Optimizing Functional Outcomes in Mandibular Condyle Reconstruction With the Free Fibula Flap Using Computer-Aided Design and Manufacturing Technology.

PURPOSE: Mandibular defects involving the condyle represent a complex reconstructive challenge for restoring proper function of the temporomandibular joint (TMJ) because it requires precise bone graft alignment for full restoration of joint function. The use of computer-aided design and manufacturing (CAD/CAM) technology can aid in accurate reconstruction of mandibular condyle defects with a vascularized free fibula flap without the need for additional adjuncts. The purpose of this study was to analyze clinical and functional outcomes after reconstruction of mandibular condyle defects using only a free fibula graft with the help of virtual surgery techniques. MATERIALS AND METHODS: A retrospective review was performed to identify all patients who underwent mandibular reconstruction with only a free fibula flap without any TMJ adjuncts after a total condylectomy. Three-dimensional modeling software was used to plan and execute reconstruction for all patients. RESULTS: From 2009 through 2014, 14 patients underwent reconstruction of mandibular defects involving the condyle with the aid of virtual surgery technology. The average age was 38.7 years (range, 11 to 77 yr). The average follow-up period was 2.6 years (range, 0.8 to 4.2 yr). Flap survival was 100% (N = 14). All patients reported improved facial symmetry, adequate jaw opening, and normal dental occlusion. In addition, they achieved good functional outcomes, including normal intelligible speech and the tolerance of a regular diet with solid foods. Maximal interincisal opening range for all patients was 25 to 38 mm with no lateral deviation or subjective joint pain. No patient had progressive joint hypomobility or condylar migration. One patient had ankylosis, which required release. CONCLUSION: TMJ reconstruction poses considerable challenges in bone graft alignment for full restoration of joint function. The use of CAD/CAM technology can aid in accurate reconstruction of mandibular condyle defects with a vascularized free fibula flap through precise planning and intraoperative manipulation with optimal functional outcomes.

Jaw in a Day: State of the Art in Maxillary Reconstruction.

BACKGROUND: Reconstruction of maxillary defects following tumor extirpation is challenging because of combined aesthetic and functional roles of the maxilla. One-stage reconstruction combining osseous free flaps with immediate osseointegrated implants are becoming the standard for mandibular defects, and have similar potential for maxillary reconstruction. METHODS: A woman with maxillary Ewing sarcoma successfully treated at age 9 with neoadjuvant chemotherapy, right hemimaxillectomy, and obturator prosthetic reconstruction presented for definitive reconstruction, complaining of poor obturator fit, and hypernasality. Her reconstruction was computer-simulated by a multidisciplinary team, consisting of left hemi-Lefort I advancement and right maxillary reconstruction with a free fibula flap with immediate osseointegrated implants and dental prosthesis. RESULTS: Full dental restoration, midface projection, and oral fistula corrections were achieved in 1 operative stage using this approach. CONCLUSIONS: This patient demonstrates a successful approach for maxillary reconstruction using computer-planned orthognathic surgery with free fibula reconstruction and immediate osseointegrated implants with dental prosthesis.

Salivary duct carcinoma ex pleomorphic adenoma of the palate: a case report.

Carcinoma ex pleomorphic adenoma is a rare malignancy of the head and neck, particularly in the minor salivary glands. Most cases arise in the major salivary glands, most commonly in the parotid gland, followed by the submandibular gland. The malignant component of the tumor varies, but can be salivary duct carcinoma, adenoid cystic carcinoma, mucoepidermoid carcinoma, squamous cell carcinoma, or adenocarcinoma, not otherwise specified. Primary salivary duct carcinoma is also a rare malignancy of the head and neck. Similar to carcinoma ex pleomorphic adenoma, it is more common in the major salivary glands, with the parotid gland accounting for 88% and the submandibular gland for 10% of cases. To date, only 25 known cases of primary salivary duct carcinoma arising in the minor salivary glands have been documented, with most arising in the palate. Salivary duct carcinoma ex pleomorphic adenoma of the minor salivary glands appears to be even rarer. Our case of salivary duct carcinoma ex pleomorphic adenoma of the palate is the first complete report, to our knowledge, in the English-language scientific literature.

