Free-Flap Mandibular Reconstruction:A 10-Year Follow-Up StudyDavid A. Hidalgo, M.D., and Andrea L. Pusic, M.D., M.H.S.New York, N.Y.

Free-flap reconstruction of oncologic mandibular de-fects has become the modern standard of care. However,no previous studies have established the long-term resultsof such reconstructions. The objective of this study was toreview functional and aesthetic outcomes in patients adecade after free-flap mandibular reconstruction.

A single surgeon’s experience with free-flap reconstruc-tion of the mandible was retrospectively reviewed. Eighty-two consecutive patients who underwent reconstructionfrom January of 1987 to December of 1990 were identi-fied. Of the 34 patients still alive, 20 agreed to participate(response rate, 59 percent). To assess complications andfunctional outcome, patients were interviewed using val-idated questions and questions developed specifically forthe study. Aesthetic outcome was judged by two indepen-dent observers. Panorex radiographs were obtained toassess bone resorption. Bone height was measured at stan-dardized locations on the body, ramus, and symphysis andcompared with the immediate postoperative Panorex ra-diographs. Differences in Panorex magnification were ad-justed for by comparison of miniplate measurements.Mean length of follow-up was 11 years. Mean patient ageat the time of the study was 48 years. Nineteen of 20patients had malignant disease, one of whom had a localrecurrence during the follow-up period. Two patients re-ceived radiation therapy preoperatively and 13 postoper-atively. 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 tobe excellent in 55 percent of patients, good in 20 percent,fair in 15 percent, and poor in 10 percent. The aestheticresults were remarkably stable over time. Slight accentu-ation of subtle postoperative asymmetry became evident asfacial aging progressed. Dental rehabilitation in the studygroup included five patients with osteointegrated im-plants and seven with conventional dentures. Seventy per-cent of patients reported a regular diet. The remainderrequired a soft diet. Food tolerance was good, as rated bythe List Scale (mean score, 77 percent). Seventeen pa-tients had easily intelligible speech, whereas three wereintelligible with effort. At the midbody of the mandible,92 percent of the postoperative bone height was pre-served; at the midramus, 93 percent was maintained; andat the symphysis, 92 percent remained. In several patients,

there was greater age-related bone loss from the residualnative mandible compared with the reconstructed site.One patient developed an orocutaneous fistula followingpostoperative radiation therapy. Nine patients hadminiplates removed, either because of plate problems orto allow implant placement. There were no cases of os-teoradionecrosis, bone fracture, or miniplate fracture.There was no significant long-term disability related to thedonor site.

Free-flap reconstruction of the mandible provides ex-cellent functional and aesthetic results that remain stableover time. Bone resorption is surprisingly minimal, evenin the face of postoperative radiation therapy. The ma-jority of patients are able to tolerate a regular diet and toeither wear dentures or acquire osteointegrated implants.Acceptable speech and appearance are restored and con-tinue to be a source of patient satisfaction at least a decadeafter surgery. (Plast. Reconstr. Surg. 110: 438, 2002.)

Oncologic resection of the mandible has amajor impact on the form and function of thelower face. Mastication, speech, and facial aes-thetics are often severely compromised withoutreconstruction.1 Early reconstructive effortswith nonvascularized bone grafts were plaguedby a high incidence of postoperative complica-tions and poor long-term outcomes.2 Thischanged significantly with the advent of micro-vascular reconstruction. Early postoperativecomplications decreased even in the setting ofpostoperative radiation, and expectations forsuccessful oral rehabilitation, including place-ment of osteointegrated implants, rose mark-edly.3,4 In addition, restoration of near-normalfacial appearance became a new standard ofcare.

Although experience with microvascularmandibular reconstruction has been very pos-itive, no previous studies have documented

From the Division of Plastic Surgery, Cornell University Medical College. Received for publication August 1, 2001; revised November 26, 2001.Presented at the Annual Meeting of the American Association of Plastic Surgeons, in Charleston, South Carolina, on May 14, 2001.

