Osteoradionecrosis of the mandible after oromandibular cancer surgery

Although postoperative radiotherapy has proved effective in improving local control and survival in patients with head and neck cancers, its complications, especially mandibular osteoradionecrosis, reduce the quality of life. Mandibular surgery before the radiotherapy adds an additional risk factor for osteoradionecrosis. This study reviews patients in Chang Gung Memorial Hospital, Taipei, Taiwan, over a 10-year period, who underwent intraoral cancer resection followed by postoperative radiotherapy and thereafter developed osteoradionecrosis of the mandible. A total of 24 men and three women with a mean age of 49.9 years were identified and included in the study. In 10 cases, tumor resection was performed with a marginal mandibulectomy; in eight cases, tumor resection was performed after mandibular osteotomy; and in three cases, a segmental mandibulectomy was performed, and the defect was reconstructed with a fibula osteoseptocutaneous flap. In six cases, tumor excisions were performed without interfering with the mandibular continuity. Patients received postoperative external beam radiotherapy into the primary site and the neck, with a mean dose (+/-SD) of 5900 +/- 1300 cGy in an average of 35 fractions during an average of 6.5 weeks. The average elapsed time between the end of radiation therapy and clinical diagnosis of osteoradionecrosis of the mandible was 11.2 months (range, 2 to 36 months). The time elapse between the end of the radiation therapy and the diagnosis of osteoradionecrosis was influenced by initial treatment (Kruskal-Wallis test: n = 27, chi-square = 12.884, p < 0.005), and this period was shorter if the mandibular osteotomy or marginal mandibulectomy was performed (the two lowest mean ranks in the test). However, if the initial surgery resulted in a segmental mandibulectomy reconstructed with a fibula osteoseptocutaneous flap, onset of the osteoradionecrosis was relatively late (Kruskal-Wallis test: n = 21, chi-square = 7.731, p = 0.052). After resection of osteoradionecrotic bone and surrounding soft tissue, 22 patients underwent reconstructive procedures with a fibula osteoseptocutaneous flap, and five patients underwent reconstructive procedures with an inferior genicular artery osteoperiosteal cutaneous flap. One fibula osteoseptocutaneous flap showed total failure and another showed a 25 percent skin loss; both were revised with pedicled flaps. The skin paddle of an inferior genicular artery flap was replaced with an anterolateral thigh flap because of anatomic variation of the skin vessel. Once the diagnosis of osteoradionecrosis is established, replacement of the dead bone and surrounding tissue with a vascularized free bone flap is inevitable, and a composite osteocutaneous free flap is a good option.     

Prosthetic rehabilitation of a patient with mandibular resection prosthesis using mini dental implants (MDIs)--case report

Physical disfigurement and functional impairments associated with facial trauma are a challenge to a prosthodontist, because even novel sophisticated surgical reconstructive techniques fail to provide adequate support for dental resection prosthesis. Therefore, different endosseous implants are often used as prosthesis-supporting elements. Manufacturers of dental implants have recently presented mini dental implants (MDIs) with diameter of only 1.8-2.4 mm. These implants allow very suitable prosthetic solutions within the range of their indications due to good osseointegration success rates, simple surgical technique, and immediate loading possibility. In this report, a case was presented for prosthetic rehabilitation including implantation of two Sendax type (IMTEC, Ardmore, Oklahoma, USA) MDIs in mental region, to obtain better retention and stability of the mandibular resection prosthesis and to improve function, phonation and aesthetics. The use of these implants, among aforementioned preferences, is also very cost-effective, so this implantation possibility should be taken into consideration during prosthetic treatment planning.     

