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Objective: Investigating the clinical efficacy of submandibular gland flap repair for postoperative defects in clinical stage III osteoradionecrosis of the jaw was the objective of this study., Methods: The study included 3 patients who declined vascularized fibula flap repair for mandibular defects and 1 patient who was not fit for mandibular reconstruction due to poor systemic condition. The postoperative defects were successfully repaired using a submandibular gland flap, and the clinical outcomes were monitored., Results: After a 6 to 8 month postoperative follow-up, all patients exhibited good wound healing, no signs of infection, no pain, and normal submandibular gland function., Conclusion: The study demonstrated that submandibular gland flap repair is an effective and feasible approach for addressing postoperative defects in clinical stage III osteoradionecrosis of the jaw, yielding satisfactory clinical results., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 by Mutaz B. Habal, MD.)

Lingual mandibular bone depression, also known as the Stafne bone cavity, commonly presents as an asymptomatic unilocular cyst-like radiolucency located below the mandibular canal. Surgical exploration of this lesion is relatively rare in the literature. A 49-year-old male was admitted to the hospital for a space-occupying lesion located in the right mandibular angle region and was performed surgical exploration. The content of the lesion was excised and prepared for histologic investigation, which revealed fibrous connective tissue, adhering muscle and nervous tissue with no evidence of epithelium tissue. Thus, the lesion was diagnosed as lingual mandibular bone depression. Of the various theories of the etiology of lingual mandibular bone depression, the most popular "glandular theory" seemed to be inapplicable in the present case. Providing misleading information in this case, B-mode ultrasonography was proved to be of little help in diagnosing this lesion., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 by Mutaz B. Habal, MD.)

Langen Beck disease, a rare idiopathic disorder, causes enlarged coronoid processes of the mandible, leading to restricted oral opening and deteriorating health. This paper presents a 10-year-old boy's case with bilateral hyperplasia of the coronoid processes (HCP), diagnosed using cranial computed tomography, severely limiting oral opening to 18 mm. Treatment involved early intraoral coronoidectomy followed by physiotherapy, yielding immediate oral opening improvement without recurrence after 1 year. Surgical timing should consider age, disease severity, and progression risk. While HCP etiology lacks conclusive evidence, genetic mutations may explain cases without identifiable causes. This case underscores the significance of timely intervention for HCP to alleviate symptoms and improve long-term outcomes, emphasizing individualized treatment strategies., Competing Interests: The authors reports no conflicts of interest., (Copyright © 2024 by Mutaz B. Habal, MD.)

Study Design: Case report. Osteoradionecrosis (ORN) of the jaw is a potentially devastating consequence of head and neck irradiation. The progression of ORN can lead to loss of bone, teeth, soft tissue necrosis, pathologic fracture, and oro-cutaneous fistula. Reconstructive surgery has mostly been reserved for late-stage disease where segmental resections are frequently necessary. Evidence is emerging to support earlier treatment in the form of debridement in combination with soft tissue free flaps for intermediate-stage ORN. The authors present a case of a 76-year-old male with persistent Notani 2 ORN of the mandible, treated with surgical removal of all remaining mandibular teeth, transoral debridement of all necrotic mandibular bone, and bone coverage with a left medial femoral condyle (MFC) periosteal free flap based on the descending genicular artery. Treatment was uneventful both intraoperatively and postoperatively. Since surgery (15 mo) the patient has remained free from clinical and radiologic signs of ORN. The MFP periosteal free flap provided an excellent result with minimal surgical complexity and morbidity in this case. Such treatment at an intermediate stage likely results in a reduction in segmental resections, less donor site morbidity, less operative time, less overall treatment time, and possibly fewer postoperative complications compared with the status quo., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 by Mutaz B. Habal, MD.)

Hyperplasia of the coronoid process of the mandible is a rare condition defined as an abnormal and progressive elongation of the coronoid process (unilateral or bilateral). Jacob disease is the name given to a pseudo-joint formation between the coronoid process and the zygomatic bone. The main clinical finding is a progressive, painless difficulty in opening the mouth, due to contact of the coronoid process with the posterior surface of the zygomatic bone or the medial surface of the zygomatic arch. To restore the mouth opening in a stable manner, resection of the elongated coronoid process followed by physiotherapy is the only effective treatment. Surgery (coronoidetomy or coronoidectomy) can be performed through intraoral or extraoral access. Intraoral coronoidectomy is the best surgical choice for most of the cases. However, in some cases, the intraoral surgical field prevents an adequate visualization of the osteotomy line. The authors present 5 consecutive clinical cases of hyperplasia of the coronoid process treated with an endoscopically assisted coronoidectomy using ultrasound bone-cutting instruments., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 by Mutaz B. Habal, MD.)

Gorham-Stout disease is an extremely rare disease characterized by progressive massive osteolysis with different clinical manifestations. The pathology is characterized by vascular proliferation, leading to destruction and resorption of the bone matrix, but the exact etiology is unknown. It can occur in any part of the body, with few reports of cases involving the maxillofacial region. Herein, the authors report a case of Gorham-Stout disease of the mandible, which started by affecting the alveolar bone and progressed to the mandibular marginal branches and even to the implanted vascularized free fibula., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of Mutaz B. Habal, MD.)

Abstract: Extensive osteomyelitis of the mandible is usually managed using elaborate procedures including resection and reconstruction of the affected part of the mandible. This brief clinical report, the authors present a case of 75-year old male with extensive osteomyelitis of the mandible, incidentally diagnosed with anemia of chronic disease and Type I diabetes mellitus and managed using an intraoral degloving approach exclusively. This has proved to be a procedure ensuring better blood supply, decreased morbidity, precluding an elaborate reconstruction procedure and an overall reduction in cost. The advantages, scientific basis, rationale and pitfalls have been discussed briefly., Competing Interests: The authors report no conflicts of interest., (Copyright © 2020 by Mutaz B. Habal, MD.)

Abstract: Central giant cell granuloma (CGCG) is a relatively uncommon benign bony lesion accounting for approximately 7% of all non-neoplastic lesions of the jaw. The clinical behavior of CGCG can vary from a slow-growing, painless lesion to fast-growing and locally destructive. When such a lesion involves the mandible, this can be quite debilitating for the patient, inhibiting oral intake and requiring an extensive resection and bone graft reconstruction. The authors present a case of effectively decreasing the surgical morbidity associated with a large and rapidly growing CGCG of the mandible in a pediatric patient. Neoadjuvant immunotherapy with denosumab (human monoclonal antibody) facilitated treatment of the tumor without the need for a large resection which would have otherwise necessitated a vascularized bony mandibular reconstruction. Consideration of neoadjuvant medical management of CGCG as the primary treatment is advocated., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2020 by Mutaz B. Habal, MD.)

