Management of Pentalogy of Cantrell with complete ectopia cordis and Double Outlet Right Ventricle.

Pentalogy of Cantrell (PoC) is a rare congenital midline defect. We present a case and its treatment of PoC with complete ectopia cordis and congenital heart disease. Postnatally the congenital heart defect was surgically corrected and the ectopic heart was covered by musculous mobilized flap. Due to cephalic orientation of the heart and limited intrathoracic space, replacement of the heart into the thoracic cavity was initially not performed. After 11 years of follow up our patient now is without relevant limitations solely wearing a thoracic shelter. This case elucidates the complexity of further management. The potential risk of disastrous hemodynamic compromise by intrathoracic shift is to compare with the limited safety of the ectopic heart.

Nasal position of nasotracheal tubes: a retrospective analysis of intraoperatively generated three-dimensional X-rays during maxillofacial surgery.

BACKGROUND: The aim of this retrospective investigation was to evaluate the position of the nasotracheal tube in the nose and to show its anatomical relationship with the maxillary sinus ostium. METHODS: Fifty data sets from patients who had undergone endonasal intubation were analyzed for tube positioning. There was a drop-out of eight data sets due to missing information concerning tube size and mode. Tube positioning was determined at the maxillary sinus ostium in the intraoperatively generated three-dimensional X-ray data sets. The type of tube, the tube size, and the presence of maxillary sinusitis were analyzed 30 minutes after intubation. RESULTS: The tube was positioned in the middle nasal meatus in 35 (83.3%) patients and not in the middle nasal meatus in 7 (16.7%) patients. The difference in comparison with equal distribution was significant (P <0.001). The test value was 83.3; the 95% confidence interval of the test value was 68.6 to 93.0%. Maxillary sinusitis was diagnosed as a chance finding in 17% of patients (n =7). CONCLUSIONS: The majority of nasal tubes are positioned in the middle nasal meatus. This result can be part of the answer to the question of the causal relationship between position of the breathing tube and the onset of maxillary sinusitis. The indications for prolonged nasotracheal intubation instead of orotracheal intubation or early tracheostomy should be considered carefully.

Long-term donor-site morbidity after microsurgical fibular graft: is there a difference between the medial approach and the lateral approach?

PURPOSE: Microvascular fibula harvesting for osseous reconstruction is a valuable aid in maxillofacial surgery. We assessed whether the lateral and the medial harvesting techniques differed with respect to long-term donor-site morbidity. MATERIALS AND METHODS: We conducted a retrospective cohort study of patients who had undergone free fibula harvesting at the University Medical Center Hamburg-Eppendorf, Hamburg, Germany, between 1987 and 2008. The primary predictor variable was the surgical approach. The primary and secondary outcome variables were the American Orthopaedic Foot & Ankle Society score and the result of the Short Form 36 Health Survey on quality of life, respectively. Other variables were age, gender, harvest length, operation time, and specific impairments and surgical complications. Statistical analysis was performed with SPSS, version 14.0 (SPSS, Chicago, IL); P < .05 was considered significant. RESULTS: The 42 patients had a mean age of 55.5 years. The mean follow-up period was 81 months (range, 7-174 months). In the medial group, the mean American Orthopaedic Foot & Ankle Society score was 94.4 points and the total number of impairments was 34, as compared with 85.6 points and 46 impairments, respectively, in the lateral group. This tendency for less morbidity with the medial approach was only found in female patients. The Short Form 36 scores were not statistically different between the 2 surgical approaches. CONCLUSIONS: The medial approach led to less functional impairment of the foot and ankle. Our results support the medial approach as a viable alternative, especially in women, but only in cases when a skin paddle is not necessary.

Leech therapy in reconstructive maxillofacial surgery.

