ACTA SCIENTIFIC DENTAL SCIENCES (ISSN: 2581-4893)

Volume 3 Issue 5 May 2019

Review Article

Evolution of Mandibular Defects Reconstruction Procedures: From Older Principles

to Newer Techniques and Technology

Deepak Pai1*, Akhilesh Wodeyar2, Pradheep Raja3, Mohammed Nishad3, Elvita Martis3 and Karthik kumar3
1
Senior Professor, Department of Oral and Maxillo-Facial Surgery, A J Institute of Dental Sciences, India
2
Senior Resident, Department of Oral and Maxillo-Facial Surgery, A J Institute of Dental sciences, India
3
Department of Oral and Maxillo-Facial Surgery, A J Institute of Dental sciences, India
*Corresponding Author: Deepak Pai, Professor, Department of Oral and Maxillo-Facial Surgery, A J Institute of Dental Sciences, India.
E-mail: [email protected]
Received: February 05, 2019; Published: April 05, 2019

Abstract
The reconstruction of the mandibular defect is a challenge to the surgeon. It requires the reconstruction of the bony structures
and soft tissue envelope in a dynamic region of the body with the restoration of the functions. The procedures has evolved since the
first use of autologous bone grafts, to the use of local and regional flaps and now to the era of free tissue transfer. This article is a
review of mandibular defects reconstruction and options currently available.
Keywords: Mandibular Reconstruction; Mandibular Defects; Autologous Bone Grafts; Free Fibula Graft

Abbreviation tion, surgeons can reconstruct and restore back maximum func-
tion and aesthetics. We have reviewed the history and evolution
FFF: Free Fibula Flap; DCIA: Dorsum Circumflex Iliac Artery.
of reconstructive options for mandibular defects enumerating the
Introduction possible application of such in various surgical settings.

Surgical management of several pathological conditions occur-

History
ring in head and neck region require the resection of the pathology
Medical literature can be seen dating back to 1860 detailing
along with good margin. After resection the patient would be left
the concept of mandibular reconstruction [3]. With the initial ex-
with considerable hard and soft tissue deficit which mandates re-
perimental sciences giving way to clinical application of free grafts
construction not only to replace the missing structural component,
from tibia, iliac crest and ribs used for small to large defects, exten-
but also to restore the associated function. This restoration of form
sive work has been done [1].
and the function becomes more and more difficult as the tissues
resected become larger and complex in nature.
Mainstay of mandibular reconstruction at the inception re-
mained the use of autogenous bone grafts. The idea of delayed re-
Since the early years, surgical management of pathology in-
construction evolved sometime during the World War I when car-
volves radical resection of the tumour and associated structures
ing for traumatically acquired defects of that era [5].
rendering the patient grossly tumour free. The reconstruction of
such defects were mostly by autogenous bone grafts [1]. The evo-
The success rate of such surgeries performed for achieving the
lution of better diagnostics, technology and understanding of sur-
continuity of the defect using free grafts with delayed reconstruc-
gical sciences, there is shift towards functional procedures which
tion saw a success rate as high as 75% under the hands of skil-
spare maximum tissue as possible. Even then reconstruction of the
ful surgeons. These surgeons were aware of absolute absence of
defect poses a challenge in the oromandibular region [2]. Recon-
sepsis required for the graft take-up. They sometimes would allow
structive options have also largely increased in recent years; and
a consolidation period of many months keeping the patient on ex-
with the possibility free vascularised composite graft reconstruc-
ternal fixator to allow most favourable conditions for successful
grafting [4].

Citation: Deepak Pai and Akhilesh Wodeyar. “Evolution of Mandibular Defects Reconstruction Procedures: From Older Principles to Newer Techniques
and Technology”. Acta Scientific Dental Sciences 3.5 (2019): 08-18.
Evolution of Mandibular Defects Reconstruction Procedures: From Older Principles to Newer Techniques and Technology

