Step-by-step surgical technique for mandibular reconstruction with fibular free flap: application of digital technology in virtual surgical planning

Abstract

At present, mandibular reconstruction with a fibular free flap is the gold standard for functional and esthetic rehabilitation after oncological surgery. The purpose of this study was to describe the computer-assisted mandibular reconstruction procedure adopting the customized solution Synthes ProPlan CMF. The study reports five consecutive patients with benign or malignant disease requiring mandibular reconstruction using a microvascular fibular free flap, pre-operative virtual planning, construction of cutting guides and customized laser pre-bent titanium plates. The surgical technique is discussed in a step-by-step fashion. The average post-operative hospital stay was 18 ± 3 days. Ischemia time was recorded in all five cases, with an average of 75 ± 8 min. No problems were encountered in any surgical step and there were no major complications. Excellent precision of cutting guides and a good fit of pre-bent plates were found on both the mandible and fibula. There was excellent precision in bone to bone contact and position between mandible and fibula graft. Measurement data from the pre-operative and post-operative CT scans were compared. The average difference (Δ) between programed segment lengths and CT control segment lengths was 0.098 ± 0.077 cm. Microsurgical mandibular reconstruction using a virtual surgical planning yields significantly shorter ischemia times and allows more precise osteotomies. The technology is becoming increasingly recognized for its ability to optimize surgical outcomes and minimize operating time. Considering that the extent of resection can be wider than predicted, this results in safer modeling of the fibula only after frozen sections have demonstrated the radicality of resection.

Intraoperative cone‐beam CT‐guided osteotomy navigation in mandible and maxilla surgery

“…CAS procedures can involve multiple technologies providing functionality for the following: 1) preoperative virtual planning, 2) surgical navigation, and 3) intraoperative imaging . Virtual planning leverages advances in the field of computer‐aided design (CAD)/computer‐aided manufacturing (CAM), which have led to the development of patient‐specific, prefabricated cutting guides and reconstruction plate templates . Surgical navigation systems based on preoperative imaging data (e.g., computed tomography [CT], magnetic resonance) are in widespread use in sinus and skull base surgery and are now increasingly used for guidance of head and neck resection and reconstruction .…”

A two‐tiered structure device based on stereolithography for residual mandible repositioning in mandibular reconstruction with fibular flap

“…Approximately 20–26 cm of bone can be harvested and divided into several pieces with periosteal blood supply, which allows the free fibula bone graft to fit to the various defects of the mandible . Furthermore, recent progress in computer‐assisted mandibular reconstruction (CAMR) has enabled surgeons to design preoperatively the location and angle of osteotomies of transplanted fibular bone and perform precise osteotomies by using attachable osteotomy templates, consequently shortening the operation time and yielding better outcomes . However, conducting CAMR in its entirety is cost‐prohibitive and requires a relatively high amount of preparation time, and thus is not an option for all institutions.…”

Reconstruction of the Midface and Palate

“…When possible, a high-resolution CT is obtained within 6 months after surgery and the data can be sent to the modeling company to measure and compare landmark points to keep records of accuracy and precision. 22…”