Three-dimensional virtual technology in reconstruction of mandibular defect including condyle using double-barrel vascularized fibula flap
OBJECTIVE: The aim of this study is to demonstrate the reconstruction of mandibular defects including the condyle using a double-barrel vascularized fibula flap aided by three-dimensional virtual technology. METHODS: Ten patients with the type H mandibular defects, who had undergone mandibular reconstruction using a double-barrel vascularized fibula flap, were reviewed for this study. Prior to the surgery, the patients CT scan data were analyzed virtually using SimPlant Pro™ software (version 11.04). The simulation allowed construction of an individual mandibular model serving to guide the clinical operation. RESULTS: The preoperative virtual surgery greatly benefitted the actual surgery. The vertical height of the neomandible and facial contour were precisely predicted. Some minor complications were encountered. Postoperative three-dimensional reconstruction revealed a close match with the simulated condyle. CONCLUSION: A double-barrel vascularized fibula flap can provide sufficient bone, both in length and vertical height, for the reconstruction of a type H mandibular condylar defect. Combined virtual three-dimensional reconstruction and rapid prototyping can improve postoperative outcomes in mandibular reconstruction.
Available from: Sean Shih-Yao Liu
- "Defects of the mandible, typically caused by tumors such as ameloblastoma, often lead to severe facial deformity and difficulty with chewing which, in turn, significantly affect a patient’s quality of life. Reconstruction of the mandibular defect has been performed by various techniques including iliac bone grafts, costochondral grafts, a sliding vertical osteotomy on the posterior border of the mandibular ramus, sternoclavicular grafts, scapular flaps
, and vascularized second metatarsal joint grafts
. Hidalgo introduced the vascularized fibular graft, which became the gold standard for the reconstruction of the mandibular condyle
, because it offers several advantages: it can supply a large amount of bone and soft tissue for harvest
; the vessel pedicle is generally long and anatomically reliable; furthermore, this procedure involves only minor donor site morbidity, with no requirement for patient repositioning during surgery
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The occurrence of mandibular defects caused by tumors has been continuously increasing in China in recent years. Conversely, results of the repair of mandibular defects affect the recovery of oral function and patient appearance, and the requirements for accuracy and high surgical quality must be more stringent. Digital techniques — including model reconstruction based on medical images, computer-aided design, and additive manufacturing — have been widely used in modern medicine to improve the accuracy and quality of diagnosis and surgery. However, some special software platforms and services from international companies are not always available for most of researchers and surgeons because they are expensive and time-consuming.
Here, a new technical solution for guided surgery for the repair of mandibular defects is proposed, based on general popular tools in medical image processing, 3D (3 dimension) model reconstruction, digital design, and fabrication via 3D printing. First, CT (computerized tomography) images are processed to reconstruct the 3D model of the mandible and fibular bone. The defect area is then replaced by healthy contralateral bone to create the repair model. With the repair model as reference, the graft shape and cutline are designed on fibular bone, as is the guide for cutting and shaping. The physical model, fabricated via 3D printing, including surgical guide, the original model, and the repair model, can be used to preform a titanium locking plate, as well as to design and verify the surgical plan and guide. In clinics, surgeons can operate with the help of the surgical guide and preformed plate to realize the predesigned surgical plan.
With sufficient communication between engineers and surgeons, an optimal surgical plan can be designed via some common software platforms but needs to be translated to the clinic. Based on customized models and tools, including three surgical guides, preformed titanium plate for fixation, and physical models of the mandible, grafts for defect repair can be cut from fibular bone, shaped with high accuracy during surgery, and fixed with a well-fitting preformed locking plate, so that the predesigned plan can be performed in the clinic and the oral function and appearance of the patient are recovered. This method requires 20% less operating time compared with conventional surgery, and the advantages in cost and convenience are significant compared with those of existing commercial services in China.
This comparison between two groups of cases illustrates that, with the proposed method, the accuracy of mandibular defect repair surgery is increased significantly and is less time-consuming, and patients are satisfied with both the recovery of oral function and their appearance. Until now, more than 15 cases have been treated with the proposed methods, so their feasibility and validity have been verified.
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ABSTRACT: We report the clinical course of a 28-year old male patient with a large aneurysmal bone cyst of the ascending ramus of the left mandible. Surgical treatment was performed as radical resection of the ascending ramus of the mandible including the condyle with one-stage reconstruction with a free fibula flap. Aggressive growth, clinical symptoms and a high recurrence rate of aneurysmatic bone cysts were the reason for this surgical treatment. The free fibula flap offers a good quality of cortical bone, which is supposed to be the best choice for reconstruction of the condyle.
Available from: Shogo Hasegawa
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Recently, medical rapid prototyping (MRP) models, fabricated with computer-aided design and computer-aided manufacture (CAD/CAM) techniques, have been applied to reconstructive surgery in the treatment of head and neck cancers. Here, we tested the use of preoperatively manufactured reconstruction plates, which were produced using MRP models. The clinical efficacy and esthetic outcome of using these products in mandibular reconstruction was evaluated.
A series of 28 patients with malignant oral tumors underwent unilateral segmental resection of the mandible and simultaneous mandibular reconstruction. Twelve patients were treated with prebent reconstruction plates that were molded to MRP mandibular models designed with CAD/CAM techniques and fabricated on a combined powder bed and inkjet head three-dimensional printer. The remaining 16 patients were treated using conventional reconstruction methods. The surgical and esthetic outcomes of the two groups were compared by imaging analysis using post-operative panoramic tomography.
The mandibular symmetry in patients receiving the MRP-model-based prebent plates was significantly better than that in patients receiving conventional reconstructive surgery.
Patients with head and neck cancer undergoing reconstructive surgery using a prebent reconstruction plate fabricated according to an MRP mandibular model showed improved mandibular contour compared to patients undergoing conventional mandibular reconstruction. Thus, use of this new technology for mandibular reconstruction results in an improved esthetic outcome with the potential for improved quality of life for patients.
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