09

The introduction of internal fixation using plate and screws it also involves a possibility of seeding cancer cells in newly dis-
post World War II with the use of antibiotics gave surgeons an sected tissue planes. It was also presumed risk of infection from
unparalleled edge over these procedures. Large case series with salivary contamination was higher during primary reconstruction
success rate reaching up-to 90% were reported. Free bone grafts [7]. In contrast; secondary reconstruction can delay postoperative
still lack the ability to be used in places where there were large soft irradiation, which can increase both morbidity and recurrence. The
tissue deficits. These grafts remained prone to infection and failure advantages of primary reconstruction include a reduction in the
by rapid colonisation of oral organisms [4]. number of surgical procedures and hospital stays, a shorter time
during which the patient has deformity and morbidity from lack
Few monumental advances in reconstructive surgery with bet- of function, the protection and preservation of vital structures, a
ter understanding of the cutaneous circulation and perfusion of reduced cost of treatment, and the rapid oral rehabilitation with
flaps gave surgeons the options of axial and pedicle flaps which a timely return to a normal social lifestyle [8]. Recent advances in
could be harvested from regional and distant site. They were com- frozen section analysis, especially of bony margins, the 2–surgical-
posite in nature which could restore the soft tissue loss too. Later team approach, and increased confidence in techniques of mandi-
techniques allowed transfer of free vascular composite grafts with ble reconstruction have all but vanquished much of the controversy
can be harvested from distant sites. These are currently the stan- that surrounds immediate reconstruction.
dard of care of mandibular reconstruction which requires compos-
ite tissue restoration [10]. If a secondary reconstruction is to be performed, the primary
surgery must include an attempt to stabilize soft tissue and bony
Classification of defects remnants in a manner that decreases their displacement with
A large complex defects can be created during resection. Func- use. Unfortunately, considerable scarring, soft tissue contracture,
tional and aesthetic outcomes become less favourable as the extent and fibrosis can precede delayed reconstruction and compromise
of resection increases [5]. The defect determines the kind of re- functional and cosmetic restoration [8]. In some areas of the body,
construction needed. Classification of defects gives a more precise functional and physiologic mechanisms are not hampered after the
description and allows us to choose from various reconstructive excision of large tumour if open wounds remain or if simple skin
options available for each patient and defect. The most complex grafts are used. However, because of the physiologic, biologic, and
reconstructions might not always be the best as they have highest functional characteristics of the oromandibular cavity, the treat-
risks of complications. ment team is not afforded the luxury of delayed reconstruction.

Many classification systems exist in the literature. They can be Furthermore many authors have classified mandibular defects
classified based on their timing, location, extent, involvement of based on factors mentioned above [9].
soft tissue, mucosa, tongue, skin, floor of mouth etc. Broadly man-
dibular reconstruction can be either primary/Immediate or sec-
ondary/delayed based on the timing.

Immediate reconstruction versus delayed reconstruction

There has always been a controversy between immediate and

delayed reconstruction which has now resurfaced with recent ad-
vances in surgical techniques, especially the increased use of Vas-
cularized bone grafts.

Immediate reconstruction is the most effective way to recon-

struct these tumours technically. Additionally, compared with de-
layed reconstruction, immediate reconstruction results in better
long-term functional outcomes [6]. Some of the opponents of im-
mediate reconstruction say that such procedure would cover the
Table 1, table 2 and figure 1 are taken from – “A new
primary site, decreasing the ability to detect recurrence. Surgical classification for mandibular defects after oncological resection:
time required for primary/immediate reconstruction is longer and James S Brown, Conor Barry, Michael Ho, and Richard Shaw”

Citation: Deepak Pai and Akhilesh Wodeyar. “Evolution of Mandibular Defects Reconstruction Procedures: From Older Principles to Newer Techniques
and Technology”. Acta Scientific Dental Sciences 3.5 (2019): 08-18.
Evolution of Mandibular Defects Reconstruction Procedures: From Older Principles to Newer Techniques and Technology

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Rationale of mandibular reconstruction

Mandible, which forms a U-shaped bony foundation of the lower

face, also serves as the attachment for tongue and muscles of the
floor of the mouth. Functions of oro-mandibular region include
mastication, deglutition, airway patency and speech which need
complex units of tissue. In addition, such tissue is important to
maintaining a socially acceptable aesthetic appearance [10].

Thus, an ideal reconstruction of a mandibular defect would need

the replacement of structural bony foundation, restoration of the
supporting muscle and soft tissue envelope, and provide a platform
for dental rehabilitation post reconstruction. The gold standard of
replacing like-with-like requires the use of composite tissues.

Thus, taking all variables into consideration the principle of re-

construction for intra-oral hard tissue defects should establish con-
tinuity, restore soft tissue loss, establish alveolar height, width and
form, improve facial contours and restore functions – mastication,
Table 2 deglutition, speech and oral competence.

