Kim et al.

Maxillofacial Plastic and Reconstructive Surgery (2015) 37:7

DOI 10.1186/s40902-015-0007-3

RESEARCH ARTICLE Open Access

Reconstruction with fibular osteocutaneous free

flap in patients with mandibular osteoradionecrosis
Min Gyun Kim, Seung Tae Lee, Joo Yong Park and Sung Weon Choi*

Abstract
Background: Osteoradionecrosis is a delayed complication from radiation therapy which causes chronic pain,
infection and constant deformity after necrosis. Most of the osteoradionecrosis occurs spontaneously or after the
primary oncologic surgery, dental extraction or by trauma of prosthesis. The treatment of osteoradionecrosis relies
on both conservative measures and surgical measures. The fibular osteocutaneous free flap has become more
popular choice for reconstruction of maxillofacial defects as a treatment of osteoradionecrosis.
Methods: We presented our experiences from 7 patients with osteoradionecrosis who have had reconstruction
surgery with fibular osteocutaneous free flap at National Cancer Center during the recent 5 years. We performed
segmental mandibular resection with fibular osteocutaneous free flap for all 7 patients of advanced osteoradionecrosis
who were not controlled by conservative treatment such as wound irrigation, debridement, and antibiotics.
Results: A wide range of techniques were available for the reconstruction of composite defects resulted from the
treatment of advanced mandibular osteoradionecrosis. Significant improvement was noted in relieving pain and
treating trismus after the surgery however difficulty in swallowing and xerostomia showed less improvement.
Conclusions: We concluded that fibular osteocutaneous free flap can be performed safely in patients with
osteoradionecrosis and yields positive outcomes with significantly increased success rate. The fibular osteocutaneous
free flap was our preferred choice for the mandibular reconstruction due to its versatility and predictability.
Keyword: Osteoradionecrosis; Mandible; Fibular; Radiation; Free flap

Background osteoradionecrosis has been reported to occur within

In the oral and maxillofacial region, surgery and radi- three years shortly after the radiation exposure. Osteor-
ation therapy are the primary treatments for malignant adionecrosis can occur spontaneously after the irradi-
tumors. Recent technological improvements in radiation ation, after the tooth extraction, or through trauma by
therapy have resulted in a significant reduction of severe dentures and surgery. Also, jaw fracture with infected
complications however pain, xerostomia, radiation caries area and chronic pain lead to permanent deformity. The
and osteoradionecrosis are still serious complications risk factors of osteoradionecrosis are the high doses of
remaining. Osteoradionecrosis causes serious aesthetic radiation in 6000-7000cGY and the frequent exposure
problem and oral malfunction which significantly reduces to radiation due to short time interval which affect the
quality of life. Osteoradionecrosis is defined as response of deterioration of bone tissue directly. A tooth extraction
impaired bone healing of irradiated bone tissue area due before or after the surgery often serves a trigger point in
to poor blood circulation and lack of vitality for more developing osteoradionecrosis. In addition, alcohol con-
than 3 months [1,2]. Osteoradionecrosis occurs most sumption, tobacco use and improper practice of oral hy-
commonly in the mandible where blood circulation is giene have also been reported as risk factors [3,4]. There
maintained from the periosteum and in the end-artery is a hyperbaric oxygen therapy, antibiotics, irrigation
system by inferior alveolar artery and vein. In general, and debridement as the conservative treatment of
osteoradionecrosis. However, reconstructive surgery
and radical jaw resection is necessary if conservative
* Correspondence: [email protected]
Oral Oncology Clinic, Research Institute and Hospital, National Cancer Center, treatment fails. Mandible is a major component of the
Il san east, Il san road 323, 2nd floor, Goyang, South Korea