Accuracy of a computer-aided surgical simulation protocol for orthognathic surgery: a prospective multicenter study.

PURPOSE: The purpose of this prospective multicenter study was to assess the accuracy of a computer-aided surgical simulation (CASS) protocol for orthognathic surgery. MATERIALS AND METHODS: The accuracy of the CASS protocol was assessed by comparing planned outcomes with postoperative outcomes of 65 consecutive patients enrolled from 3 centers. Computer-generated surgical splints were used for all patients. For the genioplasty, 1 center used computer-generated chin templates to reposition the chin segment only for patients with asymmetry. Standard intraoperative measurements were used without the chin templates for the remaining patients. The primary outcome measurements were the linear and angular differences for the maxilla, mandible, and chin when the planned and postoperative models were registered at the cranium. The secondary outcome measurements were the maxillary dental midline difference between the planned and postoperative positions and the linear and angular differences of the chin segment between the groups with and without the use of the template. The latter were measured when the planned and postoperative models were registered at the mandibular body. Statistical analyses were performed, and the accuracy was reported using root mean square deviation (RMSD) and the Bland-Altman method for assessing measurement agreement. RESULTS: In the primary outcome measurements, there was no statistically significant difference among the 3 centers for the maxilla and mandible. The largest RMSDs were 1.0 mm and 1.5° for the maxilla and 1.1 mm and 1.8° for the mandible. For the chin, there was a statistically significant difference between the groups with and without the use of the chin template. The chin template group showed excellent accuracy, with the largest positional RMSD of 1.0 mm and the largest orientation RMSD of 2.2°. However, larger variances were observed in the group not using the chin template. This was significant in the anteroposterior and superoinferior directions and the in pitch and yaw orientations. In the secondary outcome measurements, the RMSD of the maxillary dental midline positions was 0.9 mm. When registered at the body of the mandible, the linear and angular differences of the chin segment between the groups with and without the use of the chin template were consistent with the results found in the primary outcome measurements. CONCLUSIONS: Using this computer-aided surgical simulation protocol, the computerized plan can be transferred accurately and consistently to the patient to position the maxilla and mandible at the time of surgery. The computer-generated chin template provides greater accuracy in repositioning the chin segment than the intraoperative measurements.

A novel approach to frontal sinus surgery: treatment algorithm revisited.

BACKGROUND: Access to the frontal sinus remains a challenging problem for the craniofacial surgeon. A wide array of techniques including minimally invasive endoscopic approaches have been described. Here we present our technique using medical modeling to gain fast and safe access for multiple indications. METHODS: Computer-aided surgery involves several distinct phases: planning, modeling, surgery, and evaluation. Computer-aided, precise cutting guides are designed preoperatively and allowed to perfectly outline and then cut the anterior table of the frontal sinus at its junction to the surrounding frontal bone. The outcomes are evaluated by postoperative three-dimensional computed tomography scan. RESULTS: Eight patients sustaining frontal sinus fractures were treated with the aid of medical modeling. Three patients (37.5%) had isolated anterior table fractures, and 4 (50%) had combined anterior and posterior table fractures, whereas 1 patient (12.5%) sustained isolated posterior table fractures. Operative times were significantly shorter using the cutting guides, and fracture reduction was more precise. There was no statistically significant difference in complication rates or overall patient satisfaction. CONCLUSIONS: The surgical approach to the frontal sinus can be made more efficient, safe, and precise when using computer-aided medical modeling to create customized cutting guides.

Ten-year evolution utilizing computer-assisted reconstruction for giant ameloblastoma.

