Mandibular reconstruction.

Although there is no general agreement, we think immediate reconstruction with free bone graft from the iliac crest or rib is the method of choice for a small mandibular body or arch defect without concomitant significant loss of soft tissue. Soft tissue reconstruction with well-vascularized tissue should always be performed when extensive loss of soft tissue occurs after hemimandibulectomy to avoid tension on the stump and mandibular drift. When postoperative radiation is not anticipated, immediate bone grafting is appropriate. A free bone covered by well-vascularized tissue or a composite graft is our primary choice, but alloplastic trays with cancellous bone can also be considered. If postoperative radiation is anticipated, only soft tissue repair should be performed and osseous reconstruction should be deferred until radiotherapy is completed. Defects of the arch require special attention because of the severe deviation of the mandibular stumps. Immediate reconstruction is recommended in uncomplicated cases, but secondary bone grafting will be needed when the patient is in poor condition, or postoperative radiation places the bone graft in jeopardy. In such cases, immediate stabilization of the bone segments by internal or external fixation is absolutely necessary. Finally, secondary reconstruction should be considered only if there is no evidence of residual tumor. The defect should be recreated, scarred or irradiated tissue resected, and immediate reconstruction obtained with well-vascularized pedicled or free flaps.