© 2015 Kim et al.; licensee Springer. This is an open access article distributed under the terms of the Creative Commons
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Kim et al. Maxillofacial Plastic and Reconstructive Surgery (2015) 37:7 Page 2 of 7

oral and maxillofacial region containing the teeth. Fibu- have received only curative radiation therapy. The radi-
lar free flap is a well known reconstruction approach for ation dose received varied between patients, ranging from
restoring proper oral function. Fibula free flap is known 6000 cGy to 7400 cGy. The average dose of radiation a
to be a safe and reliable method to get a sufficient patient received was 6500 cGy. For example, patient with
height and appropriate thickness of corresponding man- chordoma has received the different amounts of radiation
dible [5,6]. We presented our experiences and know- (3000, 1600, and 6480 cGy) in each treatment visit for the
ledge from 7 patients with osteoradionecrosis who have first year. In addition, intraoral fistula occurred for all
had reconstruction surgery with fibular osteocutaneous free patients whereas extraoral fistula and pathologic fractures
flap at National Cancer Center during the recent 5 years. occurred to 5 patients. We also found that 6 patients had
the history of tooth extraction at the site of osteoradione-
Methods crosis preoperatively or postoperatively (Figure 1). All pa-
Fibular free flap is required for patients who have wide tients were suffered from pain and trismus (Table 2). After
exposed and necrotic bone with severe pain, infection the failure of conservative methods and when severe
resulting in patholgic fracture, extra-oral fisula or oste- bone and soft-tissue necrosis prevailed, reconstruction
olysis extending to the mandible border. We reviewed using the fibular free flap was performed after the seg-
patients who had no improvement in symptoms after mental mandible resection. Pull through approach and
the conservative treatment and were treated for man- transoral approach were used for mandible resection. In
dibular osteoradionecrosis by reconstruction with the two cases, resection was done at the site of mandible body
fibular osteocutaneous free flap from July 2009 to July only and for rest of cases, resection was performed in
2013 at National Cancer Center. Radiation image and mandible ramus including coronoid process. Among 7
medical records of patients were used to examine the patients, only 1 patient was edentulous patient. After
outcomes. This research was conducted in accordance mandibular resection, segmental mandibulectomy with
with the Helsinki Declaration. reconstruction using a fibular free flap was performed. For
the patient who had a fistula, fistulectomy was done with
Result a soft tissue graft in addition to fibular free flap (Figure 2).
A total of 7 patients were studied; five were male and Tissue transplantation was successful for all the patients.
two were female. The patients were aged between 47 Flap with a 4x12cm thickness was the most frequently
and 64 years of age (mean age 55 years). 6 cases were used flaps for reconstruction and the bone, about 5–9
from the primary lesions of oral region; 2 cases from centimeters in length, was collected and used in the sur-
tongue, 1 from lips, 2 from gingiva, 1 from submandi- gery (Figure 3). The ipsilateral neck vessels were most
buar gland. Only 1 chordoma case was from infratem- commonly used for anastomosis, except 1 patient who re-
poral region. The histopathologic diagnosis of 5 cases ceived anastomosis on the contralateral side as vessels in
was squamous cell carcinoma except the mucoepider- ipsilateral side were damaged by earlier radiation therapy
moid carcinoma of submandibular glands and chordoma treatment. Among the artery used for vascular anasto-
of infratemporal fossa (Table 1). The time to develop mosis, superior thyroid artery was the most frequently
osteoradionecrosis following radiotherapy varies widely used artery (6 times), facial artery was used twice, and
with an average of 3 years and 8 month; one case oc- transverse cervical artery was used once. For the veins
curred within the 1 year, three cases occurred in 2 to used for anastomosis, both external jugular vein and facial
3 years, two cases occurred in 5 to 6 years, and one last vein were used 5 times each, and each internal jugular
case occurred in 7 years and 9 month after the radiation vein, transverse cervical vein and anterior jugular vein
therapy. Among 7 patients, 5 patients were treated with were used once (Table 3). Vein grafts were not used. Im-
adjuvant radiation therapy after the surgery and 2 patients provement in postoperative mouth opening was observed

