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GOOD AFTERNOON

JOURNAL CLUB 05

PRESENTED BYDR. RAHUL TIWARI

FINAL YR. MDSOMFS, SIDS

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TITLE

A COMPARISON OF BONE RESORPTION OVER TIME. AN ANALYSIS OF THE FREE SCAPULAR, ILIAC

CREST AND FIBULAR MICROVASCULAR FLAPS IN MANDIBULAR RECONSTRUCTION

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ANTERIOR

ILEAC

CREST

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SCAPULAR GRAFT

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FIBULA

GRAFT

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J AO

RU TR & IN CA

L L

E

• JOMS• 6 September 2016• Tommy Wilkman, MD, DDS• University of Helsinki, Finland.• Retrospective study• Key words:• DCIA, • Scapula, • Fibula, • Free flap, Microvascular, • Mandibular reconstruction,• Resorption, Volume analysis

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AIM• Compare the resorption of the bone – • free scapular• free iliac crest • free fibular microvascular flaps

•mandibular reconstruction over time.

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INTRODUCTION• Composite microvascular tissue is considered gold standard in reconstructive

surgery of ablative or traumatic defects of the head and neck area

• The most frequently used osteomyocutaneous free flaps are the fibula, the scapula and the iliac crest (DCIA).

• Earlier studies of bone resorption and remodeling after microvascular bone transfer have mainly been based on measurements of panoramic radiographs

• This method of imaging, does not allow three-dimensional analysis.

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INTRODUCTION• Previously, assessments have been performed on measurements

of the height or width of the flap, but not on the actual volume.

• In general, these studies have only reported minor resorption of the osseous parts.

• The resorption is fastest during the first 6-12 months and seems

to decline later, but evidence exists that lesser changes may occur later on.

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REVIEW OF LITERATURE

• 48 patients - Resorption - Fibula < Ileac < Scapular

1999

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MATERIALS & METHODS• 186 patients – Onco - 136 mandibular, 44 maxillary, and 7 orbital

reconstructions.• Only mandibular included • 73 free iliac crest (DCIA) flaps • 34 scapular flaps • 23 fibular flaps.• Six radial and metatarsal bone flaps were excluded• MSCT or MRI at 6, 12 and 24 months• Advantage Workstation software 4.4. (GE Healthcare) - 1.0, 2.0, or 2.5 mm

thick reformatted axial images.

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BONE THICKNESS & HEIGHT• Volume analysis (in mm.) – 10 mm. from osteotomy.• 17 patients had postoperative CT with a different protocol excluding them from

the volume analysis. • Patients followed using magnetic resonance imaging (MRI) or pan tomography

were excluded from the analysis.• Thus, a total of 38 patients, 22 men and 16 women, were included in the study• 2 pt. - benign odontogenic tumor (ameloblastoma), 1- vascular malformation.• 35 - malignant disease.• Double blind study – By Author & Radiologist.• Statistics - Pearson´s correlation coefficient, Mann-Whitney, Fisher´s exact test,

SPSS 20.

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STATISTICS – BONE VOLUME ANALYSIS

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RESULTS• 38 patients fulfilled the study criteria. • Resorption of the osseous flaps was found to continue for several years. • At 2 years, the volume loss- • 14% for the scapula• 3% for the DCIA• 1% for the fibula. • 3D volume analysis of MSCT showed more resorption than 2D analyses of the

radiographs.• Postoperative radiation therapy, age or patient gender did not correlate with

the resorption of the bone.

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DISCUSSION• All these flaps sustained substantially greater volume than non-

vascularized grafts where a 50% resorption is to be expected after only 6 months.• Postoperative radiation therapy did not accelerate the resorption of

the bone transplant.• The scapula is a thin bone with a thicker and quite durable lateral

edge• The DCIA is a thicker block• The fibula has a rounded triangular shape of the cross section.

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OBSERVED LIMITATIONS• Low number of patients enrolled.

• This in caused by using several imaging modalities in the follow-up

•Varying schedules for the imaging.

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CONCLUSION• In microvascular mandibular reconstruction the volume reduction

over time is smallest in the fibula and greatest in scapula, the DCIA in between.

• The volume reduction continues for several years in all of these.

• For assessment of In analyzing the volume reduction of osseal reconstruction a 3D volume analysis is more reliable than height by width measurement.

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REFERENCES

94 % SUCCESS RATE

Bone resoprtion was minimalGood Union with graft

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REFERENCES

178 Pt. - Fibula has less resorption Ileac crest

112 Pt. - The bone resorption rate was higher among avascular grafts

2016

2013

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REFERENCES

Fibular height can be maintained by preservation of a direct nutrient artery to bone marrow, avoidance of osteotomies, and delayed placement of osseointegrated dental implants, all of which inhibit fibular bone resorption.

2015

34 Pt. - The scapular chimeric flap is a reliable and versatile option in composite reconstructions of the head and neck region. 2016

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THANK YOU•