Review

A new classification for mandibular defects after oncological

resection
James S Brown, Conor Barry, Michael Ho, Richard Shaw

No universally accepted classification system exists for mandibular defects after oncological resection. Here, we Lancet Oncol 2016; 17: e23–30
discuss the scientific literature on classifications for mandibular defects that are sufficiently presented either Head and Neck Surgery, Aintree
pictorially or descriptively, and propose a new classification system based on these findings. Of 167 studies included University Hospital, Liverpool,
UK (Prof J S Brown MD,
in the data analysis, 49 of these reports sufficiently described the defect for analysis. These reports were analysed
Prof R Shaw MD); Oral and
for classification, reconstruction, size of defect, number of osteotomies needed, and complications. On the basis of Maxillofacial Surgery, National
these findings, a new classification is proposed based on the four corners of the mandible (two angles and Maxillofacial Unit, St James’s
two canines): class I (lateral), class II (hemimandibulectomy), class III (anterior), and class IV (extensive). Further Hospital, and Dublin Dental
University Hospital, Dublin,
classes (Ic, IIc, and IVc) include condylectomy. The increasing defect class relates to the size of the defect, osteotomy Ireland (C Barry FRCS); Oral and
rate, and functional and aesthetic outcome, and could guide the method of reconstruction. Maxillofacial Surgery, Leeds
Dental Institute, Leeds, UK
Introduction evidence to support the use of a new classification system (M Ho FRCS); and Department
of Molecular and Clinical Cancer
Segmental mandibular resection is the most important for mandibular defects by analysing and testing Medicine, University of
decision to be made in the management of oral cancer. mandibular defects and methods of reconstruction with Liverpool, Liverpool, UK
Reconstruction is more difficult and more essential for microvascular composite grafts according to the new (Prof J S Brown, Prof R Shaw)
functional and aesthetic outcome in cases that need large classification system. Correspondence to:
defects to treat the malignancy or in those cases that Prof James S Brown, Head and
Neck Surgery, Aintree University
include the condyle. Since Pavlov’s classification of Data collection Hospital, Lower Lane,
mandibular defects was first published in 1974,1 six Search strategy and selection criteria Liverpool L9 7AL, UK
additional classification systems have been proposed. We reviewed the scientific literature for published brownjs@doctors.org.uk
The most widely cited classification system is the HCL articles that relate to the reconstruction of segmental
classification by Jewer and colleagues,2 although no mandibular defects using microvascular free flap
distinction exists between a defect that only includes reconstruction. We searched for articles published from
the lateral body of the mandible and a complete 1990—the year before Urken’s review10 of mandibular
hemimandibulectomy, which extends from the reconstruction was published—to May, 2014, to compare
subcondylar region to cross the midline. Urken and surgical reconstructive methods and the usefulness of
colleagues’ classification,3 however, is purely descriptive classifications already proposed. We searched PubMed
and cases can neither be grouped into increasing for articles using the terms “reconstruction”,
complexity, nor can they be related to the clinical difficulty “mandible”, “classification”, and “free flap” published in
of reconstruction. Several other classifications4–7 have English. After consultation with Edge Hill Library
been reported, but are not generally cited. (Aintree University Hospital, Liverpool, UK), we did a
None of these classifications are used universally, and separate systematic search in Embase using the terms
many reports either only describe the defects or use “mandible”, “oromandibular”, “flap”, “vascularised”,
pictorial presentations rather than describing the and “microvascular”. Thesaurus terms unique to the
different complexities of defects or the best methods of database and free text terms were combined to create
reconstruction and rehabilitation. the search strategy. The corresponding author (JSB)
Few publications report the results of reconstruction studied the reports, and included those cases in which
for specific problematic defects of the mandible, such as the mandibular defect was described sufficiently well to
the loss of the anterior mandible as compared with a place into a classification system. We only included
lateral defect. Some studies compare different flap studies of case series that reported on composite
options,8,9 but the reconstructed sites vary and there is microvascular free flap reconstruction with at least
little consensus on the right flap for a particular defect. ten patients.
The choice of flap is often based on the individual
surgeon’s preference of or experience with a particular Data extraction and analysis
option rather than an attempt to restore form and The author, year of publication, institution or place of
function for an optimum result. A universally accepted study, number of cases, classification method used, size
classification of the mandibular defect could help to of the defect, and the number of osteotomies were
further understand the best use of the options available. recorded by JSB onto a spreadsheet. Complications
In this paper, we discuss current practice and including fistula formations, non-union, and total flap
classifications used in the scientific literature, and failure were also recorded. Data was analysed by JSB to
propose a new classification system for mandibular reclassify cases into the newly proposed classification
defects after oncological resection. We also aim to provide system.