Table 1 The baseline characteristics of patient and tumor profiles

Patient No. Age (yr) Sex Location Diagnosis TNM stage Previouse treatment
1 52 M Right gingiva mucosa SCC T2N0M0 RT alone 6500 cgy
2 52 F Left gingiva mucosa SCC T2N0M0 OP + RT 7320 cgy
3 47 M Lower lip SCC TXN2M0 OP + RT 6300 cgy
4 53 M Infratemporal fossa Chordroma OP + RT 11480 cgy
5 64 F Submandibular gland MEC T3N2cM1 RT alone 6000 cgy
6 55 M Tongue SCC T2N0M0 OP + RT 7400 cgy
7 51 M Left tongue SCC T2N1M0 OP + RT 6000 cgy
SCC, Squamous Cell Carcinoma; MEC, Mucoepidermoid Carcinoma; RT, Radiation Therapy; OP, Operation surgery.
Kim et al. Maxillofacial Plastic and Reconstructive Surgery (2015) 37:7 Page 3 of 7

Figure 1 Panoramic view of the osteoradionecrosis progression. (A) Preoperative panoramic view of patient who extracted left 3rd molar
5 years before the operation. (B) Panoramic view after 3 years from left 3rd molar extraction. (C) Left mandible angle fractured after 5 years from
extraction. (D) Postoperative panoramic view.

with 100% increase in range of mouth opening compared therapy and also be used as part of adjuvant therapy.
with the preoperative values (Figure 4). Furthermore, sig- However, serious complications from radiation can
nificant improvement was noted in relieving pain, treating occur not only in the cancer cell but also in the normal
trismus and chewing. The present study showed that the tissue around the cancer. Tissue density is an important
overall patient satisfaction was high (Table 4). factor to determine the radiation resorption. Bone is 1.8
times more organized than the soft tissue. Also, the
Discussion maxilla is less dense than the mandible and osteoradio-
Radiation therapy is an important treatment for oral necrosis is more commonly observed in the mandible
cancer as it can be the primary treatment of curative than in the maxilla. In this study, all patients had been
diagnosed of osteoradionecrosis in the mandible. There
Table 2 Detail of postoperative outcomes are many different alternatives for osteoradioecrosis
Patient no. Pre-operation (n = 7) Post-operation (n = 7) treatment and oseoradionecosis has been defined in
Fracture 5 (71) 0 (0) many ways. Marx’s classification has been generally ac-
Trismus 7 (100) 0 (0)
cepted method. Marx described osteoradionecrosis as a
delay of advanced wound healing protocol due to the
Extraction history 6 (85)
failure of wound healing response. According to Marx’s
Fistula classification, there are 3 stages in osteoradionecorsis;
Intraoral 7 (100) 0 (0) stage 1, the presence of exposed alveolar bone without
Extraoral 5 (71) 0 (0) signs of pathologic fracture, which responds to hyper-
Pain baric oxygen (HBO) therapy; stage 2, disease does not
Severe 6 (85) 0 (0)
respond to HBO, and requires sequestrectomy and sau-
cerization; stage 3, involves full thickness bone damage
Moderate 1 (14) 0 (0)
or pathologic fracture, usually requires complete resec-
Mild 0 (0) 1 (14) tion and reconstruction with free tissue [2-4]. Recently,
No pain 0 (0) 6 (85) the Notani classification by inferior alveolar canal in
Values are presented as number (%). radiation picture is accepted to all cases of mandibular
Kim et al. Maxillofacial Plastic and Reconstructive Surgery (2015) 37:7 Page 4 of 7

Figure 2 Aggressive osteoradionecrosis formed extraoral fistula and saliva drained by fistula. Soft tissue reconstruction with fistulectomy
was required.

Figure 3 Clinical view of the fibular free flap reconstruction. (A) Initial clinical view (B) Fibular bone and soft tissue was harvested.
(C) Necrotic mandible body was resected by pull through approach. (D) Vessels anastomosis was done.
Kim et al. Maxillofacial Plastic and Reconstructive Surgery (2015) 37:7 Page 5 of 7

