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The Use of Virtual Surgery in Mandible Reconstruction, a 2 Year Review
David M. Otterburn, MD, Patrick J. Greaney, Jr., MD, David Hirsch, DDS, MD, Jamie Levine, MD.
NYU, New York, NY, USA.

PURPOSE: Fibula reconstruction at NYU has evolved rapidly in the past 2 years, with a paradigm shift to almost exclusive preoperative planning with virtual imaging. We report here our experience over this time period, including the use of preoperative CT imaging to define the location for mandibular osteotomies and the orientation and position of the fibula osteotomies. Specifically, we discuss the accuracy of surgical implementation of these designs, the use of double barreling, the immediate placement of implants and the number of patients undergoing full oral rehabilitation.
METHODS: A retrospective analysis of a prospectively managed data base of all mandibular reconstructions performed by the senior author from 9/2008 to 10/2010 was performed. Demographic data including patient age, sex, and diagnosis were recorded. Operative data including number of osteotomies, double barreling, placement of immediate endosseous implants and completion dental rehabilitation were analyzed. Postoperative scans were compared to the preoperative plan and differences measured at the condyle and gonion.
RESULTS: There were 28 mandible reconstructions performed during the study period. Average age was 45, 71% were men, average operative time was 9.5 hours, 34% of the diagnoses were for malignant tumors. There was an average of 1.44 osteotomies per fibula flap and five patients had at least one double barreled segment. Two of the double barreled segments had immediate placement of implants, while endosseous implants were immediately placed in 24% of patients. For those patients with 1 year follow up, 87% underwent successful implant placement. Postoperative positioning was accurate to within 3 mm at the condyles and 4.75mm at the gonions. Fibula osteotomy sites differed from the planned site by 3.82mm and mandibular osteotomies by 3.04 mm. There was one flap failure on a multi-segmented double barrel flap and one patient died in the perioperative period.
CONCLUSION: The use of virtual surgery in planning mandibular reconstruction is now indispensible. The mandible, because of its 3-dimentinal structure, function and aesthetics is too complex a structure to rely on intraoperative decisions to fashion it successfully in the most predictable and reproducible manner. Our experience with innovating many of these virtual planning techniques has shown a high rate of predictability in recreating the virtual surgical plan and a high rate oral rehabilitation for these patients, which is the overall best indicator of functional success. These evolving techniques have allowed outcomes not seen with any other mandibular reconstructive technique.


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