Hyperbaric oxygen therapy treatment for the fixation of implant prosthesis in oncology patients irradiated

doi: 10.1111/j.1741‐2358.2012.00636.x Hyperbaric oxygen therapy treatment for the fixation of implant prosthesis in oncology patients irradiated Objectives: This study aimed to present a clinical report of an irradiated oncologic patient who underwent hyperbaric oxygen therapy to be rehabilitated with implant‐supported prosthesis. Materials and Methods: A 67‐year‐old man was admitted at Oral Oncology Center (FOA‐UNESP) presenting a lesion on the mouth floor. After clinical evaluation, incisional biopsy and histopathological exam, a grade II squamous cell carcinoma was diagnosed. The patient was subjected to surgery to remove the lesion and partial glossectomy. Afterwards, the radiotherapy, in the left/right cervicofacial area of the supraclavicular fossa, was conducted. After 3 years of the surgery, the patient was submitted to hyperbaric oxygen therapy. Then, four implants were installed in patient’s mandible. Five months later, an upper conventional complete denture and lower full‐arch implant‐supported prosthesis were fabricated. Conclusion: The treatment resulted in several benefits such as improving his chewing efficiency, swallowing and speech, less denture trauma on the mucosa and improving his self‐esteem.     

Mandibular biomechanics after marginal resection: Correspondences of simulated volumetric strain and skeletal resorption

Serious mandibular diseases such as tumor or osteonecrosis often require segmental or marginal mandibulectomy, the latter with improved outcome thanks to preserved mandibular continuity. Nevertheless, gradual osteolytic and/or osteosclerotic skeletal changes frequently indicate repetitive resections. Based on the fundamental adaptivity of bone to mechanical loads, the question arose whether resection-related anatomical alterations trigger relevant pathological skeletal adaptations. For a clinical case after mandibular box resection due to progressive osteoradionecrosis (ORN), routine biomechanical loading was simulated by finite element method, respecting pathology-related anatomy, tissue properties, and biting capacity. By 3D-visualization of the mandible’s pathological development from follow-up-CT’s over four years, remarkable correspondences of skeletal resorptions and increased unphysiological strain were revealed. Higher unphysiological load was correlated with more serious and earlier skeletal alterations. Three months post-operatively, serious buccal destruction at the distal resection corner occurred in correspondence with dominant tensile strain. At the resection, elevated strain caused by reduced alveolar height corresponded to skeletal compromise, observed 8–9 months post-operatively. ORN-related lesions, diagnosed before resection, entailed unphysiological strain coinciding with local skeletal alterations. Simulations with “healthy” instead of pathological tissue coefficients induced quantitative improvements of 25–33%, but without fundamental change. These results suggest a decisive contribution of resection-related biomechanical skeletal adaptations to this patient’s mandibular decline with hemimandibulectomy about 2.5 years after the first resection. However, mechanical stress concentrations in sharp angles as the distal resection corner and reduced stability due to decreased alveolar height generally bear the danger of pathological biomechanics and severe skeletal adaptations for patients after mandibular box resection.     

Functional mandibular reconstruction: prevention of the oral invalid

Composite mandibulectomy for carcinoma can create an "oral invalid," with difficulty in mastication. Functional reconstruction has fallen short of ideal. Three patients were seen with significant anatomic deficits and functional debilitations resulting from large composite mandibulectomies for oral carcinoma. Each patient underwent reestablishment of the mandibular arch with a vascularized iliac crest bone graft. Following complete healing, the dental arch was replaced with a fixed prosthesis by the technique of osseointegration. The creation of a fixed osseodental unit has allowed each of these individuals to return to a state of anatomic, functional, psychological, and social good health. Follow-up has been from 6 months to 2 years.     

Clinical feasibility of mandibular implant overdenture retainers submitted to immediate load