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that the functional and aesthetic benefits aremaintained beyond 2 to 3 years of follow-up.1,5–7

The objective of this study was to evaluate pa-tients 10 years after mandibular reconstructionwith respect to mastication, maintenance of bonevolume, speech, and facial appearance.

PATIENTS AND METHODS

A retrospective review was performed of 84consecutive patients who underwent microsur-gical reconstruction of the mandible. This rep-resented a single surgeon’s experience fromJanuary of 1987 to December of 1990 and re-flected a minimum of 10 years of follow-up.Forty-eight patients had either died from theirdisease or died of other causes. Six were over-seas and could not be contacted. Of the re-maining 30 patients, 20 agreed to participate inthe study (response rate, 67 percent).

Hospital and clinic records were reviewed toidentify early and late postoperative complica-tions, including flap problems, fistula,miniplate exposure, infection, donor-site prob-lems, and reoperation. Comorbid conditionsand adjuvant therapy were also reviewed. Toassess functional outcome, a survey was devel-oped using a combination of validated ques-tions and questions specifically designed forthe study. The survey specifically assessed diet,dental rehabilitation, speech, aesthetics, anddonor-site morbidity. Patients were interviewedeither in person (14 patients) or by telephone(six patients) and were encouraged to makeadditional comments regarding their overallexperience. A clinical examination (14 pa-tients) was performed to evaluate oral excur-sion, dental occlusion, palpable plates, andtenderness. Aesthetic outcome was judged bytwo observers.

New Panorex (Imaging Sciences Interna-tional, Hatfield, Pa.) radiographs were ob-tained to assess bony resorption. Bone heightwas measured with calipers at standardized lo-cations on the body, ramus, and symphysis.The bony height of normal adjacent mandiblewas also noted. These measurements were thencompared with those obtained from the imme-diate postoperative Panorex radiographs. Dif-ferences in Panorex magnification between theearly and late studies was adjusted for by com-parison of miniplate measurements. The statusof any osteointegrated implants was alsodocumented.

Descriptive statistics were used to assess de-mographic and clinical data. Differential

changes in bone height at the three locationson the mandible were examined using theKruskal-Wallis test.

RESULTS

The mean length of follow-up was 11 years.The mean patient age at the time of the studywas 48 years (range, 16 to 68 years) (Table I).There were 12 men and eight women.

Nineteen of 20 patients had malignant dis-ease. Mean length of mandible resection was13 cm (range, 8 to 20 cm). Defect types were asfollows (Jewer’s classification5): 12 L, 4 H, 3LC, and 1 LCL (Fig. 1). Nineteen patients hadimmediate reconstruction; one was delayed.Nineteen patients underwent reconstructionwith free fibula flaps. A single patient had ascapula flap. Eighteen arterial anastomoseswere performed end to end, usually to thefacial artery. Seventeen of the venous anasto-moses were performed end to end, reflecting apreference for the external jugular vein as arecipient vessel. The mean number of osteoto-mies performed for each reconstruction (notincluding the ends of the graft) was 2.5 (range,one to five) and the mean number of platesused was six (range, three to 11). Seven pa-tients undergoing hemimandible reconstruc-tion had the native condyles removed with thespecimen, resected from it, and then fixed tothe microvascular graft as a nonvascularizedgraft. The condyle was replaced into the gle-noid fossa without specific repair of the jointcapsule when the graft was inset. These pa-tients were maintained in intermaxillary fixa-tion for 1 week. One patient, with an LCLdefect, required an external skin paddle overthe central chin and 13 patients required in-traoral skin paddles. Mean duration of anesthe-sia was 15 hours (range, 10 to 21 hours), andmean duration of hospitalization was 19 days(range, 13 to 30 days). Perioperative complica-tions occurred in 20 percent of patients. Twopatients developed donor-site infections thatrequired intravenous antibiotics, and two pa-tients developed microvascular thrombosesthat required reexploration. All flaps survived.

Two patients received radiation therapy pre-operatively and 12 postoperatively. The typicaldose was 6000 to 6500 cGy. Two patients re-ceived postoperative chemotherapy. One pa-tient had a local recurrence during the fol-low-up period that was controlled withradiotherapy. She subsequently remained freeof disease.

