Answer:
The choices to reconstruct a segment of missing mandible include nonvascularized bone grafting, vascularized bone transfer, and distraction lengthening. The choices of bone grafts are corticocancellous iliac grafts and split rib grafts. Conditions are favorable for nonvascularized bone reconstruction if there has been little or no loss of soft tissue and the bone graft is placed in a well-vascularized bed. There needs to be adequate fixation of the mandibular fragments to promote consolidation.
Vascularized bone flaps can be either pedicled or microvascularly transferred. The pedicled flaps that have been described include clavicle, pedicled on the sternocleidomastoid. Rib can be transferred on the pectoralis major muscle. The scapular spine can be pedicled on the trapezius muscle. The microvascularly transferred flaps include rib-based on the anterior or posteior intercostal. The second metatarsal can be transferred on the dorsalis pedis. The iliac crest is pedicled on the deep circumflex iliac vessels. The lateral scapula based on the circumflex scapular artery. The radius can be transferred on the radial artery. The fibular flap is based on the nutrient vessels from the peroneal. More recently, distraction lengthening has been reported with the mandible. A distraction device is applied to the mandible via pins. An osteotomy is made in the mandible and the distraction of the mandible is performed serially. After the period of active lengthening the mandible is maintained in fixation for an additional period.