Poor proprioception, weakness, and impaired reflexes increase the incidence of facial fracture in the elderly. Mandibular fractures in these people range from 10.1% to 56%. Fragment reduction and fracture consolidation are difficult due to bone atrophy, decreased capacity for bone regeneration, and lack of anatomical landmarks to guide the alignment of the fragments. This study reports 2 patients with different conducts regarding the treatment of bilateral fractures in atrophic mandible. The first patient refers to the removal of plates of the 2.4 mm system with low profile, which failed during the mandibular function, being replaced by the 2.4 mm system with high profile. The 2nd clinical reports the use of the 2.0 mm system only to simplify the mandibular fracture, and then reconstructing that with a 2.4-mm system with high profile, using the load bearing principles. Regarding mandibular fractures, an important goal is to neutralize the muscle action aiming the bone stability. There are several methods to treat that the indication should consider the load bearing and load sharing concepts. The incorrect fixation choice in these patients can result in complications as bad union, material failure, infection, and consequent treatment failure.

The objective of this study is to validate the proof of concept of a 3-dimensional (3D)-printed temporal mandibular joint (TMJ) for use in mandibular distraction in patients with severe craniofacial microsomia (CFM). Patients with Pruzansky-Kaban IIB and III have severe condylar dysplasia and abnormal or absent TMJs, often resulting in upper airway obstruction during infancy. As these patients progress, they require subsequent surgeries to correct facial asymmetry and TMJ function. While studies have shown promising outcomes with costochondral grafting or mandibular distraction without a TMJ in the setting of patients with Pruzansky-Kaban IIB and III it is often unsuccessful in avoiding tracheostomy during infancy. Using an adult head and neck cadaver, the right condylar head was removed to emulate a Pruzansky-Kaban III mandible. A 3D model of an adult skull was obtained. The 3D TMJ was replaced into the cadaver and KLS distractor applied in the vertical orientation. The authors achieved adequate distraction using a 3D-printed TMJ. The 3D structure developed here can potentially be used for clinical application in CFM patients with absent or rudimentary TMJ for distraction and further avoidance of the need for tracheostomy for airway obstruction.

Background: Facial asymmetry from unilateral condylar hyperplasia (UCH) may be definitively treated in the presence of active disease (with high condylectomy and concurrent orthognathic surgery) or after waiting for disease inactivity (orthognathic surgery alone). There is currently no consensus on the standard of care. In this study, we sought to compare functional and esthetic outcomes, as well as treatment duration, between these 2 management options., Methods: Patients who underwent treatment for UCH were identified through retrospective review. Pre- and postoperative 3-dimensional (3D) images were obtained. Short- and long-term operative outcomes of those treated during the active (group 1) were compared to those treated in the inactive phase (group 2). Total treatment time, operative time, and length of hospital stay were evaluated. Facial asymmetry was also assessed by laypersons using a Likert scale., Results: Fifteen patients (mean 25.6 years, range 14-56) were included: 6 in group 1 and 9 in group 2. All surgical outcomes were statistically independent of procedure type. Treatment time was significantly longer in the group 2 (P = 0.03). Both groups demonstrated significant improvement in facial asymmetry scores postoperatively with no significant difference in pre- or postoperative asymmetry between groups (P = 0.64)., Conclusions: In patients with active UCH, high condylectomy and orthognathic surgery is a procedure that restores facial symmetry and improves jaw function while halting mandibular growth. Good esthetic and functional outcomes, as well as reduced treatment time and disease burden, support the use of this treatment option for this population.

Previously, severe upper airway obstruction in patients with retrognathia and glossoptosis has been managed with tracheostomy. However, tracheostomy is associated with significant morbidity. In recent years, mandibular distraction has become an alternative management strategy in infants, but these applications have been limited to patient populations with retrognathia and glossoptosis. The authors present 2 unique cases of patients with KAT6B-related gene disorders, who present with a paradox of tongue-based airway obstruction in the absence of retrognathia. In both cases mandibular distraction osteogenesis with an obliquely oriented vector was successfully performed and both children avoided the need for tracheostomy.

Objective: The purpose of this study was to confirm the effectiveness and feasibility of simultaneous orthognathic surgery and mandibular contour osteoplasty with the help of the accurate surgical templates to treat mandibular protrusion with high gonial angle., Methods: Ten patients diagnosed as mandibular protrusion with high gonial angle were included in this study. Besides the traditional orthognathic surgery, mandibular contour osteoplasty was performed simultaneously. Models of the mandible were fabricated via 3D printing technology. Accurate surgical templates were produced on the 3D printing model according to preoperative design. Radiographs and medical photographs preoperatively and postoperatively were taken to compare the effectiveness of the operation. Measurement items include gonial angle (Ar-Go-Me), midlines of maxilla and mandible. The clinical manifestation of the temporomandibular joint and condylar process were observed., Results: Radiographs and photographs of the face were taken after surgery showed satisfactory esthetic outcomes. The right gonial angle improved from 128.20° ± 5.67° to 120.35° ± 0.46°, and the left gonial angle improved from 129.91° ± 2.78° to 120.74° ± 0.59°. The midlines of the maxilla and mandibular basically consisted of the facial midline. After surgery, patients' clinical manifestation of the temporomandibular joint was no significant difference compared with the preoperative and the condylar process had no absorption., Conclusion: The results of this study showed it was possible to perform orthognathic surgery and mandibular contour osteoplasty simultaneously with the help of surgical templates in the treatment of mandibular protrusion with high gonial angle.

