The Use of Bilateral Segmental Ostectomy
and Vertical Distraction
for Refinements of Reconstructed Mandible with the Free Fibular Bone
Flap
Muhitdin Eski MD, Mustafa Deveci MD, Mustafa Şengezer MD, Fatih Zor MD
INTRODUCTION: Reconstruction of mandibular bone defects with free
fibular flaps have become the method of choice for many surgeon and is
indicated primarily for segmental defects involving the ramus angle,
and body of the mandible (1,2). Although these techniques have greatly
improved the aesthetic and functional outcomes, the residual asymmetry
and malocclusion has recently been reported following reconstruction
of mandible with free fibula flap (3).
In these cases the
malocclusion and residual asymmetries are corrected with a unilateral
linear osteotomy at junction of the flap with the mandible or bilatral
segmental ostectomy (3). Also the
vertical deficiency between the
reconstructed segment and the occlusal plane
made dental
rehabititaion imposible in some cases and vertical distraction of
transplanted fibular
flap
can be used to overcome this problem
(4,5). We encountered both
problems in our
patient who had
previously
mandibular reconstructions with free fibular bone flap
due to extensive bone defect result from
gun-shot injury.
To
overcome
these deformities, first,
we used
bilateral segmental
osteoctomy at the junction of the bone flap with the mandible to set
back the free fibular flap in order to correct the malocclusion. Five
months after this operation vertical distraction of fibular flap was
performed for dental rehabilitaion in a reconstructed mandible.
CASE REPORT:A set-back operation was performed under general
anesthesia. Following the limited subperiostal dissection a vertical
ostetomy was performed at both junctions of the fibular flap and the
mandible. The native mandible was mobilized and the remaining teeth
were immobilized using intermaxillary fixation to have an optimal
occlusion. To correct the prognatism, excess bone segments on both
ends of the fibular flap (7 mm bone segment on right side and 8 mm
bone segment on left side) were excised. The initial osteotomies on
both sides were perpendicular to mandibular plane during the segmental
ostectomy. However the second osteotomy, which was mesial to first
one, was performed at
15 degrees to first osteotomy line on both
sides (Fig-2). This enabled us to move the fibular flap upward in the
vertical plane. Then the shortened fibular bone flap fixed with
minicompresion plates to the native mandible. Postoperative period was
uneventful. The prognatic appearance was no more observed in follow-up
examination at postoperative 5 months. Due to vertical deficiency in
bone height and extensive tissue scaring and associated teeth loss the
prosthetic rehabilitation
could not be performed in this patient.
Five months after first operation
vertical distraction of fibular
flap was performed to augment the vertical deficiency. Fibular bone
segments (60 mm) were distracted with using extraoral uni-directional
alveolar ridge distraction device after
a latency period of 5 days.
The
rate of distraction was
1mm/day
and the rythym was
4 times
(4X0.25 mm). Distraction was continued till the desired height was
achieved
and
the
distractor
left
in
place
for
bony
consolidation.However the patient had motorcycle traffic accident
which result panfacial fracture on the nineteenth day of the
consolidation period. Due to
this accident
the patient
had
subcondilar fracture on the right side and fracture of basal bone of
the
distraction segment on the left side. The patient had open
reduction and rigid fixation for the treatment of fractures. Without
disrupting the distraction zone and device immediate repositioning and
osteosynthesis were performed on basal bone with miniplate. Following
the surgery
weeks consolidation peroid was uneventful ( total 12
weeks) . During the removal of distraction device
new formed bone
was observed in the entire distraction gap of this case. The increase
of
vertical bone height (10mm) was stable and enabled
dental
restoration of the patients with mandibular removable partial dentures
(Figure-1). Follow-up period was 10 months. The appearance of the
patient significantly improved following segmental ostectomy and
vertical distraction and the result was satisfactory (Figure-2)
CONCLUSION: In this case report we described the use of segmental
ostectomies of the bone flap to setback the flap for the correction
of the malocclusion and asymmetry, which was developed following
reconstruction of mandible with free fibular flap. Segmental ostectomy
enables us to correct the deformity by moving the fibular flap in both
horizontal and vertical planes with limited subperiostal dissection.
Also we described vertical distraction of
fibular flap after
bilateral segmental ostectomies. The fibular bone flap can be
distracted vertically without any complication in order to overcome
vertical deficiency causing difficulties for dental restoration
Figure-1: Panoramic radiographs of the patient. (Above, left)
first operation in which reconstruction plate was used. (Below,
After reconstruction with fibular bone flap. (Above, right)
bilateral segmental ostectomy (7 mm bone segment on right side
mm bone segment on left side were excised).
(Below, right)
vertical distraction of fibular flap at postoperative 7 months.
After
left)
After
and 8
After
Figure-2: (Above, left and below, left) Preoperative appearance of the
patient. (Above, right and below, right) Postoperative appearance of
the patient following bilateral segmental osteoctomy and vertical
distraction operation.
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