- Email: [email protected]
A modified method for a customized harvest of fibula free flap in maxillofacial reconstruction
G Model
JORMAS-731; No. of Pages 3 J Stomatol Oral Maxillofac Surg xxx (2019) xxx–xxx
Available online at
ScienceDirect www.sciencedirect.com
1 2
Technical note
4
A modified method for a customized harvest of fibula free flap in maxillofacial reconstruction
5
C. Druelle a,b,c,*, M. Schlund a,b,c,d, J.-C. Lutz e,f,g, M. Constant a,b, G. Raoul a,b,c,d, R. Nicot a,b,c,d
3
6 7 8 9 10 11 12 13 14
a
University of Lille, 1, place de Verdun, 59000 Lille, France Maxillofacial and stomatology department, Lille University Hospital, 59000 Lille, France c AIMOM (Association of Oral and Maxillofacial Medecine), 7, Bis rue de la cre´ativite´, 59650 Villeneuve d’Ascq, France d Inserm (French National Institute of Health and Medical Research) U1008, University of Lille, Controlled Drug Delivery Systems and Biomaterials, 59000 Lille, France e Faculty of Medecine, University of Strasbourg, 8, rue Kirschleger, 67000 Strasbourg, France f Oral and Maxillofacial Surgery Department, Strasbourg University Hospital, 67091 Strasbourg, France g Inserm (French National Institute of Health and Medical Research) ‘‘regenerative nanomedecine’’ laboratory, UMR 1260, medicine university, 67085 Strasbourg, France b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 26 June 2019 Accepted 25 August 2019
Mandibular reconstruction using computer-aided design/computer-aided manufacturing cutting guides is currently a common procedure. However, inaccurate positioning of the cutting guide onto the fibular bone may result in osteosynthesis difficulties or imprecision in the reconstruction. A novel way to improve the stability of the cutting guides may be to add pillars in order for them to be suspended from the fibula, avoiding soft tissues interactions. We present the case of a 39-year-old male who needed mandibular reconstruction after a self-inflicted ballistic injury. We designed a customized cutting guide which included a set of 8 pillars allowing a suspension of the cutting guide 8 millimeters above the bone level. The pillars were perpendicular to one another, and allowed the operator to screw the cutting guide to the bone. The orthogonal position of the pillars enabled real stability during the osteotomies. In the operator experience, the length of the pillars was too important, and led to incomplete osteotomies, and the whole device was too bulky. However, with adaptations in the size of the pillars and the size of the whole device, this solution could be useful in cutting guide design to avoid impairments due to the soft tissues surrounding the fibula.
C 2019 Published by Elsevier Masson SAS.
Keywords: Mandibular reconstruction Computer-aided design Surgical procedure Operative Mandible
15 16
1. Introduction
17 18 19 20 21 22 23 24 25
Mandibular reconstruction with fibula free flaps using computer-aided design/computer-aided manufacturing (CAD/CAM) patient-based customized cutting guides and plates is a common procedure. It has shown increased accuracy and reduced operative time compared to ‘‘freehand’’ surgery [1,2]. Several manufacturers can provide such solutions. Furthermore, thanks to CAD/CAM’s easier access and more widespread use of three-dimensional (3D) printing, more and more practitioners can develop their own cutting guides in-house [3,4].
* Corresponding author at: Maxillofacial and stomatology department, CHRU de Lille, Avenue Emile Laine, 59000 Lille, France. E-mail address: [email protected] (C. Druelle).
One of the issues encountered during flap shaping is the inaccurate positioning of the cutting guide onto the fibular bone, as it is attached to the surrounding soft tissues (which are necessary to ensure bone viability). A common way to address this issue is to screw the cutting guide to the fibular bone to which the periosteum and a small layer of muscular fibers are left attached. This strategy can, however, lead to inaccuracy in the positioning of the cutting guide, because its design is based on the shape of the fibular bone without considering the surrounding soft tissues. We present here a conceptual improvement of current CAD/ CAM solutions. This improvement consists of pillars which are added to a rigid cutting guide. Thereby, the guide is suspended from the fibular bone and the interferences caused by the surrounding soft tissues are avoided. The use of this improved cutting guide is described in a case of mandibular reconstruction following self-inflicted ballistic injury.
