- Email: [email protected]
Stereolithographic cutting guide for fibula osteotomy
LETTERS TO THE EDITOR
OOOO June 2012
712 anterior disk displacement with and without reduction compared. Although we recorded such patients, we did not present the data, as we had too few subjects with which to make a statistical comparison, so we considered them in one group as anterior disk displacement. Finally, we acknowledge and thank Dr. Sujir for bringing the typographic error in Table V to our attention. The number of joints in the control group is indeed 28 and not 30. Yoko Hasegawa, DDS, PhD Department of Dentistry and Oral Surgery Hyogo College of Medicine Nishinomiya City, Hyogo, Japan
curate cutting guide may be discarded. Efforts are still warranted in this field to make reconstructive surgery more predictable and more accurate. Guang-sen Zheng, DDS Yu-xiong Su, DDS, PhD Gui-qing Liao, MD, DDS, PhD Department of Oral and Maxillofacial Surgery Guanghua School of Stomatology, Sun Yat-sen University Guangzhou, China REFERENCE 1. Zheng GS, Su YX, Liao GQ, Jiao PF, Liang LZ, Zhang SE, et al. Mandible reconstruction assisted by preoperative simulation and transferring templates: cadaveric study of accuracy. J Oral Maxillofac Surg. In press.
REFERENCES 1. Hasegawa Y, Kakimoto N, Tomita S, Honda K, Tanaka Y, Yagi K, et al. Movement of the mandibular condyle and articular disc on placement of an occlusal splint. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011;112:640-7. 2. Kurita H, Kurashina K, Ohtsuka A, Kotani A. Change of position of the temporomandibular joint disk with insertion of a diskrepositioning appliance. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998;85:142-5. doi:10.1016/j.oooo.2012.02.008
Stereolithographic cutting guide in mandible reconstruction To the Editor: We were honored to read the letter of Dr. Pedro Infante-Cossio. The application of image-guided techniques is growing in oral and maxillofacial surgery, especially in mandibular reconstructive surgery. At the beginning, it simply provides a mandible stereomodel that allows the surgeon to bend the reconstruction plate before surgery. Then the surgeon can do surgical simulation on the computer to optimize the surgical protocol. Recently, many surgeons are focusing on how to convert the simulation to the real surgery accurately. As mentioned in the letter of Dr. Pedro Infante-Cossio, we agree that a customized template for osteoctomy is very helpful. Actually, we have also developed triple templates defining mandibulectomy, fibula osteoctomy, and transfer for accurately implementing surgical simulation, and we have tested the accuracy via cadaveric study.1 Also, we have finished several cases of mandibular and maxillary reconstructive surgery with this technique. We found it to be effective especially in implementing some complicated cases. However, the application of image-guided technique is still in its infancy. The main concern of the cutting guide with a customized template is unpredictability of the surgical margins in some cases. When the extent of mandibulectomy is adjusted during operation, the ac-
doi:10.1016/j.oooo.2012.01.034
Stereolithographic cutting guide for fibula osteotomy To the Editor: We read with great interest the article titled “Mandible reconstruction assisted by preoperative virtual surgical simulation” by Zheng et al.1 in OOOO. The authors are to be congratulated on adding imaging techniques to oral-maxillofacial reconstructive techniques. In that study, 9 patients were indicated for mandible resection and reconstruction. Surgery was carried out with the help of the reconstructed mandible stereomodel, prebent titanium reconstruction plate, and positioning template. We would like to comment on the surgery simulation point, which is relevant to our own experience. Oral and maxillofacial surgery is well suited for image-guided techniques, particularly in the domain of osteocutaneous flaps, because preoperative awareness of the defect dimensions permits improved flap design and reliability, operative safety, and planning of the osteotomies. Furthermore, it might reduce intraoperative decision making, thus potentially contributing to a significant reduction in operative time. We have lately developed the AYRA software that can be used in conjunction with CTA to provide a detailed three-dimensional image reconstruction. This software has been applied to various reconstructive procedures.2-4 Recently we performed a similar case on a patient diagnosed with a recurrent multicystic ameloblastoma, including 8-cm segmentary mandibulectomy and primary reconstruction with 3-segment single-barrel osteocutaneous flap fixed with reconstruction plate. Unlike for the authors, in our case osteotomy of fibula bone was not only virtually recreated before surgery, but also a customized template was printed to precisely
OOOO Volume 113, Number 6
LETTERS TO THE EDITOR
713 lengths and angles (Figure 1, B). Surgery time was reduced by a average of ⬃1 hour owing to this template, which allowed us to perform ostetomies in a fast and reliable way. Therefore, we think that, in addition to preoperative virtual surgical simulation and stereolithographic models, stereolithographic cutting guides may be an alternative aid for osteotomy performance and fibula shaping, allowing for faster and more reliable surgical procedures. Hopefully, publication of larger series and investigation of new 3D image techniques, will give further insight into preoperative virtual surgical simulation and its applications into daily surgical procedures. We hope that this project will contribute to the many steps that need to be taken worldwide toward such end. Pedro Infante-Cossio, MD, PhD, DDS Purificacion Gacto-Sanchez, MD, PhD Tomas Gomez-Cia, MD, PhD Gorka Gomez-Ciriza Virgen del Rocio University Hospital Sevilla, Spain
Fig. 1. (A), Stereolitographic cutting guide in place prior to perform osteotomies on the vascularized fibula. (B), Segmented fibula and mandible prototype model fixed with a prebent reconstruction plate before clamping peroneal vessels.
