Revisiting Reconstruction of Posterior Mandible Defects in the Modern Era of CAD/CAM Technology
Stefanos Boukovalas, M.D.1, Edward I. Chang, M.D., F.A.C.S.2, Jun Liu, M.D., PhD2, Rene D. Largo, M.D.2, Patrick B. Garvey, M.D., F.A.C.S.2, Matthew M. Hanasono, M.D., F.A.C.S.2.
1The University of Texas Medical Branch, Galveston, TX, USA, 2The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
PURPOSE: Reconstruction of posterior mandibulectomy defects can be reconstructed utilizing either soft tissue or bone with relatively equivalent outcomes. However, with the emerging and growing advances in medical modeling, osteocutaneous free flaps may prove superior.
METHODS: Restrospective review of all free flap reconstruction of posterior mandibulectomy defects from 2005-2016.
RESULTS: Overall, 292 patients (mean age: 56.8 years; mean BMI: 26.2kg/m2) underwent reconstruction of a posterior mandibulectomy defect with 169 patients receiving a soft tissue flap and 123 patients receiving an osteocutaneous free flap (91 free hand vs. 32 CAD-CAM). Many of the patients had radiation (n=117) and chemotherapy (n=105). Forty patients required a double flap to reconstruct the defect, most commonly a fibula osteocutaneous flap for the mandibulectomy defect and a soft tissue flap for external coverage. There were 7 total flap losses. There were no differences in the incidence of trismus; however, malocclusion was most common in patients with soft tissue flaps (p<0.001). When comparing bony reconstruction, CAD-CAM significantly reduced the risks of malocclusion (p<0.001). Regarding speech and swallowing function, the best function was seen in patients who underwent reconstruction with a CAD-CAD assisted fibula flap. CAD-CAM patients were significantly more likely to have a regular diet (p=0.001) and trended to have superior speech (p=0.057) compared to the other cohorts.
CONCLUSION: Reconstruction of posterior mandibulectomy defects should be based on patient's comorbidities, surgeon comfort, and available resources;
however, the use of CAD-CAM-assisted fibula reconstruction provides patients with the best post-operative function following reconstruction.
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