https://doi.org/10.1016/j.jormas.2019.08.002 C 2019 Published by Elsevier Masson SAS. 2468-7855/
Please cite this article in press as: Druelle C, et al. A modified method for a customized harvest of fibula free flap in maxillofacial reconstruction. J Stomatol Oral Maxillofac Surg (2019), https://doi.org/10.1016/j.jormas.2019.08.002
26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41
G Model
JORMAS-731; No. of Pages 3 C. Druelle et al. / J Stomatol Oral Maxillofac Surg xxx (2019) xxx–xxx
2
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2. Technical note
43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82
The patient was a 39-year-old male who needed mandibular reconstruction after a self-inflicted ballistic injury. He presented with a large bony defect of the mandibular symphysis and the left horizontal branch. Only the two right premolar teeth remained on the mandibular arch. Reconstruction using a fibula free flap was decided and conducted 6 months after the trauma. Computed tomography (1 mm slices) of the head, neck and lower limbs was acquired. Standard CT-based CAD was used to plan osteotomies, shaping of the fibular bone, and design of the mandibular cutting and positioning guides, with the help of Stryker (Kalamazoo, MI, USA). Stryker manufactured these cutting guides and the customized titanium plate accordingly (Fig. 1). The cutting guide was printed by 3D Systems (Denver, Colorado, USA) with a layer thickness inferior to 100 mm. Acrylic and epoxy photopolymers were used according to the ISO 10993-1 biocompatibility regulation. The entire package was shipped and then sterilized at Lille University Hospital (Lille, France) at 134 8C in an autoclave for 18 minutes, and then dried for 1 hour before being sealed in sterilized containers. A customized 2 mm thick titanium reconstruction plate was also manufactured by Stryker (Kalamazoo, Michigan, USA) and sterilized at Lille University Hospital through the same process. The fibula free flap harvest was performed using a standard procedure. The design of the fibular cutting guide featured a set of 8 pillars screwed onto the bone. It allowed suspension of the guide 8 mm above the bone level. The pillars were designed to be perpendicular to one another to allow optimal stability after fixation. Four sawing slots, consisting of a 1-mm width and 35-mm length, were set to allow ‘‘the personalised’’ osteotomies. Once screwed to the bone, the slots presented perfect stability (Fig. 2) and allowed bone cutting and shaping according to the surgical planning. The customized titanium reconstruction plate was used for fixation of the bone flap. There was no dead space between the plate and the fibular bone during reconstruction, allowing the use of bone-level screws instead of locking ones. The duration of the whole surgical procedure was 410 minutes. No complication was encountered during the postoperative period. The patient was discharged 13 days after surgery. Postoperative imaging confirmed the accuracy of mandibular reconstruction. The final result was consistent with the virtual planning.
83
3. Discussion
84 85 86 87
Obtaining the best result with the maximum accuracy of the mandibular reconstruction is a challenge in reconstructive surgery. Virtual surgical planning increases accuracy and reduces operative time compared to ‘‘freehand’’ surgery [1]. More specifically, virtual
Fig. 1. CAD/CAM virtual simulation of the cutting guide position with the pillars.
Fig. 2. Peroperative adaption of the cutting guide to the patient’s fibula.
surgical planning results in the use of fewer burs, fewer osteotomy revisions, and reduced bone grafting in fibula free flap mandibular reconstruction [5]. However, several parameters can be modified to achieve optimal accuracy, most of which regarding the fibula harvest and the quality of osteotomies. First, the soft tissues (muscle and periosteum) lining the fibula can be responsible for instability and difficulty in positioning the cutting guide and may result in inaccuracy of osteotomies. This issue cannot be solved through soft-tissue removal since they vascularize the bone. The direct screwing of conventional cutting guides to the fibular bone induces a compression of soft tissues and might even be affected by the position of the skin palette. The novel design consisting of pillars and orthogonal fixation of the fibular cutting guide minimizes the impediment resulting from the soft tissue layer remaining on the bone. Such a suspended solution reduced the instability caused by soft tissues while protecting them and therefore the whole vascularization of the flap. This type of device improvement has not been reported previously. The orthogonal position of the pillars enabled real stability of the solution throughout osteotomy. These pillars were designed slightly too long in relation to the length of the saw blade. This design led to incomplete osteotomies because the saw blade could not reach the medial cortical surface of the fibula (osteotomies were completed by hand after removal of the cutting guide). Surgical planning shall, therefore, consider the dimensions of the saw blade commonly used by the operator. The length of the pillars could be shortened to a size of 5 mm to avoid dead space. With shorter pillars, shorter screws could be used for guide fixation. The same screws could be utilized for mandibular fixation, therefore decreasing the amount of surgical material required. The entire solution was considered to be slightly too bulky because it hampered the protection of the vascular pedicle during osteotomy. Two parameters could be adjusted to improve this issue. First, the guide could be downsized, keeping in mind that a narrower guide tends to be less rigid and, therefore, less accurate. A compromise should be obtained between the size and the rigidity of the guide. Second, the cutting guide should be positioned directly opposite to the vascular pedicle because it would allow easier removal of a small periosteum part for pedicle protection. Intraoperatively, slight bone contouring was needed after the first ‘‘guided’’ fibular osteotomies for appropriate fixation of the bone to the mandible. We observed width discrepancy between the saw blade (maximum of 0.35 mm) and the cutting guide slot (1 mm). The further the guide would be positioned from the bone, the larger the variation of the osteotomy position would be, due to blade angulation in a larger slot. Therefore, we recommend narrowing the slots and their reinforcement with metal coating.
