Fibula free flap with endosseous implants for reconstructing a resected mandible in bisphosphonate osteonecrosis.

PURPOSE: Bisphosphonates are a class of drugs with several uses. Primarily, they are used to treat bone metastases, multiple myeloma, Paget's disease, and osteoporosis. However, the use of bisphosphonates can lead to osteonecrosis of the jaws. Here, we present our experience treating this widely discussed disease. PATIENT AND METHODS: We describe a patient who underwent surgical reconstruction of the mandible with a fibula free flap after total mandibulectomy, performed to treat osteonecrosis induced by the use of intravenous bisphosphonates complicated by a mandibular fracture. Endosseous implants were inserted simultaneously to optimize the length and outcome of surgery. RESULTS: Osteonecrosis of the jaws is a treatment challenge, and several approaches have been suggested. In this patient, the use of a fibula free flap to reconstruct the mandible was a winning strategy. The patient is now free from disease, and the esthetic results were optimal. CONCLUSIONS: With the simultaneous placement of endosseous dental implants, the functional outcome was optimal, with no significant complications or recurrence.

Fresh-frozen bone blocks for horizontal ridge augmentation in the upper maxilla: 6-month outcomes of a randomized controlled trial.

PURPOSE: This randomized controlled trial compared fresh-frozen versus autologous bone blocks for maxillary horizontal ridge augmentation in patients with Cawood and Howell class IV atrophies. MATERIALS AND METHODS: Twenty-four patients were allocated to the autologous and fresh-frozen groups in a 1:1 ratio. Patients underwent computed tomography scans 1 week and 6 months after surgery for graft volume and density analysis. Doxycycline was administered at day 120 and day 150 to label new bone formation. Biopsy for histologic and histomorphometric analyses was performed at reentry for implant insertion, 6 months after grafting. RESULTS: Fresh-frozen grafts had lower density than autologous bone. Autologous and fresh-frozen grafts lost, respectively, 25% and 52% of their initial volume (p = .0041). Histology revealed the presence of newly formed bone within both graft types, but clear signs of inflammation were present in fresh-frozen blocks. CONCLUSIONS: According to these 6-month results, autologous bone blocks are preferable to fresh-frozen bone grafts.

Microvascular reconstruction of mandibular defects in paediatric patients.

BACKGROUND: During mandibular reconstruction in paediatric patients special consideration must be given to the issues related to growth when restoration of the mandibular and maxillary relationship is essential for correct development of the facial skeleton, a dynamic process whereby mandibular and maxillary growth are strongly correlated. Wide resections, irradiated fields, infection at the recipient site, and scars are strong indications for using revascularized bone-containing free flaps. METHODS: Five patients were reviewed, with a follow-up ranging from 5 to 11 years. Measurements were performed on frontal and lateral views to assess mandibular angle symmetry, midline deviation and facial angle. Measurements were also made on orthopantomograms to assess differences in growth between the normal and reconstructed sides. RESULTS: Optimal functional and aesthetic results were obtained. CONCLUSIONS: The data suggest that the reconstructed mandible undergoes growth, and that even if this process is unpredictable, it can be sufficient to allow appropriate development of the face.

A simple method of identifying the spinal accessory nerve in modified radical neck dissection: anatomic study and clinical implications for resident training.

PURPOSE: The major complication of neck dissection and surgery at the posterior triangle of the neck is the shoulder syndrome, which results from spinal accessory nerve injury. Erb's point (the great auricular nerve) and the point where the spinal accessory nerve enters the trapezius muscle are used to identify the spinal accessory nerve in the posterior nerve triangle. MATERIALS AND METHODS: Measurements were made during unilateral neck dissections in 30 patients to identify the relationship between the spinal accessory nerve and great auricular nerve and the distance between the entrance of the accessory nerve in the trapezious and clavicle. RESULTS: The distance between the spinal accessory nerve and Erb's point was ranging from 0 to 3.8 cm (mean 1.53 cm). The distance between the spinal accessory nerve entering the trapezious muscle and the clavicle was between 2.5 and 7.3 cm (mean 4.8 cm). CONCLUSIONS: Since the great auricular nerve (Erb's point) represents a constantly identifiable landmark, it allows simple and reliable identification of the course of the spinal accessory nerve. Also useful, but of secondary importance in our opinion, is identifying the nerve at the point where it enters the trapezius muscle.