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 Review
We used weighted linear regression (SPSS version 19)
to compare the different classes with regards to mean
defect size and mean number of osteotomies per case,
and Fisher’s exact test (Stata version 13) to compare the
reported flap options and complications between classes.
The mean length of the mandible in white adults was
calculated on the basis of results from Ongkosuwito and
colleagues’ study11 of 25 dried skulls, with a mean length
of 64 mm from condyle to gonion and 92 mm from
gonion to menton, to represent the mean length of
defects for each proposed classification (figure 1).
Findings
Our search of published articles after 1990 relating to the
reconstruction of segmental mandibular defects yielded
1135 titles and abstracts, of which 332 were not conference
abstracts and contained reports of mandibular recon-
struction cases. 167 of these articles contained data from
124
64
36
64
92 92
Figure 1: Dimensions (mm) of an average adult mandible
Diagrammatic representation of a scaled model to show the dimensions of
an average adult mandible as reported by Ongkosuwito and colleagues.11 The
four corners of the mandible are shaded to draw attention to the increasing
size and complexity of the defect from class I (one corner) to class IV (three or
more corners).
Classification Number of
citations (number
of citations by
own institution)
Pavlov1 By the number of remaining bone fragments: class I=one bone ..
fragment, class II=two bone fragments, class III=three bone
fragments
David et al4 A=lateral, B=unilateral angle to symphysis, C=angle and body of ..
other side, D=angle to angle, E=symphysis, F=hemimandible
including condyle
Jewer et al2 H=unilateral condyle but can cross midline, L=unilateral no 27 (4)
condyle but can cross midline, C=both canines, HC=lateral and
condyle including both canines, LC=lateral and both canines,
LCL=bilateral lateral defects including canines but not condyles,
HCL=condyle lateral, central, and controlateral lateral,
HCH=entire mandible.
Urken et al3 C=condyle, R=ramus, B=body, S=symphysis, SH=stops at the 14 (4)
midline
Iizuka et al6 Class I–IV based on the number of osteotomies of the fibula flap 1 (2)
Hashikawa et al5 C=loss of condylar head, A=loss of angle, T=loss of mental ..
tubercle, CAT=hemimandible
Baumann et al7 Type I=segment not including condyle, type II=segment including ..
condyle (specifically for osteoradionecrosis)
Table 1: Classifications and number of citations of the mandibular segmental bone defects
e24
at least ten patients and were screened in the initial
review to record the classification methods used since
1990 and to make the case for a new proposal.
Of the seven classifications of mandible defects
previously discussed, only three classifications2,3,6 were
cited, excluding self-citations (table 1).1–7 The HCL system
suggested by Jewer and colleagues2 is the most widely
cited with 27 citations outside of the Toronto Head and
Neck group, and Urken and colleagues’ descriptive
classification3 is cited 14 times, excluding self-citations.
Other publications either did not classify the defects
(54 publications), showed pictorial classifications
(13 publications), or used descriptive classifications
(48 publications).
Of the 167 screened papers, there were 49 papers in which
the classification was sufficient to analyse the mandibular
defects and place them into our new classification system:
23 papers with a descriptive classification,12–33 11 papers with
Urken and colleagues’ classification,3,34–42 and 15 papers with
a pictorial presentation.43–56
Our classification proposal (panel) is based on the
principle that the mandible has four corners: two vertical
corners that make the angles of the mandible, and
two horizontal corners that are centred at the canine
teeth on each side in the dentate mandible, and are
roughly 7 mm anterior from the mental foramen in the
edentulous jaw (figure 1). These corners show the points
of change in the form of the mandible and the increasing
need to shape a graft with osteotomies. The anterior or
horizontal corners are essential to maintain function
and aesthetics.
Figure 2 presents our new proposed classification in a
diagrammatic format from class I through to class IV:
class I lateral mandibulectomy (includes the angle
or one vertical corner but not the condyle), class Ic
lateral mandibulectomy and condyle, class II hemiman-
dibulectomy (includes the angle [vertical corner] and the
ipsilateral canine [horizontal corner], but not the
contralateral canine), class IIc hemimandibulectomy and
condyle, class III anterior mandibulectomy (includes
both canines [two horizontal corners] but neither angle),
class IV extensive mandibulectomy (includes both
canines and one or both angles [three to four corners]),
and class IVc extensive mandibulectomy and condyles
(extensive anterior mandibulectomy, including both
canines and one or both condyles).
In edentulous cases, the class of the defect is estimated
to be class II when the mandible starts to curve medially
5–10 mm anterior to the mental foramen, often needing
an osteotomy if the fibula is the preferred donor site.
Smaller resections that do not include a mandibular
corner are classified on the closest corner: any defect that
includes the condyle and does not reach the angle should
be class Ic; defects that affect the body closer to the third
molar should be class I; defects that affect the body closer
to the canine should be class II; and defects that affect
the parasymphysis should be class III.
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 Review

