Recently, several flaps have been applied to immediate mandibular defects. The soft tissue covering the grafted bone tends to be a thick and bulky skin paddle compared to thin masticatory mucosa. In such cases, further surgical intervention is required to enable dental devices to be used.
We previously reported a new reconstruction method, called the Bare Bone Graft (BBG). A DCIA pedicled iliac crest was grafted to the defect, without epithelial component (Japanese Journal of Head and Neck Cancer 29 (1) 2003). Between 1997 and 2008, we performed BBG in 25 cases for immediate reconstruction of segmental mandibular defects. Of those cases, 22 resulted in success, 2 in total failure, and 1 in partial failure. All of the 22 cases acquired tight masticatory mucosa after several weeks without any surgical intervention. Of the 22 patients, 19 were able to wear ordinary dentures. The time required for wearing dentures ranged from 7 to 72 days after primary surgery (average 38 days). Mean period of denture usage was 57.5 months (10-103). Minor problems in acquired masticatory mucosa were pointed out during this period, such as traumatic ulcer caused by dentures, plate exposure (due to bone resorption) and frictional white lesion.

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Mandibular reconstruction is necessary to overcome the problem that segmental mandibulectomy or hemi-mandibulectomy causes the loss of mandibular contour and decrease of oral function. Among the various methods reported, we usually use a vascularized scapular flap for the reconstruction. Between April 2001 and November 2009, 77 mandibular reconstructions were performed in 76 patients. Diseases that necessitated mandibular resection were malignant tumors in 55 patients, benign tumors in 18 patients and radiation osteonecrosis of the mandible in 4 patients. According to the CAT classification of mandibular defects, “A” was the most common (33.8%), followed by “A” (26.0%). Osteotomy of the scapular bone was performed in 42 cases (54.5%) to replicate the contour of the mandible. The most common defect of soft tissue was the mucosa (87.0%). Scapular flap combined with latissimus dorsi flap can be used to reconstruct large defects of the soft tissue. Repositioning of mandibular segments during the operation is mandatory to maintain post-operative oral function. The scapular osteocutaneous compound flap is considered to be a useful method for mandibular reconstruction.

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Our department has begun to use fibular flaps with a vascular pedicle frequently for reconstruction after segmental mandibulectomy because of the high degree of freedom in reconstruction, reliability of the blood flow of the flaps for soft tissue defects, and mildness of surgical invasion to the donor sites. However, it was difficult to reproduce the morphology appropriate for bone defects including curved regions or the occlusal relationship with the maxillary alveoli. To solve these problems, we introduced a new fibular flap reconstruction system. This system has not only made possible the reproduction of the morphology appropriate for bone defects including curved regions, reproduction of the occlusal relationship with the maxillary alveoli, and elimination of the dead space at bone junctions, but also offers various advantages, such as a marked shortening of the operation time. We aim to further improve the accuracy, simplicity, and cost of the system.

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Free vascularized fibular graft (FVFG) is the first choice for mandibular reconstruction after segmental/subtotal mandibulectomy. For patients with poor general condition or high tumor prognosis, however, we use free soft tissue flaps with/without a reconstruction plate (RP). In this article, we compare these procedures in terms of complication rate and postoperative function.
From September 2002 to December 2008, 47 patients underwent immediate mandibular reconstruction with free flaps in our hospital. Free vascularized osteocutaneous flaps were used in 26 patients (fibula in 22, scapula in 4), free myocutaneous/cutaneous flaps without RP in 16 (RAMC in 13, ALT in 3), and free myocutaneous flaps with RP in 5 (RAMC in 5).
Postoperative complications such as wound infections and fistulas were observed in 34%, 44%, and 80%, and a normal diet was possible in 86%, 63%, and 0% of the patients, respectively.
Based on these results, we believe that free soft tissue flaps without bone or plate could be an option for mandibular reconstruction for patients with poor general condition or high tumor prognosis.

