Background
Mandibular osteoradionecrosis (ORN) is a serious late complication of radiation therapy, most often seen in patients treated for head and neck cancer. It occurs when irradiated jawbone loses its ability to heal, leading to exposed bone, chronic infection, pain, fracture, fistula formation, and loss of function. When conservative treatment fails, segmental mandibulectomy with reconstruction is often required.
Traditionally, this reconstruction has been performed through a transcervical approach, which means the surgeon makes an incision in the neck to access the jaw, blood vessels, and reconstruction site. Although effective, this approach can increase soft-tissue disruption, scarring, wound complications, and operative burden in patients who may already have compromised tissues from radiation.
This study describes a transoral minimal-access technique for mandibular reconstruction using a fibula free flap (FFF), in which the jaw is accessed through the mouth, while vessel isolation and microvascular anastomosis are performed with limited external exposure. The goal is to reduce morbidity without sacrificing reconstructive success.
Study Objective
The purpose of the study was to describe the indications, operative strategy, and early outcomes of a limited transoral approach for segmental mandibulectomy reconstruction with minimal-access vessel isolation and anastomosis in patients with mandibular ORN.
How the Procedure Works
A fibula free flap uses bone, skin, and sometimes soft tissue harvested from the lower leg to reconstruct the jaw. The fibula provides a strong, straight segment of bone that can be shaped to match the mandible. Because the flap includes its own blood supply, surgeons connect its vessels to recipient vessels in the head and neck using microsurgery.
In a standard open approach, these recipient vessels are usually accessed through a neck incision. In the transoral method described here, the jaw resection and flap inset are performed through the mouth, and the vessels are isolated with minimal external dissection. This can be especially appealing in patients with radiation-damaged neck tissues, prior surgery, or a desire to reduce visible scarring and wound-related problems.
Methods
The investigators conducted a retrospective review of patients at their institution who underwent fibula free flap reconstruction for segmental mandibulectomy via a transoral plating and inset approach from 2022 to 2024.
Nine patients were included. The median age was 66 years, and all patients were male. Most had already failed conservative management for ORN. Eight patients had received antibiotic therapy, and seven had undergone hyperbaric oxygen therapy before surgery. Preoperative mandibular fracture or nonunion was present in seven patients, and four had fistulas, reflecting advanced disease.
Results
The median hospital stay after surgery was 6 days, with a range of 4 to 9 days. Overall, early outcomes were encouraging.
One patient developed nonunion in the postoperative period and required revision surgery with an anterolateral thigh fascia lata free flap and iliac crest bone grafting. Another patient returned to the operating room for hematoma, but the vascular supply to the flap was successfully salvaged. Aside from these two events, complications were limited. No other patients required reoperation, readmission within 30 days, or experienced hematoma, fistula recurrence, or flap compromise.
At the most recent follow-up, all patients showed clinical and radiographic arrest of ORN, meaning the disease had stopped progressing. Median follow-up was 13.9 months, with a range of 7.7 to 34 months.
Clinical Significance
These findings suggest that a transoral minimal-access approach may be a promising alternative to the traditional transcervical approach in selected patients with mandibular ORN. The main potential advantages include reduced soft-tissue dissection, less external scarring, shorter recovery, and possibly fewer wound complications in a heavily irradiated field.
That said, this technique is not a universal replacement for open neck approaches. Patient selection remains critical. Factors such as extent of ORN, vessel quality, prior surgery, anatomy, presence of infection, and surgeon experience all influence whether a transoral strategy is feasible and safe. Complex cases may still require a conventional transcervical exposure.
Why Fibula Free Flap Reconstruction Is Important
Fibula free flap reconstruction remains one of the most versatile options for mandibular repair because it provides reliable bone length, can be contoured to restore facial structure and dental function, and supports later implant-based rehabilitation in some patients. In ORN, where local tissues may be poor-quality and healing capacity limited, introducing well-vascularized tissue can help restore blood flow, support healing, and reduce the risk of persistent breakdown.
The ability to accomplish this reconstruction through a less invasive route may be particularly valuable in patients who have already endured cancer treatment and multiple prior interventions.
Limitations
The study has several limitations. It was retrospective, involved only nine patients, and came from a single institution. The follow-up period, while meaningful, is still relatively short for a condition that can recur or evolve over time. In addition, outcomes may depend heavily on surgical expertise and careful case selection, which can limit how broadly the results apply.
Because the study did not include a direct comparison with a traditional transcervical cohort, it cannot definitively prove superiority. Rather, it provides early evidence that the transoral minimal-access technique can be performed safely and may offer practical benefits.
Conclusion
In this case series, mandibular reconstruction using a transoral approach with fibula free flap showed promising results for patients with osteoradionecrosis. Most patients had previously failed conservative therapy, yet after surgery they experienced disease control with relatively low complication rates.
This approach may represent an important evolution in reconstructive surgery for ORN, offering a less invasive alternative to the standard transcervical method. Larger comparative studies with longer follow-up are needed to determine whether the transoral technique can consistently improve outcomes, reduce morbidity, and expand treatment options for patients with advanced mandibular ORN.
Reference
Vos DJ, Zhang E, Patel NN, Liu SW, Ciolek PJ, Prendes BL, Lamarre ED, Fritz MA. Transoral Minimal Access Mandibular Reconstruction Using Fibula Free Flap in Osteoradionecrosis. The Laryngoscope. 2026-03-05;136(6):2581-2590. PMID: 41786675.