Class I Class Ic
Panel: New classification system based on the four corners
Lateral not including canine or condyle Lateral with condyle
of the mandible Mean size 70 mm Mean size 84 mm
Maximum size 123 mm Maximum size 138 mm
Class I (angle)
Lateral defect not including ipsilateral canine or condyle
Class Ic (angle and condyle)
Lateral defect including condyle
Class II (angle and canine)
Hemimandibulectomy including ipsilateral but not Class II Class IIc
Hemimandibulectomy includes ipsilateral canine Hemimandibulectomy and condyle
contralateral canine or condyle Mean size 85 mm Mean size 126 mm
Maximum size 169 mm Maximum size 184 mm
Class IIc (angle, canine, and condyle)
Hemimandibulectomy including condyle
Class III (both canines)
Anterior mandibulectomy includes both canines but
neither angle
Class IV (both canines and at least one angle) Class III
Anterior includes both canines
Extensive anterior mandibulectomy including both canines Mean size 100 mm
and one or both angles Maximum size 160 mm

Class IVc (both canines and at least one condyle)

Extensive anterior mandibulectomy including both canines
and one or both condyles

From the 49 publications analysed, 1766 mandibles Class IV Class IVc

reconstructed with composite free tissue transfers were Extensive includes canines and angles Extensive includes canines, angles, and condyles
studied. As expected, fibula was the most widely used Mean size 152 mm Mean size 168 mm
Maximum size 282 mm Maximum size 312 mm
donor site (970 [55%] of 1766 mandibles), iliac crests were
used in 373 (21%) reconstructions, scapulas in 246 (14%)
reconstructions, and composite radial forearm flaps in
170 (10%) reconstructions. The other flaps reported were
two ribs with serratus anterior, and five lateral arm flaps
with humerus.
Table 2 shows flap options for the different classes of Figure 2: Proposed classification of mandibular defects
Mean defect size (dark shading); total extent of mandibular defect (light shading).
mandibulectomy, although 501 of the 1766 cases could
not be classified to a flap type.31,37,57–59 For the classified
flaps, flap type significantly differed according to the Fibula Iliac Radial Scapula Total Total not Totals
defect class (ie, subgroups I/Ic, II/IIc, III, IV/IVc; (n=831) (n=156) (n=84) (n=194) classified classified (n=1766)
(n=1265) (n=501)
p=0·001). The four main flap options are still used and
reported, and as expected fibula tops the list for most All proposed mandibular defect classes
used in all the classes followed by iliac crest, except in Class I 261 (31%) 47 (30%) 42 (50%) 105 (54%) 455 198 653 (37%)
class IV in which scapula is the most frequent second Class Ic 27 (3%) 7 (4%) 1 (1%) 1 (1%) 36 28 64 (4%)
choice. The fibula flap was used regularly for class I/Ic Class II 85 (10%) 50 (32%) 15 (18%) 43 (22%) 193 139 332 (19%)
defects, but was most often used for class III defects Class IIc 15 (2%) 5 (3%) 0 1 (1%) 21 10 31 (2%)
(figure 3). Those investigators reporting use of the iliac Class III 378 (45%) 41 (26%) 20 (24%) 31 (16%) 470 113 583 (33%)
crest tended to use it for class II/IIc defects rather than Class IV 56 (7%) 4 (3%) 6 (7%) 12 (6%) 78 13 91 (5%)
class III. All four flaps were used for extensive defects Class IVc 9 (1%) 2 (1%) 0 1 (1%) 12 0 12 (1%)
