ARTÍCULO CLÍNICO

 

Implant-supported rehabilitation using the fibula free flap

Rehabilitación implantosoportada en el colgajo libre de peroné

 

 

 

C. Navarro Cuéllar¹, S. Ochandiano Caicoya², F. Riba Garcia¹, F.J. Lopez de Atalaya²,
J. Acero Sanz², M. Cuesta Gil², C. Navarro Vila³

1 Médico Residente.
2 Médico Adjunto.
3 Jefe de Servicio. Catedrático de Cirugía Maxilofacial. Universidad Complutense de Madrid.
Servicio de Cirugía Oral y Maxilofacial. Hospital General Universitario Gregorio Marañón. Madrid, España.

Premio "Lorenzo Castillo" 2003

Dirección para correspondencia

 

 

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ABSTRACT

Free fibula flap has proved to be one of the most versatile for oromandibular reconstruction due to the available length of bone and the possibility of incorporating a long skin paddle to cover intraoral soft tissues.
The use of osseointegrated dental implants is an important technique for the oral rehabilitation of these patients. Osseointegrated implants provide the most rigid prosthetic stabilization available to withstand masticatory forces.These implants can be placed immediately or in a second time procedure.In our case, implantation in the fibula free flap is done after 6-12 months because of the large amount of osteosynthesis material required forthe fixation of the flap. Four or six months later, when osseointegration has taken place, the implants are loaded with a dental rehabilitation. We analize 12 cases of mandibular reconstruction with fibula free flap and their aesthetic and functional rehabilitation with osseointegrated implants with a 2 year follow up Fifty-six dental implants were placed developing all of them but one a correct osseointegration. All these patients recovered masticatory function and underwent a considerable improvement in labial competence, salival continence, speech articulation and facial harmony.

Key words: Mandibular reconstruction; Free fibula flap; Osseointegrated implants.

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RESUMEN

El colgajo de peroné ha demostrado ser el más versatil para la reconstrucción oromandibular, gracias a la gran longitud ósea que podemos utilizar y a la posibilidad de incorporar una amplia paleta cutánea para cobertura de tejidos blandos intraorales.
El uso de implantes dentales osteointegrados proporciona un importante método terapéutico para la rehabilitación oral de estos pacientes. Los implantes osteointegrados proporcionan la forma más rígida de estabilización protésica para soportar las fuerzas masticatorias. Estos implantes pueden ser insertados de forma inmediata o diferida. A la hora de utilizar el colgajo libre de peroné realizamos la implantología de forma diferida a los 6-12 meses debido a la gran cantidad de material de osteosíntesis necesaria para la fijación del colgajo. Cuatro o seis meses después, cuando el proceso de osteointegración ha ocurrido, los implantes son cargados con una rehabilitación dental.
Analizamos 12 casos de reconstrucción mandibular con colgajo libre de peroné y su rehabilitación estética y funcional con implantes osteointegrados y un seguimiento mínimo de 2 años. Se han colocado un total de 56 implantes, presentando todos ellos excepto uno, una correcta osteointegración. Todos estos pacientes han recuperado la función masticatoria, y mejorado de forma considerable la competencia labial, la continencia salival, la pronunciación y la armonía facial.

Palabras clave: Reconstrucción mandibular; Colgajo libre de peroné; Implantes osteointegrados.

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Introduction

Mandibular reconstruction, within the field of head and neck reconstruction, has been a very debated subject that has been studied over the years, and especially over the last fifty.¹ The removal of extensive tumor lesions often leads to considerable bone and soft tissue defects, with the resulting aesthetic and functional sequelae.²

From the aesthetic point of view, a retraction in the lower third of the face is produced, especially if the mandibulectomy includes the symphyseal and parasymphyseal area. In these cases, considerable ptosis of the lower lip will arise.

When the resection affects the mandibular body, there is clear facial asymmetry as the affected area sinks. This asymmetry is more noticeable if, in the resection, the condyle is included.

From a functional point of view, the most important sequelae are: incompetence of the lower lip, salivary continence, severe difficulty in mastication and swallowing, and difficulty in articulation.

On the one hand the non-reconstructed part of the mandible suffers retraction and deviation towards the resection side. On the other, the previous vertical movements are replaced by oblique or diagonal movements that are controlled by just one temporomandibular joint. The tongue is limited with regard to mobility and strength and proprioceptive sensitivity disorders leads to a lack of coordination in the movements of the mandible.³

The fibula flap was first described by Taylor⁴ in 1975. Gilbert, in 1979, introduced a lateral approach that was much simpler, which is the one that is used today. Ueba and Fukjikaua⁵ started to use this flap for treating congenital cubitus pseudoarthritis in 1983. In 1988 Hidalgo⁶ began using this flap for reconstructing the mandible. For approximately the last ten years this is the flap used by Navarro Vila et cols.^7-10 as one of the principal reconstruction techniques for the mandible.