Introduction: Autologous reconstruction of segmental craniomaxillofacial bone defects is limited by insufficient graft material, donor site morbidity, and need for microsurgery. Reconstruction is challenging due to the complex three-dimensional (3D) structure of craniofacial skeleton. Customized 3D-printed patient-specific biologic scaffolds hold promise for reconstruction of the craniofacial skeleton without donor site morbidity. The authors report a porcine craniofacial defect model suitable for further evaluation of custom 3D-printed engineered bone scaffolds., Methods: The authors created a 6 cm critical load-bearing defect in the left mandibular angle and a 1.5 cm noncritical, nonload bearing defect in the contralateral right zygomatic arch in 4 Yucatan minipigs. Defects were plated with patient-specific titanium hardware based on preoperative CT scans. Serial CT imaging was done immediately postoperatively, and at 3 and 6 months. Animals were clinically assessed for masticatory function, ambulation, and growth. At the 6-month study endpoint, animals were euthanized, and bony regeneration was evaluated through histological staining and micro-CT scanning compared to contralateral controls., Results: All 4 animals reached study endpoint. Two mandibular plates fractured, but did not preclude study completion due to loss of masticatory function. One zygoma plate loosened while the site of another underwent heterotopic ossification. Gross examination of site defects revealed heterotopic ossification, confirmed by histological and micro-CT evaluation. Biomechanical testing was unavailable due to insufficient bony repair., Conclusions: The presented porcine zygoma and mandibular defect models are incapable of repair in the absence of bone scaffolds. Based on the authors' results, this model is appropriate for further study of custom 3D-printed engineered bone scaffolds.

Mandibular distraction osteogenesis (MDO) is a fairly common procedure in specialized craniofacial surgery centers. The MDO is a minimally invasive technique that is able to generate new bone in patients with a severe hypoplastic ascending ramus, while also expanding the overlying soft tissues; therefore, it has become the treatment of choice for the surgical correction of mandibular hypoplasias. One of the most common postoperative complications involves misplacement of the distractor and/or corticotomy, which can result in the creation of an erroneous distraction vector. The introduction of 3-dimensional (3D) printing has revolutionized preoperative planning in several surgical fields; however, cost can hinder its application in developing nations, specially in public institutions. The aim of this work is present our experience using low-cost 3D-printed anatomic models for preoperative planning and surgical simulation in patients requiring MDO.

Introduction: This study aimed to determine the envelope of anterior segmental movement and changes in the inferior pharyngeal airway space (IPAS) and position of the hyoid bone following mandibular anterior subapical osteotomy (ASO) under local anesthesia in skeletal Class II patients with protrusion., Methods: The subjects were 33 skeletal Class II adult patients with lip protrusion. They were treated by extraction of 4 premolars and mandibular ASO under local anesthesia. Surgical movement of mandibular anterior segment and IPAS after surgery was evaluated by mandibular superimposition using lateral cephalograms between before and immediately after surgery. The depth of osteotomy and overlapping ratio were measured., Results: The mean retraction of the mandibular incisor was 4.04 mm at the tip and 4.29 mm at the root apex. The mean vertical movement of the mandibular incisor was 3.33 mm intrusion at the tip and 3.42 mm at the root apex. The axis of the mandibular incisor did not change significantly. Patients with deep curve of Spee showed significantly more intrusion of incisors, whereas the incisor axis became more proclined. The IPAS became narrower, and the hyoid bone moved downward after surgery. The decreased IPAS was positively correlated with retraction of root apex and proclination of the mandibular incisors., Conclusion: To establish precise surgical treatment objectives, a balance between the amount of intrusion and changes in axis should be sought after considering anatomical limitations. Mandibular ASO should be performed with caution in skeletal Class II patients vulnerable to airway-related problems.

Patients with craniofacial microsomia (CFM) may present with severely malformed mandibles resulting in secondary tongue-based airway obstruction. While surgical management of clinically significant airway obstruction in these patients often involves mandibular distraction osteogenesis (MDO), patients with Pruzansky III CFM typically require additional costochondral bone grafting. In this report, the authors present the successful surgical management of airway obstruction and severe obstructive sleep apnea using a cranio-mandibular fixator (Matthews device) combined with MDO in a 4-year-old female patient with Goldenhar syndrome and associated Pruzansky III CFM. The patient tolerated the procedure without complications and experienced a significant improvement in airway obstruction. With this approach, a severely deformed mandible can be successfully distracted while avoiding tracheostomy and disruption of native TMJ anatomy.

Objective: To present the dynamical evaluation of mandible and upper airway size among Chinese infant patients following mandibular distraction osteogenesis in a short-term follow-up and compare predistraction measurements with a normal age- and sex-matched control., Methods: All the patients have undergone the computed tomography (CT) scan before mandibular distraction osteogenesis (T0), at the end of the distraction phase (T1), and 3 months after the end of the distraction phase before the distractor removal (T2). A CT analyzing computer software MIMICS was utilized to analyze the anatomic variables of upper airway size and mandible size. All analysis was based on a significance level of 0.05., Results: Eight patients with Pierre Robin sequence differed mainly in the mandibular body length and the minimum anteroposterior dimension of the retroglossal airway from the control. After mandibular distraction osteogenesis, the mandibular body length and the ramus height both increased significantly, the ramus height also increased after 3 months of consolidation. Only small increase in the airway dimension of the retroglossal area at T2 was observed compared with T1., Conclusion: Mandibular distraction osteogenesis is an effective modality in treating Pierre Robin sequence. Compared with normal control, the main difference may be the length of mandibular body and the area of the retroglossal airway. There may not be an increase in the diameter of airway and the length of mandibular body after 3 months of growth and development in Pierre Robin sequence. Individual surgical plan should be made to gain a better prognosis.

This study was planned to evaluate the improvement in mandibular function, facial esthetics and quality of life after reconstruction of complex mandibular defects using patient-specific three-dimensional (3D) titanium implant. A total of 7 patients, who visited our outpatient clinic for reconstruction of mandibular defects after removal of their primary mandibular lesion and refused treatment with autologous bone grafts were treated with patient-specific implant for reconstruction of mandible. Three-dimensional virtual treatment planning was carried out using their 3D computed-tomographic data. The unaffected contralateral side of mandible was superimposed on the defect side and a customized implant was designed in the desired size and shape on the virtual model using computer aided designing and milled in titanium using selective laser melting, for precise anatomic mandibular reconstruction. There was significant improvement in their esthetics, function, and quality of life. The symmetry of the face and occlusion was restored with adequate mouth opening, closing, and lateral movements of the mandible with no deviation of jaw during movements. The patient specific implants appear to be very useful for precise reconstruction of mandible with greater accuracy. The concept of using customized implant with the help of 3D virtual treatment planning, stereolithographic models and computer aided designing greatly improves mandibular restoration and helps to achieve good facial profile, aesthetics and dental rehabilitation preventing severe complications related to autologous grafts.

