Tetrafocal intraoral bone transport for mandibular reconstruction combined with free fibula flap and mandibular zygomatic implants

Purpose This retrospective study was performed to evaluate a multiple bone transport system designed to predictably and securely perform major reconstruction of the mandible, including the mandibular symphyseal area, by using a free fibula flap. The aim of this study was to present our clinical experience in using transport DO technique (TDO) for treating mandibular bony defects after tumor ablation in patients with benign tumors, combined with a free fibula flap to correct the area of the symphysis at a single surgical session, avoiding the use of grafting in the docking site for the direct contact of the transport disk and the fibula. Methods Eight patients (5 females and 3 males; ages 27–45 years; average age 32 years) underwent tetrafocal distraction osteogenesis after major mandibular resection, including the complete symphyseal area, 2 ameloblastomas, and 2 odontogenic myxoma. All patients underwent partial mandibulectomy and reconstruction plate placement through the intraoral route. A fibular flap segment was used to reconstruct the symphyseal area. The internal distraction devices were 45 mm long and were cut, bent, and fixed over the reconstruction plate; a 7-day latency period was allowed, and 1 mm/day activation period followed. Once the transported disk or bullet reached the parasymphyseal area and met the bony segments, a docking site surgery was performed to unite the 2 segments, with adequate rigidity to the reconstruction plate. Twelve months later, transmandibular zigomatic implants were inserted, and dental rehabilitation was completed. Results All mandibles were reconstructed by using intraoral bone transport, creating 70.5 to 100.3 mm of new bone to allow dental implant placement and dental rehabilitation. No infections, fractures, or nonunions were seen. The patients were seen on a weekly basis for 3 months and then every 30 days until completion of the treatment and rehabilitation. Evaluations were made every year. Conclusions This multiple bone transport system permits mandibular reconstruction for a very difficult clinical situation and yields excellent results. The advantages and goals of this technique are excellent biologic response, feasibility for implant placement, complete functional and aesthetic rehabilitation, and no need for extraoral appliances.