The literature as well as our data show that reconstruction with plates alone is not a long-term option as a lot of complications occur over the time. Therefore, bony reconstruction is standard of care. From my opinion, the decision primary depends on the malignancy of the cause of the resection: if you have benign lesions or you can outrule positive margins, early reconstruction is a very good option. If not, you might consider delayed reconstruction.

Dear Islam

I think the decision of choosing the treatment plan for the reconstruction should be specific for every case based on the following factors

1. is the resection of the mandible due to tumor , if yes is it benign or malignant.

2. in case of malignancy, are the surgical margins free of disease???

3. is the radiotherapy planned for the patient post -operatively ??

The above mentioned factors are not only the determinants of the ideal reconstruction plan , patient's factors, surgical skills available, and proper instruments are also a major factors.

Generally speaking if you decide to go for immediate reconstruction, and no free flap and microvascular skills available ,,you might think distraction osteogenesis , it is very helpfull

The patient and the pathology should be the determinant, there is no single "best way" of doing anything so the question has to be refined. In benign disease free non vascularised bone supported by semirigid fixation provides a flexible solution.

If the disease process is malignant then optimum treatment will require postoperative radiation in the vast majority in which case there is little argument against microvascular reconstruction - which also influences survival. Depending on patient co-morbidities and preference DCIA gives the best height match for mandibular resections and high maxillectomies (both with internal oblique - the skin is precarious unless you use a groin flap as well), fibula with skin for edentulous mandibles and lower maxillectomies, composite radial forarm for atrophic mandible or low maxilla where an obturator is declined. Scapula is a good pluripotential flap if your team doesn't mind non synchronous operating. If the environment is such that this expertise is not available and the patient cannot be transferred such as in the developing world reconstruction plate and pectoralis major will fill a defect but the plate will fail long term.

I'm not sure I can envisage a scenario where distraction is available but something as straightforward as free flaps are not...

I do agree with David regarding the question and the need to refine our future discussion.

Thanks a lot to Professor Kammerer, Al Khawalde, and Mitchell to give me some perfect answers regarding mandibular reconstruction.

I just joined the RG recently and your question intrigued me, of course all the answers you got were reasonable, but i have to add another cause for continuity defects of the mandible which we see here in our practice, namely the missile injuries, in this case we opt for delayed reconstruction due to the contaminated field and the loss of soft tissue, so we stabilize the remaining parts of the mandible temporarily and we manage the soft tissue first.

When microvascular surgery is not possible best way to reconstruct the mandible is with a free graft (from illiac crest /rib). However if you resect the lesion and breach the oral mucosa, chances of failure of the free graft is very high. This is due to salivary soiling.If you are resecting a malignancy, you are very likely to resect the oral mucosa as well to get a clear margin. Then the best way to manage the problem is to use a strong recon plate and cover the wound. (If the coverage is difficult a Pect Major flap or another flap me be required.If you are using a Pect Major you can wrap the muscle nicely to cover the free graft. This will give a good seal and prevent failure.)

If you do not use a flap to get a closure you can still use the plate and leave the area to heal.The plate will maintain the gap.After about three months once the area is healed go back and graft the defect.Make sure this time you do not breach the oral lining to avoid salivary soiling.

I also have used Pect Major with rib attached to it for mandibular reconstruction (osteo myo cutaneous flap). This is bit difficult flap to raise and the reach is poor for large defects.

I believe that Prof. Mitchell described the correct approach to follow.

Immediate reconstruction of mandibular difect is the goal in both malignant and benign lesions. However, in malignant disease the reconstruction with free flaps is the best way to reconstruct the mandible.

We all agree that microvascular reconstruction is the best option.The issue is when microvascular surgery is not available, other methods have to be considered.

In order to mandibular reconstruction in malignant lesions, where can not be used free flaps, I think that should not be used bone grafts or recon plate to the high risk of exposure of the same. While it is absolutely necessary to reconstruct the oral mucosa with loco-regional flaps or pedicle flaps (pectoralis major) to avoid salivary fistula.

The problem with free flaps is the need for an expert in that field ... with excellent success at anastomosis and the post operative care facilities that are difficult to get by. If you are looking at benign jaw pathologies which are commonly dealt with in a facility with lesser facilities / resources - distraction osteogenesis can be an option if the surgeon wishes to work on it. For continuity defects, transport distraction can be done, but the limitations of the technique are numerous and distraction by itself is very technique sensitive. With distraction there is no limit but the device limitation for the bone that you can form (one stage, two stages, multi stage transport distraction )etc;)

And with free non vascularized bone graft it is again an issue where one has a limit on the length of the defect that can be reliably reconstructed. using bone plates is a problematic issue too for long term. Free flaps also fail or dehise and get infected when the region has to be irradiated as irradiation further restricts the ability to be revascularised and infection if it sets in the free non vascularized flap, it may have to be removed! A non vascularized bone graft when exposed to oral cavity or outside is a failure and will eventually be all resorbed ... We might be left at a worser state than we started out.

The state of art care is Microvascular reconstruction .. yes as all have already agred and what is more significant about this question is that it lends itself to discussions and ideas which can be applied to places with less resources like in rural or remote areas and in many developing nations where the patient may not afford microvascular reconstructions! (in that line even distraction can be a bit difficult and costly unless you get an indigenously built /made distraction device etc;)

I know this might sound outrageous, but I think leaving the defect without any reconstruction is also a viable option if the wound bed is poor and the reconstruction defect is larger than around 5cm (the limit for free non vascularized bone graft length that can be viable and successful). In those cases, a guidance flange prosthesis can be useful and until it can be inserted, the patient will be put in intermaxillary fixation so that the segments do not collapse! It is a long and painful process but has been successfully used in times where reconstruction was not a viable option ...

As for maxilla, it is more robust and is able to withstand a large defect without much of an esthetic problem (or atleast not as much as an anterior mandibular defect) ... but the issue with maxilla is more functional (oro naso antral communications) and that can be managed prosthetically - hollow bulb obturators with additional implants or such!

For maxillae, obturators are a very versatile technique which can be supplemented with screws/ implants for support if needed!

Infact, most benign lesions of mandible are common with the lateral body/ramus region of the mandible and there is considerable controversy over the need for reconstruction of such a defect .. as the esthetic and functional morbidity of the defect left untreated is not that much. But considering the risk of a major procedure like microvascular reconstruction or even free bone grafting might be problematic. It is like, if you can achieve optimum result not doing something and achieve a little better result by doing something ... what would you choose ? The ultimate answer / decision would be based on these and other factors as well as the patient's condition and the expertise available at the center... and most importantly the risk-benefit ratio of the reconstrucitve procedures. Reverse reconstruction ladder is applicable in select situations, but choice would depend on factors I think what everyone has already discussed! So nothing to add further :)

I have always been intrigued by Millard's 33 principles and every principle is a gem and a lesson when it comes to planning a reconstruction plan! I just could not stop talking of Millard's principles ... and I took the liberty ... I am curious to see how the discussion goes here ...