Reconstructive options:

In every surgical intervention, some sort of defect is addressed.

A Reconstructive ladder is a list of options starting from the sim-
plest to the more complex methods available.

1. Healing by secondary intention and/or primary closure

2. Skin graft
3. Skin graft substitutes
4. Reconstructive plate
5. Autogenous bone grafts – vascularized and non-vascularized
6. Bone graft substitutes
7. Regional flaps and distant flaps
8. Vascularized free flaps
9. Transport disc distraction osteogenesis

10. Recent advances – Modular endoprosthesis, 3D printed cus-

tom made prosthesis, tissue-engineering and stem cell tech-
nology

Discussion
Figure 1 Healing by secondary healing

The simplest method involves no attempt to close the defect,

that is, spontaneous healing through secondary intention.

Citation: Deepak Pai and Akhilesh Wodeyar. “Evolution of Mandibular Defects Reconstruction Procedures: From Older Principles to Newer Techniques
and Technology”. Acta Scientific Dental Sciences 3.5 (2019): 08-18.
Evolution of Mandibular Defects Reconstruction Procedures: From Older Principles to Newer Techniques and Technology

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Primary closure
Successful bony union (%)a
The most common solution involves direct closure of the wound
following delayed closure of the wound. Bone
Fibula free flap
graft
Skin grafts and substitutes Overall 54 88 (p < 0.005)
Split and full thickness skin grafts have been used for centu- Mandible defect size
ries, with the first description appearing in 1869 by Reverdin as < 6 cm 75 100
described by Ollier in 1972 [11]. In an 1870 review by Stele [12],
> 6 cm 44 85 (p < 0.001)
the method was first described.
6-10 cm 46 95
Mandibular plating 10-14 cm 40 100
Although many different reconstructive options exist, recon- > 14 cm - 63
struction plates are easy to use, available readily and allow rapid
Successful bony union
resumption of oral function and eliminates the need for maxillo- (regardless of the number 69 96 (p < 0.005)
mandibular fixation (MMF) in case of delayed reconstruction. of operations necessary)
Average number of
Haug evaluated titanium reconstruction plate use and demon- operations necessary to 2.3 1.1 (p < 0.001)
strated that 3 bicortical screws in each reconstruction plate seg- achieve bony union
ment provided the maximum resistance to deformation.
Table 3: Pogrel bony union success rate of
Options in plate selection include mandible reconstruction mandibular defects [17].
plates, miniplates [13], and locking plates, all of which are available
a
Percentage of patients achieving bony union
in titanium and stainless steel. Titanium plates offer the advantag- following one operative procedure.
es of being much more biocompatible and mechanically similar to Free non-vascularised bone grafts have since been used in the
bone than other metals; thus, they do not have to be removed after repair of osseous defects successfully for a long period of time. The
the graft has healed. They can be contoured easily prior to man- most used donor areas include the iliac spine, calvarial grafts, rib
dibular resection which maintains the occlusal plane and serves as grafts and intraoral bone grafts from the mental region and ramus
a template for the bone graft. of the mandible. The primary drawback to these stem from the ex-
tensive and rapid resorption where up to 60% of the grafted vol-
Free bone grafts
ume is lost within six months [18,19]. The amount of available do-
Macewen was the first to use free bone grafts (nonvascular- nor tissue is also limited, especially for local transplantations [20].
ized bone) in 1877 [14]. The first attempt at free bone grafts in
the mandible was completed by Sky off [15]. Free bone grafts were The recipient surgical bed must be vascular and not damaged by
commonly used in the First World War for the treatment of injured radiotherapy for the successful transplantation of a free bone graft.
soldiers. Free nonvascularized bone grafts have much lower mor- A direct correlation between the length of the free nonvascularized
bidity. Schliephake., et al. showed that nonvascularized bone grafts bone graft and its success is often quoted. The 6- cm rule has been
had improved contour and symmetry. Additionally, nonvascular- popularized by several authors [21]. Pogrel., et al. compared the
ized bone grafts have greater remodelling in comparison to vascu- differences in the use of vascularized and nonvascularized (free)
larized bone grafts [16]. bone grafts for reconstruction of the mandible. Pogrel., et al. study
is often quoted as the reason for a free flap being required to re-
construct any defect greater than 6.0 cm in length. Though there
is literature showing the use of free bone grafts for longer defects,
consensus remains over the 6 –cm rule.

