An analysis of the viability of avascular iliac and fibula grafts in mandibular reconstruction- A prospective randomised study

doi:10.21203/rs.3.rs-1594729/v1

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An analysis of the viability of avascular iliac and fibula grafts in mandibular reconstruction- A prospective randomised study

https://doi.org/10.21203/rs.3.rs-1594729/v1

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Purpose: Reconstruction of the mandible is a challenging task in terms of restoring its form and biomechical functions. Nonvascular iliac and fibula graft are used in mandibular reconstruction with different sets of complications and varying success rate. The aim of this study is to prospectively compare the viability of avascular iliac and fibula bone grafts in the reconstruction of mandibular defects.

Methods: A total of 14 patients, planned for reconstruction of mandibular defects from November 2016 to April 2018 were randomly allocated in two groups; nonvascular iliac and fibula graft groups. Clinical assessment for improvement in function, esthetics, wound healing, pain, donor site morbidity was done and were followed up for six months. Digital Orthopantamogram was taken for radiographic evaluation upto 6 months.

Results: Difficulty in swallowing, mastication, speech, infection, restricted limb movement, altered gait were statistically significant and were seen more in fibula group. Wound dehiscence with graft exposure was found in one subject. The overall success rate was 100% in iliac group and 85.7% in fibula group.

Conclusion: Considering the long term complications and success rate, nonvascular iliac graft was found to be more superior and can be used as an alternative to nonvascular fibula graft for a defect length upto 7cms.

nonvascular

iliac

fibula

bone graft

mandible

The mandible is an integral part of the face and it plays a key role in function and aesthetics, speech, and respiration[1]. Resection of the mandible is done for the malignant tumor, benign pathology, and gunshot injuries which cause loss of muscle attachment, and support of lips and chin[2, 3, 4]. Resection can lead to impaired oral functions such as speech, swallowing, saliva retention, noticeable facial deformity, and associated psychosocial problems. The rehabilitation of patients affected by defects of the mandible after tumor resection poses a great challenge. The ultimate goal of mandibular reconstruction is to restore its form, biomechanical functions of mastication, deglutition, speech articulation, and oral competence to a near-normal state.

Reconstruction of these defects can be done using autografts, allografts, and alloplastic materials[1, 5, 6]. Autografts have superior capacity to promote osteogenesis, with optimal ability to become incorporated without immunologic sequelae and are considered the gold standard among the reconstruction choices[5]. Choice between vascular bone graft (VBG) and nonvascular bone graft (NVBG) depends on patient factors and surgeon’s factors. NVBG is easy to perform, and convenient in structuring the graft to the required defect, thereby improving the contour and symmetry[8, 9, 10]. Greater remodeling capacity, stability against ischemia, and resistance to resorption for long years in presence of intact periosteum and soft tissue cover make NVBG a better choice over VBG[8, 9].

Iliac crest graft is easy to harvest and is the graft of choice for most surgeons because of the ease in access, good bone volume, resemblance to the lateral aspect of the mandible and its richness in osteocompetent cells[3, 11]. Fibula being the non-prime weight-bearing bone is a long tubular structure having dense cortical plates with the availability of 20–25 cms, presence of endosteal blood supply allows for multiple graft osteotomies to contour without much compromise in bone viability[12].

However, there has been a lack of proper comparable results among these two reconstructive options. There is insufficient literature on the comparison of avascular iliac and fibula grafts in the reconstruction of mandibular defects.

The purpose of this study is to prospectively compare the viability of avascular iliac and fibula bone grafts in the reconstruction of mandibular defects. This study hypothesizes that an avascular iliac bone graft is better than an avascular fibula bone graft with a superior outcome. The study aims to compare the viability of non-vascular iliac graft versus non-vascular fibular graft in mandibular reconstruction. The objectives of this study include comparison of the following between non-vascular iliac and fibula grafts in terms of a) the functional outcome b) aesthetic outcome c) wound healing d) severity of pain e) radiographic assessment f) donor site morbidity.

