**5. Fibula free flap**

osseointegrated dental implants that are installed on these flaps help to improve postopera-

Iliac crest and the fibula are the most favorable donor sides for oromandibular reconstruction with the advantages of minimal donor site morbidity, optimum pedicle length and diameter and two team approach. Various factors must be considered such as localization, residual bone dimensions with or without soft tissue defects, vessels, and bone volume for dental

The iliac crest composite free flap has proven to be the one of the most effective and reliable choice for oromandibular reconstruction due to its appropriate and sufficient bone volume and corticocancellous structure and shape. It allows immediate reconstruction that avoids

The iliac bone vascularization is maintained by circumflex arteries including the deep, lateral, superficial ones, epigastric superficial inferior and superior gluteal artery, and branches. The deep circumflex iliac artery (DCIA) is the principal blood supply for the flap. The incision should be designed according to need of the skin paddle. Following soft tissue dissection, the periosteum on the superior bone crest is elevated. Down to the level of the deep circumflex iliac artery, internal oblique and iliacus muscles are dissected and divided. According to shape of desired reconstruction of the mandible, the bone osteotomy and vascular pedicles are harvested, and rigid fixation is performed with by plates/screws. Finally, microvascular

implant rehabilitation, when deciding which flap is the most suitable.

**Photo 3.** Interpositional bone grafting from left mandible to the right side.

14 Bone Grafting - Recent Advances with Special References to Cranio-Maxillofacial Surgery

tive masticatory function.

**4. Iliac crest free flap**

contour distortions of the mandible.

anastomoses of the vessels are finalized.

The free fibula flap has gained popularity due to its bone graft and vessel length for reconstruction of extended mandibular defects. Bone flap can be harvested with adjacent periosteum and soft tissue with or without a skin paddle. The incision starts 5 cm below the lateral epicondyle of the fibula and runs 10–15 cm in a distal direction. After elevating the skin flap anteriorly/ posteriorly, the muscle dissection through the intermuscular septum to peroneal muscle and sural muscle is performed to identify fibula. A muscle cuff of 3 mm is left along the fibula. Anterior intermuscular septum is incised by protecting the anterior tibial vessels. Then hallucis longus and tibial muscle through interosseous membrane is dissected. Proximal and distal cuts are performed around minimum 7 cm blow the proximal neck and superior to lateral malleolus according to desired bone length of the reconstruction site. The soleus, hallucis longus, and tibial muscles are dissected to elevate the peroneal vessel pedicles. At the distal site, the outward traction of the bone would help to reach tibial posterior muscle with its raphae, which help to secure the vessels when the muscle dissection is carried out along this raphae. Facial and supra thyroid arteries and external jugular vein is generally preferred for anastomoses. By osteotomy cuts on the harvested fibula, the required shape for mandibular reconstruction is achieved.