PURPOSE: Corrective plastic surgery is indicated after accidents, burns, cancer surgery, or postoperative wound healing disorders with large tissue defects. The range of reconstructive techniques includes local skin flaps, pedicle grafts, and microvascular anastomosed flaps in the case of large defects. Main complications such as arterial and venous insufficiency caused by a vessel collapse or a vascular spasm are reported regularly in the area of anastomosed vessels and are the concern of any surgeon. Today, leeches are used if wound healing is at risk because of hemodynamic imbalance or a venous insufficiency. PATIENTS AND METHODS: A retrospective evaluation of 148 patients who underwent medical leech therapy in the case of local or pedicaled flaps and some patients who had undergone reconstruction with microvascular flaps from 2005 and 2010 was conducted. Our sample had the typical symptoms of venous congestions of their flaps, despite suture removal, relief of pressure on the flap, and the elimination of a hematoma beyond the flap after surgery. Medical leech therapy was used in these cases. RESULTS: Our series has confirmed the excellent and predictable healing after medical leech therapy for local and microsurgical anastomosed flaps in the case of venous congestion. CONCLUSION: Leech therapy should be considered as a reliable additional procedure and an advantage in maxillofacial and plastic reconstructive surgery to remedy complications resulting from a hemodynamic imbalance or venous insufficiency in the immediate postoperative period.

Influence of lip closure on alveolar cleft width in patients with cleft lip and palate.

BACKGROUND: The influence of surgery on growth and stability after treatment in patients with cleft lip and palate are topics still under discussion. The aim of the present study was to investigate the influence of early lip closure on the width of the alveolar cleft using dental casts. METHODS: A total of 44 clefts were investigated using plaster casts, 30 unilateral and 7 bilateral clefts. All infants received a passive molding plate a few days after birth. The age at the time of closure of the lip was 2.1 month in average (range 1-6 months). Plaster casts were obtained at the following stages: shortly after birth, prior to lip closure, prior to soft palate closure. We determined the width of the alveolar cleft before lip closure and prior to soft palate closure measuring the alveolar cleft width from the most lateral point of the premaxilla/anterior segment to the most medial point of the smaller segment. RESULTS: After lip closure 15 clefts presented with a width of 0 mm, meaning that the mucosa of the segments was almost touching one another. 19 clefts showed a width of up to 2 mm and 10 clefts were still over 2 mm wide. This means a reduction of 0% in 5 clefts, of 1-50% in 6 clefts, of 51-99% in 19 clefts, and of 100% in 14 clefts. CONCLUSIONS: Early lip closure reduces alveolar cleft width. In most cases our aim of a remaining cleft width of 2 mm or less can be achieved. These are promising conditions for primary alveolar bone grafting to restore the dental bony arch.

Metastases in odontogenic cysts: literature review and case presentation.

Malignant tumors in the oral cavity are relatively rare. About 5% of all malignant growths in the body are localized in the oral cavity. The vast majority of oral malignancies are primary tumors with squamous cell carcinoma being the most frequent and sarcomas occurring very seldom. Secondary tumors caused by hematogenous spread arising from a tumor localized elsewhere in the body are extremely rare. About 1% of all oral cancers are metastases to the jawbones and the surrounding soft tissues. Metastases to the jaws are mainly caused by malignant tumors of the breast, lung, kidney, bone, and colon. They occur in the late state of the disease and are regularly detected by staging examinations including scintigraphy. Even more rare are metastases into odontogenic cysts. Odontogenic cysts include dentigerous cysts, periapical or radicular cysts, and the keratocysts-nowadays declared as keratocystic odontogenic tumor. The incidence of odontogenic cysts is about 10% to 15% of all oral biopsies and therefore general dentists are frequently faced with these types of lesions. The aim of this study was to review the literature regarding metastasis into odontogenic cysts and to further highlight this rare entity with the help of a clinical case.

Clinical follow-up examination of surgically treated fractures of the condylar process using the transparotid approach.

PURPOSE: The surgical approaches for the open treatment of condylar process fractures have been controversial. In our study, we evaluated the morbidity of the transparotid approach during 2 years of follow-up. PATIENTS AND METHODS: A total of 48 patients with condylar process Class II and IV fractures according to classification of Spiessl and Schroll, were included in the present study. Of the 48 patients, 16 were female and 32 male. The patient age range was 16 to 79 years (average 36.52). All patients were treated using the transparotid approach, with rigid internal fixation using miniplates. Follow-up examinations were performed for a minimum of 6.5 months and a maximum of 25 months (average 12.16) after surgical treatment. At the follow-up examination, the patients completed the Mandibular Function Impairment Questionnaire, and the examiner completed the Helkimo index. X-rays taken before, directly after, and 6 months after surgery were compared. RESULTS: None of our patients had problems with wound healing; 2 patients developed a fistula of the parotid gland; and 4 patients developed palsy of the facial nerve that was completely reversible after 6 weeks. The results of the Mandibular Function Impairment Questionnaire and the Helkimo index revealed only a few subjective and objective problems after 6 months. CONCLUSIONS: The transparotid approach to condylar process fractures is most appropriate for strongly displaced Class II fractures. Especially for very old patients with dementia, for whom maxillomandibular fixation is contraindicated, this approach is very appropriate. Another benefit to this type of patient is the short operating time, with an average of 45 minutes.