Stem cell therapy is a revolutionary new way to stimulate mesenchymal tissue regeneration. The platelets concentrate products started with platelet-rich plasma (PRP), followed by platelet-rich fibrin (PRF), whereas concentrated growth factors (CGF) are the latest generation of the platelets concentrate products which were found in 2011. The aim of the present study was to evaluate the potential of combining autologous bone marrow concentrates and CGF for treatment of bone defects resulting from enucleation of mandibular pathologic lesions. Twenty patients (13 males and 7 females) with mandibular benign unilateral lesions were included, and divided into 2 groups. Group I consisted of 10 patients who underwent enucleation of the lesions followed by grafting of the bony defects with autologous bone marrow concentrates and CGF. Group II consisted of 10 patients who underwent enucleation of the lesions without grafting (control). Radiographic examinations were done immediately postoperative, then at 1, 3, 6, and 12 months, to evaluate the reduction in size and changes in bone density at the bony defects. Results indicated a significant increase in bone density with respect to the baseline levels in both groups (P < 0.05). The increase in bone density was significantly higher in group I compared with group II at the 6- and 12-month follow-up examinations (P < 0.05). The percent of reduction in the defects' size was significantly higher in group I compared with group II after 12 months (P = 0.00001). In conclusion, the clinical application of autologous bone marrow concentrates with CGF is a cost effective and safe biotechnology, which accelerates bone regeneration and improves the density of regenerated bone.

This prospective study evaluated the clinical effectiveness of the new approach of partial autogenous bone chip grafts for the treatment of mandibular cystic lesions related to the inferior alveolar nerve (IAN). A total of 38 patients treated for mandibular cysts or benign tumors were included in this prospective study and subsequently divided into 3 groups depending on the bone grafting method used: cystic enucleation without a bone graft (group 1), partial bone chip graft covering the exposed IAN (group 2), and autogenous bone graft covering the entire defect (group 3). We evaluated the symptoms, clinical signs, and radiographic changes using dental panorama preoperatively, immediate postoperatively, and at 1, 3, 6, and 12 months postoperatively. Radiographic densities were compared using Adobe Photoshop CS5 (Adobe Systems Inc., San Jose, CA). Repeated measures analysis of variance was used for statistical evaluation with SPSS 22.0 (SPSS Inc, Chicago, IL), and P < 0.05 was considered statistically significant.Radiopacities were the most increased at 1 year postoperative in group 3; groups 2 and 3 did not show statistically significant differences, whereas groups 1 and 3 were statistically significant. In terms of radiographic bone healing with clinical regeneration of the exposed IAN, healing occurred in all patients, although the best healing was achieved in group 2.This autogenous partial bone chip grafting procedure to cover the exposed IAN is suggested as a new surgical protocol for the treatment of cystic lesions associated with the IAN.

Background: Mycobacterium abscessus has been implicated as the cause of various infections in the setting of healthcare-related "outbreaks." Mandibular osteomyelitis caused by M abscessus is exceedingly rare, with only 1 patient reported in the literature. The authors describe the surgical management of 12 pediatric patients with M abscessus-related mandibular osteomyelitis and cervical lymphadenitis caused by exposure to contaminated water at a regional dental clinic., Methods: Following institutional review board approval, new suspected patients were reviewed and followed prospectively. A multidisciplinary team coordinated the surgical approach, antibiotic regimen, and follow-up for each patient., Results: Twelve patients (median age 7.5 years) received treatment of M abscessus infection. Eleven had mandibular osteomyelitis and underwent debridement along with extraction of affected teeth. Eight had lymphadenitis and underwent excision of involved nodes. Four patients (in whom surgical debridement was considered inadequate) received antibiotic therapy with a regimen of amikacin, cefoxitin, and azithromycin for 4 months. Nine of 12 patients have been followed for a median of 5 months (range 1-11 months); no patient has evidence of persistent clinical infection. Three of 4 patients treated with amikacin have high-frequency hearing loss., Conclusions: The authors describe a pediatric cohort with mandibular osteomyelitis and cervical lymphadenitis due to M abscessus following pulpotomy at a single dental clinic. Diagnosis required a high index of suspicion. Patients in our series had resolution of infection even without antibiotic therapy, suggesting that early complete surgical debridement and removal of affected lymph nodes can be sufficient as a sole treatment modality.

The purpose of this study was to determine the changes in hard tissues, soft tissues, and teeth after bilateral sagittal split ramus osteotomy and orthodontic treatment for the treatment of mandibular protrusion. Cephalometric analysis was used to evaluate the aesthetic effects and occlusal relationships obtained. The subjects included 11 women and 9 men (aged 18-27 years; average, 20 years) with mandibular protrusion who underwent bilateral sagittal split ramus osteotomy. Based on a preoperative computer-aided manufacturing/design-assisted, model surgical design and an occlusal guide plate, new occlusal relationships were established for the patients. In addition, the preoperative and the end of postoperative orthodontic treatment cephalometric radiographs were systematically analyzed. In all patients, the surgical incisions underwent primary healing, with no infection or osteonecrosis. Significant differences were observed in the preoperative and the end of postoperative orthodontic treatment values of all hard tissue and teeth parameters, except for SNA°, ANB°, GoGn-SN°, SE (mm), NP-FH°, SGn-FH°, OP-FH°, 1-MP°, Li-E (mm). The most obvious significant differences were seen in SNB°, SND°, 1&#95;-NA°, 1&#95;-NA (mm), 1-NB (mm), 1-NB°, Po-NB (mm), NA-PA°, AB-NP°, 1-OP°, Ui-E (mm), and S-N'-B'° (P < 0.001). Postoperative follow-up lasted for 10 to 12 months. All patients eventually achieved normal downjaw relationship, tooth arch forms, and spee curves. There were no evident irregularities of teeth arrangement or abnormal occlusal relationships were observed. All patients were satisfied with their facial appearance and occlusal relationships at the end of postoperative orthodontic treatment. The authors found a precise preoperative model surgical design combined with postoperative orthodontic treatment is a simple and time-saving technique. It can be used to correct mandibular protrusion with satisfactory occlusal relationship, facial appearance, and minimal postoperative complications.

Idiopathic bone cavity (IBC) is a rare, asymptomatic, unilateral, oval-shaped radiolucent defect in the mandible. It is extremely rare that IBC occurs in the mandibular branch and condylar process. This article presents a 16-year-old male with IBC occuring in the mandibular branch.

Aneurysmal bone cyst (ABC) is a rare, rapidly expanding, locally destructive, and easily misdiagnosed lesion. An ABC of the condyle is rare. This report presents a 25-year-old female with a giant ABC in the left mandibular condyle. This patient was treated with surgical resection of the affected bone and immediate mandibular reconstruction using autologous bone. Follow-up to date showed no signs of recurrence. The clinical feature, imaging finding, pathogenesis, and treatment methods of ABCs are discussed.

