation, the groups in swallowing and speech function and subjective satisfaction（P>0.05）, and at 12 months after surgery（P<0.05）. Conclusion:The segmented perforator flap of free peroneal artery is flexible and can repair different anatomical structures of postoperative composite defect of oral cancer, which can effectively improve postoperative functional recovery and patient satisfaction. Therefore, the peroneal artery segmented perforator flap is the ideal flap for reconstructing postoperative composite defect of oral cancer.

Asunto(s)

RESUMEN

OBJECTIVE: To evaluate the dimensional changes in free gingival grafts (FGG) at implant sites in mandibular reconstruction patients. METHODS: Patients who received FGG 4 months after implant placement in the reconstructed mandible with no keratinized mucosa (KM) present were invited for re-examination after 36.7 ± 16.8 months (3.06 ± 1.4 years). Immediately after graft extraction (T0), graft width (GW), graft length (GL), graft thickness (GT), graft dimension (GD), and vertical bone height were documented. Re-examination (T1) included clinical examinations (GW, GL, GD, peri-implant probing depths, and modified Sulcus Bleeding Index), radiographic examination (marginal bone level), and medical chart review. RESULTS: Twenty patients and 62 implants (47 in fibula flaps and 15 in iliac flaps) were included. A significant decrease in GW (51.8%), GL (19.2%), and GD (60.2%), were found between T0 and T1 (p < .001). The univariate analysis showed that GW change was not significantly associated with reconstruction technique, baseline GL, baseline GT, baseline GD, implant location, or type of prosthesis. Implant survival rate of 100% was observed at follow-up. CONCLUSIONS: Within the limitations of the study, free gingival grafts at implant sites in the reconstructed mandible undergo dimensional change that result in a reduction of approximately 60% of the original graft dimension. Graft width decreased over 50%. CLINICAL RELEVANCE: FGG is the standard of care intervention for increasing the amount of KM around implants. This study was the first to evaluate the dimensional change in FGG at implant sites in mandibular reconstruction patients after a medium-term follow-up. CLINICAL TRIAL REGISTRATION: Clinical trial registration is not applicable as this study comprehends a retrospective analysis.

Asunto(s)

RESUMEN

BACKGROUND: Segmental mandibulectomy and reconstruction of resulting defect can be performed via intraoral approach (IOA) or extraoral approach (EOA). Both approaches have advantages, disadvantages, indications, and contraindications to consider during their selection. OBJECTIVE: To compare IOA vs EOA of segmental mandibulectomy and microvascular reconstruction with fibula free flap (FFF). METHODS: We conducted a retrospective cohort study in which 51 patients who underwent segmental mandibulectomy and microvascular reconstruction with FFF from 2020 to 2024 were included, especially 17 patients by IOA and 34 patients by EOA, representing both groups of this study. Clinical characteristics, surgery parameters, and patients' prognosis were evaluated. Patients' satisfaction and Derriford Appearance Scale (DAS59) were assessed during follow-up. RESULTS: Ameloblastoma was the most frequent diagnosis (52.9% managed by IOA vs 70.6% by EOA); FFF was frequently positioned as double barrel (94.1% managed by IOA vs 88.2% by EOA). Compared with EOA group, IOA group had less intraoperative blood loss (mean difference [MD] = -112.2, 95% confidence interval [CI]: -178.9 to -45.5, p = 0.001), higher satisfaction score (MD = 1.3, 95% CI: 0.9 to 1.7, p ˂ 0.001), and lower DAS59 score (MD = -0.5, 95% CI: -0.7 to -0.2, p ˂ 0.001). CONCLUSION: Both IOA and EOA were found safe and feasible, presenting similar perioperative features and postoperative outcomes. Patients managed with IOA were more satisfied with aesthetic outcomes than patients managed with EOA. In the absence of simultaneous immediate implant during mandibular FFF reconstruction, after stability of FFF on the defect site, patients should always be referred to an implantologist and/or prosthodontist for teeth restoration to improve functional and aesthetic outcomes.