Citation: Deepak Pai and Akhilesh Wodeyar. “Evolution of Mandibular Defects Reconstruction Procedures: From Older Principles to Newer Techniques
and Technology”. Acta Scientific Dental Sciences 3.5 (2019): 08-18.
Evolution of Mandibular Defects Reconstruction Procedures: From Older Principles to Newer Techniques and Technology

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Local and regional flaps in mandibular reconstructions Latissimus dorsi flap

Small- to medium-sized defects in the oral cavity can be man- In 1978, Quillen [25] first described the use of the latissimus
aged using local mucosal or cutaneous flaps. dorsi (LD) flap in head and neck reconstructions. LD provides a
large amount of muscle and cutaneous lining with minimal donor
Pectoral major myocutaneous flap site morbidity [26-28]. In addition, LD provides a reliable solution
The pectoralis major myocutaneous (PMMC) flap is a widely to both primary as well as secondary reconstructions, especially in
used workhorse in head and neck reconstruction, first used on a vessel-depleted neck [29]. Compared to other local options such
thoracic defects by Pickrell [22] in 1947. In addition, in 1979, Ary- as PMMC and trapezius flaps, LD features the longest reach, the
ian [23] used the pectoral flap in head and neck reconstruction fewest variations in the vascular bundle, easiest harvesting, most
on four patients. Pectoralis major is supplied by pectoral vessels, versatile soft tissue tailoring possibilities and highest success rate.
along with lateral thoracic artery, the superior thoracic artery and LD also provides the largest musculocutaneous flap that can be har-
the intercostal artery with concomitant veins. The most commonly vested [30].
used supply is the pectoral branch originating from the thoracoac-
romial supply.

It is reliable and relatively easy to harvest, features a large vol-

ume of muscle and subcutaneous tissue and can fill large defects
obliterating dead spaces in reconstruction. In addition, PMMC is
used as secondary reconstruction if the primary microvascular op-
tion fails or if additional surfacing is needed. Very obese patients or
aplasia of the pectoralis muscle, characteristic of Poland syndrome,
are considered contraindications. The use of the pectoral flap also
impairs the functioning of the shoulder [24].

Figure 3

Microvascular mandibular reconstruction:

Microvascular free tissue transfer has been one of the greatest

milestones in reconstruction of the mandible after tumour ablative
surgery popularized by hidalgo in 1989 paper [31]. During its evo-
lution in the past three decades we have seen around twenty differ-
ent types of free flaps being used in oro-mandibular reconstruction
[32]. Patients are now undergoing complete mandibular recon-
struction with dental rehabilitation termed as ‘jaw in a day’ surgery
owing to the success of vascularized free tissue transfer [33].

The most frequently used composite tissue flaps in mandibular

reconstructions include free flaps of the fibula, iliac crest and scap-
ula. The primary advantages of the free flaps include the possibility
of reconstructing missing parts using tissue with similar proper-
Figure 2: Reconstructive oral and maxillofacial ties. Such reconstructions are more reliable compared to local or
surgery – Holzle, Frank et al.

Citation: Deepak Pai and Akhilesh Wodeyar. “Evolution of Mandibular Defects Reconstruction Procedures: From Older Principles to Newer Techniques
and Technology”. Acta Scientific Dental Sciences 3.5 (2019): 08-18.
Evolution of Mandibular Defects Reconstruction Procedures: From Older Principles to Newer Techniques and Technology

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pedicled flaps. Finally, the vascularised osseous flap integrates into the scapula because of its reliability, the functional outcomes and
the patient and yields the best long-term result [34]. minimal donor site morbidity. It is found that the scapula flap is
recommended for complex restorations with extensive soft tissue.
Fibula flap