Gerodontology 2010; doi: 10.1111/j.1741‐2358.2010.00374.x
Clinical feasibility of mandibular implant overdenture retainers submitted to immediate load Introduction: Millions of people around the world do not have access to the benefits of osseointegration. Treatments involving oral rehabilitation with overdentures have been widely used by specialists in the oral medicine field. This is an alternative therapy for retention and stability achievement in total prosthesis with conventional treatment, and two implants are enough to establish a satisfactory overdenture. Objective: The objectives of the study were to evaluate 16 patients of both sexes, with an average age of 47.4 ± 4 years, using electromyographic analysis of masseter and temporal muscles and analyse the increase of incisive and molar maximal bite force with their existing complete dentures and following mandibular implant overdenture therapy to assess the benefits of this treatment. Materials and methods: For these tests, the Myosystem‐BR1 electromyograph and the IDDK Kratos dynamometer were used. Statistical analysis was performed using the repeated measures test (SPSS 17.0). Results: A decrease in electromyographic activity during the rest, lateral and protrusion movements and increase of the maximal incisive and molar bite force after 15 months with a mandibular implant overdenture was observed. Conclusion: All the patients in this study reported a considerable improvement in the masticatory function and prostheses stability following treatment. It is possible to propose that the use of mandibular implants overdenture should become the selected treatment for totally edentulous patients to facilitate oral function and quality of life.     

Use of virtual surgery and stereolithography-guided osteotomy for mandibular reconstruction with the free fibula

Fibular osteotomy remains a challenging aspect of mandibular microsurgical reconstruction, dependent largely on surgeon experience, intraoperative judgment, and technical speed. Virtual surgical planning and stereolithographic modeling is a relatively new technique that can allow for reduction in the learning curve associated with neomandible contouring, enhanced levels of accuracy, and acceleration of a time-consuming intraoperative step. The authors present a video (narrated and edited from planning sessions and intraoperative use of technique to illustrate the technology) and describe their favorable results. Five patients underwent composite resection of the mandible and free fibula osteocutaneous reconstruction over a 6-month period (December of 2009 to June of 2010) at a single institution using a virtual planning session and stereolithographic modeling. Outcomes assessed included technical accuracy, aesthetic contour, and functional outcomes. All patients achieved negative margins with cutting guide-directed resection. Use of this technique eliminated the need for intraoperative measurement and yielded fibular segments with excellent apposition and faithful duplication of the preoperative plan. Minimal adjustments were needed for inset. Flap survival was 100 percent. All patients have maintained preoperative occlusion and a symmetric mandibular contour on Panorex study, three-dimensional computed tomography, and clinical examination. Accuracy of the reconstructed contour was confirmed using computed tomographic image overlay. This virtual surgical planning technique combined with stereolithographic model-guided osteotomy is the mainstay of the authors' approach to fibular osteotomy when dealing with patients requiring mandibular reconstruction. The authors feel this technology facilitates realization of technical accuracy, aesthetic contour, and functional outcomes and may be particularly useful if free fibular mandibular reconstruction is performed less frequently. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.     

Mandibular angle reduction versus mandible reduction

The terms "mandibular angle reduction" and "reduction angleplasty" refer to operations to reduce the width of the lower face and change a square face to an oval one. Because the terms emphasize the word angle, however, they imply that the operations apply to the mandibular angle. The most frequent complaint after these operations is that the change in the lateral appearance is clear but that the change in the frontal appearance is not noticeable. Such a result is related to the fact that bone resection is performed mainly in the mandibular angle area and is focused particularly on resection of the posterior projection through curved ostectomy. That is, because operations limited to the mandibular angle area cannot properly satisfy patients' requirements, the operation must be applied to a larger area. Therefore, it seems reasonable to change the terms "mandibular angle reduction" and "reduction angleplasty" to "mandible reduction" and "reduction mandibuloplasty." In addition, the most important technique in the operation is the resection of the outer cortex of the mandible. In particular, the corticectomy technique using a reciprocating saw is quite safe and effective for the maximum resection of lateral flaring within a very short time.     