Asunto(s)

RESUMEN

ABSTRACT: The free fibular flap has been elevated by a "lateral approach" from the posterior edge of the peroneal muscle for more than 40 years. However, in this approach, the surgical view is limited because flap elevation in mandibular reconstruction is performed simultaneously with tumor resection in the supine position, even when using positioning pillows. We herein propose an "anterior approach" as a new surgical method. We retrospectively investigated free fibular flap surgeries performed using the anterior approach, which consists of three anterior approaches, over a seven-year period. First, to avoid the course of the superficial peroneal nerve, the crural fascia was incised 1-2 cm posterior to the anterior edge of the peroneal muscle. The anterior edge of the peroneus muscle is detached from the anterior intermuscular septum. After performing osteotomies distal and proximal to the fibula, the interosseous membrane was incised from the anterior view. Pulling out the fibula to the anterior space between the anterior intermuscular septum and the peroneal muscle made the surgical field shallow. No postoperative superficial or deep peroneal nerve palsies were found in the 55 patients. Only one tourniquet was used in 31 of the 55 cases (56.4%), with an average of 95 min. Twenty-four patients (43.6%) required a second tourniquet 38 min after an interval. Only one tourniquet was used in 25 of the 30 (83.3%) cases in the last 3 years. Moreover, double flaps were used in 21 cases (38.2%), all of which involved ipsilateral ALT flaps. In 18 cases, double-flap elevation and prefabrication were successfully finished before the completion of tumor resection by otorhinolaryngologists.

Asunto(s)

RESUMEN

ABSTRACT: Myoepithelial carcinomas of soft tissue are rare, and most are malignant. The optimal treatment is surgical excision. The arches of the foot are a composite structure responsible for weight bearing and pressure distribution, so it is a vast challenge in reconstruction. We report a case of reconstruction of the midfoot with a free fibular bone flap and tendon graft. We review the literature to compare various options in foot reconstructions and sort out the outcomes of different bone flaps. The free fibula osteocutaneous flap is the superior choice for midfoot reconstruction owing to its sufficient length, strength, flexible skin paddles, easy-to-withstand osteotomy, and simultaneous tendon graft harvesting.

Asunto(s)

RESUMEN

Distal humerus intra-articular comminuted open fracture is a challenging injury, with nonunion, infection and stiffness considered as major concerns. We report a 58-year-old woman who was admitted to the emergency department from a car accident, sustaining an open wound with severe comminution of distal humerus and complete articular fracture, classified as AO/OTA 13C2 and Gustillo Anderson type IIIA. Debridement and external fixation was done first, followed by open reduction and internal fixation with fibular strut allograft. The patient showed excellent results in radiological and functional outcomes. Level of Evidence: Level V (Therapeutic).

Asunto(s)

Asunto(s)

Asunto(s)

RESUMEN

OBJECTIVES: This study aimed to compare the risk of osteoradionecrosis and implant survival in oral cancer patients undergoing immediate dental implants during jaw reconstruction, termed "Jaw in a Day" (JIAD), with those receiving no implants or delayed implants (non-JIAD). PATIENTS & METHODS: Clinicopathologic data were collected from prospectively enrolled JIAD patients (n = 10, 29 implants) and retrospectively from non-JIAD patients (n = 117, 86 implants). Survival analyses were performed to assess implant survival and osteoradionecrosis-free survival. RESULTS: Osteoradionecrosis occurred in 0 % of JIAD cases compared to 19.3 % in non-JIAD cases without implants and 71.4 % in non-JIAD cases with delayed implants (p = 0.008). Osteoradionecrosis-free survival was significantly better in the JIAD group than the non-JIAD group (p = 0.0059). Implants in the JIAD group all survived regardless of radiation therapy (29/29, 100 %) and 95.1 % (58/61) of implants survived in delayed implants in non-irradiated fibula without radiotherapy. Meanwhile, only 11 of 25 implants placed in irradiated fibula flaps survived, even when the implants were placed after a median time interval of 624 days after radiotherapy, and none of them were earlier than 360 days. The survival analysis revealed a significant difference (p < 0.0001). CONCLUSION: JIAD appears to offer superior outcomes in terms of implant survival and osteoradionecrosis prevention compared to delayed implant placement. Placing implants in irradiated fibula, even after years, significantly poses high risk of implant failure and osteoradionecrosis. JIAD represents a promising approach for optimal rehabilitation, particularly in oral cancer patients requiring postoperative radiotherapy. Proper positioning and orientation of implants and flaps are crucial for implant survival.

