Autogenous non-vascularized bone graft in segmental mandibular reconstruction: a systematic review

Abstract

The restoration of mandibular bone defects with non-vascularized bone grafts depends on the diagnosis, anatomical site, extent of the defect, and the patient’s age, as well as the surgeon’s experience. The aim of this study was to perform a systematic literature review on mandibular reconstruction for segmental mandibular bone defects using non-vascularized bone grafts to answer the following question: Is there scientific evidence to support the use of this technique? The initial literature search in PubMed, Scopus, and Cochrane databases identified 862 articles. Of these, 25 were included in the final review. These articles encompassed 926 procedures with non-vascularized bone grafts; 76.1% were from the iliac crest. Benign tumours were the major cause of these defects (56.8%), and 44.7% of defects were located in the lateral mandibular area. Although this technique showed a high occurrence of complications (290 in 873 patients, some with more than one complication), these did not account for treatment failure. The restoration of bone defects due to malignant tumours treated with radiation therapy had lower success rates, and these appear to be a contraindication for the technique. Although standardized randomized controlled clinical studies are needed to obtain better clinical evidence for treatment choices in general, the use of non-vascularized bone grafts for mandibular reconstruction showed an 87.6% success rate in this review.

Mandibular bone defects due to resections for a pathology or trauma result in a loss of bone continuity and create a ‘socially mutilated’ patient due to the significant loss of function and aesthetics. The treatment of these defects should preferably be performed by means of immediate bone reconstruction, with the aim of maintaining facial contours, aesthetics, and function, with correct maxillomandibular positioning. The restoration of mandibular segmental defects can be done with either non-vascularized or vascularized grafts.

Although vascularized grafts are the best reconstruction technique because of the graft blood supply and soft tissue support, they do have limitations and do not assure the best procedure results. High costs, a longer surgical time, the need for two specialized surgical teams, morbidity, complications, and a longer hospital stay are some of the disadvantages presented by this technique.

Reconstruction using non-vascularized grafts is preferable in cases of minor defects, preserved mandibular continuity, or benign tumours. Some available donor sites are the iliac crest, ribs, tibia, fibula, calvaria, and sternum. The iliac crest is most often used due to the ease of access and availability of cortical and medullary bone; also, when used properly, such grafts can facilitate dental implant placement and prosthetic rehabilitation.

However, there is no consensus on the success and complication rates with the use of non-vascularized graft reconstruction: the success rate varies between 46% and 100% and the complication rate between 20% and 35%. This wide variety of results can be explained by the various existing variables in the planning and surgery itself that can lead to procedure failure. Currently, mandibular reconstruction with non-vascularized grafts relies on the surgeon’s experience and familiarity with the technique.

The aim of this study was to perform a systematic review of the literature on mandibular reconstruction for segmental bone defects using non-vascularized bone grafts to answer the following question: Is there scientific evidence to support the use of this technique?

Materials and methods

Search strategy and selection criteria

An initial literature search in PubMed (MEDLINE), Scopus, and Cochrane Library databases was performed by scanning the subject of interest through four lines of search elements: (1) ‘mandibular defect’ AND ‘non-vascularized bone graft’, (2) ‘mandibular defect’ AND ‘nonvascularized bone graft’, (3) ‘mandibular defect’ AND ‘non vascularized bone graft’, (4) ‘mandibular defect’ AND ‘free bone graft’.

For the initial selection, three independent reviewers (LBM, PHAC, and OLCJr) analysed the title and/or abstract against the following inclusion criteria: studies on humans, specific studies using non-vascularized grafts for segmental mandibular defect restoration, studies reported in English, and a case series, retrospective study, or prospective study design; there was no time restriction with regard to publication date.

After the initial selection, the three examiners read the full-text articles using the same selection criteria to determine the final inclusion or exclusion of studies. Disagreements between reviewers were settled by further discussion. All selection criteria were established prior to the start of the study.

Data collection

Data from selected studies were collected by the examiners, and the following variables were included: type of study, donor site, mandibular involvement according to the HCL classification proposed by Jewer et al., size and cause of the defect, postoperative complications, and the success rate. Data were analysed by descriptive statistics.

Quality evaluation

The evaluation of methodological quality was performed using the PRISMA statement criteria to verify the strength of the scientific evidence available in the current literature for clinical decision-making. The following criteria were used to classify the potential risk of bias of each study, as applied in previous reviews : random selection in the population (sample), definition of inclusion/exclusion criteria, report of losses to follow-up (monitoring, follow-up), validated measurements obtained, and statistical analysis. Studies meeting all of these criteria were classified as having a low risk of bias; those that did not meet one of the criteria were classified as having a moderate risk of bias and those that did not meet two or more criteria were classified as presenting a high risk of bias.