Surgical and prosthetic treatment in an elderly patient affected by unilateral idiopathic gingival fibromatosis: a case report

doi: 10.1111/j.1741‐2358.2011.00564.x Surgical and prosthetic treatment in an elderly patient affected by unilateral idiopathic gingival fibromatosis: a case report Objectives: The aim was to present the diagnosis and treatment of a case of unilateral idiopathic gingival fibromatosis (IGF) in a geriatric patient. Background: IGF is a rare condition characterised by an enlargement of the attached and marginal gingivae with no obvious association to any causative factor. Gingival overgrowth causes inaesthetic changes and clinical symptoms such as speech disturbances, tooth movement, and occlusal problems. Materials and methods: A 65‐year‐old female presented localised enlargement of mandibular gingiva, malpositioning of anterior mandibular teeth, and difficulty in speech and mastication. IGF also causes numerous aesthetic and psychological problems. Treatment consisted of multiple extractions, surgical therapy, and early prosthetic rehabilitation to restore function and appearance and to prevent recurrence. Results: Excellent aesthetic result and psychological benefit were achieved, and no fibromatosis recurrence was detected after 1 year following surgery. Conclusion: Gingival resection of the tissue excess and early oral rehabilitation with removable dentures have so far greatly improved patient’s quality of life.     

The use of botulinum toxin type A in aesthetic mandibular contouring

The lower third of Asian faces is wider than that of Caucasians and it is determined by the size and width of the mandibular bone and the thickness of muscles and subcutaneous fat tissues surrounding it. Efforts to create an aesthetically slim and smooth facial contour line in nonobese people have led the authors to focus on two approaches: surgical resection of the masseteric muscle and modeling ostectomy of the square-angled mandibular bone. Because these procedures present some problems, the authors adopted a nonsurgical concept that chemically denervates muscles and reduces the bulk of the muscle. The authors have conducted a total of 1021 clinical cases from March of 2001 through September of 2002, in which patients were treated with botulinum toxin type A (Dysport; Ipsen Ltd, Slough, United Kingdom) for remodeling the lower facial contour line; 383 of those cases were followed up for at least 3 months after the initial injection. A database was made by measuring the change in the thickness of the injected muscle with an ultrasonogram. Eleven patients underwent resection of the mandibular angle before injection. The preinjection ostectomy group was involved in the study as a result of their dissatisfaction with the surgical results; they had a rather thick masseter muscle and not a bone problem. Some had both bone problems and a thick masseter muscle. Three months after the botulinum toxin injection, the thickness of the muscle was reduced by 31 percent on average. The atrophic effect of injection was observed after 2 to 4 weeks for most patients. Seventy percent of the 383 patients tracked were greatly satisfied with the result, with another 23 percent generally satisfied. No long-term side effects were reported. Masseteric hypertrophy is frequent in Asians because of racial characteristics and dietary habits. Botulinum toxin type A has made a new epoch in facial contouring for Asians. Considering that Asians have a prominent malar and a prominent mandible angle, the reduction in the thickness of the masseter can provoke relative prominence of the malar and mandible angle. Therefore, precise indication and anatomy of the facial muscle should be thoroughly understood, which will decrease the incidence of side effects and problems. Botulinum toxin type A (Dysport) injection is simple in technique, has few side effects, and promises a rapid return to daily life. The authors conclude that the injection of botulinum toxin type A can replace surgical masseter resection.     

Costs of minimally invasive laser surgery compared with transurethral electrocautery resection of the prostate.

We reviewed hospital charges for patients undergoing uncomplicated endoscopic surgical resection for symptomatic bladder outlet obstruction due to benign prostatic hyperplasia over a 1-year period at a single institution. Of 115 patients, 67 underwent transurethral electrocautery resection of the prostate, and 48 underwent endoscopic neodymium:yttrium-aluminum-garnet laser ablation of the prostate under direct vision. Analysis showed a cost differential between these 2 surgical treatments in excess of $2,000, favoring laser prostatectomy (P < .0001) over transurethral electrocautery resection. The single greatest difference between the treatments was the ability to manage all patients receiving laser treatment as outpatients, whereas the mean and median hospital stay after transurethral electrocautery resection was 3.0 days. Taking additional cost variables into account and decreasing the cost of laser delivery systems would further increase this cost differential in favor of laser therapy. The diminished postoperative morbidity associated with laser treatment also promises lower total costs over the long term.     