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Seventy-four cases of mandibular reconstruction using vascularized bone grafts—44 fibular flaps, 23 scapular flaps and 7 iliac crest flaps—were studied. The numbers of diseases treated by mandibular reconstruction were classified as: 42 patients with malignant disease, 15 with benign tumor, 13 with osteoradionecrosis, and 4 with other diseases. Of these cases, 35 patients simultaneously underwent reconstructive surgery following mandibulectomy, and the remaining 39 patients underwent secondary mandibular reconstruction after mandibulectomy. The graft survival rate of fibular flaps was 88.6%, and those of the other two flaps were 100%. Iliac crest flaps are suitable bone if reconstruction is indicated for defect type A and body in the CAT classification. Scapular flaps are used for relatively diverse types of defect in the CAT classification. On the other hand, fibular flaps are used for a much wider range of mandibular defects than scapular flaps, and for very small defect types. The choice between scapular flaps and fibular flaps depends not only on the type of mandibular defect, but also on a strategy for cancer treatment and on the proficiency of the surgeon in using the specified flap.

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Secondary lengthening of a reconstructed mandible using a gradual distraction technique is a useful option for patients after tumor resection. Distraction osteogenesis has the benefit of simultaneously increasing bone length and the volume of surrounding soft tissues. This technique allows dental implant treatment and has the potential to improve masticatory function in patients with reconstructed mandible.

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We report here a case of schwannoma of the cervical vagus nerve that occurred high in the parapharyngeal space. The patient was a 71-year-old female who visited our hospital with the chief complaint of a sensation of foreign matter in the pharynx. Findings in the oral cavity included a painless mass of about 50 × 60 mm in size in the left palatopharyngeal arch. CT and MR showed a mass occupying the left carotid space. The mass had caused dissociation of the common carotid artery and internal jugular vein and extended to the base of the skull. We resected the tumor using the subcutaneous mandibulotomy approach. The histopathological diagnosis was schwannoma. After surgery, the patient showed dysphagia and hoarseness but she underwent rehabilitation and was able to ingest food orally. Two years postoperatively, no signs of recurrence have appeared.

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We report a case with carcinoma of the upper gingiva and N3 treated successfully with retrograde superselective intra-arterial chemoradiotherapy combined with hyperthermia.
A 39-year-old male with swelling of the left cervical region was referred to our department. The mass was 65 × 55 mm. The tumor was diagnosed as squamous cell carcinoma of the upper gingiva and cervical lymph node metastasis (T2N3M0) by radiological and pathological diagnosis. The patient underwent chemoradiotherapy using superselective intra-arterial infusion via the superficial temporal artery and occipital artery combined with hyperthermia. The total dose of cisplatin was 150 mg/m², and that of docetaxel was 60 mg/m². External irradiation was performed five times a week at 2 Gy per fraction, for a total of 60 Gy. Hyperthermia was performed 5 times for 6 weeks.
Pathological complete response was achieved in the primary site 1 month after the completion of the treatment. However, the clinical effect of the lymph node was partial response. Therefore, the patient underwent bilateral neck dissections and soft tissue reconstruction. The pathological diagnosis of the resected lymph node was complete response. The patient has been free of disease for 20 months. This method may be an effective treatment for cervical lymph node metastasis, N3.

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Neck recurrence after neck dissection is an important problem in the treatment of oral cancer. The neck recurrence rate is estimated at about 10% in radical neck dissection and the prognosis for such patients is extremely poor. Surgical resection of the recurrent lesion in the neck is still an effective method, but surgical treatment is not possible for level II neck recurrence due to anatomical reasons. Recently, selective intra-arterial chemotherapy concurrent with radiotherapy (SIACRT) has become popular in advanced head and neck carcinoma treatment, and some reports described that SIACRT was also very effective for controlling nodal disease, even for bulky nodal ones. In this report, we describe two cases of oral cancer with neck recurrence after neck dissection which were successfully treated by SIACRT using docetaxel-nedaplatin.

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