The fibula free flap offers great advantages in mandibular reconstruction. One of the most important is the length of bone that is provided, as a minimum of 4 cm and a maximum of 25 cm is supplied.¹¹

The size of the skin island that is to be incorporated depends principally on the size of the resection and the size of the flap that is needed for reconstructing the oromandibular defect. The skin is irrigated by septocutaneous and musculocutaneous branches of the peroneal artery. The most important study on vascularization of the skin was carried out by Wei¹². One of their conclusions was that there tended to be between 4 and 7 cutaneous branches, with the more numerous musculocutaneous vessels being at a proximal level and the septocutaneous branches at a distal level. It is because of this that the pedicle has a fusiform design and it is centered in the intermuscular septum where the middle and distal third meet.

 

Moreover, Hayden and O’Leary¹³ described the sensory re-innervation of a skin patch by means of anastomosis of the lateral sural cutaneous nerve with an appropriate receptor nerve. Nevertheless, we have not carried this out as a routine procedure as the sensitive reinnervation of the flap does not require anastomosis of the nerves in a large number of cases.

The implant-supported prosthetic dental rehabilitation offers these patients a definitive solution for restoring masticatory function and for improving other sequelae. Branemark y Lindstrom¹⁴ used implants with free bone grafts. Riediger¹⁵ was the first to place them in an iliac crest flap, Navarro Vila7 in the trapezius osseomyocutaneous flap and Urken¹⁶ was the first in placing them immediately, at the time of the reconstruction.

 

Material y methods

In this paper 12 patients are presented who underwent mandibular resection and reconstruction with the fibula free flap. They were fitted with osseointegrated implants by means of delayed placement at 6-12 months after the reconstruction (Table 1).

The sex distribution was 10 males (88%) and two females (12%), between the ages of 21 and 73. The mean age was 50.7 years. Within our series, the most common reason was malignant tumors in seven out of the 12 cases (58%). In another two patients the cause was mandibular ameloblastoma, there was one patient with osteoradionecrosis and we had one case of oncological sequelae that was operated on by another center and sent to ours for reconstruction. Lastly, and as regards etiology, we reconstructed one case of complete right-sided hemimandibular agenesis. With regard to when reconstruction of the oncological cases not treated previously took place, this was carried out in all cases immediately after surgical resection.

 

Titanium miniplates were used in all patients (100% of cases) for fixing the fibula free flap into the remaining mandible. In none of the patients did we carry out intermaxillary fixation in order to avoid any movements that could damage the vascular pedicle.

Seven of the 11 oncological patients (63%) received radiotherapy, two of them preoperatively and five postoperatively.

All patients were fitted with osteointegrated titanium implants that were covered with hydroxyapatite. In all cases (100%) the implantology was carried out as a delayed procedure between six and 12 months after the mandibular reconstruction. A total of 56 implants were placed into fibula flaps. Similarly, for those edentulous maxilla patients and/or mandible remnant patients, implants were also placed in the same surgical act in order to achieve a more stable dental prosthetic solution. The size of the implants were, in most cases, 10 mm in length and 4mm in width although we were able to insert five implants of 13 mm and three of 15mm in the case of mandibular agenesis after previous bone distraction. For the initial placement, a second intervention was necessary in which the large amount of osteosynthesis material that was necessary for fixing the flap was removed. All patients were given widespectrum antibiotic treatment for 7-10 days. The implants required a period of osseointegration that was 4-6 months for patients not given radiotherapy, and 6-9 months for irradiated patients.

The second surgical phase for exposing the implants was carried out using local anesthesia, except in one case that required general anesthesia due to the limited oral opening of the patient. Once the closure screws had been replaced with transmucosal healing abutments, there was a wait of 10 to 15 days before impressions were taken.

 

Results

Of the 56 implants that were placed into fibula flaps, initial osseointegration was 98.2% and there was only one failure following prosthetic loading. There was a minimum two-year followup, and the success rate was 94.6% (three lost implants). Preoperative radiotherapy did not have a negative effect on the implants that was statistically significant. Postoperative radiotherapy led to minimal peri-implant bone loss in two patients. Nevertheless, osseointegration of these implants was correct and there were no problems with later rehabilitation. Of the 12 patients, eight were fitted with implant-supported fixed prostheses, and four with removable implant-retained prostheses. The fixed prosthesis requires a minimum of six implants, while three may be sufficient for the removable one.

With regard to complications, we registered symptoms of epidermolysis of the flap and dehiscence of an intraoral wound, both responded satisfactorily with local treatment. In two of the cases the defects had been reconstructed previously with iliac crest flaps, one of which had been removed because of thrombosis of the pedicle and osteomyelitis of the flap. The other was removed because of carcinoma recurrence. One of the patients in our study had various complications that included partial necrosis of the lateral fibular muscle and an orocutaneous fistula; both were resolved with conservative treatment. The bone flap suffered a right-sided parasymphyseal fracture that required surgical reintervention and reduction and fixation with two titanium miniplates.

