Department of Otorhinolaryngology - Head and Neck Surgery

Case Study from our Complex Cases Series

Rabie M. Shanti, DMD, MD, Assistant Professor of Otorhinolaryngology - Head and Neck Surgery
Steven B. Cannady, MD, Assistant Professor of Clinical Otorhinolaryngology - Head and Neck Surgery

A 45-year-old man sustained a gunshot wound to the anterior mandible and was treated at an outside institution. Four years post-surgery, he presented at Penn seeking full oral rehabilitation with dental implants requiring definitive mandibular reconstruction.

Surgery presented numerous complexities including an irregular continuity defect of the anterior mandible with existing hardware in place with multiple compromised mandibular teeth and significant oral soft tissue contracture (Figure 1). Fibula free flap reconstruction utilizing virtual surgical planning (VSP) was selected as the best reconstructive option.

VSP allowed Penn's team of surgeons and biomedical engineers to determine the optimal surgical plan by simulating positioning of fibula bone within the mandible considering cephalometric jaw relations, correction of occlusion if necessary, and fibula position for dental implant placement (Figure 2).

VSP for Patient-Specific Reconstructive Microsurgery Case Study Figure 1
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VSP for Patient-Specific Reconstructive Microsurgery Case Study Figure 2
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This process yielded double-barrel, four segment fibula free flap using a custom milled titanium 2.0 mm reconstruction plate (Figure 3a) with a custom mandibular cutting jig (Figure 3b) as the best options for reconstruction – with all aspects of the components determined using VSP.

VSP for Patient-Specific Reconstructive Microsurgery Case Study Figure 3a
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VSP for Patient-Specific Reconstructive Microsurgery Case Study Figure 3b
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A two-team surgical approach allowed for simultaneous removal of existing mandibular hardware, performing mandibular osteotomies, and placement of the reconstruction plate while the reconstructive team harvested the right fibula osteomyocutaneous free flap. Following flap harvest, the explanted flap was osteotomized (Figure 4a, 4b), the right facial artery and right common facial vein were skeletonized with ensuring inset of flap and microvascular anastomosis.

The reconstructive plan was successfully achieved (Figure 5a and Figure 5b) and the patient is scheduled to undergo dental implant placement and fabrication of dental prosthesis 6-9 months following surgery.

VSP for Patient-Specific Reconstructive Microsurgery Case Study Figure 4a
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VSP for Patient-Specific Reconstructive Microsurgery Case Study Figure 4b
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VSP for Patient-Specific Reconstructive Microsurgery Case Study Figure 5a
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VSP for Patient-Specific Reconstructive Microsurgery Case Study Figure 5b
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Discussion

VSP allows both ablative and reconstructive surgeons to incorporate cross-sectional imaging and CAD/CAM technology to carry out any customized osseous (bony) reconstruction. This robust technology optimizes precision and efficiency in complex reconstructions of the skull and jaws. Using the patient’s own high-resolution CT imaging with 1 mm cross-sections the VSP technology allows for customization of the patients skull and jaw reconstruction. When distant flaps are needed such as a fibula free flap, the CT obtained to assess for candidacy of a patient for fibula free flap harvest can be used to further increase the precision of the reconstructive outcome.

This approach allows surgeons treating post-oncologic, congenital, and post-traumatic patients to recreate the often absent or disfigured bony structures while also considering the patient's dental occlusion. This state-of-the art technology enables a more collaborative team-based approach to planning, the most precise restorative surgical results, and reduces surgical time by an hour or more.

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