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At 10-year follow-up, aesthetic outcome wasjudged to be excellent in 55 percent of pa-tients, good in 20 percent, fair in 15 percent,and poor in 10 percent (Table II). The aes-thetic results remained remarkably stable overtime, with little to no change in contour orprojection of the mandible (Figs. 2 through 8).Normal, age-related soft-tissue atrophy andptosis appeared to affect the reconstructed sideof the lower face slightly more than the sidethat did not undergo operation, accentuatingany early postoperative asymmetry. This wasmost notable among patients who had receivedpostoperative radiotherapy.

Mean oral excursion, as measured at thecentral incisors, was 36 mm (range, 22 to 50mm). Patients with condyle graft replacementhad a similar degree of function comparedwith those in whom the joint was not disturbed.Seventy percent of patients reported a regulardiet. The remainder required a soft diet. Foodtolerance by the List Scale8 was 79 (range, 50 to100). This validated scale assesses food toler-ance along a list of food types that requireincreasing amounts of mastication and biteforce. A score between 75 and 80 correspondsto an ability to eat a full diet with the exceptionof nuts and steak.

Five patients received osteointegrated dentalimplants during the follow-up period. One pa-tient developed infection, which necessitated

FIG. 1. Study patients grouped by bone defect type (Jewerclassification system). H, hemimandible segment that in-cludes the condyle; L, lateral segment without the condyle; C,central segment including the canine teeth.

TABLE IPatient Summary and Defect Classification

PatientAge(yr)

Follow-Up(yr) Pathology

DefectLength(cm)

Classification(Modified Jewer)

1 36 11 SCC 20 H-m2 34 13 Osteofibroma 13 H3 68 13 SCC 12 LC-m4 52 13 Osteogenic sarcoma 10 L5 64 14 Osteogenic sarcoma 12 L6 61 11 SCC 20 L-m7 41 12 SCC 13 L8 60 12 SCC 13 LC-m9 53 10 SCC 9 L-mt

10 16 11 Lymphoma 12 LC-m11 55 11 SCC 18 L-m12 43 11 SCC 12 L-mt13 51 11 Mucoepidermoid carcinoma 10 L14 33 11 Adenoid cystic carcinoma 12 L-m15 59 11 SCC 14 LCL-sm16 40 10 SCC 8 L-m17 36 10 Mucoepidermoid carcinoma 14 L18* 54 10 SCC 12 L-m19 13 10 Osteofibroma 13 H20 39 10 SCC 14 H-m

SCC, squamous cell carcinoma.* Scapula flap reconstruction. All other reconstructions with fibula flap.

440 PLASTIC AND RECONSTRUCTIVE SURGERY, August 2002

removal of three of five implants; there wereno other implant-related complications. Of the15 patients who required dentures, seven wereable to wear their prostheses without difficulty.For the remaining eight patients who experi-enced difficulty with their dentures, intraoralnumbness and difficulty with food manipula-tion because of partial glossectomy were themain difficulties that limited the usefulness ofthe prostheses.

Seventeen patients had easily intelligiblespeech, whereas three were intelligible witheffort (Table II). The latter three patients hadpartial or hemiglossectomies as part of theiroriginal oncologic resection.

There was minimal loss of bone volume asmeasured by graft height over time. At themidbody of the mandible, 92 percent (range,71 to 100 percent) of the postoperative boneheight was maintained. At the midramus, 93percent (range, 80 to 100 percent) remained,and at the symphysis, 92 percent (range, 77 to100 percent) was preserved. In the three eden-tulous patients, age-related bone loss from theresidual native mandible was equal to orgreater than on the side that was recon-structed. Importantly, there was no statisticallysignificant difference in long-term volume lossbetween irradiated and nonirradiated free-flapbone grafts, although the sample size wassmall.