BACKGROUND: The authors describe our current practice of computer-aided virtual planned and pre-executed surgeries using microvascular free tissue transfer with immediate placement of implants and dental prosthetics. METHODS: All patients with ameloblastomas treated at New York University (NYU) Medical Center during a 10-year period from September 2001 to December 2011 were identified. Of the 38 (36 mandible/2 maxilla) patients that were treated in this time period, 20 were identified with advanced disease (giant ameloblastoma) requiring aggressive resection. Reconstruction of the resultant defects utilized microvascular free tissue transfer with an osseocutaneous fibular flap in all 20 of these patients. RESULTS: Of the patients reconstructed with free vascularized tissue transfer, 35% (7/20) developed complications. There were two complete flap failures with consequent contralateral fibula flap placement. Sixteen patients to date have undergone placement of endosteal implants for complete dental rehabilitation, nine of which received immediate placement of the implants at the time of the free flap reconstruction. The three most recent patients received immediate placement of dental implants at the time of microvascular free tissue transfer as well as concurrent placement of dental prosthesis. CONCLUSIONS: To our knowledge, this patient cohort represents the largest series of comprehensive computer aided free-flap reconstruction with dental restoration for giant type ameloblastoma.

Computer-aided design and manufacturing in craniomaxillofacial surgery: the new state of the art.

The goal of this article was to illustrate the ease in which virtual surgery and computer-aided design and manufacturing can be used by the craniomaxillofacial surgeon to create tremendously accurate postoperative results and provide confidence with even the most complex three-dimensional bony reconstructions. With advancements in software technology and three-dimensional printing, our ability to plan and execute precise bony reconstruction has become a reality. With this technology, guides can be made to ensure exact bony repositioning or replacement. These guides can help guide cutting of the bone and can act as splints to precisely reposition the bone and direct plate placement. With use of these computer-aided design and manufacturing guides and the addition of guidance technology, the position of the bone can be guaranteed intraoperatively. We review our unique and advanced method in approaching some of these problems and illustrate the application of these techniques in mandibular reconstruction, orthognathic surgery, maxillofacial trauma, and temporomandibular joint reconstruction. This technology continues to evolve, and our indications for its application continue to grow. This article represents only a small portion of the types of cases in which these techniques have already been applied.

Increasing bony contact and overlap with computer-designed offset cuts in free fibula mandible reconstruction.

BACKGROUND: The free fibula flap is the standard of care in mandibular reconstruction; however, procedural nuances continue to optimize results. More accurate and efficient osteotomies for graft insetting can be envisioned, which address the difficulty in obtaining a perfect match between the cut ends of the fibula and the mandible and the subsequent giving up of maximal bone contact. We propose a method of complementary offset osteotomies. The angled cuts were virtually planned using three-dimensional computed tomographic images. Optimal offset cuts maximized surface area contact and facilitated intraoperative repositioning in the setting of additional native bone margin requirement. METHODS: Using previously described protocols, three-dimensional virtual reconstructions of the facial skeleton and the fibula (average, series of five) were used to simulate osteotomies at 25, 30, 45, 60, 75, and 90 degrees to the long axis of the fibula. Complementary osteotomies were then simulated at the mandibular body just distal to the first molar in simulated free fibula reconstructions. Total area of apposing surfaces was calculated using computer-aided design. The results from the 25-, 30-, 45-, 60-, and 75-degree cuts were compared with the conventional 90-degree cut. Resin-based mandibular osteotomy guides and a complementary fibula jig were manufactured using computer-aided design. Two representative clinical cases were presented to illustrate proof of principle and benefits. RESULTS: The total surface area of apposing fibula and mandible surfaces in a conventional 90-degree cut was 103.8 ± 2.05 mm. Decreasing this angle to 75, 60, 45, 30, and 25 degrees yielded increased surface areas of 0.86%, 10.3%, 35.3%, 136.7%, and 194.3%, respectively. Cuts of 25 degrees also allowed for adequate bony contact in the setting of additional margin requirements up to 2.77 cm. Complementary 45-degree cuts provided excellent bone-to-bone contact in a free fibula reconstruction using resin guides and a jig. This angle also facilitated access of the saw to the distal mandible. CONCLUSIONS: Virtual surgical planning is an increasingly recognized technology for optimizing surgical outcomes and minimizing operative time. We present a technique that takes advantage of the precision complementary osteotomies that this technology affords. By creating offset cuts, we can maximize bony contact and ensure adequate contact should additional margins or intraoperative adjustments be required. This flexibility maximizes the precision of premanufactured cutting guides, mitigates the constraints of sometimes unpredictable intraoperative environments, and maximizes bony contact.