Patients were randomly allocated into two groups who required reconstruction of mandibular defects. A total of 14 patients fulfilling the inclusion and exclusion criteria were included with 7 patients in each group who presented to the Department of Oral and Maxillofacial Surgery at Bapuji Dental College and Hospital, Davangere, Karnataka during the period from November 2016 to April 2018. Subjects eligible for study inclusion were between the age of 20 years and 60 years, with mandibular defect up to 7cm, with the availability of complete soft tissue coverage post defect at the recipient site, Patients with circulatory problems such as varicose veins and consented to study enrollment. Subjects were excluded for study enrollment of ASA3 and ASA4 category, with infection at recipient site, had undergone radiation therapy or refused study enrollment. One group reconstruction was done using non-vascular iliac crest graft (group 1), in another group reconstruction was done using non-vascular fibula graft (group 2).

Ethical committee approval was obtained from institutional review board and structural informed consent was taken from all patients included in the study.

Surgical technique

Patients were operated in general anesthesia under aseptic condition with standard draping. The recipient site was exposed either intraorally or extraorally. Blunt dissection was done to expose the defect keeping the periosteum intact and with minimal trauma to the soft tissue cover. For mandibular continuity defects reconstruction plate was adapted prior to the resection and was fixed using monocortical screws to maintain the anteroposterior length of the defect. Reconstruction plate and screws were removed from the mandible. Resection of the defect site was done using burs. A template was used to measure the size of the defect. For harvesting the graft simultaneously two teams operated at recipient site and graft harvesting site. Anterior iliac crest graft was harvested by infiltrating the iliac crest site using local anesthesia with adrenaline. Marking was placed on the skin overlying the anterior iliac spine (AIS) by retracting it medially which facilitated the postoperative scar to be lateral to the iliac crest and to prevent the irritation from clothing. Incision was of 4-6cm in length, 2cm posterior to the tubercle of the ilium and 1cm inferior to AIS, obliquely along the anterior iliac crest in order to avoid damage to iliohypogastric, subcostal and lateral femoral nerves. The dissection layers included skin, subcutaneous tissue and scarpa fascia. The dissection was continued onto the dense fibrous periosteum of the iliac crest to avoid postoperative pain and gait disturbances due to the transection of tensor fascia lata and external and transverse abdominal muscle. After reflection of the periosteum, the iliac crest bone was exposed. To avoid the fracture of AIS, 2.5cm of the bone posterior to it was maintained. With the help of template, adequate size of the corticocancellous graft was obtained and osteotomies were done as per the requirement. Drain was placed to limit the postoperative fluid collection, closure was achieved in multiples layers involving periosteal envelope over the iliac crest, subcutaneous layer and skin layer. Bed rest was advised for 2 days followed by assisted ambulation.

Before harvesting fibula graft leg was elevated for ten minutes for venous drainage. Tourniquet was applied at 100mm of Hg above systolic blood pressure at mid-thigh region, sand bag was placed under the hip, standard draping and painting was done under strict aseptic conditions. Fibula head and lateral malleolus were marked with upper limit of the incision placed 6cm away from the fibular head till 6cm above lateral malleolus to prevent damage to peroneal nerve and to avoid ankle instability. Infiltration was done using local anesthesia with adrenaline. Vertical incision was placed through the skin and subcutaneous tissue. Intermuscular septum was exposed and incised, dissection plane between peroneus longus and soleugastronemus complex, lateral border of the fibula bone was reached. Required defect length was measured, osteotomy cuts were placed taking care of medial structures. Tourniquet was removed. Drain was inserted. Closure was done in layers. Post operatively the leg was supported by splint of plaster of paris. All the patients were ambulated after 7 days post operatively with the help of walker.