(class IV/IVc), but the fibula flap would probably be Condylar resections combined mandibular defect classes
preferred because it is the longest in length (figure 4). Class I/Ic 288 (35%) 54 (35%) 43 (51%) 106 (55%) .. .. ..
The length of the flaps or the defects in Class II/IIc 100 (12%) 55 (35%) 15 (18%) 44 (23%) .. .. ..
11 reports13,20,23,30,44–46,48,52,53,56 were recorded and a mean Class III 378 (45%) 41 (26%) 20 (24%) 31 (16%) .. .. ..
length of resection calculated and related to the Class IV/IVc 65 (6%) 6 (4%) 6 (7%) 13 (7%) .. .. ..
suggested classification (table 3). Results of weighted
Table 2: Frequency of flap options used to reconstruct mandibular defects according to the proposed
linear regression showed that the mean length of
classification
mandibular defect correlated with class of defect

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 Review
A A
Figure 3: Postoperative orthopantomograms for class I–III mandibular defects
(A) Class I, fibula reconstruction without osteotomy and secondary implants in
the non-reconstructed mandible. (B) Class II, reconstructed mandible with
non-osteotomised iliac crest and secondary implants. (C) Class IIc, paediatric
patient (aged 11 years) after mandibular resection for a desmoblastic fibroma
reconstructed with a fibula flap with a single osteotomy. (D) Class III, paediatric
patient (aged 7 years) after mandibular resection for ameloblastoma
reconstructed with fibula and two osteotomies.
(r²=0·71; p=0·015). The frequency of osteotomies could
be matched to the new classification in five reports
(table 4), which shows an increasing need for osteotomy
throughout the classes. Results of weighted linear
regression showed that our proposed classification
system correlated with the mean value of osteotomies
per case (r²=0·61; p=0·04), which adds evidence to the
clinical logic of the method.
Table 5 shows complications that could be
related to the new classification system in
e26
Figure 4: Example of class IV reconstruction after ablation for
ameloblastoma
(A) A cutting guide is used to make three fibula osteotomies with a template at
the donor site before graft transfer and revascularisation. (B) Postoperative
posteroanterior radiograph of the mandible.
22 papers.3,12,13,15,17,19–21,23,24,28,30,32,36,39,41,42,48,49,54–56 There is evidence
that the proportion of patients with risk of non-union
increases from class I to class IV (p=0·05), but the
proportion of patients with fistula formation (p=0·49)
and flap failure (p=0·39) did not increase with severity of
defect class. Although only three papers19,23,39 included
sufficient data to relate the use of implant-retained
dental rehabilitation to the classification, there was a
trend suggesting that this treatment was related to the
class as follows: class I (21%), class II (31%), class III
(45%), and class IV (47%) (p=0.01).
Reclassification of mandibular defects from previous
publications provides a good idea of the number of cases
described or presented pictorially that could be placed in
the new classification system, with 653 (37%) out of the
1766 resected mandible cases in class I, 332 (19%) in
class II, 583 (33%) in class III, and 91 (5%) in class IV
(table 2). Class IV cases are extensive and usually need a
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 Review