determine where to perform fibula osteotomies with the use of a rapid prototype modeling technology (Figure 1, A). The plastic template was sterilized for intraoperative use and temporarily fixed to the vascularized fibula with the use of monocortical screws. Afterward, a reciprocating saw blade was inserted into the cutting guide slots to perform osteotomies before clamping peroneal vessels. We found this template to be extremely helpful when performing osteotomies, for both
REFERENCES 1. Zheng G, Su Y, Liao G, Chen Z, Wang L, Jiao P, et al. Mandible reconstruction assisted by preoperative virtual surgical simulation. Oral Surg Oral Med Oral Pathol Oral Radiol Endod In press. 2. Gacto P, Barrera F, Sicilia-Castro D, Miralles F, Collell M, Leal S, et al. A three-dimensional virtual reality model for limb reconstruction in burned patients. Burns 2009;35:1042-6. 3. Gacto-Sánchez P, Sicilia-Castro D, Gómez-Cía T, Lagares A, Collell T, Suárez C, et al. Use of a three-dimensional virtual reality model for preoperative imaging in DIEP flap breast reconstruction. J Surg Res 2010;162:140-7. 4. Gacto-Sánchez P, Sicilia-Castro D, Gómez-Cía T, Lagares A, Collell T, Suárez C, et al. Computerized tomography angiography with VirSSPA 3D-software for perforator navigation improves perioperative outcomes in DIEP flap breast reconstruction. Plast Reconstr Surg 2010;125:24-31.
doi:10.1016/j.oooo.2011.11.033
OOOO June 2012
712 anterior disk displacement with and without reduction compared. Although we recorded such patients, we did not present the data, as we had too few subjects with which to make a statistical comparison, so we considered them in one group as anterior disk displacement. Finally, we acknowledge and thank Dr. Sujir for bringing the typographic error in Table V to our attention. The number of joints in the control group is indeed 28 and not 30. Yoko Hasegawa, DDS, PhD Department of Dentistry and Oral Surgery Hyogo College of Medicine Nishinomiya City, Hyogo, Japan
curate cutting guide may be discarded. Efforts are still warranted in this field to make reconstructive surgery more predictable and more accurate. Guang-sen Zheng, DDS Yu-xiong Su, DDS, PhD Gui-qing Liao, MD, DDS, PhD Department of Oral and Maxillofacial Surgery Guanghua School of Stomatology, Sun Yat-sen University Guangzhou, China REFERENCE 1. Zheng GS, Su YX, Liao GQ, Jiao PF, Liang LZ, Zhang SE, et al. Mandible reconstruction assisted by preoperative simulation and transferring templates: cadaveric study of accuracy. J Oral Maxillofac Surg. In press.