Primary osteoplasty using calvarian bone in patients with cleft lip, alveolus and palate.

PURPOSE: The results of primary bone grafting in terms of initial cleft width, existence or absence of a lateral incisor and scar formation in the donor area are compared. METHODS: After primary osteoplasty with calvarian bone at an average age of 24 months (4-56 months) radiographic assessment was carried out in 31 patients with 40 alveolar clefts. The bone formation in the grafted area was assessed using dental radiographs taken at 66 months on average (13-114 months) after primary bone grafting. According to the Abyholm classification patients were assigned to 4 groups (indices I-IV) with indices I and II being rated as a success. RESULTS: We observed success (indices I and II) in 76% and poor results (index IV) in 14%. The causes for the poor results were an alveolar cleft width of 11-12 mm in three cases, an extraction of a decayed deciduous tooth 17 months after bone grafting in one case and a traumatic transplant loss in another case. The non-existence of a lateral incisor and a broad cleft are related to poor results. CONCLUSION: Based on the results presented, primary bone grafting using calvarial bone seems to be a promising alternative in bridging narrow alveolar defects. This method allows early intervention at an age in which children do not recognize themselves as cleft patients. The preservation of the deciduous teeth is equally important regarding their functional stimulus for bone development.

The use of navigation (BrainLAB Vector vision(2)) and intraoperative 3D imaging system (Siemens Arcadis Orbic 3D) in the treatment of gunshot wounds of the maxillofacial region.

PURPOSE: Gunshot wounds are a rare occurrence during times of peace. The removal of projectiles is recommended; in some cases, however, this is a controversy. The reproduction of a projectile image can be difficult if it is not adjacent to an anatomical landmark. Therefore, navigation systems give the surgeon continuous real-time orientation intraoperatively. The aim of this study was to report our experiences for image-guided removal of projectiles and the resulting intra- and postoperative complications. PATIENTS AND METHODS: We investigated 50 patients retrospectively; 32 had image-guided surgical removal of projectiles in the oral and maxillofacial region. Eighteen had surgical removal of projectiles without navigation assistance. RESULTS: There was a significant correlation (p = 0.0136) between the navigated surgery vs. not-navigated surgery and complication rate, including major bleeding (n = 4 vs. n = 1, 8% vs. 2%), soft tissue infections (n = 7 vs. n = 2, 14% vs. 4%), and nerval damage (n = 2 vs. n = 0, 4% vs. 0%; p = 0.038) and between the operating time and postoperative complications. A high tendency between operating time and navigated surgery (p = 0.1103) was shown. When using navigation system, we could reduce operating time. CONCLUSION: In conclusion, there is a significant correlation between reduced intra- and postoperative complications, including wound infections, nerval damage, and major bleeding, and the appropriate use of a navigation system. In all these cases, we could present reduced operating time. Cone-beam computed tomography plays an important role in detecting projectiles or metallic foreign bodies intraoperatively.

Cooperative trial CWS-91 for localized soft tissue sarcoma in children, adolescents, and young adults.