One patient developed an orocutaneous

fistula following postoperative radiation ther-apy that required operative debridement andclosure. Nine patients had between one andfive miniplates removed (mean, threeplates): one because of miniplate exposure,four for impending extrusion through skin,and four to prepare for osteointegrated im-plant placement. There were no cases of os-teoradionecrosis or fracture of the mandible.There was no miniplate breakage that re-quired operative intervention. One patientwith a condyle graft reconstruction com-plained of moderate temporomandibularjoint discomfort but had not sought medicaltherapy for this. One patient complained ofdysesthesia in the mental nerve distributionthat necessitated reexploration and plate re-moval without improvement. Seventy-fivepercent of patients experienced some degreeof oral incontinence, which was usually mildand intermittent. This was primarily relatedto decreased sensation in the mental nervedistribution. In one patient with a centralmandibular defect and an external skin pad-dle, this problem was severe.

There was no significant disability related tothe donor site. Although three of 20 patientsdescribed mild, intermittent leg weakness orpain, only one had symptoms severe enough tocurtail physical activities such as jogging. Onepatient reported running a marathon withoutany difficulty.

TABLE IISurgical Outcomes

Patient Aesthetics Speech DietOral

Excursion Dental Rehabilitation

1 Good Easily intelligible Soft 22 No2 Excellent Easily intelligible Regular 48 No3 Good Intelligible w/effort Soft 40 Dentures4 Excellent Easily intelligible Regular 39 Osteointegrated implants (5)5 Excellent Easily intelligible Regular 50 Osteointegrated implants (3)6 Good Easily intelligible Regular 30 Dentures7 Excellent Easily intelligible Regular 37 Dentures8 Fair Easily intelligible Soft 37 Osteointegrated implants (3)9 Excellent Intelligible w/effort Soft * No

10 Excellent Easily intelligible Regular 25 Dentures11 Poor Easily intelligible Regular 28 No12 Excellent Easily intelligible Soft 30 Dentures13 Excellent Easily intelligible Regular 38 No14 Fair Easily intelligible Regular 30 No15 Poor Intelligible w/effort Soft 47 No16 Good Easily intelligible Regular 35 No17 Excellent Easily intelligible Regular 50 Osteointegrated implants (6)18 Excellent Easily intelligible Regular 38 Dentures19 Excellent Easily intelligible Regular 40 Osteointegrated implants (4)20 Fair Easily intelligible Regular 34 No

* Unable to obtain measurement. Patient had recently suffered cerebral vascular accident.

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DISCUSSION

There are few published long-term follow-upstudies on free-flap mandible reconstruc-

tion.1,2,9 As a result, there are many unresolvedquestions regarding the long-term function,appearance, and fate of the microvascular

FIG. 2. Patient 2 in Tables I and II. (Above) Postoperative views at 2 years 4 months. (Center) Postoperative views at 13 years4 months. (Below, left) Early postoperative Panorex radiograph. (Below, right) Panorex radiograph at long-term follow-up showshealed osteotomies and maintenance of bone height.

442 PLASTIC AND RECONSTRUCTIVE SURGERY, August 2002

grafts. The most important issues addressed bythis study are as follows:

1. Stability of bone graft volume.2. Osteotomy site integrity.3. Fate of retained miniplate fixation devices.4. Fate of condyles transplanted as nonvascu-

larized grafts.5. Stability of osseointegrated implants.6. Effect of postoperative radiation therapy

on graft viability.7. Opening ability and mastication (diet).

8. Speech.9. Stability of associated graft soft-tissue

volume.10. Effects of mandible reconstruction on fa-

cial aging.

This study provides insight into all of theseissues on the basis of its review of patients whohave been followed at least 10 years since re-construction. Two issues that this study doesnot address are the long-term effects on man-

FIG. 3. Patient 17 in Tables I and II. (Above) Postoperative views at 4 months. (Below) Post-operative views at 10 years 3 months.

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dibular growth in the pediatric population andthe fate of osseointegrated implants placed inirradiated mandibular grafts.