The author presents an innovative device to decompress odontogenic cystic lesions of the jawbones. Its use and characteristics are described.

Objective: The Rosai-Dorfman disease (RDD) is a rare disorder known as sinus histiocytosis with massive lymphadenopathy which affects other organs besides the lymphatic nodes. The most frequent clinical presentation is the skin involvement, but the most serious one is when the central nervous system is compromised. There are not clinical cases in the literature reporting the mandibular involvement and its management. The aim of this study is to report the case of a patient with this disease, her treatment, and her follow-up., Study: A 32-year-old woman with RDD, who underwent a right mandibulectomy to treat osteomyelitis, and who suffered hemolytic anemia, lymphoproliferative syndrome, and bacterial meningitis by meningococcus treated successfully, is presented. She also had osteosynthesis plate exposure in 3 occasions. The authors performed a mandibular reconstruction with a fibula free flap. Vertical osteogenic distraction was done to improve the vertical height of the bone for osteointegrated implants and later oral rehabilitation., Methods: The senior authors performed mandibular reconstruction with a fibula free flap. Vertical osteogenic distraction was performed to improve the vertical height of the bone for osteointegrated implants and later oral rehabilitation. The patient achieved adequate function with a good mandibular height and occlusion., Results: The patient had a follow-up of 6 months. She is highly satisfied with her result. Preoperative and postoperative photos are shown., Discussion: In this rare case, the authors show the difficulties when treating this disease. The follow-up of the patient showed a successful reconstruction with good functional results.

Background: Improving quality of human life has been the rationale for increase in the applications of bone substitute materials for bone regeneration. High prevalence of loss of bone tissue due to disease remains a major challenge for reconstruction. Shortcomings of autografts and allografts have made the clinicians go for artificial implant materials., Aim and Objective: To prospectively study the structural and esthetic reconstruction of resected mandibular site with biograft porous block hydroxyapatite (BBHA). The study evaluated the efficacy of BBHA as a material for reconstruction of large bone defects., Methods: Patients requiring reconstruction after resection of cyst/tumors and who denied conventional reconstruction were enrolled for BBHA reconstruction during 2008 to 2015. All patients were clinically and radiologically followed and assessed for a range of 4 to 60 months for outcome., Results: During follow-up periods no one had infection, dissolution, migration, or absorption, but new bone formation and bridging observed in proximity with graft and bone interface., Conclusion: Structural and esthetic reconstruction using BBHA significantly reduces donor site morbidity. BBHA have satisfactory results in relation to esthetics and are useful material for reconstruction. Clinical application of this technique will minimize an additional surgical procedure required to harvest donor bone. BBHA provides good esthetics and structural balance to face. As this is an ongoing study the outcome is expected to improve. The incorporation of implants in the BBHA block may fulfill the function also in near future.

The natural mandible has 2 arcs, the marginal arc and the occlusal arc. The marginal arc is situated along the lower margin of the mandible and affects the contour of the lower third of the face. The occlusal arc is situated along the dental arc and affects the stability of prosthodontics. The gap between these 2 arcs widens in the molar area. Our developed concept of "double arc reconstruction" involves making these 2 arcs for the reconstructed mandible. For the double-barrel fibula reconstruction, 2 bone segments are used to make both arcs. For reconstructions using the iliac crest, the double arc is made by inclination of the top of the bone graft toward the lingual side. Ten patients underwent double arc reconstruction: 2 underwent reconstruction with the double-barrel fibula, and 8 underwent reconstruction with the iliac crest. Four patients had a removable denture prosthesis, 1 had an osseointegrated dental implant, and 5 did not require further prosthodontic treatment. The shape of the reconstructed mandible after double arc reconstruction resembles the native mandible, and masticatory function is good with the use of a dental implant or removable denture prosthesis, or even without prosthodontics.

Aim: The purpose of this study was to analyze the accuracy of computer-assisted free fibula flap for reconstruction of large mandibular defects for benign tumors., Materials and Methods: Between December 2012 and January 2014, a total of 4 free osteocutaneous computer-assisted fibula flaps have been used in an equal number of patients for reconstruction of the mandible at the Division of Maxillofacial Surgery, Città della Scienza e della Salute Hospital, University of Turin. Inclusion criteria were large mandibular defects due to benign tumors. The computer-assisted fibula flap was chosen when 2 or more osteotomies were requested. Intraoperative complication, mean ischemia time, operative time, and morphologic outcomes were analyzed in all cases. After surgery, a postoperative computed tomography compared the virtual plan with the surgical results., Results: All 3 flaps were harvested and transplanted successfully. For the free flaps examined in this work, no intraoperative complications were noted. Postoperative computed tomography showed high correspondence in terms of bone contour according to the virtual plan. The immediate and long-term morphologic results were satisfactory., Conclusions: Microsurgical mandible reconstruction using a computer-assisted fibula flap technique is the best available method to manage complex defects.

Fibular osteoseptocutaneous flap has been widely used for unilateral mandibular reconstruction. However, reports about the effects of fibular osteoseptocutaneous flap for the reconstruction of bilateral mandibular defects are limited. In this study, we used free vascularized fibular flaps to successfully manage bilateral mandibular osteoradionecrosis(ORN) in 5 patients. Functional aspects were evaluated during the reconstruction process. All 5 patients had bilateral refractory ORN of the mandible and underwent radical resection between 2003 and 2011. The reconstruction surgery was performed in 2 stages using 2 free fibular flaps in 3 patients. In the other 2 patients, reconstruction was performed in a single stage using 2 separate flaps prepared from a single fibula. All patients had a healthy mandibular symphysis and meniscus of the temporomandibular joint, and these structures were preserved during the reconstruction.Of the 10 defects involving the mandible sides, 9 were successfully reconstructed. One microvascular composite flap failed because of radiation injury to the arterial endothelium at the recipient site. After the treatments, all patients had good esthetic and functional outcomes. Preoperative clinical features such as trismus and dysphagia were also markedly improved. Our surgical method may be an effective alternative for the clinical management of advanced bilateral mandibular ORN.