PURPOSE: To improve risk-adapted therapy for localized childhood soft tissue sarcoma within an international multicenter setting. PATIENTS AND METHODS: Four hundred forty-one patients younger than 21 years with localized rhabdomyosarcoma and rhabdomyosarcoma-like tumors (ie, extraosseous tumors of the Ewing family, synovial sarcoma, and undifferentiated sarcoma) were eligible. Therapy was stratified according to postsurgical stage, histology, and tumor site. In unresectable tumors, treatment was further adapted depending on response to induction chemotherapy, TN classification, tumor size and second-look surgery. A novel five-drug combination of etoposide, vincristine, dactinomycin, ifosfamide, and doxorubicin (EVAIA) was evaluated for high-risk patients, but cumulative chemotherapy dosage and treatment duration were reduced for the remaining individuals as compared with that of the previous trial CWS-86. Hyperfractionated accelerated radiotherapy (HART) was recommended at doses of either 32 or 48 Gy. RESULTS: At a median follow-up of 8 years, 5-year event-free survival (EFS) and overall (OS) survival for the entire cohort was 63% +/- 4% and 73% +/- 4%, respectively (all survival rates in this abstract are calculated and displayed with +/-95% CI). EFS/OS rates by histology were 60% +/- 5%/72% +/- 5% in rhabdomyosarcoma, 62% +/- 10%/69% +/- 10% for Ewing tumors of soft tissues, 84% +/- 12%/90% +/- 10% for synovial sarcoma, and 67% +/- 38%/83% +/- 30% for undifferentiated sarcoma, respectively. Response to one cycle of the five-drug combination EVAIA was similar to that of the four-drug combination VAIA used in CWS-86. Two hundred twelve patients with rhabdomyosarcoma underwent radiation (EFS, 66% +/- 6%); 53 of those patients had a favorable risk profile and received 32 Gy of HART (EFS, 73% +/- 12%). TN classification, tumor site, tumor size, histology, and age were prognostic in univariate analysis. CONCLUSION: Improved risk stratification enabled decreased therapy intensity for selected patients without compromising survival. Intensified chemotherapy with EVAIA did not improve outcome of localized high-risk rhabdomyosarcoma.

Intraoperative cone-beam computed tomography in oral and maxillofacial surgery using a C-arm prototype: first clinical experiences after treatment of zygomaticomaxillary complex fractures.

PURPOSE: To describe the first clinical applications of intraoperative cone-beam computed tomography with an integrated flat-panel detector in oral and maxillofacial surgery after surgical treatment of zygomaticomaxillary complex fractures PATIENTS AND METHODS: Nine cone-beam computed tomography datasets of patients with zygomaticomaxillary complex fractures were intraoperatively acquired using a mobile isocentric C-arm (PowerMobil; Siemens Medical Solutions, Erlangen, Germany), including a flat-panel detector. Datasets based on 400, 200, and 100 fluoroscopic images were performed with different tube currents (4.6 mA, 3.3 mA, 2.3 mA, 1.2 mA, and 0.5 mA) and a current tube voltage of 100 kV. Postprocessing resulted in 15 different datasets available for comparison with corresponding preoperative computed tomography datasets. Four oral and maxillofacial surgeons and 2 experienced radiologists evaluated each dataset regarding noise, transition, and the delimitation of landmarks. RESULTS: All examinations were successfully performed. Reconstructed datasets showed high-resolution images of all midfacial osseous structures in near-computed tomography quality. Regarding high-contrast structures, detailed analyses of datasets acquired in this study suggest that the parameters 400 projections, 1.2 mA, and 100 kV are sufficient. In terms of soft-tissue visualization, a higher level of mA seems preferable. CONCLUSIONS: The tested prototype predicts a new era in cone-beam computed tomography imaging. The integration of a flat-panel detector will overcome the limitations of current available systems. The size of the field of view is increased allowing regularly the visualization of the whole facial skeleton. Particularly in cases of open reduction of unilateral fractures, the assessment of symmetry is of clinical value.

Conditioning of myocutaneous flaps.

PURPOSE: The improvement of the ischaemic tolerance of myocutaneous flaps is of clinical importance and hence the subject of numerous investigations. METHODS: In an attempt to increase the ischaemic tolerance, 20 myocutaneous flaps (rectus abdominis muscle) in pigs were elevated and perfused with various, established solutions prior to the onset of ischaemia. The flaps were elevated, utilizing the superior epigastric vessels as the pedicle. Ten flaps were flushed with the University of Wisconsin solution, five with the Euro-Collins solution and the last five with a Ringer-Lactate solution, prior to the 6h long, normothermic ischaemia. On the day of operation, the first, third, fifth, seventh and tenth postoperative day clinical examinations and thermography were performed as well as biopsies. Additionally, on the tenth postoperative day, the rate of necrosis was determined morphometrically as the average of three measurements. RESULTS: Ten days after surgery, the flaps pretreated with the University of Wisconsin solution displayed a vital surface area of 89%, the Euro-Collins solution 23% and the Ringer-Lactate solution 14%. Histologically, muscle tissue proved to be more susceptible to ischaemia than skin. CONCLUSION: Regarding the rectus abdominis flap in a pig model, the University of Wisconsin solution proved superior in the prevention of ischaemic injury compared with the Euro-Collins solution and Ringer Lactate. In accordance with the literature, muscle tissue proved to be more susceptible to ischaemia than skin in our study.