Double-Barrel Versus Single-Barrel Fibula Flaps for Mandibular Reconstruction: Safety and Outcomes.

OBJECTIVES/HYPOTHESIS: Fibula flaps are routinely used for osseous reconstruction of head and neck defects. However, single-barrel fibula flaps may result in a height discrepancy between native mandible and grafted bone, limiting outcomes from both an aesthetic and dental standpoint. The double-barrel fibula flap aims to resolve this. We present our institution's outcomes comparing both flap designs. STUDY DESIGN: Retrospective cohort study. METHODS: We conducted a retrospective review of all patients undergoing free fibula flap mandibular reconstruction at our institution between October 2008 and October 2020. Patients were grouped based on whether they underwent single-barrel or double-barrel reconstruction. Postoperative outcomes data were collected and compared between groups. Differences in categorical and continuous variables were assessed using a Chi-square test or Student's t-test, respectively. RESULTS: Out of 168 patients, 126 underwent single-barrel and 42 underwent double-barrel reconstruction. There was no significant difference in postoperative morbidity between approaches, including total complications (P = .37), flap-related complications (P = .62), takeback to the operating room (P = .75), flap salvage (P = .66), flap failure (P = .45), and mortality (P = .19). In addition, there was no significant difference in operative time (P = .86) or duration of hospital stay (P = .17). After adjusting for confounders, primary dental implantation was significantly higher in the double-barrel group (odds ratio, 3.02; 95% confidence interval, 1.2-7.6; P = .019). CONCLUSION: Double-barrel fibula flap mandibular reconstruction can be performed safely without increased postoperative morbidity or duration of hospital stay relative to single-barrel reconstruction. Moreover, the double-barrel approach is associated with higher odds of primary dental implantation and may warrant further consideration as part of an expanded toolkit for achieving early dental rehabilitation. LEVEL OF EVIDENCE: 3 Laryngoscope, 132:1576-1581, 2022.

Importance of computer-aided design and manufacturing technology in the multidisciplinary approach to head and neck reconstruction.

Head and neck reconstruction is a multidisciplinary field, requiring communication among various surgical and dental specialists. The free fibular flap is the standard method for reconstructing large mandibular defects after benign or malignant tumor ablation. The graft has to be precisely contoured to fit the three-dimensional defect to meet the functional and aesthetic goals.Virtual surgical planning using computed tomographic imaging and computer-aided design and manufacturing technology allows the surgeons to perform virtual surgery and generates templates and cutting guides that allow for the precise and expedient recreation of the plan in the operating room. The authors describe 2 cases where virtual planning was used for the extirpative and reconstruction phases to achieve precise reconstruction and decreased time under anesthesia.

The Latest Evolution in Virtual Surgical Planning: Customized Reconstruction Plates in Free Fibula Flap Mandibular Reconstruction.

BACKGROUND: Virtual surgical planning has contributed to technical advancements in free fibula flap mandible reconstruction. The authors present the largest comparative study on the latest modification of this technology: the use of patient-specific, preoperatively customized reconstruction plates for fixation. METHODS: A retrospective chart review was performed on all patients undergoing mandibular reconstruction with virtually planned free fibula flaps at a single institution between 2008 and 2018. Patient demographics, perioperative characteristics, and postoperative outcomes were reviewed. Reconstructions using traditional fixation methods were compared to those using prefabricated, patient-specific reconstruction plates. RESULTS: A total of 126 patients (mean age, 48.5 ± 20.3 years; 61.1 percent male) underwent mandibular reconstruction with a free fibula flap. Mean follow-up time was 23.5 months. A customized plate was used in 43.7 percent of cases. Reconstructions with patient-specific plates had significantly shorter total operative times compared with noncustomized fixation methods (643.0 minutes versus 741.7 minutes; p = 0.001). Hardware complications occurred in 11.1 percent of patients, with a trend toward a lower rate in the customized plate group (5.5 percent versus 15.5 percent; p = 0.091). Multivariate regression showed that the use of customized plates was a significant independent predictor of fewer overall complications (p = 0.03), shorter operative time (p = 0.014), and shorter length of stay (p = 0.001). CONCLUSIONS: Compared to traditional fixation methods, patient-specific plates are associated with fewer complications, shorter operative times, and reduced length of stay. The use of customized reconstruction plates increases efficiency and represents the latest technological innovation in mandibular reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Resection of a large, central hemangioma with reconstruction using a radial forearm flap combined with zygomatic and pterygoid implants.