Bone graft volume has proven uniformly sta-ble, with only small losses occurring over adecade. There were no cases of significant graftdissolution with impending fracture. More-over, the degree of volume loss was compara-ble and not greater than that of the remainingnative mandible. In one particular case involv-ing an edentulous mandible, the reconstructedportion aged significantly better than the re-maining native portion. This may reflect inpart the differences in embryologic origin be-tween the microvascular graft (endochondralbone) and the native mandible (membranousbone).

Most reconstructions had between two andthree osteotomies within the graft in additionto requiring fixation at each end. Therefore,each patient had at least four sites requiringstabilization. There were no osteotomy sitefractures or nonunions in any patient. It cantherefore be concluded that multiply osteoto-mized microvascular bone grafts have ade-quate blood supply and heal like normal bone.It has also been demonstrated that the multi-ple screws and plates necessary at each site of

fixation do not compromise graft blood supplyin a manner that would encourage long-termloss of bone volume.

Miniplate fixation was originally attractivebecause it enabled accurate fabrication of thegraft by sequential osteotomy and fixation, aprocess aided in accuracy by mandibular tem-plates and measurements taken from the sur-gical specimen.10,11 This method is inherentlymore precise than the alternative of using asingle reconstruction plate and avoids addingunwanted bulk to the external surface of thegraft. The use of miniplates for osteotomy sitefixation has proven durable and trouble-free inthis study. The need to remove plates or screwsbecause of impending external extrusionthrough the skin occurs occasionally. When ithappened, it was usually because of inadequatesoft-tissue coverage and was not a problem at-tributable directly to the hardware. Removal ofplates because of intraoral soft-tissue break-down was also unusual. When it occurred, onlythe exposed plates in the immediate vicinity ofthe wound breakdown were removed, and onlyafter the bone had healed. This rare need toremove miniplates, now proven by long-termfollow-up, is remarkable given the contami-

FIG. 4. (Left) This patient’s completed fibula free-flap graft is shown before insetting with the transplantedcondyle in place. (Right) Close-up Panorex view at long-term follow-up shows condyle graft condition. Comparisonof miniplate and screw landmarks on radiography with adjacent flap view verifies complete survival of the condylegraft.

444 PLASTIC AND RECONSTRUCTIVE SURGERY, August 2002

FIG. 5. Patient 10 in Tables I and II. (Above) Postoperative views at 10 months. (Center) Postoperative views 10 years 7 monthslater. There is atrophy of the submental soft-tissue volume (flexor hallucis longus muscle) and ptosis of the chin pad. (Below,left) Early postoperative Panorex radiograph. (Below, right) Panorex radiograph at long-term follow-up shows good symmetry andhealed osteotomy sites.

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nated oral wound environment that is oftenopen for more than 12 hours during surgery.

A previous study has shown that the condylecan be resected from the surgical specimen

when deemed to be oncologically safe, fixed tothe end of the free-flap bone graft, and insetinto its native position within the glenoid fossaduring reconstruction.12 This restores tandem

FIG. 6. Patient 5 in Tables I and II. (Above) Postoperative views at 1 year 6 months. (Center) Postoperative views at 12 years7 months. Facial asymmetry has become more obvious with aging (Below, left) Early postoperative Panorex radiograph. (Below,right) Panorex radiograph at long-term follow-up shows extensive dental reconstruction with osseointegrated implants.

446 PLASTIC AND RECONSTRUCTIVE SURGERY, August 2002

temporomandibular joint function across themidline, a unique property of the mandible.Follow-up Panorex studies have confirmed thatthese grafts can survive intact for over a decade(Figs. 3 and 4). There were two patients inwhom the nonvascularized condyle graft failedto survive completely. Function was not com-promised by pain, trismus, or ankylosis even inthese patients. There were no instances whereuse of the condyle had negative oncologic con-sequences. This safety record is largely a reflec-tion of conservative judgment in selecting can-didates for condyle transplantation. The resultsof this study support the use of the condyle asa nonvascularized graft when specimen tran-section is planned at the midramus level orhigher. It seems to be a superior alternative tonot reconstructing the condyle at all, shapingthe end of the graft to resemble a condyle, orusing a prosthetic condyle.