Please cite this article in press as: Druelle C, et al. A modified method for a customized harvest of fibula free flap in maxillofacial reconstruction. J Stomatol Oral Maxillofac Surg (2019), https://doi.org/10.1016/j.jormas.2019.08.002
88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135
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JORMAS-731; No. of Pages 3 C. Druelle et al. / J Stomatol Oral Maxillofac Surg xxx (2019) xxx–xxx
136 137 138 139 140 141 142 143 144 145 146 147
Such improvement would increase sawing accuracy and prevent the output of polymer particles resulting from friction between the saw and the guide. A slot width of 0.5 mm should be accurate enough. Some studies have recommended the use of 2-edge narrow slots, which seems to ensure a better correlation between surgical planning and effective shaping of the bone free flap [6]. That is why this design was chosen for our patient. Finally, the cutting guide could be paired with a positioning guide during osseous reconstruction. Although reconstruction could be slightly more accurate with such a positioning solution [7], its use should be based on surgeon preference.
148
4. Conclusion
149 150 151 152 153 154 155 156 157 158
The suspended customized cutting guide allowed more accurate osteotomies because the instability due to soft tissues was overcome. Some parameters of the cutting guide design, such as the pillars length, slot width, and the whole device size and position could be modified for an even better outcome. We believe that the novel suspended design of the cutting guide could benefit both to the industry which produces such personalised devices and the medical departments which produce them in-house. The improved accuracy and overall results elicited by such solutions should be tested in further studies.
3
Disclosure of interest The authors declare that they have no competing interest.
159 160
References
161
[1] Wang YY, Zhang HQ, Fan S, Zhang DM, Huang ZQ, Chen WL, et al. Mandibular reconstruction with the vascularized fibula flap: comparison of virtual planning surgery and conventional surgery. Int J Oral Maxillofac Surg 2016;45:1400–5. [2] Bouchet B, Raoul G, Julieron B, Wojcik T. Functional and morphologic outcomes of CAD/CAM-assisted versus conventional microvascular fibular free flap reconstruction of the mandible: a retrospective study of 25 cases. J Stomatol Oral Maxillofac Surg 2018;119(6):455–60. [3] Bosc R, Hersant B, Carloni R, Niddam J, Bouhassira J, De Kermadec H, et al. Mandibular reconstruction after cancer: an in-house approach to manufacturing cutting guides. Int J Oral Maxillofac Surg 2017;46(1):24–31. [4] Weitz J, Wolff KD, Kesting MR, Nobis CP. Development of a novel resection and cutting guide for mandibular reconstruction using free fibula flap. J Craniomaxillofac Surg 2018;46(11):1975–8. [5] Chang EI, Jenkins MP, Patel SA, Topham NS. Long-term operative outcomes of preoperative computed tomography-guided virtual surgical planning for osteocutaneous free flap mandible reconstruction. Plas Recon Surg 2016;137(2):619–23. [6] Dong Z, Li B, Xie R, Wu Q, Zhang L, Bai S. Comparative study of three kinds of fibula cutting guides in reshaping fibula for the reconstruction of mandible: an accuracy simulation study in vitro. J Craniomaxillofac Surg 2017;45(8):1227–35. [7] Lim SH, Kim MK, Kang SH. Precision of fibula positioning guide in mandibular reconstruction with a fibula graft. Head Face Med 2016;12:7.
