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Surgical reconstruction of a damaged or resected mandible is performed to restore functional mastication, the oral phase of swallowing, dental occlusion, and cosmesis of the lower face. Trans-oral and trans-cutaneous approaches are the two ways to access the defect for surgical repair with either vascularized or non-vascularized autologous bone grafts. Commonly, mandibular reconstruction is necessary after a traumatic injury or surgical resection due to benign tumors of the jaw or malignant oral cavity neoplasms. Chronic infections and pathologic fractures resulting from osteonecrosis can also necessitate the reconstruction of the mandible. This activity reviews the evaluation and repair of the mandible and highlights the role of the interprofessional team in evaluating and treating mandibular defects. Objectives: Identify the different anatomical regions of the mandible and surgical options for their reconstruction. Review the surgical equipment, personnel, preparation, and technique required for free tissue transfer in mandible reconstruction. Outline the potential complications and clinical significance of mandible reconstruction. Summarize the interprofessional team strategies for improving care and communication to advance mandible reconstruction and improve outcomes. Access free multiple choice questions on this topic.

The mandible is essential for mastication, speech and articulation, swallowing, and facial symmetry. Major defects in the mandible, from various causes, can produce deleterious effects not only on activities of daily living but also on psychosocial health. Herein, different methods of reconstructing major defects of the mandible are reviewed. A multidisciplinary team approach is critical for reconstructive success and optimal patient outcomes.

The most feared complication of mandible reconstruction is graft failure and the need for a second reconstructive surgery. Infection, early movement of the jaw (often from early chewing), and poor nutrition either from the flap vessels or surrounding tissues, all increase the risk of reconstructive failure. Patients with a jaw radiotherapy history, hypothyroidism, protein deficiency, uncontrolled diabetes, active tobacco use, and other conditions are at increased risk of poor wound healing; efforts should be made to control these conditions much as possible before surgery.[15] In osseous free tissue transfer, success rates are generally above 95%; however, the most common complication is a vascular compromise with subsequent partial or complete flap failure. Venous compromise is more common than arterial compromise. Both are most likely to occur in the first 72 hours after microvascular anastomosis, as this is the time during which re-endothelialization of the vessels is occurring. Vascular compromise can occur at any time after flap transfer up until angiogenesis renders the tissue independent of its pedicle, which usually takes at least 2 to 3 weeks. Several complications may develop after the reconstruction is fully healed; improper sizing, positioning, or shaping of the graft or reconstructive plate can cause a malocclusion, facial asymmetry, and chronic temporomandibular joint pain. Additionally, radiotherapy, major infection, or additional surgery - such as placement of dental implants - that occurs after healing can still compromise the blood supply to the area and cause partial or complete flap failure.

A multidisciplinary approach is essential to reconstructive success. The process of reconstructing a mandible can take weeks to months before the final result is achieved, and patients will need follow-up, counseling, and reassurance throughout the course of recovery. If patients require dental rehabilitation, an oral surgeon should be involved in initial operative planning and throughout the reconstructive process. For patients undergoing free tissue transfer, an operative team (anesthesiologist, circulating nurse, surgical tech) comfortable with free flap physiology and microsurgical needs are critical for surgical success. Subsequently, a hospital team (intensivist, hospitalist, nursing staff) comfortable with free flap care is essential for flap survival. Effective and ongoing communication among medical personnel with a focus on patient-centered care will greatly improve patient outcomes.[29]