Asunto(s)

Asunto(s)

Asunto(s)

RESUMEN

Recent studies on fibular osteotomy for varus gonarthrosis and possible subsequent biomechanical changes have attracted increasing attention to the topic. Existing studies have focused mainly on proximal fibular osteotomy with short follow-up periods. The aim of this study was to investigate changes in the alignment of the coronal plane of the ankle and knee joints in patients who underwent vascularized fibula graft harvest (VFGH). The evaluation was based on functional outcomes and radiological measurements.In the comparison between the VFGH side and the contralateral side, no significant differences in the knee inclination (KI) or talar inclination (TI) angle, knee medial clear space (K-MCS) or ankle medial clear space (A-MCS) distance were noted. However, a significant difference in the hip knee (HKA) angle was observed between the operated and nonoperated sides (0.3° ± 1.8° and 1.5° ± 1.9°, respectively [p = 0.019]). Statistically significant differences in both the knee society score (KSS) and the AOFAS scores were found between the ipsilateral donor limb and the contralateral healthy limb. Although the contralateral healthy side had better clinical scores than the VFGH side, the outcomes of the VFGH side were still satisfactory or excellent.

Asunto(s)

RESUMEN

INTRODUCTION: Complex open long bone fractures present a multidisciplinary surgical challenge. Various treatment options are discussed with no consensus. Fibula flaps (FF) are frequently used in maxillofacial surgery, however their use in limb injuries is less common. With the tremendous improvement in microsurgery, orthoplastic surgery gained importance. Our retrospective study aims to assess the long-term results and the quality of life of the patients operated by FF for complex traumatic limb reconstruction. PATIENTS AND METHODS: We conducted an observational mono centric retrospective study from the year 2011 to the year 2021. Patients operated for complicated traumatic limb fractures using FF were included in the study. Not only long-term clinical results were evaluated, but also Patient-reported outcome measures (PROM). These included the Lower Extremity Functional Scale (LEFS), Quick Disabilities of the Arm, shoulder and hand (Qdash), and the Visual Analogue Scale (VAS). The statistical analysis was done using the R Software. RESULTS: Twenty patients were included in our study. 80% achieved complete union with no re fracture rate at a median follow-up of 41 months. All of the patients (n = 4) who underwent amputation were smokers (p = .09), were operated for lower limb fractures (p = .54), and were males (p = 1). The length of hospital stay was associated with an increased duration to complete bony union (p = .01, coefficient = 2.88). At the end of follow-up, the LEFS median score was 67 for the total population and 63.5 for the lower limb reconstructed sub group. CONCLUSION: VFF is an important tool in the armamentarium of orthoplastic surgeons. Encouraging long term functional and clinical outcomes were obtained in patients with complex traumatic limb fractures.

Asunto(s)

RESUMEN

CASE: We describe 2 case studies, involving a 10-year-old girl with an aneurysmal bone cyst and a 12-year-old adolescent boy with Ewing sarcoma. The patient with Ewing sarcoma was previously managed with wide surgical excision and fibular graft reconstruction and subsequently experienced significant graft resorption, hardware failure, and fracture 24 months after operation. A revision limb salvage attempt was undertaken. In both cases, fibular strut grafts were harvested and fixed with intramedullary k-wires to recreate the medial and lateral columns of the distal humeral triangle. CONCLUSION: The technique achieved complete osseous integration, structural support, and functional restoration of the elbow in both cases, with good functional outcomes.