Distraction osteogenesis in secondary microsurgical mandible reconstruction: report of seven cases.

INTRODUCTION: Fibula, ilium and scapula are the preferred donor areas for vascularised bone grafts. For secondary mandibular reconstruction, however, compromises often have to be made as a result of the poor quality of the covering soft tissue and recipient vessels especially in irradiated patients. Callus distraction osteogenesis is a complementary method for optimising the intermaxillary relationship and the facial profile from an aesthetic point of view. MATERIALS AND METHODS: Thirteen distractions were performed in seven patients following microsurgical mandibular reconstruction over a period of 4 years, all by the same surgeon. Intra-oral distraction devices were predominantly applied. After a 7-day healing period, the callus distraction was begun, involving two advisements per day of 0.5mm each. The distraction devices were removed after a consolidation phase of 4-5 months. RESULTS: Ten of the 13 distractions were uneventful with an average bone lengthening of 20mm, retained after a follow-up time of 6-47 months (average 27 months). The intermaxillary relationship and the facial profile were improved in all cases. Distraction plate fractures, screw loosening or absence of new bone formation were the complications encountered in the other three patients. CONCLUSION: Regarding the high complication rate, a successful outcome cannot be expected with greater certainty. Thus the indication should be stringent when including this procedure within the possible treatment alternatives available to the clinician.

Mechanical aspects of a multidirectional, angular stable osteosynthesis system and comparison with four conventional systems.

BACKGROUND: Following open reduction, internal fixation of fractures of the mandible is predominantly achieved using plates and screws. Today, a multitude of osteosynthesis systems are available on the market. One therapy modality, primarily developed for orthopaedic surgery, is using angular stable osteosynthesis plate systems. The dominating principle of these is the bond between screw and plate following insertion. This principle of an "internal fixateur" results in a more stable fixation of the fragments associated with less compression of the bone surfaces. MATERIAL: A new multidirectional osteosynthesis system (TiFix=Smartlock, Hamburg - Germany) was modified to fit the maxillofacial region and compared with four other well established osteosynthesis systems developed by Mondial, Medicon, Synthes, Leibinger-Stryker, one of these (Unilock by Synthes) being also angular stable. The resistance to deformation in varying directions was investigated following fixation in four different materials. RESULTS: The TiFix system proved more resistant to deformation even when mounted with fewer screws than the non-angular stable systems. CONCLUSION: This system results in greater stability even when fewer screws are used. For the clinician this means smaller access incisions, less soft tissue trauma, better aesthetic results, decreased duration of operation and a reduction of costs.

Clinical implementation of a multidirectional, angular stable osteosynthesis system in maxillofacial traumatology.

AIM: To investigate whether a multidirectional, angular stable osteosynthesis system is suitable for the treatment of mandibular fractures and to compare it with well established available systems. MATERIAL AND METHODS: Following preliminary testing in an animal model, the multidirectional angular stable system TiFix 2.3 obtained from Litos (Hamburg, Germany) was utilised for internal fixation of 39 mandibular fractures. These involved four symphyseal fractures, 17 parasymphyseal, 16 of the angle of the mandible and two comminuted fractures. The surgical and postoperative course was closely scrutinised. Radiographs were taken after 6 months and all plates removed under local anaesthesia. Photographs were taken intraoperatively and the plates and surrounding soft tissues were salvaged for histological analysis. Additionally, these operations were compared with treatment of equivalent fractures which were treated with conventional, non-angular stable systems. The relative costs have also been evaluated. RESULTS: In 33 of the 39 fractures one TiFix plate sufficed for osteosynthesis. The plate most often used was a 2-hole plate which was applied in 25 (55.5%) fractures, followed by the 4-hole plates used in 16 (35.5%) fractures. In two comminuted fractures, four 6-hole plates were used (9%). In 17 patients the operation lasted less than 30 min, in 20 patients less than 60 min, in two less than 120 min. In all cases, the operations were shorter, and due to the plates' dimensions fewer screws had to be used, thus reducing the costs. DISCUSSION: This angular stable system enabled reduction of the amount of the implant material. Also reduced were the operation time and the cost of the procedure. Furthermore, in the future it will allow smaller access incisions and better preservation of the soft tissue integrity.

The medial approach to the fibula: a feasible alternative.