Hypothermia reduces neurologic deficits associated with placement of a vascular prosthesis in the abdominal aorta of rabbits

Treatment for atherosclerotic vascular disease in human beings ranges from medical management to interventional therapy, such as angioplasty, atherectomy, and bypass grafting. Recently, bypass grafting with a vascular prosthesis has received increased attention and clinical use. In the course of studies to optimize use of a small-caliber vascular prosthesis, five of six rabbits undergoing implantation of a polytetrafluoroethylene vascular prosthesis in the infrarenal abdominal aorta developed hind limb neurologic deficits, which resulted from focal ischemic damage to the spinal cord attributable to temporary vascular occlusion of the abdominal aorta during placement of the vascular prosthesis. In subsequent studies, induction of systemic hypothermia decreased the rate of development of neurologic deficits from 83 to 9% without any apparent perioperative complications associated with decreased body temperature. We determined that mild hypothermia (rectal temperature of 32 to 35 degrees C), combined with aortic occlusion time of < 40 min, is sufficient to afford protection from ischemic injury to the spinal cord in the rabbit.     

Accelerated rehabilitation of an edentulous patient with an implant retained dental prosthesis: a case report

This case report details the successful rehabilitation of an edentulous patient using a complete upper prosthesis and a lower implant retained overdenture. The provision of care was split between a specialist centre and a primary care setting. This approach reduced inconvenience to the patient. Modern surgical and prosthodontic techniques also reduced the total delivery time. After initial consultation a new set of complete dentures was prescribed with changes in design to the originals. The patient was also planned for placement of two mandibular implants to stabilise and retain the mandibular denture. The first line of treatment involved provision of a new set of dentures constructed by the patient's general dental practitioner. Dental implants were then placed in a specialist centre and the patient returned to the dental practice for attachment of the lower denture to the dental implants. The benefits and success of mandibular implant retained dentures are well documented. With delivery of the overdenture, the patient reported increased satisfaction with his prostheses which allowed him to eat a greater range of foods and enabled him to feel confident when speaking and socialising.     

Dacron fabric-enveloped hydroxyapatite prosthesis for sternal tumor defect: an autopsy report

A 38-year-old housewife with solitary plasmacytoma of the manubrium who underwent a subtotal sternectomy treated by resection of the lesion is reported. This was followed by replacement with a Dacron fabric-enveloped hydroxyapatite prosthesis. The Dacron fabric was sutured to the surrounding tissues, and then the clavicle was passed through the cylindrical-shaped Dacron fabric to form a sternoclavicular joint capsule. The patient returned to her daily life 3 months after the operation. She had no trouble in her daily living, without any dislocation of the sternoclavicular joints or any displacement of the artificial sternum. The autopsy examination about 1 year after the operation showed that the Dacron fabric enveloping the artificial sternum became stronger with time. The sternoclavicular joint also was stably fixed, and the Dacron fabric fulfilled its function as an artificial articular capsule and biologic fixation of the surrounding supporting tissues.     

Portable PET probes are a novel tool for intraoperative localization of tumor deposits

Background

The emergency treatment of incisional hernias is infrequent but it can be complicated with strangulation or obstruction and in some cases the surgical approach may also include an intestinal resection with the possibility of peritoneal contamination. Our study aims at reporting our experience in the emergency treatment of complicated incisional hernias.

Methods

Since January 1999 till July 2008, 89 patients (55 males and 34 females) were treated for complicated incisional hernias in emergency. The patients were divided in two groups: Group I consisting of 33 patients that were treated with prosthesis apposition and Group II, consisting of 56 patients that were treated by performing a direct abdominal wall muscles suture.

Results

All the patients underwent a 6-month follow up; we noticed 9 recurrences (9/56, 16%) in the patients treated with direct abdominal wall muscles suture and 1 recurrence (1/33, 3%) in the group of patients treated with the prosthesis apposition.

Conclusions

According to our experience, the emergency treatment of complicated incisional hernias through prosthesis apposition is always feasible and ensures less post-operative complications (16% vs 21,2%) and recurrences (3% vs 16%) compared to the patients treated with direct muscular suture.     

