Prosthetically Guided Maxillofacial Surgery: Evaluation of the Accuracy of a Surgical Guide and Custom-Made Bone Plate in Oncology Patients after Mandibular Reconstruction

ArticleinPlastic and Reconstructive Surgery 131(6):1376-1385 · June 2013with46 Reads
DOI: 10.1097/PRS.0b013e31828bd6b0 · Source: PubMed
Abstract
Background: The aim of the present study was to evaluate the accuracy of prosthetically guided maxillofacial surgery in reconstructing the mandible with a free vascularized flap using custom-made bone plates and a surgical guide to cut the mandible and fibula. Methods: The surgical protocol was applied in a study group of seven consecutive mandibular-reconstructed patients who were compared with a control group treated using the standard preplating technique on stereolithographic models (indirect computer-aided design/computer-aided manufacturing method). The precision of both surgical techniques (prosthetically guided maxillofacial surgery and indirect computer-aided design/computer-aided manufacturing procedure) was evaluated by comparing preoperative and postoperative computed tomographic data and assessment of specific landmarks. Results: With regard to midline deviation, no significant difference was documented between the test and control groups. With regard to mandibular angle shift, only one left angle shift on the lateral plane showed a statistically significant difference between the groups. With regard to angular deviation of the body axis, the data showed a significant difference in the arch deviation. All patients in the control group registered greater than 8 degrees of deviation, determining a facial contracture of the external profile at the lower margin of the mandible. With regard to condylar position, the postoperative condylar position was better in the test group than in the control group, although no significant difference was detected. Conclusions: The new protocol for mandibular reconstruction using computer-aided design/computer-aided manufacturing prosthetically guided maxillofacial surgery to construct custom-made guides and plates may represent a viable method of reproducing the patient's anatomical contour, giving the surgeon better procedural control and reducing procedure time.
    • "Unfortunately, however, positioning a fibula segment in the mandible is more difficult during an actual reconstruction surgery than it is in the surgical simulation. Methods for placing the fibula bone segments into mandibular reconstruction sites have been reported previously[6,7]. Fibula segments can be fixed with plates of various sizes and materials, including metal reconstructive plates, mini plates, or resorbable plates. "
    [Show abstract] [Hide abstract] ABSTRACT: This study examined the usefulness of the fibula positioning guide for boosting the accuracy of mandible reconstructions. Thirty mandibular rapid prototype (RP) models were allocated to experimental (N = 15) and control (N = 15) groups. For reference, we prepared a reconstructed mandibular RP model with a three-dimensional printer, based on surgical simulation. In the experimental group, a fibula positioning guide template and fibula cutting guide, based on simulation, were used to reconstruct the mandible with a fibula graft. In the control group, only the fibula cutting guide, with reference to the reconstructed RP mandible model, was used to reconstruct the mandible with a fibula graft. The two mandibular reconstructions were compared to the surgical simulation by registering images with the non-surgical right side of the mandible. On the reconstructed side, 3D measurements were compared between the surgical simulation and actual surgery, and the sum of differences was taken as the total error. The combined use of the fibula cutting and positioning guides produced a smaller total error (mean ± SD: 10.0 ± 7.9 mm) than the fibula cutting guide alone (12.8 ± 8.8 mm; p = 0.015). The greatest point error was the vertical error at the mesial point of the anterior fibula segment. The anteroposterior and lateral errors were not significantly different between groups. These results showed that these two methods were not significantly different, except in the total and vertical errors. Considering the CAD/CAM processes required for creating positioning devices, the benefit provided with a positioning guide justified its use over the fibula cutting guide alone.
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    • "3. Surgery [2]. The clinical indications for virtual surgical planning include the following: The advantages of virtually planned surgery over conventional surgery include the following: "
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    • "Besides EBM, the technologies of direct metal laser sintering (DMLS) and selective laser melting have been developed recently for manufacturing high-quality metallic components [88,89]. For example, Mazzoni et al. fabricated a customized mandible cutting guide through the DMLS to precisely reproduce the site and orientation of the osteotomies for tumor ablation from the virtual plan into the surgical environment [90]. "
    [Show abstract] [Hide abstract] ABSTRACT: The surgical template is a guide aimed at directing the implant placement, tumor resection, osteotomy and bone repositioning. Using it, preoperative planning can be transferred to the actual surgical site, and the precision, safety and reliability of the surgery can be improved. However, the actual workflow of the surgical template design and manufacturing is quite complicated before the final clinical application. This paper aims to present a review of the necessary procedures in the template-guided surgery including the image processing, 3D visualization, preoperative planning, surgical guide design and manufacturing. In addition, the template-guided clinical applications for various kinds of surgeries are reviewed, and it demonstrated that the precision of the surgery has been improved compared with the non-guided operations. The major goal of the paper is to provide a comprehensive reference source of the current and future development of the template design and manufacturing for relevant researchers.
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