PURPOSE: Since the first harvesting of a microsurgical fibula in 1974 by Ueba and in 1975 by Taylor, using the fibula for osseous reconstruction has proven to be a valuable approach. The harvesting technique, which has been refined by subsequent investigators, has become increasingly standardized, today providing a clear, reproducible method. The procedure involves elevating the fibular graft from lateral, choosing the shortest route to reach the fibula. One disadvantage of this approach is that the bone often obstructs visualization of the vascular pedicle, which lies medially, promoting unintentional injury. In addition, this method is associated with some donor site morbidity, prompting further investigations into accessing the fibula. Here we present an alternative approach for harvesting the fibula and highlight the pros and cons of each approach. PATIENTS AND METHODS: Between 1999 and 2006, a total of 38 microsurgical (23 for the mandible, 9 for the extremities, and 6 for the maxilla) fibula grafts were harvested through the medial approach. RESULTS: In all cases, the patency of the posterior tibial, peroneal vessels, and the tibial nerve could be visualized. Two flaps failed (both mandible, for a success rate of 94.7%). No ischemic or wound healing complications of the lower limb were observed. CONCLUSIONS: The medial approach for harvesting the fibula is a feasible alternative to the lateral approach and provides the surgeon with a comparable likelihood of success. If for some reason access from the lateral approach is contraindicated, then the medial route should be considered.

Major mandibular surgical procedures as an indication for intraoperative imaging.

PURPOSE: This study investigated 3-dimensional (3D) imaging with intraoperative cone beam computed tomography (CBCT) in major mandibular reconstruction procedures. PATIENTS AND METHODS: The study group was comprised of 125 patients (83 males, 42 females) admitted for surgical treatment of the mandible. The patients ranged in age from 3 months to 91 years (average age, 40.72 +/- 22.843 years). Surgical procedures of the mandible were subdivided into repair of body fractures (17 patients), angle fractures (21 patients), condylar fractures (14 patients), and multiple fractures (30 patient). In addition, the study group included 21 patients undergoing orthognatic surgery and 22 undergoing reconstructive surgery on the mandible. Intraoperatively, 3D images were generated with a mobile CBCT scanner (Arcadis Orbic 3D; Siemens Medical Solutions, Erlangen, Germany). RESULTS: During open reduction of mandibular fractures, not all fracture sites can be readily exposed for direct visual control. For example, the lingual cortical bone of the mandible is difficult to assess intraoperatively. This structure and others can be effectively visualized using the 3D mode of CBCT. Furthermore, screw placement can be evaluated, specifically in insertions near the alveolar nerve. The intraoperative acquisition of the data sets is uncomplicated, and the image quality is sufficient to allow evaluation of the postoperative result in all cases. CONCLUSION: Intraoperative CBCT has proven to be a reliable imaging technique for providing visual control during major mandibular procedures.

Retrospective assessment of the peri-implant mucosa of implants inserted in reanastomosed or free bone grafts from the fibula or iliac crest.

PURPOSE: To investigate the susceptibility of implants to inflammation following autogenous bone transplantation and to evaluate whether various factors affect outcomes. MATERIALS AND METHODS: This retrospective cross-sectional clinical investigation involved patients who were treated between the years 1994 and 1996. The donor site, mode of transplantation, primary disease, gender, smoking habits, and age were evaluated with respect to outcomes. Clinical and radiologic assessments were the basis for the classification into 3 categories: (1) no inflammation, (2) mucositis, and (3) peri-implantitis. Lost implants were also noted. The data were evaluated statistically to determine whether significant differences existed. RESULTS: Forty-three patients (23 men and 20 women) were involved in this retrospective study. These patients received a total of 216 oral implants over a follow-up time of 8 to 10 years. Depending on the type of reconstruction, rates of peri-implant inflammation between 9% and 38% were observed. For mucositis, rates of 16.3% to 24.1% were seen, and 30% to 70.9% of sites showed no inflammation. CONCLUSION: High rates of soft tissue inflammation adjacent to implants were observed. The choice of donor site in conjunction with the mode of transplantation seemed to influence the development of peri-implant inflammation. The microsurgically reanastomosed fibula seemed most resistant to inflammatory processes, followed by the microsurgically reanastomosed iliac crest, free iliac crest, and free fibula. No significant differences could be observed for primary disease. These findings should be taken into consideration prior to surgery and when establishing individual recall systems.