Mandibular growth after paediatric mandibular reconstruction with the vascularized free fibula flap: a systematic review

Abstract

The reconstruction of mandibular defects with vascularized fibula flaps remains challenging in the paediatric population. The ability of the reconstructed mandible to grow remains controversial, and associated factors are unclear. A systematic search of the English-language and Chinese literature was conducted for the period January 1989 to April 2014 using selected key words associated with the topic. Individual patients aged <18 years who underwent mandibular reconstruction with the vascularized fibula flap and had known outcomes related to growth potential were included. Data on postoperative growth and associated factors, including condylar management, age at reconstruction, malignancy, and postoperative radiotherapy or chemotherapy, were reviewed systematically. In total, 51 patients reported in 15 articles were included. The proportion of patients with a preserved growth potential (58.8%) was higher than that of patients with no growth potential. Condylar preservation and reconstruction during the rapid growth period showed a trend towards an influence on the growth potential. Reconstruction after benign lesion resection seemed to facilitate postoperative growth, while postoperative radiotherapy inhibited growth. Reconstruction after benign lesion resection, reconstruction between 8 and 12 years of age, and condylar preservation facilitate postoperative mandibular growth, while postoperative radiotherapy inhibits the same.

The vascularized fibula flap was first introduced by Hidalgo in 1989, and since then it has become a popular graft for use in mandibular reconstruction. Compared with non-vascularized flaps, vascularized flaps offer the advantages of a minimal infection risk, a low absorption rate, the possibility of simultaneous implant insertion, and the ability to reconstruct soft tissue defects. Furthermore, vascularized fibula flaps can adapt to bone defects of various shapes and provide large vessel length and calibre for microvascular anastomosis and a double cortex layer for implant stability. Therefore, this flap is considered feasible for adult mandibular reconstruction.

However, mandibular reconstruction in the paediatric population remains a challenge, although it is gradually evolving with the development of appropriate anaesthesia techniques. Paediatric mandibular reconstruction with the vascularized fibula flap was first reported in 1993. Although the above-mentioned advantages, along with the high survival rate and minimal donor site morbidity, have lent immense popularity to this flap, the postoperative growth potential of the neomandible remains controversial. This uncertainty stems from several factors. Because the condyle is considered to be the growth centre for the entire mandible, its involvement by the lesion and preservation during surgery may affect the outcomes to a large extent. Patient age, which is related to the growth rate, is another potential contributing factor, along with factors such as malignancy and postoperative radiotherapy and chemotherapy. Impaired growth after surgery may affect functional and cosmetic outcomes, possibly leading to malocclusion and facial asymmetry. Such undesired outcomes, in turn, may affect nutrient ingestion, general health, and even the self-esteem of the child throughout life. However, there appears to be no systematic review on this topic available in the literature.

Therefore, this systematic review was conducted to evaluate the mandibular growth potential after reconstruction using the vascularized fibula flap in children. Details relevant to postoperative growth and associated influencing factors were collected, and the general outcomes and effects of those factors were assessed.

Patients and methods

Study identification

An initial online search of the PubMed, Ovid, and Embase databases for English-language articles and of the China National Knowledge Infrastructure (CNKI) and Chinese Scientific and Technological Journal (VIP) databases for Chinese publications was conducted for the period January 1989 to April 2014. A broad search strategy was implemented, utilizing the following key words: ‘mandibular reconstruction’, ‘paediatric’, ‘mandibular defects in children’, ‘vascularized fibula flap’, and ‘free fibula flap’. Two reviewers screened the titles and abstracts of the articles retrieved. Full-text articles were obtained for relevant studies and studies where the title and abstract information was insufficient to allow a consensus. The reference lists were also screened, and relevant citations were included in the next round.

Study selection

Two reviewers obtained and evaluated the full-text of articles retrieved during the first search round and from the reference list search. The following inclusion criteria were applied: individual age at reconstruction of <18 years, mandibulectomy and reconstruction with the vascularized fibula flap as the primary clinical procedure, and available follow-up data on the postoperative mandibular growth potential. The exclusion criteria were as follows: age >18 years, preoperative radiotherapy or chemotherapy, and no data on the growth ability of the grafted fibula segment. Articles in languages other than English and Chinese were also excluded.

During the retrieval procedure, the first reviewer reviewed the abstract and selected studies according to the inclusion and exclusion criteria. The second reviewer then reviewed and checked all the abstracts again and made his selection using the same criteria. The entire text of all selected studies was reviewed again by both reviewers in detail. Any differences were then discussed in consultation with a third party, until consensus was reached.