Table 3 Mandibular reconstruction with free vascularized fibular flap

Patient no. Skin paddle Bone length Artery Vein
1 4.0 × 12.0 5.0 Superior Thyroid Facial and External jugular
2 3.0 × 8.0 5.0 Superior Thyroid Facial and Internal jugular
3 4.0 × 12.0 5.0 Superior Thyroid Facial and External jugular
4 4.0 × 12.0 6.0 Superior Thyroid Facial and Anterior jugular
5 4.0 × 12.0 9.0 Superior Thyroid Facial and External jugular
6 4.0 × 12.0 7.0 Superior Thyroid Facial and External jugular
7 5.0 × 13.0 7.0 Transverse Cervical Transverse cervical and External jugular
Values are presented as number (cm).

osteoradionecrosis. Class I refers to when osteoradione- ongoing debate about its effectiveness. Study by Annane
crosis is limited to dentoalveolar bone. Class II refers to et al. showed no benefit of hyperbaric oxygen therapy over
when necrosis progress above inferior alveolar canal. placebo [11]. When conservative treatments are unsuc-
Class III is when oseteoradionecrosis progress to inferior cessful, surgical treatment is needed for the management
alveolar canal or pathologic fracture occur [7]. Conser- of stage 2 and stage 3 osteoradionecrosis. Resection of
vative treatments including antibiotic treatment, gargling wide range of tissue and reconstruction with free flap are
or enhancing oral hygiene are the basic treatment for the commonly suggested surgical intervention. Aggressive
osteoradionecrosis. Various treatments have been used surgical approach is more effective when bone necrosis is
in osteoradionecrosis. However according to Happnen advanced [6]. Fibular free flap provide support for dental
et al., 25 ~ 46% of patients have failed the long-term implantation and denture which helps in recovery of oc-
antibiotic treatment and had to receive mandibular clusal function. Since a donor site is away from a receiving
resection due to the progression of necrosis [8]. In the site, 2 team approaches are available. It is known to have a
study of Weissman and Rankow (1971), patients took a very high success rate and useful in the reconstruction of
one-year non-surgical treatment such as antibiotic treat- mandible. In addition, fibular free flap can provide suffi-
ment and removal of the oral cavity stimulating factor, cient amount of bone and soft tissue for mandible recon-
but 25% of failed patients still had to receive hemi- struction with a minor risk of donor site complications
mandibulectomy [9]. In study of Drane and Daly, they [12]. Blood vessels harvesting procedure is required for
repeated sequestrectomy to osteoradionecrosis patients fibular free flap to suppy the tissue at the recipient site
and 64% of the patients had to receive segmental mandi- and an appropriate length of the blood vessles must be
bulectomy [10]. Thereafter, ultrasonic, high-frequency selected to provide anastomosis with no tension. However,
electromagnetic stimulation and hyperbaric oxygen ther- the recipient vessels may be available for anastomosis due
apy which can accelerate the formation of new blood ves- to a prior neck dissection surgery and a prior radiation
sels and cells were introduced. Marx et al. have proposed therapy. Vein grafts are occasionally required under cer-
a treatment protocol which is a basic requirement to use tain circumstances. Vein grafts from the saphenous vein is
HBO therapy before and after the surgery combined with considered to be the most versatile and reliable vein graft
surgical debridement [2,4]. Hyperbaric oxygen therapy has for an interposition. However, vein graft is known for high
been regarded as the effective treatment, but there is still risk of thrombosis and hemorrhagic complications. Vein

Figure 4 Improvement of maximum mouth opening after the surgery. (preoperative mouth opening limitation in the left and postoperative
mouth opening in the right).
Kim et al. Maxillofacial Plastic and Reconstructive Surgery (2015) 37:7 Page 6 of 7