162 163 164 165 166 167 168 169 170 171 172 173 174 175 176 177 178 179 180 181 182 183 184
Please cite this article in press as: Druelle C, et al. A modified method for a customized harvest of fibula free flap in maxillofacial reconstruction. J Stomatol Oral Maxillofac Surg (2019), https://doi.org/10.1016/j.jormas.2019.08.002
JORMAS-731; No. of Pages 3 J Stomatol Oral Maxillofac Surg xxx (2019) xxx–xxx
Available online at
ScienceDirect www.sciencedirect.com
1 2
Technical note
4
A modified method for a customized harvest of fibula free flap in maxillofacial reconstruction
5
C. Druelle a,b,c,*, M. Schlund a,b,c,d, J.-C. Lutz e,f,g, M. Constant a,b, G. Raoul a,b,c,d, R. Nicot a,b,c,d
3
6 7 8 9 10 11 12 13 14
a
University of Lille, 1, place de Verdun, 59000 Lille, France Maxillofacial and stomatology department, Lille University Hospital, 59000 Lille, France c AIMOM (Association of Oral and Maxillofacial Medecine), 7, Bis rue de la cre´ativite´, 59650 Villeneuve d’Ascq, France d Inserm (French National Institute of Health and Medical Research) U1008, University of Lille, Controlled Drug Delivery Systems and Biomaterials, 59000 Lille, France e Faculty of Medecine, University of Strasbourg, 8, rue Kirschleger, 67000 Strasbourg, France f Oral and Maxillofacial Surgery Department, Strasbourg University Hospital, 67091 Strasbourg, France g Inserm (French National Institute of Health and Medical Research) ‘‘regenerative nanomedecine’’ laboratory, UMR 1260, medicine university, 67085 Strasbourg, France b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 26 June 2019 Accepted 25 August 2019
Mandibular reconstruction using computer-aided design/computer-aided manufacturing cutting guides is currently a common procedure. However, inaccurate positioning of the cutting guide onto the fibular bone may result in osteosynthesis difficulties or imprecision in the reconstruction. A novel way to improve the stability of the cutting guides may be to add pillars in order for them to be suspended from the fibula, avoiding soft tissues interactions. We present the case of a 39-year-old male who needed mandibular reconstruction after a self-inflicted ballistic injury. We designed a customized cutting guide which included a set of 8 pillars allowing a suspension of the cutting guide 8 millimeters above the bone level. The pillars were perpendicular to one another, and allowed the operator to screw the cutting guide to the bone. The orthogonal position of the pillars enabled real stability during the osteotomies. In the operator experience, the length of the pillars was too important, and led to incomplete osteotomies, and the whole device was too bulky. However, with adaptations in the size of the pillars and the size of the whole device, this solution could be useful in cutting guide design to avoid impairments due to the soft tissues surrounding the fibula.
C 2019 Published by Elsevier Masson SAS.
Keywords: Mandibular reconstruction Computer-aided design Surgical procedure Operative Mandible
15 16
1. Introduction
17 18 19 20 21 22 23 24 25
Mandibular reconstruction with fibula free flaps using computer-aided design/computer-aided manufacturing (CAD/CAM) patient-based customized cutting guides and plates is a common procedure. It has shown increased accuracy and reduced operative time compared to ‘‘freehand’’ surgery [1,2]. Several manufacturers can provide such solutions. Furthermore, thanks to CAD/CAM’s easier access and more widespread use of three-dimensional (3D) printing, more and more practitioners can develop their own cutting guides in-house [3,4].
* Corresponding author at: Maxillofacial and stomatology department, CHRU de Lille, Avenue Emile Laine, 59000 Lille, France. E-mail address: [email protected] (C. Druelle).
One of the issues encountered during flap shaping is the inaccurate positioning of the cutting guide onto the fibular bone, as it is attached to the surrounding soft tissues (which are necessary to ensure bone viability). A common way to address this issue is to screw the cutting guide to the fibular bone to which the periosteum and a small layer of muscular fibers are left attached. This strategy can, however, lead to inaccuracy in the positioning of the cutting guide, because its design is based on the shape of the fibular bone without considering the surrounding soft tissues. We present here a conceptual improvement of current CAD/ CAM solutions. This improvement consists of pillars which are added to a rigid cutting guide. Thereby, the guide is suspended from the fibular bone and the interferences caused by the surrounding soft tissues are avoided. The use of this improved cutting guide is described in a case of mandibular reconstruction following self-inflicted ballistic injury.