Asunto(s)

RESUMEN

OBJECTIVES: Dermal substitutes are classically used in a 2-stage procedure followed by skin graft for wound healing. This study aims to evaluate the possibility to use an alternative technique for radial forearm and fibula donor sites coverage using one-stage Pelnac reconstruction. MATERIALS AND METHODS: 21 patients who underwent radial forearm and fibula flaps harvest for reconstruction of head and neck defects after oncological surgery were enroled in the study. 13 patients were treated by one-stage Pelnac reconstruction of the donor site defect, 8 patients underwent full thickness skin graft. The Vancouver Scar Scale was used to evaluate the scar quality. RESULTS: Most patients treated with one-stage Pelnac reconstruction showed good healing of the flap donor site, with minor complications, scar quality comparable to other treatment options and unimpaired function of the implicated limb. One patient had wound dehiscence at the radial forearm site, which was treated with secondary full thickness skin graft. In the group treated with FTSG we had three patients that developed complications, such as dehiscence of the graft and seroma. Overall, we reported comparable satisfaction with donor sites both for aesthetic and functional outcomes, in both groups of patients. CONCLUSION: The use of Pelnac without a following skin graft provides a viable method for the reconstruction of radial forearm and fibula flaps donor site. A longer postoperative care is needed, but the long-term aesthetic and functional results are satisfactory in comparison with full thickness skin graft.

Asunto(s)

RESUMEN

Congenital pseudarthrosis of the forearm bones (CPFBs) is rare, with only 106 reported cases, and is frequently associated with neurofibromatosis (NF). Approximately 5% of patients with NF develop pseudarthrosis, and 50% of patients with pseudarthrosis have NF. Achieving bone union is difficult in congenital pseudarthrosis. Many methods have been attempted, including casting, internal fixation with or without grafting, and electrical stimulation, but failure is frequent. Free vascularized fibular flaps (FVFs) have been used to bridge long bone defects since 1975 and in tibial pseudarthrosis since 1979. In CPFB, FVF is more successful than other methods in achieving union and is the current treatment of choice. Here, we presented three cases of forearm pseudarthrosis treated with FVF, reviewed the literature on CPFB, and discussed some technical aspects of FVF treatment. Three cases of congenital pseudoarthrosis were treated with free fibula flaps, diagnosed at ages of 7 years (ulna), 15 months (radius), and 9 years (radius and ulna). Two flaps were stabilized with intramedullary wires and latterly, one with compression plates. One persistent nonunion received revision nonvascularized bone grafting and plating. All patients achieved union by 11 months after index surgery. Reconstruction with vascularized fibula is the treatment of choice because it offers the highest published union rates and good functional results. Complete resection of the affected bone and stable fixation, latterly with compression plates are critical to success. Surgery is technically demanding, and complications are common. Secondary surgery may be required, but outcomes are favorable. LEVEL OF EVIDENCE: IV.

Asunto(s)

RESUMEN

A calcifying epithelial odontogenic tumor is a rare, benign odontogenic neoplasm. Surgical treatment is the option, and late recurrence is very rare. Radiologically, the lesions are commonly present scattered calcifications. This case report details a 64-year-old female patient with a recurrence of a right mandibular calcifying epithelial odontogenic tumor 2 decades after successful initial surgical removal. A segmental mandibulectomy and immediate reconstruction were performed using a planned vascularized free fibula flap with virtual surgery, custom reconstruction plate, and intraoperative computed tomography. Modifications were made to the design of the reconstruction plate to improve the cervicofacial profile and subsequent rehabilitation with dental implants. Fully guided implant surgery with point-of-care manufacturing protocol was done to improve prosthetically driven implant planning. The case presented highlights the usefulness of new technologies for mandibular reconstruction with the free fibula flap and the concept of point-of-care with technical notes that increase precision and reduce morbidity in implant-supported rehabilitation.

Asunto(s)