Objective: The objective of this study is to evaluate our 10-year clinical experience in surgical management of patients with osteoradionecrosis (ORN) unresolved with conservative nonoperative treatment., Patients and Methods: The medical records of 120 patients who had been surgically treated for ORN during a 10-year period (January 2003 to January 2013) were retrospectively reviewed., Results: The most predilection ORN site was mandible (82.5%), followed by the maxilla (11.7%). ORN developed within initial 12 months in 39.2% and within the first 3 years in 68.3%. The median radiation dose was 68.1 Gy (range, 35-148 Gy), but 51 patients (42.5%) experienced ORN even though radiation doses were controlled under 60 Gy. Surgical trauma, as we believed, was the most important factor leading to this result. Among all the patients, 12 (10.0%) patients were found ineligible for operative treatment due to comorbid systematic diseases whereas none healed or improved. In terms of surgical management of the rest of the 108 patients, 90 (75.0%) patients underwent radical resection (4 patients unhealed), and 18 (15.0%) patients underwent mild surgical procedures such as sequestrectomy or debridement (1 patient unhealed). Of the 90 radical resection patients, 58 patients underwent radical resections and immediate microvascular flap reconstruction (19 bone flaps and 39 soft flaps), and 32 patients only experience radical resection (5 patients received second-stage reconstruction). According to follow-up information, 55 patients were free of disease., Conclusion: Though priority should be given to surgical treatment for the patient whose ORN does not respond to conservative nonoperative treatment, we may as well take into account more individualized regimens based on ORN severity. A hard lesson learned from our article is that the oral maxillofacial surgeon should minimize the trauma for jaws as possible as he can, especially to patients who need to receive postoperative radiotherapy.

Gorham disease, or massive osteolysis, is a rare condition of unknown etiology. The disease is characterized by spontaneous progressive osteolysis of 1 or more skeletal bones. The mandible is the most commonly involved bone in the maxillofacial region. This article reports a case of Gorham disease with mandibular involvement in a 46-year-old male patient with a 7-year follow-up. In this case, we performed lower right mandibular osteotomy and reconstruction with a phased titanium plate. Postoperative follow-up showed continued mandibular bone loss that was progressing to the contralateral mandible. Massive osteolysis of the mandible is a rare clinical condition that must be differentiated from mandibularosteomyelitis, benign and malignant tumors, as well as hyperparathyroidism. Improved differential diagnoses and disease follow-up are required to effectively manage massive osteolysis.

Objective: The aim of this study is to discuss the application of rapid-prototyping model and surgical guide in the treatment of mandibular asymmetry malformation with normal occlusal relationship., Study Design: Twenty-four mandibular asymmetry malformation patients with relatively normal occlusal relationship were included in this study. Surgical 3-dimensional rapid-prototyping mandibular models were made for all patients from the computed tomography (CT) DICOM data. The presurgical plan was designed on the model, and the surgical guiders for the osteotomy lines were manufactured. Genioplasty and/or mandibular osteotomy based on the presurgical plan were performed on these patients with the combined use of the rapid-prototyping model and surgical guides. All patients underwent postoperative CT scan and had at least 3-month follow-up., Result: All patients were satisfied with the final results. According to the postoperative CT images and 3-month follow-up, all patients' mandibular asymmetry malformation was significantly improved, and the operation time was distinctly shortened relative to the conventional method., Conclusion: Rapid-prototyping model and surgical guide are viable auxiliary devices for the treatment of mandibular asymmetry malformation with relatively normal occlusal relationship. Combined use of them can make precise preoperative design, improve effects of operation, and shorten operating time.

Aneurysmal bone cyst is a benign pseudocystic osseous lesion characterized by a fibrous connective tissue stroma with cellular fibrous tissue, multinucleated giant cells, and large blood-filled spaces with no endothelial lining. The entity is uncommon in facial bones, and it rarely involves the mandibular condyle. Resection of the lesion is the most accepted treatment. The present case is the 11th reported case of aneurysmal bone cyst of the mandibular condyle in the existing literature and the first where, rather than using conventional extra oral approach, sagittal split ramus osteotomy was used to excise the lesion successfully with no recurrence after 3 years of follow-up.

Background: Bone morphogenetic protein 2 (BMP-2) has been used to reconstruct mandibular defects. An elegant addition to this reconstruction method would be incorporation of a nerve graft wrapped in a BMP-2 carrier to reconstitute the inferior alveolar nerve (IAN) and restore sensation to the lower face. We developed a rabbit model to determine the effect BMP-2 has on nerve regeneration following neurorrhaphy., Methods: An inferior border mandibulectomy was created in 16 adult New Zealand white rabbits. The IAN was protected, divided, and repaired with either primary neurorrhaphy or reverse autografts. Bone defects were treated with no treatment controls (n = 2), absorbable collagen sponge (ACS) (vehicle controls) (n = 7), and ACS soaked in BMP-2 (treatment group) (n = 7). Animals underwent computed tomography (CT) 2 days and 6 weeks postoperatively. The percent bone defect healing was calculated using Amira 3D imaging software. At 6 weeks, IANs were harvested mesial to the reconstruction and were evaluated with toluidine blue histology to identify myelinated axons. Reconstructed mandible segments were evaluated with micro-CT and hematoxylin-eosin histology., Results: Bone morphogenetic protein 2-treated animals demonstrated significantly more bone healing than did the ACS and empty defect groups (82%, 38%, 44%, respectively; P < 0.01). One hundred percent of ACS-treated nerves (n = 4) demonstrated axon regrowth, whereas only 25% of BMP-2-treated nerves (n = 4) did. Micro-CT and histology showed BMP-2 caused bone growth around the IAN, but regenerated bone infiltrated the repair site and created a physical barrier to axon growth., Conclusions: Bone morphogenetic protein 2 can successfully heal bone defects in the rabbit mandible, but ectopic bone growth can inhibit IAN recovery after repair. Level of Evidence: Not gradable.

Objective: Vascularized bone flaps are currently indicated for reconstructing mandibular defects 6 cm or larger. This technique can result in donor-site morbidity and requires microsurgery. To explore alternative methods of mandibular reconstruction, we sought to compare bone graft obtained with the reamer-irrigator-aspirator (RIA) device with the free fibula (FF) flap for the reconstruction of a critical-sized mandibular defect., Methods: Sixteen 3-month-old Yorkshire pigs underwent 6-cm full-thickness resection of the left mandible. For the FF group (n = 8), an osseous FF flap was raised from the left leg and placed into the defect. For the RIA group (n = 8), a RIA Instrument Set was used on the ipsilateral femur to ream the femoral canal and harvest RIA putty. This putty containing medullary bone marrow contents and cortical bone was packed into the defect. At the study end point, volumetric, biomechanical, and histologic analyses were performed., Results: Operative times were significantly shorter in the RIA group (RIA,126 [30] min; FF, 346 [50] min; P < 0.05). Biomechanical testing of reconstructed sites showed no significant difference in maximum fracture loads between both groups (RIA, 468 [97] N; FF, 689 [262] N; P = 0.11). Mean (SD) volume ratio of bone growth at the reconstructed sites was comparable between both groups (RIA, 71% [4.5%]; FF, 72% [3.3%]; P = 0.60). Equal bone quality was confirmed histologically., Conclusions: The RIA technique significantly reduces operative time and provides bone of equal strength and histologic quality to FF flap reconstruction in a large animal model. The RIA method may represent an efficient technique for the reconstruction of craniomaxillofacial defects.

