Foster R D, Anthony J P, Sharma A, Pogrel M A
Division of Plastic and Reconstructive Surgery, University of California at San Francisco, 94102, USA.
Head Neck. 1999 Jan;21(1):66-71. doi: 10.1002/(sici)1097-0347(199901)21:1<66::aid-hed9>3.0.co;2-z.
Functional restoration following resection or traumatic injury to the mandible depends on the reliability of the bony reconstruction to heal primarily and support endosseous implants. Although vascularized bone flaps (VBF) and nonvascularized bone grafts (NVBG) are both widely used to reconstruct the mandible, indications for each remain ill-defined. The purpose of this study was to compare bone graft/flap healing and success of implant placement in patients reconstructed with VBF versus NVBG.
Over the past 10 years, 75 consecutive mandibular reconstructions were performed (26 free bone grafts, 49 vascularized bone flaps). Etiology of the defect, history of irradiation, bone defect size, number of operations, graft/flap success, and dental implant success rates were determined and compared. Bone graft/flap success was defined as complete bony union. Implant success was defined as complete osseointegration. Mean follow-up was 3 years.
Free flaps were used primarily for malignant disease (78%, 38/49). Bone grafts were used primarily for benign disease (88%, 23/26). History of prior irradiation: 11% (3/26) NVBG versus 45% (22/49) VBF. Length of bony defect (mean): 8.1 cm NVBG versus 9.4 cm VBF. Successful bony union, any size defect: 69% (18/26) NVBG versus 96% (47/49) VBF (p < .0005); lateral defects only: 75% (15/20) NVBG versus 100% (17/17) VBF (p < .05). Number of operations to achieve bony union (mean), any size defect: 2.3 NVBG versus 1.1 VBF (p < .001); lateral defects only: 1.9 NVBG versus 1.0 VBF (p < .005). Twenty-two patients (29%) had a total of 104 endosseous implants placed (NVBG: 8 patients, 33 implants; VBF: 14 patients, 71 implants). Immediate implants placed: 0/33 NVBG versus 54% (38/71) VBF. Overall implant success: 82% (27/33) NVBG versus 99% (70/71) VBF (p < .0001). Implant success in VBF patients with a history of RT: 100% (15/15).
Despite the fact that patients reconstructed with VBFs were older, had larger defects, and were treated primarily for malignant disease and therefore had a higher incidence of irradiation to the affected mandible than in patients treated with NVBGs, the incidence of bony union was higher, requiring fewer operations to achieve union, and the implant success rate was significantly greater than for NVBG patients. Results were similar when considering lateral defects only. Based on these results, VBFs are indicated in most cases of mandibular reconstruction; NVBGs are effective for short bone defects (<5-6 cm), in nonirradiated tissue, and/or in patients determined to be too medically compromised to tolerate the additional operative time required for a free-flap reconstruction.
下颌骨切除或创伤性损伤后的功能恢复取决于骨重建的可靠性，以实现一期愈合并支持骨内种植体。尽管带血管蒂骨瓣（VBF）和非带血管蒂骨移植（NVBG）都广泛用于下颌骨重建，但每种方法的适应证仍不明确。本研究的目的是比较接受VBF与NVBG重建的患者的骨移植/骨瓣愈合情况及种植体植入成功率。
在过去10年中，连续进行了75例下颌骨重建手术（26例游离骨移植，49例带血管蒂骨瓣）。确定并比较缺损的病因、放疗史、骨缺损大小、手术次数、移植骨/骨瓣成功率和牙种植体成功率。骨移植/骨瓣成功定义为完全骨愈合。种植体成功定义为完全骨整合。平均随访时间为3年。
游离骨瓣主要用于恶性疾病（78%，38/49）。骨移植主要用于良性疾病（88%，23/26）。既往放疗史：NVBG为11%（3/26），VBF为45%（22/49）。骨缺损长度（平均值）：NVBG为8.1 cm，VBF为9.4 cm。任何大小缺损的成功骨愈合：NVBG为69%（18/26），VBF为96%（47/49）（p <.0005）；仅外侧缺损：NVBG为75%（15/20），VBF为100%（17/17）（p <.05）。实现骨愈合的手术次数（平均值），任何大小缺损：NVBG为2.3次，VBF为1.1次（p <.001）；仅外侧缺损：NVBG为1.9次，VBF为1.0次（p <.005）。22例患者（29%）共植入104枚骨内种植体（NVBG：8例患者，33枚种植体；VBF：14例患者，71枚种植体）。即刻种植：NVBG为0/33，VBF为54%（38/71）。总体种植体成功率：NVBG为82%（27/33），VBF为99%（70/71）（p <.0001）。有放疗史的VBF患者的种植体成功率为100%（15/15）。
尽管接受VBF重建的患者年龄较大、缺损较大，且主要因恶性疾病接受治疗，因此受影响下颌骨的放疗发生率高于接受NVBG治疗的患者，但骨愈合发生率更高，实现愈合所需的手术次数更少，且种植体成功率显著高于NVBG患者。仅考虑外侧缺损时结果相似。基于这些结果，VBF适用于大多数下颌骨重建病例；NVBG对短骨缺损（<5 - 6 cm）、未接受放疗的组织和/或被判定因医学原因无法耐受游离骨瓣重建所需额外手术时间的患者有效。