Class I Class Ic Class II Class IIc Class III Class IV Class IVc
Fibula cases, n 21 8 36 11 46 16 5
Mean length (range), mm 65 (40–100) 89 (70–120) 85 (45–160) 127 (70–180) 103 (30–130) 161 (100–220) 168 (130–210)
Iliac cases, n 5 0 14 3 7 0 0
Mean length (range), mm 95 (50–125) NA 86 (40–120) 123 (110–150) 101 (70–120) NA NA
Radial cases, n 4 0 5 0 5 5 0
Mean length (range), mm 88 (90–120) NA 86 (60–120) NA 88 (50–110) 124 (110–135) NA
Scapula cases, n 15 1 1 0 3 0 0
Mean length (range), mm 64 (40–80) 45 (NA) 50 (NA) NA 65 (50–75) NA NA
Total cases, n 45 9 56 14 61 21 5
Mean length (range), mm 70 (40–125) 84 (45–120) 85 (50–160) 126 (70–180) 100 (30–180) 152 (100–220) 168 (130–210)

Table 3: Length of mandibular defects, overall and per flap type, according to the proposed classification

Class I Class Ic Class II Class IIc Class III Class IV Class IVc Total
Total (all flap options) 11/19 (0·58) 4/2 (2·0) 28/29 (0·97) 26/14 (1·9) 42/31 (1·4) 62/30 (2·1) 18/4 (4·5) 191/129 (1·5)
Fibula 11/17 (0·65) 4/2 (2·0) 26/21 (1·2) 11/26 (2·4) 38/26 (1·5) 62/30 (2·1) 18/4 (4·5) 185/111 (1·7)
Reychler and Iriarte Ortabe, 199452 0/1 (0) 0/0 4/3 (1·3) 0/0 13/9 (1·4) 6/3 (2·0) 0/0 23/16 (1·4)
Santamaria et al, 199853 2/5 (0·40) 0/0 4/3 (1·3) 0/0 7/4 (1·75) 0/0 0/0 13/12 (1·1)
Jones et al, 200321 3/3 (1·0) 0/0 0/1 (0) 0/0 9/5 (1·8) 15/7 (2·1) 0/0 27/16 (1·7)
Zenha et al, 201132 0/3 (0) 0/0 2/4 (0·5) 5/4 (1·3) 7/7 (1·0) 17/12 (1·4) 0/0 31/30 (1·0)
Hanasano and Skoracki, 201318 6/5 (1·2) 4/2 (2·0) 16/10 (1·6) 21/7 (3·0) 2/1 (2·0) 24/8 (3·0) 18/4 (4·5) 91/37* (2·5)
Iliac; Zenha et al, 201132 0/2 (0) 0/0 2/8 (0·25) 0/3 (0) 4/5 (0·8) 0/0 0/0 6/18 (0·33)

Data are number of osteotomies divided by number of assessable cases (frequency). *Data available for only 37 of the 38 patients who underwent mandibular reconstruction in this study.

Table 4: Frequency of osteotomy, overall and per fibula and iliac flap type, according to the proposed classification

fibula flap and several osteotomies. In most modern

Fistula Non-union Flap
practices, computer-generated models would be used to formation failure
make pre-bent plates and cutting guides to improve the
All mandibular defect classes
accuracy of planned osteotomies and save time in the
Class I (n=119) 3 (3%) 3 (3%) 4 (3%)
operating room (figure 4). Resection of the condyle is less
Class Ic (n=24) 1 (4%) 0 2 (8%)
common, accounting for 107 (6%) of the 1766 resections
Class II (n=92) 2 (2%) 2 (2%) 5 (5%)
in total, with 64 (4%) in class Ic, 31 (2%) in class IIc, and
Class IIc (n=21) 0 2 (10%) 0
12 (1%) in class IVc. The challenge in retaining occlusion
Class III (n=110) 6 (5%) 7 (6%) 3 (3%)
and mandibular form in such cases, however, justifies
Class IV (n=34) 1 (3%) 1 (3%) 3 (9%)
their distinct classification.
Class IVc (n=10) 0 4 (40%) 1 (10%)
Total (n=410) 13 (3%) 19 (5%) 18 (4%)
Discussion
Our proposed mandibular defect classification is logical Condylar resections combined with mandibular defect classes