Purpose: Odontogenic keratocysts (OKCs) have high recurrence potential. The aim of the study is to evaluate the correlation of radiographic features and treatments with the frequency of recurrence in OKCs in the mandible., Materials and Methods: This is a cohort retrospective study. The size of the lesions was measured on orthopantomography. Radiographic features (unilocular or multilocular), location, treatment type (enucleation or marsupialization), follow-up time, age, and sex were variable factors. Subjects were studied in 2 groups: a recurrence group and a nonrecurrence group. The radiographic size was considered to be a predictive factor, and the frequency of recurrence was an outcome of the study. An independent t-test and chi-squared test were used to compare variables between recurrence and nonrecurrence groups. Cox regression was applied to the time effect evaluation of the lesion's size and recurrence. A receiver operating characteristic test was used to find a cutoff point for recurrence in the size of radiographic views., Results: Ninety-one subjects were studied. Radiographic features and sizes were different between the 2 groups. The frequency of recurrent lesions was significantly different in various sites of the mandible. Cox regression demonstrated a positive effect of follow-up time on the risk of recurrence. In a 1-year increase in the follow-up time, the recurrence rate increased 1.07 times. An analysis of the data showed a positive relationship between radiographic size and recurrence rate. A 1-cm increase in the lesion's size increased the recurrence rate 1.67 times. A receiver operating characteristic test demonstrated 5.25 cm as a cutoff point in radiographic size; the radiographic size sensitivity was 88.5% (69.8%-97.4%), and specificity was 93.8% (85%-98.3%) for recurrence lesions. Lesions that were 5.25 cm or more on radiographic views had a significant relationship with recurrence rate (P < 0.05). The positive predictive value was 85.2% (65.4%-95.1%), and the negative predictive value was 95.3% (86%-98.8%)., Conclusions: The radiographic size may be a predictive factor for the frequency of recurrence lesions in OKCs. Primary multilocular lesions had a greater probability for recurrence than unilocular lesions.

This article reports a case of a boy with LEOPARD syndrome with unusual mandibular osteolytic osteoclastic-like lesions and eruption disorder. The patient was referred to our department for bilateral facial swelling: systemic examinations, diagnosis, and dental and maxillofacial care are reported.

Condylar hyperplasia (CH) is a pathologic condition that causes overdevelopment of the condylar head and neck as well as the mandible. Slowly progressive unilateral enlargement of the head and the neck of the condyle causes crossbite malocclusion, facial asymmetry, and shifting of the midpoint of the chin to the unaffected side. The etiology and the pathogenesis of CH remain uncertain. The diagnosis is made by clinical and radiologic examinations and bone scintigraph. A difference in uptake of 10% or more between condyles is regarded as indicative of CH, and the affected condyles had a relative uptake of 55% or more. When the diagnosis of active CH is established, the treatment consists of removal of the growth center by a partial condylectomy. The authors present the case of a 46-year-old male patient with right active type II CH or hemimandibular hyperplasia who underwent a high condylectomy.

Objective: Growth factors contained in platelet-rich plasma (PRP) can induce osteoblast differentiation in certain studies, whereas in others, osteogenesis of PRP on mandible bone defects has not been proved clinically. The aim of the study was to investigate the effect of autologous PRP on the osteogenic potential of combining bovine porous bone mineral (BPBM) and bio-guide membrane (BGM) in promoting mandible bicortical bony defects in rabbits., Methods: One circular mandible bicortical bony defects were created in each of 54 rabbits, which were divided into 3 groups: group 1: 18 of the defects were left unfilled as a negative control; group 2: 18 of the defects were grafted with autologous PRP and BPBM/BGM; group 3: 18 of the defects were grafted with BPBM/BGM without PRP. Animals were killed at 4, 8, and 12 weeks after operation. Harvested tissue and specimens were evaluated histologically and radiographically, and metabolized observation was performed. Histological parameters associated with osteoblast activities, bone trabecula, neovascularization, newly formed mineralized bone, rudimental grafts and connective tissue formation were measured. Densities of the bones at 4, 8, and 12 weeks were studied by radiographic. The bone defect closure ratio was measured at 12 weeks. The bone metabolized parameter alkaline phosphatase was also measured and compared between 4, 8, and 12 weeks., Results: The platelet concentration of PRP is 4.19- to 4.43-fold to that of the whole blood. Histological analysis showed new bone formation at all therapeutic sites including BPBM/BGM grafts with or without PRP. A statistically significant difference in new bone formation between group PRP/BPBM/BGM and group BPBM/BGM was observed. Untreated defects of group control showed the less bone regeneration. There was significant difference of bone density between group PRP/BPBM/BGM and control, and group BPBM/BGM and control, at 4, 8, and 12 weeks postoperative. There were more bone defects filling, and the grafts were absorbed at 12 weeks of group PRP/BPBM/BGM compared with group BPBM/BGM. Defects treated with PRP/BPBM/BGM demonstrated significantly increased activity of osteoblasts, enhanced amount of mitochondria and rough endoplasmic reticulum in osteoblasts, and increased concentration of alkaline phosphatase at 4, 8, and 12 weeks compared with those treated with BPBM/BGM and control group. Complete closure ratio of bone defects treated with PRP/BPBM/BGM (50%) was significantly increased compared with that treated with BPBM/BGM (16.6%)., Conclusions: The study suggested that PRP combination of BPBM and BGM had significant therapeutic effects on mandible bicortical bony defects of rabbits. The effects are associated with the high concentration of platelet in PRP and the porous configuration of BPBM. Although we cannot reveal the detailed statistical relationship of PRP on promoting BPBM/GBM osteoinductive effects, PRP demonstrated superior results of bone regeneration.