Cavernous hemangiomas are rare, benign proliferations of vessels that usually occur at or just after birth. Few cases have been reported in the literature, however, involving the maxilla. We report a rare case of central cavernous hemangioma of the maxilla in an elderly male, review the literature, and discuss treatment options. An algorithm for treatment of all vascular lesions has been developed based on current literature, modern imaging and endovascular technology. With proper diagnosis, planning and treatment, large vascular lesions can be managed with minimal blood loss and morbidity. This patient was reconstructed to full function utilizing zygomaticus implants and an implant-retained prosthesis.

A novel approach to palatomaxillary reconstruction: use of radial forearm free tissue transfer combined with zygomaticus implants.

Pathologic resections involving the maxilla/hemimaxilla offer a unique reconstructive challenge to the maxillofacial reconstructive surgeon. Traditionally, reconstruction and replacement of lost tissues have been achieved with a variety of methods including obturators, local/regional flaps, and microvascular free tissue transfer. All these techniques have distinct disadvantages. We present a novel approach to palatomaxillary reconstruction using a combination of free tissue transfer and zygomaticus implants. To our knowledge, this specific technique has not been previously reported.

Plating in microvascular reconstruction of the mandible: can fixation be too rigid?

OBJECTIVE: Determine long-term loss of mandible height with use of stress-shielding reconstruction plates for free fibula flap mandible reconstruction. DESIGN: Retrospective single-blinded medical record review. SUBJECTS: Seventy patients who had fibula free flap mandible reconstructions performed for 10 years. Patients who underwent radiotherapy were excluded. METHODS: Review of 70 fibula free flap mandible reconstructions performed for the last 10 years in a city hospital revealed 7 patients (10%) who had resections for benign odontogenic diseases. All had a three-dimensional cast model made, on which the reconstruction plate was bent to the desired shape preoperatively. Free fibula height on panoramic x-ray images taken preoperatively and at 2 and 12 months postoperatively. RESULTS: Seven (10%) patients met criteria for the study. Bone height was maintained at 2 months postoperatively, but at 12 months, there was a statistically significant loss of fibular bone height averaging 20% in the anterior, body, and ramus areas (P < 0.05). Despite this, all patients were considered eligible for dental rehabilitation, and 4 of 7 patients have had osseointegrated implants placed. CONCLUSIONS: As opposed to miniplates, increased resorption may have been due to the stress-shielding phenomenon unique to a reconstruction plates. However, this did not seem to affect the ability to place osseointegrated implants.

Analysis of microvascular free flaps for reconstruction of advanced mandibular osteoradionecrosis: a retrospective cohort study.