Incongruity between Affinity Patterns Based on Mandibular and Lower Dental Dimensions following the Transition to Agriculture in the Near East,Anatolia and Europe

While it has been suggested that malocclusion is linked with urbanisation, it remains unclear as to whether its high prevalence began 8,000 years earlier concomitant with the transition to agriculture. Here we investigate the extent to which patterns of affinity (i.e., among-population distances), based on mandibular form and dental dimensions, respectively, match across Epipalaeolithic, Mesolithic, and Neolithic samples from the Near East/Anatolia and Europe. Analyses were conducted using morphological distance matrices reflecting dental and mandibular form for the same 292 individuals across 21 archaeological populations. Thereafter, statistical analyses were undertaken on four sample aggregates defined on the basis of their subsistence strategy, geography, and chronology to test for potential differences in dental and mandibular form across and within groups. Results show a clear separation based on mandibular morphology between European hunter-gatherers, European farmers, and Near Eastern transitional farmers and semi-sedentary hunter-gatherers. In contrast, the dental dimensions show no such pattern and no clear association between the position of samples and their temporal or geographic attributes. Although later farming groups have, on average, smaller teeth and mandibles, shape analyses show that the mandibles of farmers are not simply size-reduced versions of earlier hunter-gatherer mandibles. Instead, it appears that mandibular form underwent a complex series of shape changes commensurate with the transition to agriculture that are not reflected in affinity patterns based on dental dimensions. In the case of hunter-gatherers there is a correlation between inter-individual mandibular and dental distances, suggesting an equilibrium between these two closely associated morphological units. However, in the case of semi-sedentary hunter-gatherers and farming groups, no such correlation was found, suggesting that the incongruity between dental and mandibular form began with the shift towards sedentism and agricultural subsistence practices in the core region of the Near East and Anatolia.     

Gastrocnemius transposition flap in conjunction with limb-sparing surgery for primary bone sarcomas around the knee

A primary gastrocnemius transposition flap is a useful technique for prosthetic coverage following extensive soft-tissue and bone resection for sarcomas of the knee joint. The gastrocnemius transposition flap is also a useful secondary procedure to treat local complications following attempted limb-sparing surgery. The gastrocnemius transposition flap is a simple procedure with minimal morbidity. Both medial and lateral flaps may be utilized if necessary. In addition, such flaps do not jeopardize local tumor control. We now recommend primary gastrocnemius transposition flaps for most limb-sparing procedures around the knee joint, especially when a prosthesis is utilized with or without adjuvant chemotherapy.     

Fresh-frozen human bone graft to repair defect after mandibular giant follicular cyst removal: a case report

The purpose of this article is to report the clinical, radiographical and histological findings about a case of a young woman affected by a mandibular giant follicular cyst. Conservative tumor resection was followed by immediate reconstructive treatment using fresh frozen human bone graft, instead of autologous bone graft, as material for bone regeneration. Follicular cyst is a benign, non invasive lesion with slow but progressive growth. Radiological and histological examination of the lesion confirmed the presence of a follicular cyst which underwent biopsy evaluation before enucleation. According to literature, conservative treatment was performed with optimal prognosis. At 24?months post surgery no evidence of recurrency was objective; the CT scan revealed optimal bone formation inside the reconstructed site. The use of fresh frozen bone allograft, thanks to its osteoinductive and osteoconductive properties, can be a safe choice for reconstruction of bone defects after jaw cysts removal.     