 

 

From the aesthetic point of view, all patients were satisfied and they all had a correct facial contour. As a result of the prosthetic rehabilitation by means of osteointegrated implants, all patients except one were able to eat normal food. Proprioceptive sensitivity in approximately half of the cases was restored, and in many of the cases acceptable lingual mobility was achieved. All the osteointegrated implants were used except four, because there was no occlusion.

As a result of the mandibular reconstruction carried out and the functional rehabilitation with osteointegrated implants, there have been considerable improvements for the patients with problems in the areas of mastication, swallowing, salivation and labial competence, and spectacular improvements have been achieved with regard to aesthetic facial harmony.

 

Discussion

Reconstructive surgery has experienced great advances over the last 20-30 years. Until recently mandibular reconstruction was based on pedicled bone flaps, reconstruction plates, bone grafts and alloplastic bands of bone particles. As a result of the development of microsurgical techniques and osteointegrated implants, integral treatment of oncological patients has improved considerably.¹⁷

Oromandibular rehabilitation is an arduous task that requires complex reconstruction that is individualized for each defect and adapted to the needs of the patient. Individualizing each case is fundamental, as is studying each patient in detail in order to select the right microsurgical flap for the reconstruction.

The microsurgical fibula flap has a series of advantages with regard to other flaps in oromandibular reconstruction:

• Usable bone of great length (up to 25 cm).
• Two different surgical teams can work in the same intervention.
• The considerable periosteal vascularization that allows the possibility of carrying out multiple osteotomies for remodeling.¹⁸
• Sensate reinervation of the skin island.¹³
• Minimum morbidity at the donor site.

Nevertheless, the fibula flap also has a series of disadvantages, of note:

• Multiple osteotomies for remodeling are required together with large amounts of osteosynthesis material.
• The bone height obtained is poor, and posterior functional rehabilitation with the osteointegrated implants is hampered. Moscoso.²⁰ claimed that in approximately 15% of males and somewhat more in females, implants cannot be placed because the fibula lacks height.
• The placement of implants has to be done in a second stage due to the surgery required for such a large amount of osteosynthesis material. ²¹
• Bone has little height for segmental defects, and there is a difference in height between the flap and the remaining mandible and an unfavorable crown-prosthetic-implant relationship. This can be solved successfully by means of secondary vertical distraction of either the fibula²² or by a "double-barrel" fibular graft as described by Jones.²³
• The irrigation of the cutaneous component is very inconsistent, due to the large amount of anatomic variants. This is the main problem with this flap. In order to overcome these inconveniences we follow a set of measures that are:

- The patch should be centered on the two distal thirds of the leg where there are more perforating branches of the peroneal artery.
- The skin paddle should be as long as possible so that as many perforating vessels as possible are incorporated.
- The patch of skin should be approached anteriorly until the septum is reached and the muscular wedge formed by the soleus and long flexor muscle of the big toe should be included so that musculocutaneous perforating vessels are incorporated.

• Although angiographic studies are still the object of discussion, we used them systematically to demonstrate, on the one hand that the peroneal artery was free of disease, and on the other to confirm that it did not have dominant circulation in the leg, as in this case the use of this flap would be contraindicated.²⁴
• The patient is required to remain immobile after the operation for five to seven days, and for up to three weeks if a dermoepidermal graft is used.

 

 

 

Currently the indications for using a fibula free flap are well established:

• Mandibular reconstruction in conjunction with considerable intraoral soft tissue defects.
• Reconstruction of symphyseal mandibular defects, either near total or total that may be over 14 cm.
• Reconstruction of the branch and condyle as the bone can be moved to the glenoid cavity with minimal dissection and with no damage to the facial nerve.
• Mandibular reconstruction during childhood. Genden ²⁵ established it as the flap of choice during childhood. Firstly, because it does not affect the distal and proximal growth centers, and growth of the leg is not affected. And secondly, because the new mandible grows at the same rhythm as the remaining mandible. Omokawa²⁶ indicated that patients under the age of 8 should carryout a synostosis of the ankle in order to avoid the development of valgus deformity.

The incorporation of osteointegrated implantology in the oromandibular rehabilitation of oncological head and neck patients has improved aesthetic and functional results spectacularly. ⁹

Branemark and Lindstrom¹⁴ used free bone grafts. Riediger¹⁵ was the first in placing them into iliac crest flaps and Navarro Vila et cols.⁷ into the trapezius osseomyocutaneous flap.