Results

The electronic search was conducted on 5 January 2015 and 862 articles were identified. Thirty-nine articles were classified as relevant after reading the title and/or abstract. One full-text article could not be obtained ; the full texts of the remaining 38 studies were evaluated against the previously established inclusion criteria. Thirteen articles did not meet one or more criteria for inclusion and were excluded from the study. At the end of the selection process, 25 articles were included. A flowchart of the selection and inclusion process is given in Fig. 1 .

Fig. 1
Flowchart of the systematic review process.

Of the articles included in the final review, 21 were retrospective studies, two were prospective, and two were case series. In the quality evaluation, three articles showed a low risk of bias, seven showed a moderate risk of bias, and 15 showed a high risk of bias ( Table 1 ).

Table 1
Quality assessment of the studies.
Year Author and reference Random selection in population Defined inclusion/exclusion criteria Report loss to follow-up Validated measurements Statistical analysis Estimated potential risk of bias
2014 Akbay and Aydogan Yes No No Yes Yes High
2014 Ndukwe et al. Yes No No Yes No High
2013 Ahmad and Choudhary Yes No No No No High
2013 Bai et al. Yes Yes Yes Yes No Moderate
2013 Magesh et al. Yes Yes No Yes Yes Moderate
2012 Guerrier et al. Yes Yes Yes Yes Yes Low
2012 Okoje et al. Yes Yes No Yes Yes Moderate
2011 Gadre et al. Yes Yes Yes Yes No Moderate
2011 Handschel et al. Yes No No Yes Yes High
2011 Rana et al. Yes Yes Yes Yes Yes Low
2010 Maurer et al. Yes No No Yes Yes High
2010 Mooren et al. Yes Yes Yes No No High
2010 Ogundale et al. Yes No No No No High
2009 Van Germet et al. Yes No Yes Yes Yes Moderate
2008 Chiapasco et al. Yes Yes Yes Yes Yes Low
2003 Jin et al. Yes Yes No Yes Yes Moderate
1999 Foster et al. Yes No No Yes Yes High
1999 Schliephake et al. Yes No Yes Yes Yes Moderate
1997 Pogrel et al. Yes No No Yes Yes High
1996 Holtz Yes No Yes Yes No High
1996 Shirota et al. No No No No No High
1994 Cheung et al. Yes No No Yes Yes High
1992 El-Sheikh et al. Yes No No Yes No High
1990 Tidstrom and Keller No No No Yes No High
1980 Giordano et al. Yes No Yes Yes No High

Table 2 shows the data collected and the results of all of the studies included in the review. In all, 926 non-vascularized mandibular reconstruction grafts were performed. The most frequent donor site was the iliac crest ( n = 705, 76.1%), followed by the ribs ( n = 150, 16.2%) and fibula ( n = 52, 5.6%); calvaria, sternum, and scapula grafts, as well as combinations of grafts, were also used.