Osseointegrated implant placement as a sec-

ondary procedure after free-flap mandible re-construction has proven to be a worthwhileprocedure.3,13,14 However, not all mandible re-construction patients are candidates for dentalreconstruction with this method. Excludingfactors include extent of disease, amount ofremaining dentition, postoperative radiationtherapy, patient preference, and expense.7,14

There were 21 implants placed in five patientsin this study. A few implants were ultimatelynot loaded because of alignment problems.Only one patient required implant removalbecause of infection and nonintegration. Im-plants were subsequently replaced successfullyin this case. A decade of follow-up has proventhis method of dental reconstruction to besafe, effective, and durable.

Twelve of 20 patients (60 percent) in thisstudy received full radiation therapy followingmandible resection and primary reconstruc-tion. This study has shown that radiation ther-

FIG. 7. Patient 1 in Tables I and II. (Above and below, left) Preoperative views. (Above and below,center) Postoperative views after two-stage reconstruction with fibula free flap for bone and scapulafree flap for additional soft-tissue augmentation. (Above and below, right) Postoperative views at11 years 11 months.

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apy does not delay the healing of osteotomysites or compromise bone graft viability. Inaddition, there was no statistically significantdifference in long-term volume loss demon-strated between irradiated and nonirradiatedfree-flap bone grafts, although the sample sizewas small. There were no patients in whomosseointegrated implants were placed into irra-diated grafts as a secondary procedure. As aresult, no conclusions were possible regardingthe safety or efficacy of this practice, which stillhas few advocates.

Previous studies15 have suggested that micro-vascular reconstruction can successfully restorepreoperative occlusion and satisfactory masti-cation, at least in short-term follow-up. This hasbeen confirmed in this study, in which themajority of patients maintained adequate oralexcursion and were able to tolerate a normal tonear-normal diet for at least 10 years (TableII). This is a highly important outcome from aquality-of-life standpoint. Placement of os-teointegrated implants is an important contrib-uting factor to this success even though masti-catory function was generally good amongpatients who did not receive implants.

It is well documented that ablative surgeryof the oral cavity can significantly alterspeech.16 However, 85 percent of patientshad easily intelligible speech in this series

(Table II). Microvascular reconstruction ofthe mandible enhances the potential for ex-cellent postoperative speech quality by re-storing a stable platform for tongue mobility.Significant speech disability should be ex-pected only among those patients who re-quire significant tongue resections.

There was little change in facial symmetry adecade after reconstruction; nor were theresignificant changes in aging attributable to it.Soft-tissue asymmetry was more progressiveover time among patients who had receivedpostoperative radiotherapy. One patient exhib-ited ptosis of the chin pad (Fig. 5). Minor facialasymmetry became slightly more pronouncedin older individuals (Fig. 6), but changes inneck laxity were largely consistent with a nor-mal aging process.

It became apparent during this study thatfunctional and aesthetic results correlate morewith the extent of the soft-tissue defect thanwith the extent of the bone defect. Althoughthe latter can be accurately reconstructed, thequality of the soft-tissue reconstruction can suf-fer from inadequate volume replacement, askin patch effect externally, or substitution ofnonfunctional bulk for specialized tissue suchas tongue or facial mimetic muscles. Classifica-tion of mandible defects should therefore in-clude a soft-tissue designation to be most useful

FIG. 8. (Left) Preoperative computed tomographic scan of patient from Figure 7 shows extent of original tissuedefect. (Right) Panorex radiograph at long-term follow-up. Note the symmetric contour of the inferior border ofthe mandible, the primary determinant of lower facial symmetry restoration.

448 PLASTIC AND RECONSTRUCTIVE SURGERY, August 2002

in describing the likely aesthetic and func-tional impact of a particular defect. The Jewerclassification system can be effectively used forthis purpose when one or more letters areincluded to categorize the associated soft-tissuedefect. This is a simple method that has asmuch predictive value as more complex classi-fication systems.15 According to the modifiedJewer description, “o” indicates a bone-only de-fect, “m” an associated mucosal defect, and “s”an external skin defect.17 A combination ofletters is possible. Using the letter “t” to indi-cate a significant tongue defect would makethis system even more useful. Reconstructionof an LCL bone-only defect, for example,would be expected to have a significantly betterfunctional and aesthetic result than an LCL-smor LCL-mt defect. The patients in this study aredescribed using this new classification systemin Table I, where “o” has been deleted in thecase of bone-only defects.