Table 4 Maximum mouth opening limitation of occlusal function can be expected through the dental im-
pre-operation and post-operation plant installation. Through the long term follow up study,
Patient no. Pre-operation Post-operation we observed the panoramic view of the miniplate fracture
1 15.0 33.0 and the bone loss in the mandible ramus and fibular bone
2 17.5 35.0 junction (Figure 5). In addition, patients showed trismus
and incisor deviation. All patients had the occlusal func-
3 18.0 40.0
tion through non-surgical side of teeth. Since occlusal load
4 15.0 41.0
was concentrated in the opposite site of teeth after the
5 10.5 35.0 surgery, stress was concentrated in the ramus fibular bone
6 19.0 40.0 junction which generated bone resorption and miniplate
7 17.0 45.0 fracture [15]. To overcome this stress barring effect, more
Values are presented as number (mm). stress shielding methods in the mandible ramus and fibula
junction were required, such as increasing miniplate unit.
graft should be used carefully [13]. This study demon- However, further studies are needed on this topic.
strates that fibula free flap is a safe and reliable method
for comprehensive functional and esthetic mandibular Conclusions
defect reconstruction. All patients showed the good func- The mandible reconstruction with fibula free flap is a
tional results related to the pain, trismus and chewing. In stable method which effectively eliminates pain and tris-
the study of Lin Wang et al., mandible reconstruction with mus. We can also expect the improvement of chewing
fibula free flap effectively eliminated pain and trismus, and swallowing by dental implantation in the recon-
whereas there were no significant improvement of swal- struction site. However, there are remaining limitations.
low, speech and xerostomia [14]. Our study showed simi- A long period of time is required for osteoradionecrosis
lar result to Lin Wang et al. Furthermore, improvement in treatment. Also, there are serious complications of

Figure 5 Panoramic view of the postoperative fibular free flap follow ups. Paired pictures refer to the same person; (A) – (B), (C) – (D),
(E) – (F). Pictures (A), (C), and (E) are postoperative panoramic view of two days after surgery. (B) and (D) shows panoramic view of miniplate
fracture and bone resorption on the ramus and fibular distal area about 3 years after the surgery. (F) mandible ramus resorption is shown 5 years
the after surgery. Trismus and midline deviation occurred.
Kim et al. Maxillofacial Plastic and Reconstructive Surgery (2015) 37:7 Page 7 of 7

osteoradionecrosis remaining such as severe facial de- 11. Annane D, Depondt J, Aubert P, Vilart M, Gehanno P, Gajdos P et al (2004)
formity, intolerable pain, loss of occlusal function and Hyperbaric oxygen therapy for radionecrosis of the jaw: A randomized,
placebo-controlled, double blind trial from the OR96 study group. J Clin
fistula. It is difficult to say that the treatment of oral Oncol 22:4893–900
cancer was successful if oral malfunction related to 12. Etezadi A, Ferguson H, Emam HA, Walker P (2013) Multiple remediation of
osteoradionecrosis still remains. It is important to keep soft tissue reconstruction in osteoradionecrosis of the mandible: a case
report. J Oral Maxillofac Surg 71:e1–6
a long term follow up study as recurrence of osteora- 13. Park JH, Min KH, Eun SC (2004) Scalp free flap reconstruction using
dionecrosis can happen. Excellent oral hygiene care anterolateral thigh flap pedicle for interposition artery and vein grafts. Arch
and minimizing dental trauma can reduce the risk of Plast Surg 39:55–8
14. Wang L, Su Y-X, Liao G-Q (2009) Quality of life in osteoradionecrosis
osteoradionecrosis. patients after mandible primary reconstruction with free fibula flap. Oral
Surg Oral Med Oral Pathol Oral Radiol Endo 108:162–8
15. Powell HR, Jaafar M, Bisase B, Kerawala CJ (2014) Resorption of fibula bone
Consent following mandibularreconstruction for osteoradionecrosis. Br J Oral
Written informed consent was obtained from the patient Maxillofac Surg 52:375–8
for the publication of this report and ant accompanying
images.

Competing interests
The authors declare that they have no competing interests.

Authors’ contributions
MG wrote the manuscript and participated in data collection and analysis. ST
participated in data collection. JY participated in study design. SW conceived
of the study and participated in data collection and manuscript preparation.
All authors read and approved the final manuscript.

Authors’ information
MG and ST are a certified resident dentist at National Cancer Center,
Republic of Korea. JY is a certified oral and maxillofacial surgeon at National
Cancer Center, Republic of Korea. SW is a professor at oral oncology clinic,
National Cancer Center, Republic of Korea.

Acknowledgements
We would like to thank English corrector, Jinju Park and her encouraging
advice in conducting the study.

Received: 6 December 2014 Accepted: 13 January 2015

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