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Computer Assisted Mandibular Reconstruction With/Without Vascularized Fibula Graft
Halil I. Canter, Associate Professor1, Mehmet V. Karaaltın, Asistant Professor2, Ethem Guneren, Professor3, Mustafa E. Cakmakci, M.D.4, Kahraman B. Yilmaz, Asistant Professor1.
1Acibadem University Faculty of Medicine Depart of Plastic Reconstructive and Aesthetic Surgery, Istanbul, Turkey, 2BezmiAlem University Faculty of Medicine Department of Plastic Reconstr and Aesthetic Surgery, Istanbul, Turkey, 3BezmiAlem University Faculty of Medicine Depart of Plastic Reconstructive and Aesthetic Surgery, Istanbul, Turkey, 4Acibadem Bakirkoy Hospital Department of ENT Surgery, Istanbul, Turkey.

Purpose: The intention of mandibular reconstructive surgery is not only to restore the continuity of mandible but also to achieve maximum possible functionality.Computer-aided design (CAD) and computer-aided manufacturing (CAM) have facilitated accurate presurgical planning and modeling, precise manufacturing of the tridimensional cutting guides, and therefore to execute the surgery with absolute accuracy. The purpose of this study is to illustrate the utility of preoperative virtual surgical planning and reverse engineering in reconstruction of the mandible.
Methods: Six patients, age 25 to 68 years, treated in last six months were reviewed. Each required segmental reconstruction of mandible and were managed with presurgical virtual planning. Bone defects of the four patients were treated with vascularized fibula bone graft, while admixture of autografts combined with demineralized bone matrix were used in two patients. Based on preoperative CT data imported into the specific surgical planning software, virtual planning was performed to locate the condylar location of the each mandibular segment precisely. Then in order to exactly translate the virtual surgery plan into the operation site, cutting guides were designed both for mandible and fibula, which made reverse engineering possible for cases treated with vascularized fibula bone grafting. Rapid medical prototyping of the mandible and/or fixation apparatus were used in rest of the cases for reverse engineering purposes.
Results: The virtual plan reduced both the amount of bone removed for reconstruction and the operative time. The patients who underwent computer- assisted reconstruction had a higher degree of satisfaction in terms of functional outcome.
Conclusion: Virtual surgical planning provides accurate presurgical planning. This allows seamless reconstruction in patients requiring mandibular reconstruction via fibula free tissue transfer. Combination of mandibular and fibular cutting guides and templates allows for a precise and efficient surgical reconstruction by making it possible to conduct reverse engineering. In our experience, this technology is most useful in the mandibular reconstructions requiring large reconstruction plates and multiple fibular osteotomies. Rapid medical prototyping of the custom made mandibular fixation apparatus can be an alternative method where cutting guides and templates cannot be manufactured and/or free fibular transfer is not preferred as method of treatment.


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