Table 2
Descriptive analysis of the studies included in the final review.
Year Author and reference Type of study Graft performed Number of patients Defect classification (HCL) Defect size, cm Aetiology Complications Success rate (%)
2014 Akbay and Aydogan Retrospective 9 iliac crest
1 scapula
1 fibula
11 7 L
2 C
2 LCL
1.5–14.0
Mean 5.0
2 benign tumours
9 gunshot injuries
2 infections
2014 Ndukwe et al. Retrospective 17 rib
8 iliac crest
25 10 LCL
8 LC
4 L
2 H
1 C
24 benign tumours
1 gunshot injury
8 infections
3 graft loss
2 dehiscence
88.0
2013 Ahmad and Choudhary Retrospective 50 rib 50 50 benign tumours 2 infections
1 graft loss
90.0
2013 Bai et al. Retrospective 7 particulate iliac crest 7 3 L
3 LC
1 C
6.0–13.0
Mean 9.1
7 benign tumours No complications 100.0
2013 Magesh et al. Prospective 13 iliac crest 13 13 benign tumours 2 infections
2 dehiscence
100.0
2012 Guerrier et al. Retrospective 35 iliac crest 35 14 L
9 LCL
7 LC
5 C
16 grafts <5.0
19 grafts >5.0
35 gunshot injuries 3 total graft loss
4 partial graft loss
80.0
2012 Okoje et al. Retrospective 47 iliac crest 47 21 L
12 LC
8 H
6 C
42 benign tumours
3 malignant tumours
1 trauma
1 gunshot injury
12 infections
4 dehiscence
89.4
2011 Gadre et al. Retrospective 68 iliac crest
16 fibula
3 rib
87 47 L
27 LC
11 HC
2 H
54 benign tumours
33 malignant tumours
10 graft loss
8 dehiscence
7 infections
3 recurrence
88.5
2011 Handschel et al. Retrospective 84 iliac crest 84 55 L
17 LC
12 C
Mean 4.9 ± 2.1 57 malignant tumours
23 benign tumours
1 osteomyelitis
1 trauma
2 other causes
27 infections
6 dehiscence
5 fixation failure
7 other complications
75.0
2011 Rana et al. Retrospective 80 iliac crest
39 rib
31 fibula
16 sternum
166 30 graft loss
18 infections
81.9
2010 Maurer et al. Retrospective 26 iliac crest
4 fibula
30
2010 Mooren et al. Retrospective 20 iliac crest associated with particulate iliac crest 20 2.0–12.0 10 malignant tumours
7 benign tumours
3 trauma
3 dehiscence
3 infections
85.0
2010 Ogundale et al. Retrospective 37 iliac crest 37 36 benign tumours
1 gunshot injury
10 infections 91.9
2009 Van Germet et al. Retrospective 74 iliac crest 74 42 L
29 LC
2 C
1 LCL
29 benign tumours
26 malignant tumours
8 osteomyelitis
7 osteoradionecrosis
27 infections 75.7
2008 Chiapasco et al. Retrospective 14 iliac crest
2 calvaria
16 5 L
5 LC
3 H
2 C
1 HC
14 benign tumours
2 malignant tumours
1 fixation failure
1 dehiscence
93.7
2003 Jin et al. Retrospective 15 iliac crest 15 5 LC
4 L
4 H
1 C
1 LCL
15 benign tumours 4 infections
1 fixation failure
1999 Foster et al. Retrospective 22 iliac crest
4 particulate iliac crest
2.5–11.0
Mean 8.1
21 benign tumours
3 malignant tumours
2 osteoradionecrosis
8 graft loss 69.2
1999 Schliephake et al. Retrospective 23 iliac crest 23 2.0–12.0
Mean 6.7
20 malignant tumours
3 benign tumours
1997 Pogrel et al. Retrospective 22 iliac crest
4 particulate iliac crest
3 rib
29 3.0–14.0
Mean 8.3
20 benign tumours
5 malignant tumours
3 infections
1 trauma
8 graft loss
3 infections
75.9
1996 Holtz Retrospective 10 iliac crest 10 4 H
2 LC
2 L
1 C
1 LCL
4.0–14.0
Mean 9.0
No complications 100.0
1996 Shirota et al. Prospective 7 particulate iliac crest
3 iliac crest
10 4 LC
4 L
2 C
9 malignant tumours
1 benign tumour
No complications 100.0
1994 Cheung et al. Retrospective 20 particulate iliac crest
2 particulate iliac crest associated with rib
22 12 LC
4 L
3 C
1 LCL
1 H
1 HC
3.5–12.5
Mean 7.5
7 benign tumours
7 malignant tumours
3 osteoradionecrosis
1 osteomyelitis
4 reoperations
7 plate removal
3 infections
3 dehiscence
2 positive margin
1 recurrence
2 other complications
72.7
1992 El-Sheikh et al. Retrospective 38 rib 38 14 H
8 LC
8 L
6 C
2 LCL
33 benign tumours
2 malignant tumours
3 other causes
15 aesthetic loss
7 graft loss
5 fixation removal
1 recurrence
94.7
1990 Tidstrom and Keller Case series 34 iliac crest 34 10 LC
10 LCL
6 L
5 H
2 C
1 HC
17 infection/trauma
11 malignant tumours
6 benign tumours
4 infections
1 graft loss
1 dehiscence
1 fixation failure
100.0
1980 Giordano et al. Case series 17 particulate iliac crest 17 12 L
4 C
1 LCL
2.0–12.0
Mean 4.2
9 gunshot injuries
8 trauma
1 infection
1 plate removal
88.2
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Dec 15, 2017 | Posted by in Oral and Maxillofacial Surgery | Comments Off on Autogenous non-vascularized bone graft in segmental mandibular reconstruction: a systematic review
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