and simple, and groups defects into categories that can be Class I/Ic (n=143) 4 (3%) 3 (2%) 6 (4%)

compared in a meaningful way (figure 2). The use of the Class II/IIc (n=113) 2 (2%) 4 (4%) 5 (4%)
corners of the mandible at the angles and the canine Class III (n=110) 6 (5%) 7 (6%) 3 (3%)
regions make this classification system a logical approach Class IV/IVc (n=44) 1 (2%) 5 (11%) 4 (9%)
to classify defects, increasing in size and complexity from p value* 0·49 0·05 0·39
class I (a simple lateral defect not including the condyle Data are number of events (% of assessable cases). *Fisher’s exact test.
involving the angle or vertical corner) to class IV
(which involves at least three corners) and class IVc Table 5: Frequency of fistula formation, non-union, and flap failure,
according to the proposed classification
(which includes total mandibulectomy). The proposed
classification system shows the increase in morbidity in
terms of aesthetics and function from class I to class IV. Although a condyle ramus defect (class Ic) might not
This morbidity is certain to increase with non- need composite reconstruction as shown by Hanasono
reconstructed cases in line with the size of the defect, and colleagues,60 reconstruction of the condylar head and
increasing from 70 mm in class I, 85 mm in class II, maintenance of a functioning occlusion is difficult, hence
100 mm in class III, and 152 mm in class IV (table 3). the inclusion of a separate class for any condylar resection.

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 Review
When this defect reaches the canine and midline
(class IIc) and includes the whole parasymphysis
(class IVc), the length of bone needed increases (table 3),
and the difficulty of achieving a three-dimensional
accurate reconstruction becomes more complex.
Class Ic–IVc defects that include the condyle tend to be
larger resections ranging from 84 mm in class Ic to
126 mm in class IIc and 168 mm in class IVc (table 3).
The introduction of this new classification is a step
forward because existing suggestions of classification
have not been widely adopted. Urken and colleagues’
classification3 is purely descriptive and, although cited
14 times excluding self-citation, does not predict morbidity
or suggest a method of reconstruction. Descriptive and
pictorial methods provide the same information without
any form of grouping to make comparisons.
Although the number of publications referring to the
HCL classification is the most cited classification of the
167 studies included in this analysis, poor distinction
between class I and II defects and class Ic and IIc defects
is a major disadvantage of their system because we have
shown that the number of osteotomies per case increases
from class I (0·58) to class II (0·97), and that there is no
low-risk grouping (class I) because H and L defects can
extend as far as the controlateral canine, which includes
the parasymphysis. There are, in fact, three classes of the
anterior defect: C (a central defect including both canines
but no larger), LC (both canines, but one side extends to
include the first molar), and LCL (extended to include the
first molar bilaterally). We acknowledge, however, that
extensive resections of the mandible (class IV, IVc) are
needed because of the increased complexity and for
completeness. Using the principle of increasing defect
size by referring to the corners of the mandible seems
more logical than using the molar teeth as a guide,
because molar teeth are often not present in edentulous
and partially edentulous mandibles, making the angle
more reliable for defect classification.
A drawback of our new classification is that soft tissue
defects and type of mandible, in terms of dentate status,
have not been incorporated. Adaptations of Jewer’s
classification include facial skin and oral mucosa,2,61
similar to Urken’s proposal,3 but these additional
factors are not included in papers citing these
classifications. For a classification to be adopted,
simplicity and logic are paramount and we can see no
effective method to incorporate further elements to
describe this oncological defect.
At Aintree University Hospital (Liverpool, UK), we use
four common composite flaps (iliac crest, fibula,
scapula, and radial) on a regular basis,25,62 and we have
our own view about what works best for each situation
when considering comorbidity, prognosis, dentate
status, intra-oral and extra-oral soft tissue loss, and
donor site complications. Although the development of
an algorithm is tempting, because it could help decide
the most appropriate reconstruction for the mandibular
e28
defect, many confounding factors would make use of
this algorithm cumbersome. We have compared the
frequency of flap use according to our classification
system (table 2). However, little can be drawn from this
data to assist decision making in terms of flap choice.
The fibula is very versatile; it is the longest bone flap
and can be double-barrelled to increase the vertical
dimension, hence its wide use from class I to IV. The
iliac crest is more likely to be used for the classic
hemimandibulectomy (class II) because of the natural
shape of the crest, but is often too bulky for condylar
reconstruction so the fibula tends to be favoured
(figure 3). In our unit, we work closely with a restorative
dentist specialising in oral oncological rehabilitation, to
directly address the dental needs of the patient
postoperatively. The main concerns in mandibular
reconstruction are restoration of the occlusion in a
dentate case and obtaining a functional jaw in
edentulous cases. In class II or III cases, implants
might need to be placed directly into the grafted bone,
which has been reported regularly in the medical
literature.18,32,63–67 The use of stereolithography and 3D
printers helps with the planning of reconstructive
surgery, ensuring that the position of the graft is correct
for restoration of occlusion and form and placement of
immediate or secondary implants.
This paper does not aim to provide guidance for
management choices in mandibular reconstruction, but
is directed at how the proposed classification relates to
the size of the defect (table 3), number of osteotomies per
case (table 4), and complications (table 5). The size of the
defect and the number of osteotomies per case both
clearly increase from class I to class IV. Non-union is
more likely as the number of osteotomies increases,48
which corroborates with our finding that showed that
there is an increasing risk of non-union with increasing
defect class (p=0·05, table 5). The occurrence of other
complications recorded, fistula formation (3%) and flap
failure (4%), was low and not related to the class of the
defect, emphasising the reliability of composite
mandibular reconstruction.
The confidence of the surgeon to adequately and
appropriately resect the mandible in head and neck
cancer is intimately linked to the ability to reconstruct
the resultant defect. Borrowing a comparison from
medical oncology, the ability to rescue myelosuppression
using granulocyte colony-stimulating factors allows the
freedom to prescribe a sufficient dose of cytotoxic
chemotherapy to maximise the chance of patient survival.
As well as oncological safety, the functional and aesthetic
outcomes for survivors are clearly of crucial importance
for this uniquely specialised and visible anatomical
region. A patient’s face is their window to the world and
support for the lower third of the face is largely dependent
on mandibular form. The revolution in mandibular
reconstruction offered by microvascular free-tissue
transfer of composite flaps has greatly improved
www.thelancet.com/oncology Vol 17 January 2016