Aneurysmal bone cyst is a non-neoplastic expansile lesion characterized by replacement with fibro-osseous tissue and blood-filled cavernous spaces. Involvement of the condyle is rare, and only 11 cases have been reported in English-language literature to date. Its common treatment modalities are lesion excision or condylar resection, but recurrence is high in patients treated with the former. The authors reported a 19-year-old female patient with swelling of the right preauricular region, who had a surgical curettage history in another hospital. The lesion was completely resected and the jaw was immediately reconstructed with costochondral graft with the help of SurgiCase software. The patient has been symptom-free for 6 months postoperatively.

We describe the surgical management of an uncommon case of synchronous presentation of central giant cell granuloma and ossifying fibroma in the mandible. A mandibular resection was performed and a fibula-free flap was harvested to reconstruct the defect.

Dentists are often faced with extensively resorbed mandibular ridges with shallow buccal vestibule and high insertion of the mentalis muscle in relation to the crest of the ridge, causing the displacement of the prosthesis. Vestibuloplasty techniques aim at eliminating the muscle insertions, reposition the mucosa, and increase the area chapeável, giving more stability to the prosthesis. Among the techniques to deepen the vestibule are submucosal vestibuloplasties by secondary epithelialization and with mucosal and skin grafts. We will discuss vestibuloplasty by secondary epithelialization with emphasis on the so-called modified Kazanjian technique. This technique provides an appropriate result and does not require hospitalization, additional surgery at the donor, or prolonged periods without the use of prosthesis.

Mandibular continuity defects occur after tumor resection, maxillofacial injury, or osteomyelitis. In this clinical pilot study, we report a novel method for reconstruction of mandibular continuity defect by in vivo tissue engineering. In 3 patients with critical-size mandibular bone defects, the allogenic mandibular bone scaffold was customized, loaded by ex vivo expanded mesenchymal stem cells, and transplanted into the surgical defect site. According to the bone scintigraphy, vascularized bone was identified in 2 cases. In spiral computed tomography, normal bone healing without significant bone resorption was seen at the 2 viable grafts, but at the failed construction, there was a lack of osteointegration to the adjacent host bone and a higher density in the medullary bone. According to the serial panoramic imaging, the patients with viable bone grafts had normal bone healing, whereas the other patient had progressive overall bone resorption. Our results demonstrate the feasibility of allogenic bone scaffold loaded by mesenchymal stem cells in the reconstruction of mandibular continuity defects. Although long-term results are not yet available, it may be a novel method of reconstruction and a basis for further studies.

Objective: Bisphosphonate-related osteonecrosis of the jaw (BRONJ) is a clinical condition found in patients who have received intravenous or oral bisphosphonate therapy for various diseases related to bone. This report describes a novel treatment of BRONJ using autologous bone marrow stem cells, platelet-rich plasma, beta tricalcium phosphate, and demineralized bone matrix., Study Design: We report a 71-year-old woman with history of multiple myeloma treated with intravenous zoledronic acid during 4 years. After a tooth extraction, the patient presented with a painful BRONJ lesion with no healing wound and cortical bone exposure. The patient was surgically managed with a standardized protocol of autologous stem cell therapy combining bone marrow harvest, cell concentration procedures, and intraoral surgery., Results: CT scan performed 6 months later showed improvement of bone and concentric ossification. Cellular therapy might be considered a new strategy to heal BRONJ lesions.

Computer-aided design has gained increasing popularity in clinical practice, and the advent of rapid prototyping technology has further enhanced the quality and predictability of surgical outcomes. It provides target guides for complex bony reconstruction during surgery. Therefore, surgeons can efficiently and precisely target fracture restorations. Based on three-dimensional models generated from a computed tomographic scan, precise preoperative planning simulation on a computer is possible. Combining the interdisciplinary knowledge of surgeons and engineers, this study proposes a novel surgical guidance method that incorporates a built-in occlusal wafer that serves as the positioning reference.Two patients with complex facial deformity suffering from severe facial asymmetry problems were recruited. In vitro facial reconstruction was first rehearsed on physical models, where a customized surgical guide incorporating a built-in occlusal stent as the positioning reference was designed to implement the surgery plan. This study is intended to present the authors' preliminary experience in a complex facial reconstruction procedure. It suggests that in regions with less information, where intraoperative computed tomographic scans or navigation systems are not available, our approach could be an effective, expedient, straightforward aid to enhance surgical outcome in a complex facial repair.

Background: Fibrous dysplasia (FD) is a tumor-like growth that consists of replacement of the medullary bone with fibrous tissue, causing the expansion and weakening of the areas of bone involved. The most commonly affected bones are facial bones, causing a number of facial cosmetic and functional problems., Methods: From December 2008 to July 2012, 10 patients with craniomaxillofacial fibrous dysplasia were treated by conservative resection and local recontouring. The patients were followed up yearly, with an average of 3 years; the longest follow-up period was 5 years., Results: All the 10 patients received appropriate treatment and histopathological examinations were performed to confirm the diagnosis of FD. Four patients with zygoma involved had received partial zygoma osteoectomy and 2 patients received mandibular partial osteoectomy. Average time of follow-up was 3 years, with a range from 1 to 5 years, and all patients obtained satisfactory aesthetic and functional results., Conclusion: In most patients, a conservative surgery will achieve good functional and aesthetic results. For patients with mild symptoms, the aesthetic effect should be given priority while for the heavier patients the restoration of function and aesthetic effects should all be taken into account.

We designed one-and-a-half-barrel vascularized free fibular flap which is a further modification of the double-barrel technique, and we tried to overcome the discrepancy between mandible and fibula flap. We used this flap in case of a segmental mandibular defect that occurred as a result of a giant cell reparative granuloma excision. This new modification eliminated volume insufficiency of the classical technique and volume excess of the double-barrel technique.A segmental mandibular defect that occurred as a result of giant cell reparative granuloma excision was reconstructed using one-and-a-half-barrel vascularized free fibular flap. The size discrepancy between mandible and free fibula flap is a well-known problem, and this new modification of free fibular flap eliminated volume insufficiency or excess problems of the other techniques.

Aneurysmal bone cyst (ABC) is an uncommon osteolytic lesion of the bones, usually affecting the long bones and spine. The lesion is rare in the jaws and is found most commonly in the body and ramus of the mandible. In some cases, ABCs may be present as rdestructive lesions simulating malignancies. In these cases, a careful diagnosis should be done, including in the differential diagnosis malignant tumors such as telangiectasic osteosarcoma and intraosseous fibrosarcoma. Removing the lesion is usually easy if it is confined within the bone, but it may prove difficult if the lesions are multilocular, expansive, divided by multiple bony septa, or destructive or when the cortical is perforated. Therefore, the surgical treatment of the destructive ABCs should be more radical.