In conclusion, this study has shown that re-construction of the mandible with a microvas-cular free flap is functionally and aestheticallydurable a decade later. This confirms thepromise reported in previous short-termstudies.1,7,18,19

David A. Hidalgo, M.D.655 Park AvenueNew York, N.Y. 10021hidalgod@drdavidhidalgo.com

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2. August, M., Tompach, P., Chang, Y., and Kaban, L. Fac-tors influencing the long-term outcome of mandibu-lar reconstruction. J. Oral Maxillofac. Surg. 58: 731,2000.

3. Gurlek, A., Miller, M. J., Jacob, R. F., Lively, J. A., andSchusterman, M. A. Functional results of dental res-toration with osseointegrated implants after mandiblereconstruction. Plast. Reconstr. Surg. 101: 650, 1998.

4. Curtis, D. A., Plesh, O., Miller, A. J., et al. A comparisonof masticatory function in patients with or withoutreconstruction of the mandible. Head Neck 19: 287,1997.

5. Jewer, D. D., Boyd, J. B., Manktelow, R. T., et al. Oro-

facial and mandibular reconstruction with the iliaccrest free flap: A review of 60 cases and a new methodof classification. Plast. Reconstr. Surg. 84: 391, 1989.

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7. Hidalgo, D. A., and Rekow, A. A review of 60 consec-utive fibula free flap mandible reconstructions. Plast.Reconstr. Surg. 96: 585, 1995.

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10. Hidalgo, D. A. Titanium miniplate fixation in free flapmandible reconstruction. Ann. Plast. Surg. 23: 498,1989.

11. Hidalgo, D. A. Aesthetic improvements in free-flapmandible reconstruction. Plast. Reconstr. Surg. 88: 574,1991.

12. Hidalgo, D. A. Condyle transplantation in free flapmandible reconstruction. Plast. Reconstr. Surg. 93: 770,1994.

13. Zlotolow, I. M., Huryn, J. M., Piro, J. D., Lenchewski, E.,and Hidalgo, D. A. Osseointegrated implants andfunctional prosthetic rehabilitation in microvascularfibula free flap reconstructed mandibles. Am. J. Surg.164: 677, 1992.

14. Weischer, T., and Mohr, C. Ten-year experience in oralimplant rehabilitation of cancer patients: Treatmentconcept and proposed criteria for success. Int. J. OralMaxillofac. Implants 14: 521, 1999.

15. Urken, M. L., Buchbinder, D., Weinberg, H., et al.Functional evaluation following microvascular oro-mandibular reconstruction of the oral cancer patient:A comparative study of reconstructed and nonrecon-structed patients. Laryngoscope 101: 935, 1991.

16. Hufnagle, J., Pullon, P., and Hufnagle, K. Speech con-siderations in oral surgery: Part II. Speech character-istics of patients following surgery for oral malignan-cies. Oral Surg. Oral Med. Oral Pathol. 46: 354, 1978.

17. Boyd, J. B., Gullane, P. J., Rotstein, L. E., Brown, D. H.,and Irish, J. C. Classification of mandibular defects.Plast. Reconstr. Surg. 92: 1266, 1993.

18. Disa, J. J., Winters, R. M., and Hidalgo, D. A. Long-termevaluation of bone mass in free fibula flap mandiblereconstruction. Am. J. Surg. 174: 503, 1997.

19. Cordeiro, P. G., Disa, J. J., Hidalgo, D. A., and Hu, Q. Y.Reconstruction of the mandible with osseous freeflaps: A 10-year experience with 150 consecutive pa-tients. Plast. Reconstr. Surg. 104: 1314, 1999.

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