Study design

Considering the dearth of studies on the selected topic, those included in this review were limited to retrospective studies and case reports. There was no restriction on the publication date or status.

Outcome measures

Data on specific variables, including patient age, sex, pathological characteristics (benign or malignant), condylar management, postoperative radiotherapy or chemotherapy, follow-up period, and outcomes related to neomandibular growth or facial symmetry, were collected from each article. Cases reported from the same medical centre were contrasted to match and identify duplicate patient cases. The outcomes reported in the most recent study were adopted for such cases.

Data extraction and analysis

The first reviewer collected the data and imported it into an electronic database (Microsoft Excel). The second reviewer checked the extracted data for omissions or inaccuracies. The two reviewers discussed any differences and arrived at a consensus after consultation with a third party.

For the selected studies, preserved growth potential or postoperative growth potential was identified as an obvious actual subsequent growth after surgery. When a study included patients with both condylar resection and preservation, patients with preservation were classified into a ‘condyle preserved’ group, while those with resection were classified into a ‘condyle resected’ group.

A systematic review was conducted for patients with available postoperative growth potential data. The following factors were evaluated: age, condylar management (preserved or resected), pathological characteristics (benign or malignant), and postoperative radiotherapy or chemotherapy. According to the results of an anthropology study, children aged from 8 to 12 years show a high-level mandible growth rate, thus this period was termed the rapid growth stage. Based on this theory, the patients were divided into three age groups: 0–8, 8–12, and 12–18 years. The research and review strategy adopted in this study is presented in Fig. 1 .

Fig. 1
Flowchart of the search strategy and data retrieval process used in this study.

Results

In total, 548 articles (167 in English and 381 in Chinese) were reviewed. Among these, 15 articles reporting the cases of 51 patients met the study inclusion criteria and were retrieved. Details of these 51 patients are presented in Tables 1 and 2 .

