Background Reconstruction of mandibular defects following ablative surgery remains a challenge even for experienced surgeons. Virtual planning and guided surgery, including computer-aided design/computer-aided manufacturing (CAD/CAM), afford optimized ways by which to plan complex surgery. This study aimed to evaluate and compare aesthetic outcome and surgical efficiency of free fibular flap (FFF) with and without CAD/CAM customized osteotomy guide (COG) for reconstruction of onco-surgical mandibular defects. Methods Twenty-two patients indicated for segmental mandibulectomy were randomly assigned to either CAD/CAM with COG group or that without COG- Model based reconstruction (MB group) at a 1:1 ratio. Aesthetic outcomes were evaluated by means of morphometric assessment and comparison for each differential area (DAr) and angle (DAn) in the affected side to the contralateral side of the mandible using computerized digital imaging analysis (CDIA) based on the post-operative 3D CT-scan. Subjective evaluation was performed using the Visual Analogue Scale (VAS) and Patient’s Satisfaction Score (PSS). Surgical efficiency was a secondary outcome and evaluated as total operative time and ischemia time. Results The mean sagittal DAr was significantly lower in the COG group (277.28 ± 127.05 vs. 398.67 ± 139.10 mm2, P = 0.045). Although there was an improvement in the axial DAr (147.61 ± 55.42 vs. 183.68 ± 72.85 mm2), the difference was not statistically significant (P = 0.206). The mean differences (Δ) in both sagittal and coronal DAn were significantly lower in the COG group than in the MB group (6.11 ± 3.46 and 1.77 ± 1.12° vs. 9.53 ± 4.17 and 3.44 ± 2.34°), respectively. There were no statistically significant differences in the axial DAn between the two groups (P = 0.386). The PSS was significantly higher in the COG group, reflecting better aesthetic satisfaction than in the MB group (P = 0.041). The total operation and ischemia time were significantly shorter in favor of the COG group with a mean of (562.91 ± 51.22, 97.55 ± 16.80 min vs. 663.55 ± 53.43, 172.45 ± 21.87 min), respectively. Conclusion The CAD/CAM with COG is more reliable and highly valuable in enhancing aesthetic outcomes and surgical efficiency of mandibular reconstruction by FFF compared to that without COG (MB reconstruction). Trial registration This trial was registered at ClinicalTrials.gov. Registration number: NCT03757273. Registration date: 28/11/2018.

Background When the resected specimen is sent for intraoperative margin assessment, all margins are grossly checked, and selected margins undergo a frozen section (FS) examination. Therefore, there is a possibility of sampling error. This study evaluated the effectiveness of using toluidine blue (TB) as an intraoperative triage screening tool to detect positive mucosal margins of the resected specimens of oral squamous cell carcinoma (OSCC) and serve as a guide for FS sampling. Methods Surgical samples of 30 consecutive patients with biopsy-proven OSCC were included in the study. A total of 140 mucosal margins were analyzed intraoperatively by TB and FS, the results were compared with the final histopathology. Results Of the 140 examined mucosal tumor margins, 14 stained positives with TB, six were true-positives, eight were false-positives, and there were no false-negatives, as confirmed by final histopathology of the same margins. The diagnostic performance measures were sensitivity 100.0%; specificity 94.0%; positive predictive value (PPV) 42.9%; negative predictive value (NPV) 100.0%; and accuracy 94.3% (95% CI: 89.0–97.5%). For FS, there were three true-positives, three false-negatives, and no false-positives. The diagnostic performance measures were sensitivity 50.0%; specificity 100.0%; PPV 100.0%; NPV 97.8%; and accuracy 97.9% (95% CI: 93.9–99.6%). Conclusion TB is less specific but more sensitive than FS for detecting positive mucosal margins of resected OSCC. Screening the tumor mucosal margins with TB before FS sampling may help identify more tumor-bearing margins. Trial registration This trial was registered at ClinicalTrials.gov. Registration number: NCT03554967. Registration date: June 13, 2018.

Background Submental artery island flap (SIF) is a viable alternative to free flaps for selected oral‐cavity defects, however, concerns about its oncologic safety still exists. A novel harvesting technique and its outcome is described in here. Methods This is a prospective study for patients with lateralized oral tongue and/or floor of mouth (FOM) cancers who undergone reconstruction using pedicled SIF based on contralateral submental vessels (CSIF) following resection. Results Forty‐one patients were included. Twenty‐four patients had T2, 13 had T3, and 4 had T1 tumors. The largest flap skin paddle was 15 × 9 cm. One patient sustained complete and five sustained partial flap loss. Three patients developed tongue tethering. Median follow‐up was 13.6 months. Locoregional recurrence occurred in 11 patients (26.8%); 6 oral‐cavity recurrences (14.6%), 6 ipsilateral, and 1 contralateral neck recurrences (2.4%). Conclusion CSIF is a reliable flap that addresses the oncologic controversy and overcomes the disadvantages of ipsilateral flap.

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Background Reconstruction of mandibular defects following ablative surgery remains a challenge even for experienced surgeons. Virtual planning and guided surgery, including computer-aided design/computer-aided manufacturing (CAD/CAM), afford optimized ways by which to plan complex surgery. This study aimed to evaluate and compare aesthetic outcome and surgical efficiency of free fibular flap (FFF) with and without CAD/CAM customized osteotomy guide (COG) for reconstruction of onco-surgical mandibular defects. Methods Twenty-two patients indicated for segmental mandibulectomy were randomly assigned to either CAD/CAM with COG group or that without COG- Model based reconstruction (MB group) at a 1:1 ratio. Aesthetic outcomes were evaluated by means of morphometric assessment and comparison for each differential area (DAr) and angle (DAn) in the affected side to the contralateral side of the mandible using computerized digital imaging analysis (CDIA) based on the post-operative 3D CT-scan. Subjective evaluation was performed using the Visual Analogue Scale (VAS) and Patient’s Satisfaction Score (PSS). Surgical efficiency was a secondary outcome and evaluated as total operative time and ischemia time. Results The mean sagittal DAr was significantly lower in the COG group (277.28 ± 127.05 vs 398.67 ± 139.10 mm2, P = 0.045). Although there was an improvement in the axial DAr (147.61 ± 55.42 vs 183.68 ± 72.85 mm2), the difference was not statistically significant (P = 0.206). The mean differences (Δ) in both sagittal and coronal DAn were significantly lower in the COG group than in the MB group (6.11 ± 3.46 and 1.77 ± 1.12° vs 9.53 ± 4.17 and 3.44 ± 2.34°), respectively. There were no statistically significant differences in the axial DAn between the two groups (P = 0.386). The PSS was significantly higher in the COG group, reflecting better aesthetic satisfaction than in the MB group (P = 0.041). The total operation and ischemia time were significantly shorter in favor of the COG group with a mean of (562.91 ± 51.22, 97.55 ± 16.80 min vs 663.55 ± 53.43, 172.45 ± 21.87 min), respectively. Conclusion The CAD/CAM with COG is more reliable and highly valuable in enhancing aesthetic outcomes and surgical efficiency of mandibular reconstruction by FFF compared to that without COG (MB reconstruction). Trial registration: This trial was registered at ClinicalTrials.gov. Registration number: NCT03757273. Registration date: 28/11/2018.

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