Harvested graft was placed in previously created defect. Contouring osteotomies was done on the table. Fixation of graft on either side was done using reconstruction plates. In anterior mandibular defects hitching of the muscles to the graft was done. Adequate care was taken to cover reconstruction plate and graft by water tight closure confirming a good oral seal. Suction drain was placed. Intermaxillary fixation for a time period of 14 days was done if required. The patients were advised to maintain good oral hygiene.

Evaluation of subjects

Assessment of the patients was done for improvement in 1) functional outcomes which included difficulty in swallowing, speech and mastication, 2) aesthetic outcome in terms of facial asymmetry, patients opinion 3) donor site outcomes- restricted limb movement, altered gait, paresthesia 4) complications of recipient and donor site- infection and wound dehiscence, 5) radiographic assessment was done using digital Orthopantomagram (OPG) and at immediate,1^st month, 3^rd month and 6 months post operatively(op) .6) Pain assessment at recipient and donor site was done using Visual analog (VAS) scale and was recorded as mild (score1-3), moderate ( score 4-6), severe (score 7-10) at 1^st week, 1 month, 3 month and 6 month postoperatively.

Data was entered in excel and analyzed using SPSS 21. Results are expressed as-Mean ± SD and percentage. Assessment of functional outcome, aesthetic outcome, donor site morbidity, complications, and the radiographic outcome was done using the Chi-Square test. P-value 0.5 was considered as significant. Assessment of pain was done using an Independent-test.

14 patients were included in this study with 8 females and 6 males in a ratio of 1.33:1, the age distribution was between 13–50 years with the mean age of subjects being 27.00 ± 12.55. 9 (64.3%) 2 patients in the iliac group had midline defect and 5 patients had the lateral defect of the mandible, in fibula group 5 patients had midline defect, 2 patients had the lateral defect of the mandible. (Table 1)

Table 1

Common characteristics of the study population
	Iliac group( group 1)	Fibula group ( group 2)
Gender
Male	4	2
Female	3	5
Type of mandibular defect
Midline defect	2	5
Lateral defect	5	2

Difficulty in mastication was evaluated and was given a score of 1 if the difficulty was present, a score of 0 was given if difficulty in mastication was absent. In1st month, 6(85.8%) patients in the fibula group and 1(14.2%) patient in the iliac group showed difficulty in mastication (p = 0.008). Improvement was noted and by the 3rd month and at 6th month, only 1(14.2%) patients in fibula group showed difficulty (p = 0.299). Difficulty in swallowing was evaluated and was given a score of 1 if difficulty in swallowing was present, score of 0 was given if difficulty in swallowing was absent. At 1 month, 7(100%) patients in the fibula group and iliac group none (0%) of the patients had difficulty in swallowing (p = 0.000). At 3rd month and 6th month, difficulty in swallowing was seen in 1(14.2%) patient in fibula group and 0(0%) patients in iliac group (p = 0.299). Difficulty in speech was evaluated and was given a score of 1 if difficulty in speech was present, score of 0 was given if difficulty in speech was absent in the patient. Difficulty in speech was seen in 5(71.4%) in fibula group and 1(14.2%) in iliac group (p = 0.031) at 1 month. At 3rd month and 6th month, all patients showed improvement. (Table 2) Statistically significant difference was seen at only at the 1 month between the two groups (p < 0.05)

Table 2

Recipient site - Functional outcome in both the groups
Functional outcome	1 month		P value	3 months		P value	6 months		P value
Mastication	Group 1	1(14.2)	.008	Group 1	0(0)	0.299	Group 1	0	0.299
Mastication	Group 2	6(85.8)	.008	Group 2	1(14.2)	0.299	Group 2	1(14.2)	0.299
Swallowing	Group 1	0(0)	.000	Group 1	0(0)	0.299	Group 1	0	0.299
Swallowing	Group 2	7(100)	.000	Group 2	1(14.2)	0.299	Group 2	1(14.2)	0.299
Speech	Group 1	1(14.2)	0.031	Group 1	0	1	Group 1	0	1
Speech	Group 2	5(71.4)	0.031	Group 2	0	1	Group 2	0	1