Table 1
Details of the 51 cases (15 articles) analysed in this study.
First author No. Age, y Sex Diagnosis Malignancy Extension of the lesion Condyle involved Postop. XRT Postop. Chemo Follow-up Outcome
Posnick, Iconomou, Phillips 1 6 F Intraosseous arteriovenous malformation Benign Left parasymphysis to left ramus; 5 cm No No No 15 y Growth
Posnick, Iconomou, Phillips 2 6 M Primitive neuroectodermal tumour Malignant Left parasymphysis to right angle; 10 cm No No Yes 14+ y Growth arrested
Iconomou, Phillips 3 7 M Recurrent aggressive fibromatosis Benign Right parasymphysis to right condyle;12 cm Yes No No 15 y Growth arrested
Iconomou, Phillips 4 17 F Ewing sarcoma Malignant Left parasymphysis to left subcondyle; 10 cm No NA NA 6+ y Growth arrested
Iconomou, Phillips 5 17 F Hemifacial microsomia and frontal dysplasia Benign Left angle to left condyle; 8 cm Yes No No 6+ y Growth arrested
Iconomou, Phillips 6 3 M Fibrous dysplasia/ossifying fibroma Benign Right parasymphysis to left angle; 9 cm No No No 6+ y Growth arrested
Phillips, Fenton 7 5 M Metastatic retinoblastoma Malignant Left body to right body No NA Yes 4 y Growth arrested
Olvera-Caballero 8 10 M Giant dental cyst Benign Left condyle to midline Yes NA NA 1 y Growth
Olvera-Caballero 9 10 M Osteoid osteoma Benign Chin to the right ascending ramus No NA NA 1 y Growth
Olvera-Caballero 10 15 F Ameloblastoma Benign Chin to the right mandibular angle No NA NA 1 y Growth
Olvera-Caballero 11 10 M Ossifying fibroma Benign Left mandible body to left condyle Yes NA NA 1 y Growth
Olvera-Caballero 12 11 M Osteomyelitis Benign Right mandible body to right condyle Yes NA NA 1 y Growth
Olvera-Caballero 13 9 M Loss of bone after wound infection Benign Right mandible body No NA NA 1 y Growth
Genden 14 8 M Aggressive juvenile fibromatosis Benign Left ramus, body, and hemisymphyseal portion of mandible No No No 4 y 2 mo Growth
Nahabedian 15 10 M Ameloblastoma of the right mandible Benign Right angle to the condylar neck No NA NA 18 mo Growth
Warren 16 6 M Fibrous dysplasia Benign Right mandibular angle to left parasymphyseal area No NA NA 9–14 y Growth
Bilkay 17 14 M Osteosarcoma Malignant Mandible body No NA NA 2 y Growth
Crosby 18 12 F Rhabdomyosarcoma Malignant Left condyle, 10 cm Yes No No 10 y Growth
Crosby 19 5 M Desmoid fibromatosis Benign Left neck to parasymphysis, 6 cm No No Yes 6 y 5 mo Growth
Crosby 20 7 M Giant cell granuloma Benign Right angle to left mid-body, 10 cm No No No 4 y 9 mo Growth
Crosby 21 5 F Ewing sarcoma Malignant Right mandible, 7 cm Yes No No 4 y 9 mo Growth arrested
Crosby 22 14 M Desmoid fibromatosis Benign Parasymphysis to body, 10 cm No No No 2 y 8 mo Growth arrested
Crosby 23 14 M Osteosarcoma Malignant Left mandible, 8 cm Yes Yes Yes 2 y 4 mo Growth
Crosby 24 12 F Rhabdomyosarcoma Malignant Left mandible, 7 cm Yes No No 2 y Growth arrested
Crosby 25 6 M Desmoid fibromatosis Benign Right parasymphysis to left angle, 9 cm No No No 1 y 7 mo Growth
Crosby 26 13 M Ewing sarcoma Malignant Left mandible, 10 cm Yes No No 1 y 6 mo Growth
Crosby 27 13 F Ameloblastoma Benign Parasymphysis to parasymphysis, 6 cm No No No 11 mo Growth
Crosby 28 9 F Ameloblastoma Benign Right mandible, 16 cm No No No 9 mo Growth
Guo 29 18 NA Hemifacial microsomia, type 3 Benign NA NA No No 2+ y Growth arrested
Guo 30 16 NA Lymphoepithelioma Benign NA NA Yes Yes 2+ y Growth arrested
Guo 31 15 F Hemifacial microsomia, type 3 Benign Left ramus and condyle Yes No No 2+ y Growth arrested
Guo 32 8 NA Fibrosarcoma Malignant NA NA Yes No 2+ y Growth arrested
Guo 33 4 NA Gunshot wound to neck, chin Benign NA NA No No 2+ y Growth arrested
Guo 34 13 NA Ewing sarcoma Malignant NA NA No No 2+ y Growth arrested
Guo 35 11 F Ewing sarcoma Malignant Whole mandible Yes No Yes 2+ y Growth arrested
Guo 36 17 NA Rhabdomyosarcoma Malignant NA NA Yes Yes 2+ y Growth arrested
Guo 37 8 M Rhabdomyoma Benign Hemimandible Yes No No 2+ y Growth arrested
Guo 38 5 NA Neuroectodermal tumour Benign NA NA Yes No 2+ y Growth arrested
Guo 39 3 NA Rhabdomyosarcoma Malignant NA NA Yes Yes 2+ y Growth arrested
Guo 40 10 mo NA Germ cell tumour Malignant Right hemimandible Yes No Yes 2+ y Growth arrested
Sinno 41 1.7 M Fibromatosis (desmoid tumour) Benign Left mandible, 37 cm × 23 cm × 23 cm No NA NA 6 y Growth
Li 42 12 F Ameloblastoma Benign Right angle to left body, approximately 10 cm No NA NA 23 mo Growth
Li 43 13 F Ossifying fibroma Benign Lateral segment without condyle No NA NA 18 mo Growth
Li 44 14 M Ameloblastoma Benign Lateral segment without condyle No NA NA 16 mo Growth
Li 45 14 M Ameloblastoma Benign Hemimandible segment with condyle Yes NA NA 24 mo Growth
Li 46 15 F Fibrous dysplasia Benign Central segment No NA NA 28 mo Growth
Li 47 12 F Ameloblastoma Benign Lateral segment without condyle No NA NA 36 mo Growth
Bianchi 48 16 M Ewing sarcoma Malignant Right second premolar to right condyle Yes No Yes 6 y Growth
Bianchi 49 14 M Chronic sclerosing osteomyelitis Benign Left canine to left condylar neck No No No 6 y Growth
Bianchi 50 8 M Embryonal rhabdomyosarcoma Malignant Right second premolar to right condyle neck No No Yes 5 y Growth
Pierse 51 15 M Ganglioneuroma Benign Right condylar neck to right first premolar No No No 1 y Growth
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Jan 16, 2018 | Posted by in Oral and Maxillofacial Surgery | Comments Off on Mandibular growth after paediatric mandibular reconstruction with the vascularized free fibula flap: a systematic review
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