PURPOSE: Previous studies have suggested that radiation therapy does not impact local complication rates after microvascular free flap (MVFF) reconstruction for head and neck cancer. There is little data, however, indicating whether or not the presence of osteoradionecrosis (ORN) affects treatment outcome. The purpose of this retrospective cohort study is to review the outcome of patients undergoing MVFF reconstruction for ORN and to determine if there is a difference in outcome and/or complications when compared to similarly reconstructed patients who received radiation therapy but did not develop ORN, as well as un-radiated controls. PATIENTS AND METHODS: The records of 305 consecutive patients who underwent MVFF reconstruction for a variety of cancer-related therapies or post-traumatic craniofacial defects from 1994 to 2004 were reviewed. Of these, all patients who underwent surgery for Marx stage III ORN involving the mandible were identified (n = 21). For purposes of comparison, patients who received preoperative radiation therapy (XRT) and underwent similar reconstruction but did not have ORN were identified and included in the study group. Similarly matched patients who never received XRT served as controls. Patients were reconstructed with a variety of MVFFs harvested from the fibula (n = 48), radial forearm (n = 11), rectus abdominus (n = 3), latissimus dorsi (n = 3), serratus anterior (n = 1) and iliac crest (n = 1). The study cohort was divided according to XRT status: group 1 (ORN), patients that received XRT and developed ORN (n = 21); group 2 (no ORN), patients that received XRT but did not develop ORN (n = 21); and group 3 (control), patients that never received XRT (n = 25). The following data were collected: age, gender, diagnosis, recipient site, donor site, hyperbaric oxygen therapy (HBO), flap complications, flap survival, patient survival. Outcome measures were defined as flap survival, complications and resolution of ORN. Descriptive statistics were recorded and an analysis of variance was calculated to evaluate differences between the 3 groups. The Fisher's exact test was used to evaluate whether a complication occurred more frequently in any one particular group. RESULTS: The mean age of the 67 patients included in the study was 57 years (SD = 15.4) years (M = 32, F = 35) and there were no significant demographic differences between the 3 groups (P = .8528). All patients were successfully reconstructed although 21% required reoperation for various reasons. Overall flap survival was 88% (ORN = 86%, no ORN = 87%, control = 90%) and there was no difference between the 3 groups studied (P = 1.0). Complications were evenly distributed among the 3 groups (50% overall) and included skin necrosis (P = .824), wound infection (P = .6374), salivary fistula (P = .1178), and partial flap loss (P = 1.0). Carotid blowout occurred in 2 patients in the ORN group, however, this was not statistically significant (P = .1844). Fourteen of the 21 patients in the ORN group had received preoperative HBO. CONCLUSION: Overall MVFF survival and complication rates among patients with ORN versus control groups are the same in this study cohort. Free tissue transfer is a viable option for advanced mandibular ORN.

Technique to Improve Tracheostomy Speaking Valve Tolerance after Head and Neck Free Flap Reconstruction.

Increased upper airway resistance from postoperative changes after major head and neck surgery may cause elevated transtracheal pressures and result in tracheostomy speaking valve intolerance. This may be particularly true among patients with baseline pulmonary disease. We describe a patient recovering from oral cancer resection and flap reconstruction who demonstrated prolonged ventilator dependence and tracheostomy speaking valve intolerance with abnormal tracheal manometry. We attempted to improve speaking valve tolerance through the adaptation of a valve modification intended to reduce transtracheal pressures. Drilling holes into the 1-way speaking valve allowed for excess air egress and resulted in normalization of transtracheal pressures with improved speaking valve tolerance. This 1-way speaking valve modification may serve as a simple method to allow for earlier restoration of voicing and potentially reduce the number of ventilator- dependent days in this patient population.

Functional outcomes of virtually planned free fibula flap reconstruction of the mandible.

BACKGROUND: The free fibula osteocutaneous flap has become the criterion standard for reconstruction of complex mandibular defects. The authors present their institutional experience with optimization of flap contouring and inset using virtual planning and prefabricated cutting jigs. METHODS: All free fibula-based mandible reconstructions performed at the authors' institution using virtual planning technology between 2009 and 2012 were retrospectively analyzed. The authors evaluated a variety of patient and procedural variables and outcomes. A series of cases performed before virtual planning was reviewed for comparison purposes. RESULTS: Fifty-four reconstructions were performed in 52 patients. Patients were divided evenly between a private university-affiliated medical center and a large county hospital. The most common indications were malignancy (43 percent), ameloblastoma (26 percent), and osteonecrosis/osteomyelitis (23 percent). Thirty percent of patients had irradiation of the recipient site and 38 percent had previous surgery. Sixty-three percent of patients received dental implants, with 47 percent achieving functional dentition. Twenty-five percent of patients had immediate dental implant placement, and 9 percent had immediate dental restoration. Postoperative imaging demonstrated excellent precision and accuracy of flap positioning. Comparison with cases performed before virtual planning demonstrated increased complexity of flap design along with reduced operative time in the virtually planned group. CONCLUSIONS: Preoperative virtual planning along with use of prefabricated cutting jigs allows for precise contouring and positioning of microvascular fibula free flaps in mandibular reconstruction. Using this technique, the authors have achieved unprecedented rates of dental rehabilitation along with reduced operative times. The authors believe that virtual planning technologies are an emerging criterion standard in mandible reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.