https://doi.org/10.1016/j.jormas.2019.08.002 C 2019 Published by Elsevier Masson SAS. 2468-7855/
Please cite this article in press as: Druelle C, et al. A modified method for a customized harvest of fibula free flap in maxillofacial reconstruction. J Stomatol Oral Maxillofac Surg (2019), https://doi.org/10.1016/j.jormas.2019.08.002
26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41
G Model
JORMAS-731; No. of Pages 3 C. Druelle et al. / J Stomatol Oral Maxillofac Surg xxx (2019) xxx–xxx
2
42
2. Technical note
43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82
The patient was a 39-year-old male who needed mandibular reconstruction after a self-inflicted ballistic injury. He presented with a large bony defect of the mandibular symphysis and the left horizontal branch. Only the two right premolar teeth remained on the mandibular arch. Reconstruction using a fibula free flap was decided and conducted 6 months after the trauma. Computed tomography (1 mm slices) of the head, neck and lower limbs was acquired. Standard CT-based CAD was used to plan osteotomies, shaping of the fibular bone, and design of the mandibular cutting and positioning guides, with the help of Stryker (Kalamazoo, MI, USA). Stryker manufactured these cutting guides and the customized titanium plate accordingly (Fig. 1). The cutting guide was printed by 3D Systems (Denver, Colorado, USA) with a layer thickness inferior to 100 mm. Acrylic and epoxy photopolymers were used according to the ISO 10993-1 biocompatibility regulation. The entire package was shipped and then sterilized at Lille University Hospital (Lille, France) at 134 8C in an autoclave for 18 minutes, and then dried for 1 hour before being sealed in sterilized containers. A customized 2 mm thick titanium reconstruction plate was also manufactured by Stryker (Kalamazoo, Michigan, USA) and sterilized at Lille University Hospital through the same process. The fibula free flap harvest was performed using a standard procedure. The design of the fibular cutting guide featured a set of 8 pillars screwed onto the bone. It allowed suspension of the guide 8 mm above the bone level. The pillars were designed to be perpendicular to one another to allow optimal stability after fixation. Four sawing slots, consisting of a 1-mm width and 35-mm length, were set to allow ‘‘the personalised’’ osteotomies. Once screwed to the bone, the slots presented perfect stability (Fig. 2) and allowed bone cutting and shaping according to the surgical planning. The customized titanium reconstruction plate was used for fixation of the bone flap. There was no dead space between the plate and the fibular bone during reconstruction, allowing the use of bone-level screws instead of locking ones. The duration of the whole surgical procedure was 410 minutes. No complication was encountered during the postoperative period. The patient was discharged 13 days after surgery. Postoperative imaging confirmed the accuracy of mandibular reconstruction. The final result was consistent with the virtual planning.
83
3. Discussion
84 85 86 87
Obtaining the best result with the maximum accuracy of the mandibular reconstruction is a challenge in reconstructive surgery. Virtual surgical planning increases accuracy and reduces operative time compared to ‘‘freehand’’ surgery [1]. More specifically, virtual
Fig. 1. CAD/CAM virtual simulation of the cutting guide position with the pillars.
Fig. 2. Peroperative adaption of the cutting guide to the patient’s fibula.
surgical planning results in the use of fewer burs, fewer osteotomy revisions, and reduced bone grafting in fibula free flap mandibular reconstruction [5]. However, several parameters can be modified to achieve optimal accuracy, most of which regarding the fibula harvest and the quality of osteotomies. First, the soft tissues (muscle and periosteum) lining the fibula can be responsible for instability and difficulty in positioning the cutting guide and may result in inaccuracy of osteotomies. This issue cannot be solved through soft-tissue removal since they vascularize the bone. The direct screwing of conventional cutting guides to the fibular bone induces a compression of soft tissues and might even be affected by the position of the skin palette. The novel design consisting of pillars and orthogonal fixation of the fibular cutting guide minimizes the impediment resulting from the soft tissue layer remaining on the bone. Such a suspended solution reduced the instability caused by soft tissues while protecting them and therefore the whole vascularization of the flap. This type of device improvement has not been reported previously. The orthogonal position of the pillars enabled real stability of the solution throughout osteotomy. These pillars were designed slightly too long in relation to the length of the saw blade. This design led to incomplete osteotomies because the saw blade could not reach the medial cortical surface of the fibula (osteotomies were completed by hand after removal of the cutting guide). Surgical planning shall, therefore, consider the dimensions of the saw blade commonly used by the operator. The length of the pillars could be shortened to a size of 5 mm to avoid dead space. With shorter pillars, shorter screws could be used for guide fixation. The same screws could be utilized for mandibular fixation, therefore decreasing the amount of surgical material required. The entire solution was considered to be slightly too bulky because it hampered the protection of the vascular pedicle during osteotomy. Two parameters could be adjusted to improve this issue. First, the guide could be downsized, keeping in mind that a narrower guide tends to be less rigid and, therefore, less accurate. A compromise should be obtained between the size and the rigidity of the guide. Second, the cutting guide should be positioned directly opposite to the vascular pedicle because it would allow easier removal of a small periosteum part for pedicle protection. Intraoperatively, slight bone contouring was needed after the first ‘‘guided’’ fibular osteotomies for appropriate fixation of the bone to the mandible. We observed width discrepancy between the saw blade (maximum of 0.35 mm) and the cutting guide slot (1 mm). The further the guide would be positioned from the bone, the larger the variation of the osteotomy position would be, due to blade angulation in a larger slot. Therefore, we recommend narrowing the slots and their reinforcement with metal coating.