Infection was not seen at recipient site at 1st month in terms of pus discharge and fistula formation. At 3rd month pus discharge with sinus opening was noted extraorally in 1(14.2%) patient in fibula group (p = 0.299) (Fig. 1). Antimicrobial therapy was started and local debridement was done, it healed in a week time and by 6th month none of patients in both the group had any signs of infection (p = 1). Wound dehiscence at recipient’s site, at 1 month it was noted in 1(14.2%) patient in fibula group with midline defect (Fig. 2) and in no patient in iliac group (p = 0.299). Revision of the site with wound dehiscence in fibula group was done. At 3rd month wound dehiscence recurred in the same patient with graft exposure in fibula group while in iliac group none of the patient had any signs of dehiscence (p = 0.299) (Table 3).

Table 3

Recipient site - Wound healing in both the groups
Wound healing	1 month		P value	3 months		P value	6 months		P value
Infection	Group 1	0(0)	1	Group 1	0(0)	0.299	Group 1	0(0)	1
Infection	Group 2	0(0)	1	Group 2	1(14.2)	0.299	Group 2	0(0)	1
Wound dehiscence	Group 1	0(0)	0.299	Group 1	0(0)	0.299	Group 1	0(0)	0.299
Wound dehiscence	Group 2	1(14.2)	0.299	Group 2	1(14.2)	0.299	Group 2	1(14.2)	0.299

At donor site restricted limb movement was evaluated and was given a score of 1 if restricted limb movement was present, score of 0 was given if restricted limb movement was absent in the patient. At 1 month, 5(71.4) patients in fibula group and in iliac group 0 (0%) patients had restricted limb movement (p = 0.005). At 3rd and 6th month none of the patients in both group had restricted limb movement (p = 1). Statistically significant difference was seen at 1 month between the two groups (p < 0.05). Altered gait was evaluated and was given a score of 1 if altered gait was present, score of 0 was given if altered gait was absent in patient. At 1 month, 5(71.4%) patients in fibula group and 1(14.2%) patient in iliac group presented with altered gait (p = 0.031). At 3rd month, 5(71.4%) patients in fibula group and none in iliac group presented with altered gait (p = 0.005). At 6th month 1(14.2%) patient in fibula group and no patient in iliac group presented with altered gait (p = 0.299). Statistically significant difference was seen at 1 month and 3rd month between the two groups (p < 0.05). Paraesthesia was evaluated and was given a score of 1 if paraesthesia was present, score of 0 was given if paraesthesia was absent in patient. Paraesthesia was noted in 4(57.2%) patients in fibula group and none in iliac group at 1 month (p = 0.018). Improvement was noted, and 1(14.2%) patient in fibula group and no patient in iliac group presented with paresthesia at 3rd month (p = 0.299). None of the patients in both groups had paresthesia by 6th month (p = 1). Statistically significant difference was seen at 1 month between the two groups (p < 0.05). Infection and wound dehiscence was not noted in any patients till 6 months (p = 1). Statistically no significant difference was seen between the two groups (p > 0.05) (Table 4).