In 1975, Taylor [35] introduced the use of the fibula bone as a Other free osseal flaps
free graft. The osseocutaneous fibula composite flap, as the most Radial bone flap
popular option, allows for harvesting of the fibula simultaneously The osteocutaneous radial flap is considered one of the most
with tumour resection by a second team without necessitating pa- common reconstruction options alongside those described above.
tient repositioning. In general, the fibula flap is widely regarded as The radial free flap evolved from the ‘Chinese’ flap described by
the first choice for large mandibular reconstructions. The fibular Muhlbauer in 1982 [48], and was used as an osseous flap in oral
osteo-septo-cutaneous flap stands as the most common osseous reconstructions by Soutar., et al [49,50]. It is a safe and reliable op-
flap in head and neck reconstructions, with its favourability over tion for mandibular reconstruction, as it offers sufficient bone for
other options increasing [36]. reconstructing large defects. In particular, the pedicle length offer-
ing the possibility of anastomosis to the contralateral neck is an
The main difficulties in the reconstructions are lack of FFF
advantage.
height, absence of a vestibular groove, limitation of mouth open-
ing, skin paddle thickness, and the reconstruction of surrounding Metatarsal bone flap
tissues including the lip [37]. Other drawbacks include limited size
The transfer of the metatarsal bone—typically the second meta-
of the soft tissue and a potential unreliable blood supply in the skin
tarsal—has primarily been used in the reconstruction of the con-
island. The osseocutaneous fibula composite flap also carries a
dyle of the mandible. As early as 1958, Entin [51] reported on four
relatively small capacity to fill large soft tissue defects. In older pa-
patients with hemifacial microsomia, in whom the rudimentary
tients, smokers and patients with diabetes, the risk of atheroscle-
condyle was successfully reconstructed using the fifth metatarsal
rosis and subsequent changes to arterial flow must be addressed.
bone.
Hanasono [38] recently reviewed DCIA against other commonly
Rib graft flap
used options. While DCIA stood as the most popular option at the
beginning of microvascular osseous mandibular repair; other op- The ribs have been used in mandibular reconstructions for
tions emerged as more favourable. In a comparison of the fibula some time already. In 1975, Ostrup., et al. [52] published their ex-
and scapula, donor site morbidity was highest in DCIA. The DCIA perimental work on the microvaslular transfer of the rib in radiated
vessels emerged as the least reliable, while the pedicle emerged mandibular reconstructions in dogs. Futhermore, Harashina., et al
as the shortest. Furthermore, the cutaneous island was ranked as [53]. documented two successful free rib transfers to the mandibles
the lowest. of cancer patients.

Scapula flap In 1992, Guyuron [54] discussed the unpredictable growth of

costal grafts. Guyuron recommended including sufficient cartilage
Teot., et al. first described the vascularity in the scapular system
in the graft, using the fourth or fifth rib, placing soft tissue in the
while Swartz [39] used it in maxillofacial reconstructions. The flap
glenoid fossa and postponing corrective osteotomies until growth
is well-suited for larger soft tissue defects. Its drawbacks include a
is completed. Using the rib was also recommended only in patients
maximum length of 14 cm while the thin membranous brittle bone
with severe defects.
is typically considered inferior to the fibula and the iliac crest flap.
Donor site morbidity is low, although harvesting requires reposi- Surgical complications and risks
tioning of the patient. Nevertheless, the scapula is used for lateral
Minor complications treated at bedside or through medication
mandibular reconstruction with success in many centres. Dental
may increase treatment costs. But major wound- or flap-related
implantation relying on a scapula flap has also enjoyed success
complications affect overall patient outcomes by delaying recovery
[40-47]. In 2009, Brown., et al [47]. published their indications
and postponing oncological treatment.
for scapular reconstructions among 46 patients. They favoured

Citation: Deepak Pai and Akhilesh Wodeyar. “Evolution of Mandibular Defects Reconstruction Procedures: From Older Principles to Newer Techniques
and Technology”. Acta Scientific Dental Sciences 3.5 (2019): 08-18.
Evolution of Mandibular Defects Reconstruction Procedures: From Older Principles to Newer Techniques and Technology

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The preoperative parameters predicting major complications the new bony, technical difficulties of controlling the direction of
included a low body mass index (BMI), high Washington Univer- the distraction, failure of the device, and so on. Better understand-
sity Head and Neck Comorbidity Index (WUHNCI) score – 200, high ing with time will allow for greater use of this procedure.
white blood cell count, low haematocrit value and planned neck
dissection and/or tracheostomy.

Post-operative complications

The most frequent complications are thrombosis of the vein or

artery of the pedicle leading total or partial loss of flap. The princi-
pal risk factors for flap loss are prior operations on the neck, ath-
erosclerosis, and previous radiation treatment. New developments
include the use of perforator flaps, which can be anastomosed to
very small vessels in the face, and wrist-carriers, which offer com-
plete independence from head and neck vessels.