outcomes in past decades. However, most publications
on this subject discuss specific technical enhancements
rather than present a comprehensive overview or
strategies for management. Methodological challenges
make progress arising from randomised trials unlikely;
as a result we remain reliant on lessons learned from
carefully documented clinical cohorts.
The new classification of the mandibular segmental
defect that we propose offers an enhanced staging
system for this common and challenging surgical
problem. In common with other established staging
systems, our classification will help with the assessment
of outcomes in different centres, cohorts, surgical
methods, and in systematic reviews. Since the challenges
in mandibular reconstruction increase stepwise from
classes I to IV, the classification system will help
prognostic prediction of functional and aesthetic
outcome. We believe that this new classification system
will contribute to the continuing progress in the
multidisciplinary management of head and neck cancers
in or adjacent to the mandible.
Conclusion
A new classification system of mandibular defects based
on the four corners of the mandible is suggested and
qualified by this Review to show its usefulness in the
prediction of morbidity and the guidance of reconstructive
options. We hope that future studies will use this
classification, and in so doing establish a criteria for
more effective and scientific assessment of reconstructive
outcomes following mandibular ablative surgery.
Contributors
JSB contributed to all aspects of the study. CB, MH, and RS contributed
to data analysis and interpretation and study design, and gave advice on
writing and the figures.
Declaration of interests
We declare no competing interests.
Acknowledgments
We thank Michelle Maden (University of Liverpool, Liverpool, UK) for
consultation on the systematic Embase search. We thank Derek Lowe
(Astraglobe, Congleton, Cheshire, UK) for medical statistics assistance.
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