Table 4

Donor site morbidity in both the groups
Outcomes	1 month		P value	3 months		P value	6 months		P value
Restricted Limb movement	Group 1	0(0)	.005	Group 1	0(0)	1	Group 1	0(0)	1
Restricted Limb movement	Group 2	5(71.4)	.005	Group 2	0(0)	1	Group 2	0(0)	1
Altered gait	Group 1	1(14.2)	.031	Group 1	0(0)	.005	Group 1	0(0)	0.299
Altered gait	Group 2	5(71.4)	.031	Group 2	5(71.4)	.005	Group 2	1(14.2)	0.299
Paraesthesia	Group 1	0(0)	.018	Group 1	0(0)	0.299	Group 1	0(0)	1
Paraesthesia	Group 2	4(57.2)	.018	Group 2	1(14.2)	0.299	Group 2	0(0)	1
Infection	Group 1	0(0)	1	Group 1	0(0)	1	Group 1	0(0)	1
Infection	Group 2	0(0)	1	Group 2	0(0)	1	Group 2	0(0)	1
Wound dehiscence	Group 1	0(0)	1	Group 1	0(0)	1	Group 1	0(0)	1
Wound dehiscence	Group 2	0(0)	1	Group 2	0(0)	1	Group 2	0(0)	1

Pain scores was 4.71 ± 2.69, 2.43 ± 2.50, 2.57 ± 3.55, 2.71 ± 3.68, 0.71 ± 1.89 in fibula group and 5.43 ± 1.27, 3.00 ± 1.86, 1.57 ± 1.51, 0.71 ± 1.25, 0.57 ± .98 in iliac group at 1st week, 1st month, 3rd month and 6th month at recipient site. At donor site pain score was 4.86 ± 2.41, 3.14 ± 2.268, 1.29 ± 1.89, 1.14 ± 1.57, 0.71 ± 1.89 in fibula group and 3.29 ± 1.704,, 2.57 ± 1.813, 1.14 ± 1.574, .86 ± 2.268, 0 ± 0.00 in iliac group at 1st week,1st month, 3rd month and 6th month. Statistically no significant difference was seen at any interval (p > 0.05) (Table 5).

Table 5

Pain assessment through VAS scale in both the groups
	Recipient site			Donor site
	Group 1	Group 2	P value	Group 1	Group 2	P value
1 week	5.43 ± 1.27	4.71 ± 2.69	0.293	3.29 ± 1.704	4.86 ± 2.41	0.247
1 month	3.00 ± 1.86	2.43 ± 2.50	0.473	2.57 ± 1.813	3.14 ± 2.26	0.228
3 months	0.71 ± 1.25	2.71 ± 3.68	0.199	.86± 2.268	1.14 ± 1.57	0.221
6 months	0.57 ± .98	0.71 ± 1.89	0.213	0 ± 0.00	0.71 ± 1.89	0.229

Radiographic evaluation was done using digital OPG, and score of 0 was given for visible jaw/graft interface and if trabeculae was absent, score of 1 was given for invisible jaw/graft interface and if trabeculae was present. Immediate radiograph showed visible jaw and graft bone interface in both the groups. At 1st month it was interpreted as invisible in 1(14.2%) patient in fibula group and 2(28.6%) in iliac group (p = 0.515). At 3rd month it was interpreted as invisible in 4(57.2%) patients in fibula group and 6(85.8%) in iliac group (p = 0.237). At 6th month it was interpreted as invisible in 7(100%) patients in iliac group (Fig. 3) and 6(85.8%) patients in fibula group (Fig. 4) (p = 0.299). Trabecular pattern was noted at immediate post op OPG, 1st month, 3rd month and 6th month in both the groups (p = 1). Statistically no significant difference was seen between the two groups (p > 0.05) (Table 6).

Table 6

OPG radiographic assessment of both the groups
	Graft-mandible interface -invisible			Trabecular Pattern- present
	Group 1	Group 2	P value	Group 1	Group 2	P value
Immediate	0	0	1	7	7	1
One month	2	1	0.515	7	7	1
3 months	6	4	0.237	7	7	1
6 months	7	6	0.299	7	7	1

Autogenous bone grafting is the mainstay for reconstruction and is considered as gold standard, as it transfers osteocompetant cells (transfer osteogenesis) to the recipient site[11, 13]. NVBG are best suited for oromandibular reconstruction following ablation of benign lesions, trauma and non-continuity defects. Iliac crest and fibula bone graft are good choices for its reconstruction. The purpose of this study was to evaluate the efficiency of avascular iliac and fibula bone grafts in the reconstruction of mandibular defects. This study hypothesized that avascular iliac bone graft is better than avascular fibula bone graft in mandibular reconstruction with superior results. Our goal was to compare the viability of non-vascular iliac graft versus non-vascular fibular graft in mandibular reconstruction with objectives of comparison of the functional outcome, aesthetic outcome, wound healing, severity of pain, radiographic assessment and donor site morbidity.