Please cite this article in press as: Druelle C, et al. A modified method for a customized harvest of fibula free flap in maxillofacial reconstruction. J Stomatol Oral Maxillofac Surg (2019), https://doi.org/10.1016/j.jormas.2019.08.002
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G Model
JORMAS-731; No. of Pages 3 C. Druelle et al. / J Stomatol Oral Maxillofac Surg xxx (2019) xxx–xxx
136 137 138 139 140 141 142 143 144 145 146 147
Such improvement would increase sawing accuracy and prevent the output of polymer particles resulting from friction between the saw and the guide. A slot width of 0.5 mm should be accurate enough. Some studies have recommended the use of 2-edge narrow slots, which seems to ensure a better correlation between surgical planning and effective shaping of the bone free flap [6]. That is why this design was chosen for our patient. Finally, the cutting guide could be paired with a positioning guide during osseous reconstruction. Although reconstruction could be slightly more accurate with such a positioning solution [7], its use should be based on surgeon preference.
148
4. Conclusion
149 150 151 152 153 154 155 156 157 158
The suspended customized cutting guide allowed more accurate osteotomies because the instability due to soft tissues was overcome. Some parameters of the cutting guide design, such as the pillars length, slot width, and the whole device size and position could be modified for an even better outcome. We believe that the novel suspended design of the cutting guide could benefit both to the industry which produces such personalised devices and the medical departments which produce them in-house. The improved accuracy and overall results elicited by such solutions should be tested in further studies.
3
Disclosure of interest The authors declare that they have no competing interest.
159 160
References
161
[1] Wang YY, Zhang HQ, Fan S, Zhang DM, Huang ZQ, Chen WL, et al. Mandibular reconstruction with the vascularized fibula flap: comparison of virtual planning surgery and conventional surgery. Int J Oral Maxillofac Surg 2016;45:1400–5. [2] Bouchet B, Raoul G, Julieron B, Wojcik T. Functional and morphologic outcomes of CAD/CAM-assisted versus conventional microvascular fibular free flap reconstruction of the mandible: a retrospective study of 25 cases. J Stomatol Oral Maxillofac Surg 2018;119(6):455–60. [3] Bosc R, Hersant B, Carloni R, Niddam J, Bouhassira J, De Kermadec H, et al. Mandibular reconstruction after cancer: an in-house approach to manufacturing cutting guides. Int J Oral Maxillofac Surg 2017;46(1):24–31. [4] Weitz J, Wolff KD, Kesting MR, Nobis CP. Development of a novel resection and cutting guide for mandibular reconstruction using free fibula flap. J Craniomaxillofac Surg 2018;46(11):1975–8. [5] Chang EI, Jenkins MP, Patel SA, Topham NS. Long-term operative outcomes of preoperative computed tomography-guided virtual surgical planning for osteocutaneous free flap mandible reconstruction. Plas Recon Surg 2016;137(2):619–23. [6] Dong Z, Li B, Xie R, Wu Q, Zhang L, Bai S. Comparative study of three kinds of fibula cutting guides in reshaping fibula for the reconstruction of mandible: an accuracy simulation study in vitro. J Craniomaxillofac Surg 2017;45(8):1227–35. [7] Lim SH, Kim MK, Kang SH. Precision of fibula positioning guide in mandibular reconstruction with a fibula graft. Head Face Med 2016;12:7.
162 163 164 165 166 167 168 169 170 171 172 173 174 175 176 177 178 179 180 181 182 183 184
Please cite this article in press as: Druelle C, et al. A modified method for a customized harvest of fibula free flap in maxillofacial reconstruction. J Stomatol Oral Maxillofac Surg (2019), https://doi.org/10.1016/j.jormas.2019.08.002