Use of the "double barrel" free vascularized fibula in mandibular reconstruction

Purpose: Microvascularized fibula transplants have become established in reconstruction of the mandible. However, because of the Limited diameter of the fibula compared with, the height of the mandible, the vertical distance between the reconstructed segment and the occlusal plane can be substantially large. This is a particular problem in nonatrophic or dentate mandibles, especially when rehabilitation with dental implants or an implant-borne denture is contemplated. The large leverage forces resulting from the high vertical dimension of the prosthetic construction can lead to overloading of the osseointegrated implants and endanger the longevity of the prosthetic restoration. This article describes experience with a new method of circumventing this problem. Patients and Methods: This procedure was used in eight patients. A fibula graft corresponding to at least twice the length of the mandibular defect was harvested, halved perpendicular to its length, and the resulting struts folded on top of each other to form a "double barrel." The struts are then fixed to each other with screws and plates and stabilized in the defect using a reconstruction plate. Results: Compared with the conventional one-strut fibula transplant, the "double-barrel" graft achieved more bone height and appreciably reduced the vertical distance to the occlusal plane. Conclusions: This technique creates better conditions for prosthetic rehabilitation. In comparison with the iliac graft, the fibula is easier to harvest, more reliable regarding anastomosis, and is associated with less postoperative morbidity.