For perfect functional rehabilitation of patients we should resolve the problems that affect mastication, swallowing, salivation and the aesthetic results should be improved. In order to achieve this, it is necessary for the dental surfaces of the jaw fit together perfectly. In addition to this, proper vascularization of the microsurgical flaps favors the incorporation of the implants and the restoration of masticatory function for patients.^27,28,30

As a result of mandibular reconstruction and radiotherapy, changes take place in the orofacial muscles. There are bone irregularities, vestibular loss, changes in sensitivity, xerostomia and mucosal atrophy that contraindicates the use of conventional prostheses as irritation, ulceration and bone exposure may occur²⁹ that can sometimes lead to osteoradionecrosis.

As a result of the prosthetic stability provided by the osteointegrated implants, refining the flap is not necessary, nor is carrying out secondary vestibuloplasties,²⁹ which in many cases facilitates the therapeutic procedure.

There are two minimum conditions that are required for placing osteointegrated implants:

- minimum bone height of 10 mm²⁰
- bone width of approximately 5.3 mm so that an implant with a width of 3.3 mm can be placed, while leaving 1 mm of alveolar bone in each cortical layer.³¹

It has been demonstrated statistically that microvascularized bone flaps are better at accepting implants than normal alveolar bone due to their greater vascularization and, as a result, the adverse effect of radiotherapy is minimal. The iliac crest flap has the best vascular supply followed by the fibula and the scapula.3

During the follow-up of our 12 patients, we were able to observe that in nine of the patients there was no periimplant bone loss, which is considered normal for implants into non-transplanted bone, after prosthetic loading (0.1 mm/year).³²

Placing the implants can be carried out immediately (in the same surgical act)³³ or this can be delayed until six months after the surgery. Our criteria is to carry out, whenever possible, the implantology immediately as this has a series of advantages:

• Faster functional rehabilitation.⁹
• Access to the new mandible is simpler than in delayed loading.
• Retraction of soft tissues and lower lip is avoided.
• For those patients that are to undergo postoperative radiotherapy, this is reduced by a year.

Nevertheless, there is considerable controversy with regard to when implants should be placed in patients that are going to undergo radiotherapy. Some authors such as Kroll³⁴ and Kuriloff³² recommend that they are not placed immediately and for there to be a delay of approximately 12 months. Sanger²⁷ like ourselves does not contraindicate this.⁹ On the contrary, we believe that this is another factor to recommend the immediate placement of the implants. On the one hand, if more than 4-6 weeks evolve between the reconstruction and the beginning of the radiotherapy, there are 4-6 additional weeks until the start of the adverse radiotherapy effects on the bone. This provides a window period of 12 weeks. During this period in which radiotherapy has not been affecting bone vascularization, the osteophylic and osteoconductive phases of osseointegration have taken place.^17,35 Furthermore, if delayed implant placement is carried out, the new mandible has poorer vascularization and peri-implant bone resorption can increase, which creates more difficulties and more possibilities of complications with regard to the correct rehabilitation of the patient.

 

 

However, with the fibula flap, delayed implantology was carried out six months after the reconstruction of non-irradiated patients, and 12 months later in patients that underwent radiotherapy. The motives behind this decision are based on the fibula bone lacking height and that multiple remodeling osteotomies are carried out. The large amount of osteosynthesis material will, in most cases, prevent the correct number of implants to be placed in the correct position.

When deciding if rehabilitation should include a fixed prosthesis or a removable prosthesis, a series of factors should be analyzed:

• Number and position of implants.
• Occlusal space.
• Antagonist arcade.
• TMJ function.
• Labial or lingual hypoesthesia.
• Patient’s attitude to prosthetic hygiene.

The fixed prosthesis requires a larger number of implants, occlusal adjustment is more complex and maintaining hygiene is more difficult. Similarly, treatment is more costly, but it provides greater satisfaction for the patient in comparison with the removable prosthesis. This requires a lower number of implants for rehabilitation, occlusal adjustment is simpler, maintaining hygiene is easier and the cost is lower.

 

Conclusions

To conclude this paper we should say that, in spite of healing being our priority and objective, the development of microsurgical techniques and osteointegrated implantology has made ostensive improvements with regard to the integral treatment of oncological patients. Therefore, we would like to stress the real possibility that we have of offering mandibulectomized patients that have been reconstructed with a fibula flap, dental rehabilitation with an implant-supported prosthesis and/or implant-retained prosthesis that will improve facial harmony and quality of life. The satisfaction index with this type of treatment is very high, given that what most patients demand after surgery and radiotherapy, is the possibility of having teeth again and eating normally.

 

 

Correspondencia:
Carlos Navarro Cuéllar
C/ María Molina 60, 7ºA
28006 Madrid, España
e-mail: cnavarrocuellar@mixmail.com

Recibido: 14.07.2003
Aceptado: 06.10.2006

 

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