In our study mandible resection was done following benign pathological lesions, skeletal defect, trauma and Temporomandibular joint ankylosis. We limited the length of defect up to 7cm in our study as the aim was to compare two different bone grafts so we avoided the bias of graft failure due to the defect length as noted by various authors[9]. Success of graft was defined with restoration of bone continuity and complete consolidation with no signs of infection both clinically and radiographically[2].

When compared to iliac group (upto 14.2%) higher percentage of patients in fibula group (upto 100%) showed difficulty in mastication, speech and swallowing. This could be explained by extended maxillomandibular fixation which was done in our study to avoid the mobility of the graft because of suprahyoid musculature, dissection of the masticatory and tongue muscles restricting its mobility[3]. However difficulty subsided by 6th month except in one patient in fibula group with midline defect, this could be explained due to loss of attachment of the muscles in the floor of mouth[3, 8]. Mastication and swallowing were found to be better in iliac group when compared with fibula graft which was also noted in our study[14].

Facial asymmetry was noted in one patient in the fibula group and 2 patients in the iliac group at the end of 6th month, this could be explained as the shaping of iliac bone grafts is a more difficult task compared to fibula grafts. Secondly iliac bone graft has large degree of resorption compared to fibula graft due to its robust cortex[2, 12]. Deficient graft length can be one of the cause of asymmetry, and to avoid this, it is advocated to harvest the graft atleast 2-4cm more than the defect length.

Pus discharge was present in one patient in fibula group of 7 cm defect length, this could be explained due to immediate reconstruction with saliva contamination leading to necrosis and sequestrum formation[3, 5, 6, 8, 15] Antimicrobial therapy was started and local debridement of the site was done, it resolved in a week time[4]. In fibula group, one patient had intraoral wound dehiscence in midline defect involving the mandibular symphysis region, graft was exposed in anterior region of the mandible, it could be as a result of inadequate soft tissue cover or lack of blood supply, multiple vectors of hard and soft tissue mobility along with torsional forces of mandible[1–3, 12, 16–18]. Authors have also commented that when compared with lateral defects the rate of complications are higher in midline defects due to inability of NVBG to reconstruct the anatomic alteration which was found to be in consensus with our study[3, 17].

Restricted limb movement was seen in 5 patients in fibula group and in iliac group none of the patients had restricted limb movement in the early postoperative period. The probable reason could be patient ambulation with the help of walker. Altered gait was noted in 5 patients in fibula group and 1patient in iliac group at 1st month. Extensive dissection and muscular detachments is the primary cause for gait disturbances, meticulous harvesting in fibula group showed minimal altered gait[12], but in the iliac group because of excessive stripping of tensor fascia lata and gluteus medius muscle the study patients experienced noticeable altered gait[13]. Paraesthesia at donor site was noted in 4 patients in fibula group at 1 month which resolved by 3rd month, this could be explained as result of injury to peroneal nerve, in order to avoid it the proximal part of fibula should be preserved up to 4cm[19].

The mean pain on VAS Scale in both Groups depicted significant reduction with time in a similar fashion with score slightly higher in fibula group at recipient site, but statistically there was no significant difference between two Groups.