Maxillary reconstruction with a fibula osteoseptocutaneous free flap and simultaneous insertion of osseointegrated dental implants

The fibula osteoseptocutaneous flap is a good option for reconstruction of three-dimensional composite maxillary defects. This flap provides both bone and soft-tissue reconstruction and allows osseointegrated dental implantation, either simultaneously or in a second-stage procedure. Simultaneous placement of osseointegrated dental implants reduces operative sessions and allows faster oral rehabilitation for properly selected patients. The defects may result from trauma or resection of benign tumors or low-grade malignancies. Between August of 1999 and July of 2001, three patients underwent maxillary reconstruction with the fibula osteoseptocutaneous flap and simultaneous osseointegrated dental implants. The cause of the defect was trauma in two cases and resection of an adenoid cystic carcinoma in the other. The mean length of the fibula used for bony reconstruction was 4.7 cm. One osteotomy was performed in one case and no osteotomy was necessary in the other two. Skin islands of 8 x 2.5 cm and 16 x 3.5 cm were used for two patients. For the other patient, a double skin island was used for both nasal (6 x 4 cm) and oral (6 x 5 cm) reconstructions. Two osseointegrated implants were inserted into the fibular bone for each patient. Six months after the first-stage procedure, palatal rotation flaps or mucosa grafts were used to cover the exposed implant necks and prepare the implants for prostheses. One month after the second-stage procedure, prostheses were placed. An implant-supported prosthesis was used for one patient and implant/tissue-supported prostheses were used for the others. At a mean follow-up time of 30 months (range, 16 to 38 months), all patients were able to use the dental prosthesis for chewing (beginning 6 weeks after the final procedure) and all patients were satisfied with the cosmetic results.     

Free-flap mandibular reconstruction: a 10-year follow-up study

Free-flap reconstruction of oncologic mandibular defects has become the modern standard of care. However, no previous studies have established the long-term results of such reconstructions. The objective of this study was to review functional and aesthetic outcomes in patients a decade after free-flap mandibular reconstruction.A single surgeon's experience with free-flap reconstruction of the mandible was retrospectively reviewed. Eighty-two consecutive patients who underwent reconstruction from January of 1987 to December of 1990 were identified. Of the 34 patients still alive, 20 agreed to participate (response rate, 59 percent). To assess complications and functional outcome, patients were interviewed using validated questions and questions developed specifically for the study. Aesthetic outcome was judged by two independent observers. Panorex radiographs were obtained to assess bone resorption. Bone height was measured at standardized locations on the body, ramus, and symphysis and compared with the immediate postoperative Panorex radiographs. Differences in Panorex magnification were adjusted for by comparison of miniplate measurements. Mean length of follow-up was 11 years. Mean patient age at the time of the study was 48 years. Nineteen of 20 patients had malignant disease, one of whom had a local recurrence during the follow-up period. Two patients received radiation therapy preoperatively and 13 postoperatively. Mean length of mandible resection was 13 cm. Defect types were as follows (Jewer's classification): 12 L, 4 H, 3 LC, and 1 LCL. All flaps survived.At 10-year follow-up, aesthetic outcome was judged to be excellent in 55 percent of patients, good in 20 percent, fair in 15 percent, and poor in 10 percent. The aesthetic results were remarkably stable over time. Slight accentuation of subtle postoperative asymmetry became evident as facial aging progressed. Dental rehabilitation in the study group included five patients with osteointegrated implants and seven with conventional dentures. Seventy percent of patients reported a regular diet. The remainder required a soft diet. Food tolerance was good, as rated by the List Scale (mean score, 77 percent). Seventeen patients had easily intelligible speech, whereas three were intelligible with effort. At the midbody of the mandible, 92 percent of the postoperative bone height was preserved; at the midramus, 93 percent was maintained; and at the symphysis, 92 percent remained. In several patients, there was greater age-related bone loss from the residual native mandible compared with the reconstructed site. One patient developed an orocutaneous fistula following postoperative radiation therapy. Nine patients had miniplates removed, either because of plate problems or to allow implant placement. There were no cases of osteoradionecrosis, bone fracture, or miniplate fracture. There was no significant long-term disability related to the donor site.Free-flap reconstruction of the mandible provides excellent functional and aesthetic results that remain stable over time. Bone resorption is surprisingly minimal, even in the face of postoperative radiation therapy. The majority of patients are able to tolerate a regular diet and to either wear dentures or acquire osteointegrated implants. Acceptable speech and appearance are restored and continue to be a source of patient satisfaction at least a decade after surgery.