Radiotherapy and irradiated mandible

Figure 4: "Segmental Mandibular Regeneration by Distraction
Head and neck surgeons are often confronted with reconstruc-
Osteogenesis: An Experimental Study" - Costantino, P. D. Et al.
tive procedures following surgical salvage of post-radiation fail-
ures, after persistent malignancies of the oromandibular region,
or with the realization that irradiation is required following free 3D planning and 3D printing in mandibular reconstructions

tissue transfer. Irradiation has been shown to affect large vessels The emergence of 3D imaging and planning was first described
by accelerating atherosclerosis and by causing obliterative end- by Mankovich., et al [59]. in 1990. Methods including computer-
arteritis and thrombosis; use of careful technique may eliminate assisted design and manufacturing (CAD/CAM), CT guided stereo-
further risk to the free flap. Choi showed no differences between lithographic models have enjoyed wide use in orthognathic treat-
radiated and nonradiated patients who underwent fibular free flap ment planning and surgery, orbital.
reconstruction for mandibular defects [55].

Distraction osteogenesis:

Distraction osteogenesis is a technique discovered and popu-

larized by a Russian orthopaedic surgeon Illizarov in 1950. Since
then, it has found its use in craniofacial and maxillo-facial speciali-
ties and continues to evolve as a treatment modality. A modifica-
tion of this technique known as transport disc distraction osteo-
genesis (TDDO) is used for mandibular reconstruction. A segment
of bone is cut adjacent to the defect and moved gradually across the
defect by a mechanical device. New bone forms in between the two
distracted bony segments. The piece of bone which is transported
acts as a source of osteogenesis and is referred to as the transport
disc. Costantin., et al [56]. in 1995, successfully applied transport
distraction to restore the continuity of a mandibular defect formed
as a result of cancer ablation. External devices were employed in
early cases but these caused problems of facial scarring along the
pin tracks [57]. An internal plate guided distraction device was
described by Herford [58] overcomes this problem. The primary Figure 5: "Mandibular Reconstruction after Cancer: An In-House
Approach to Manufacturing Cutting Guides" - Bosc, R. Et al.
drawback of distraction remains the time required to regenerate

Citation: Deepak Pai and Akhilesh Wodeyar. “Evolution of Mandibular Defects Reconstruction Procedures: From Older Principles to Newer Techniques
and Technology”. Acta Scientific Dental Sciences 3.5 (2019): 08-18.
Evolution of Mandibular Defects Reconstruction Procedures: From Older Principles to Newer Techniques and Technology

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Surgeries, which is now being adapted to mandibular recon- Conclusion

struction. The primary benefit of the model consists of patient edu-
Mandibular defects reconstruction has evolved over many years.
cation, treatment planning, pre-contouring of hardware, perform-
Even with the latest advancements in surgical techniques, technol-
ing mock surgeries and producing preoperatively patient-specific
ogy and skills of the surgeons, the ability for an ideal reconstruc-
osteotomy guides and patient-specific plates [60].
tion is farfetched. The requirement of high resources for advanced
technique and high failure rates in hands of good surgeons have
Tissue engineering in mandibular reconstructions
created a resistance in employing such procedures immediately
The most studied bone engineering tool consists of recombi-
in practice. Challenges also remain in restoring the complete func-
nant human bone morphogenetic protein-2 (BMP-2). Mandibular
tions after radical resection. Replacing like-with-like remains gives
defects due to benign conditions have been reconstructed using
the best results, though is not possible in some clinical scenarios.
a collagen carrier with BMP-2178 and allogenic bone with BMP-2
Nevertheless, tremendous improvements are seen in the field of
and platelet-rich plasma yielding good results. These results held
tissue engineering, 3D printing, virtual and navigational surger-
even for successful maturation of an erupting tooth in the area
ies. Robotic surgeries are also in its infancy which can be adopted
[61]. In addition, rib grafts were used as a carrier for BMP. How-
for such procedures. For now, vascularized free composite tissue
ever, in vivo studies of the adverse effects in oral cancer cells using
transfer has revolutionized the reconstruction of such defects. It is
BMP raised concerns regarding its safe use in cases of malignancies
matter of time other technologies catch up.
[62].
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and Technology”. Acta Scientific Dental Sciences 3.5 (2019): 08-18.
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Citation: Deepak Pai and Akhilesh Wodeyar. “Evolution of Mandibular Defects Reconstruction Procedures: From Older Principles to Newer Techniques
and Technology”. Acta Scientific Dental Sciences 3.5 (2019): 08-18.