Digital OPG was done at different intervals to assess the bony continuity and consolidation and it was found to be satisfactory in 100% in the iliac group and 85.7% in fibula group which was in consensus with the literature[15, 16, 19–21]. Recipient site healing of the graft relies mainly on the cellularity, vascularity as revascularisation of the graft is of paramount importance for its survival and presence of Bone morphogenic proteins[12]. By the process of osteoconduction and osteoinduction, new bone is formed following the resorption of the mineral matrix called as creeping substitution[7, 12, 21]. To achieve this, rigid fixation of the graft was done using reconstruction plates in our study[10, 12, 20]. If the fixation of the graft is non rigid, it can cause micromovement of the graft jeopardizing the viability of the graft[3–5, 7]. In a favourable environment new vessels growth is seen in the non vascular bone graft as early as 3 days after grafting, with abundant vascularization by 2nd week[15]. In one subject mild to moderate resorption was seen in one patient in fibula group but it cannot be regarded as the failure of graft as the grafts resorbs at a faster rate in the first year and later it is controlled by remodeling process[6].

In our study the overall success rate was 100% in iliac group and 85.7% in fibula group which is in range with the success rate noted by various authors in the literature[3, 4, 9]. The high percentage of success in our study in both the groups could be due to short span of graft length (upto 7cm), low incidence of infection, nonirradiated lesions, adequate graft fixation, extensive coverage of soft tissue as well as proper postoperative care[3, 8, 10, 16, 17, 22–24]. Considering loss of graft in one subject was purely due to wound dehiscence, not because of length of defect so it is advisable to do a two stage procedure after oral seal is formed or a local flap can be used to compensate for oral tissue loss and allowing water tight closure and with prolonged period of maxillomandibular fixation should be done. Advantages were it is quick, simple, inexpensive, two team can work simultaneously, lower morbidity, regeneration of fibula bone in a young child in our study which is in consensus with literature[1]. Disadvantages could be longer time to achieve bony union. Non vascular iliac crest graft can be a good alternative to non vascular fibula graft.

NVBG can be used as a first choice in reconstruction of defects with adequate soft tissue cover and blood supply, to restore the aesthetics and functions of mandible. In our study functional difficulty was noted higher in fibula group in early postoperative period which resolved and was comparable to the iliac group by the end of 6th month. Facial asymmetry was higher in iliac group. Pain was higher in the fibula group. Infection was noted in one patient in fibula group which was intervened and it resolved. Donor site morbidity was highly noticeable in terms of gait in fibula group in the early postoperative period when compared to iliac group which then resolved by the 6th month. The overall success rate was 100% in iliac group and 85.7% in fibula group. Graft failure was noted in one patient with midline defect in fibula group as a result of intraoral wound dehiscence which led to the exposure of the graft, therefore to avoid midline dehiscence it is recommended to consider a primary reconstruction with two layered intraoral water tight closure with good soft tissue coverage with adequate blood supply. The other option to avoid intraoral dehiscence would be to carry out a delayed reconstruction after 6-8weeks via an extraoral approach which would facilitate a complete intraoral seal. However considering the complications and success rate, nonvascular iliac bone graft is more preferable than non vascular fibula bone graft for a defect length up to 7cms.

Acknowledgement:

Dr.Ekta Sinha for her contribution in statistical analysis.

Funding

The authors declare that no funds, grants, or other support were received during the preparation of this manuscript

Competing Interests

The authors have no relevant financial or non-financial interests to disclose

Author Contributions

All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by [Dr. Nirdhum Shikha], [Dr.Amarnath P Upasi] and [Dr.Parvathy Reghunadhan]. The first draft of the manuscript was written by [Dr. Nirdhum Shikha] and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Ethical Approval

This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of Bapuji Dental College and Hospital (23-11-2016/No-BDC Exam/283/2016-17.)

Consent to participate

Informed consent was obtained from all individual participants included in the study.

Consent to publish

The authors affirm that human research participants provided informed consent for publication of the images in Figures 1, 2 and 3.

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An analysis of the viability of avascular iliac and fibula grafts in mandibular reconstruction- A prospective randomised study

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