REFERENCES 1. Hasegawa Y, Kakimoto N, Tomita S, Honda K, Tanaka Y, Yagi K, et al. Movement of the mandibular condyle and articular disc on placement of an occlusal splint. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011;112:640-7. 2. Kurita H, Kurashina K, Ohtsuka A, Kotani A. Change of position of the temporomandibular joint disk with insertion of a diskrepositioning appliance. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998;85:142-5. doi:10.1016/j.oooo.2012.02.008
Stereolithographic cutting guide in mandible reconstruction To the Editor: We were honored to read the letter of Dr. Pedro Infante-Cossio. The application of image-guided techniques is growing in oral and maxillofacial surgery, especially in mandibular reconstructive surgery. At the beginning, it simply provides a mandible stereomodel that allows the surgeon to bend the reconstruction plate before surgery. Then the surgeon can do surgical simulation on the computer to optimize the surgical protocol. Recently, many surgeons are focusing on how to convert the simulation to the real surgery accurately. As mentioned in the letter of Dr. Pedro Infante-Cossio, we agree that a customized template for osteoctomy is very helpful. Actually, we have also developed triple templates defining mandibulectomy, fibula osteoctomy, and transfer for accurately implementing surgical simulation, and we have tested the accuracy via cadaveric study.1 Also, we have finished several cases of mandibular and maxillary reconstructive surgery with this technique. We found it to be effective especially in implementing some complicated cases. However, the application of image-guided technique is still in its infancy. The main concern of the cutting guide with a customized template is unpredictability of the surgical margins in some cases. When the extent of mandibulectomy is adjusted during operation, the ac-
doi:10.1016/j.oooo.2012.01.034
Stereolithographic cutting guide for fibula osteotomy To the Editor: We read with great interest the article titled “Mandible reconstruction assisted by preoperative virtual surgical simulation” by Zheng et al.1 in OOOO. The authors are to be congratulated on adding imaging techniques to oral-maxillofacial reconstructive techniques. In that study, 9 patients were indicated for mandible resection and reconstruction. Surgery was carried out with the help of the reconstructed mandible stereomodel, prebent titanium reconstruction plate, and positioning template. We would like to comment on the surgery simulation point, which is relevant to our own experience. Oral and maxillofacial surgery is well suited for image-guided techniques, particularly in the domain of osteocutaneous flaps, because preoperative awareness of the defect dimensions permits improved flap design and reliability, operative safety, and planning of the osteotomies. Furthermore, it might reduce intraoperative decision making, thus potentially contributing to a significant reduction in operative time. We have lately developed the AYRA software that can be used in conjunction with CTA to provide a detailed three-dimensional image reconstruction. This software has been applied to various reconstructive procedures.2-4 Recently we performed a similar case on a patient diagnosed with a recurrent multicystic ameloblastoma, including 8-cm segmentary mandibulectomy and primary reconstruction with 3-segment single-barrel osteocutaneous flap fixed with reconstruction plate. Unlike for the authors, in our case osteotomy of fibula bone was not only virtually recreated before surgery, but also a customized template was printed to precisely
OOOO Volume 113, Number 6
LETTERS TO THE EDITOR
713 lengths and angles (Figure 1, B). Surgery time was reduced by a average of ⬃1 hour owing to this template, which allowed us to perform ostetomies in a fast and reliable way. Therefore, we think that, in addition to preoperative virtual surgical simulation and stereolithographic models, stereolithographic cutting guides may be an alternative aid for osteotomy performance and fibula shaping, allowing for faster and more reliable surgical procedures. Hopefully, publication of larger series and investigation of new 3D image techniques, will give further insight into preoperative virtual surgical simulation and its applications into daily surgical procedures. We hope that this project will contribute to the many steps that need to be taken worldwide toward such end. Pedro Infante-Cossio, MD, PhD, DDS Purificacion Gacto-Sanchez, MD, PhD Tomas Gomez-Cia, MD, PhD Gorka Gomez-Ciriza Virgen del Rocio University Hospital Sevilla, Spain
Fig. 1. (A), Stereolitographic cutting guide in place prior to perform osteotomies on the vascularized fibula. (B), Segmented fibula and mandible prototype model fixed with a prebent reconstruction plate before clamping peroneal vessels.
determine where to perform fibula osteotomies with the use of a rapid prototype modeling technology (Figure 1, A). The plastic template was sterilized for intraoperative use and temporarily fixed to the vascularized fibula with the use of monocortical screws. Afterward, a reciprocating saw blade was inserted into the cutting guide slots to perform osteotomies before clamping peroneal vessels. We found this template to be extremely helpful when performing osteotomies, for both
REFERENCES 1. Zheng G, Su Y, Liao G, Chen Z, Wang L, Jiao P, et al. Mandible reconstruction assisted by preoperative virtual surgical simulation. Oral Surg Oral Med Oral Pathol Oral Radiol Endod In press. 2. Gacto P, Barrera F, Sicilia-Castro D, Miralles F, Collell M, Leal S, et al. A three-dimensional virtual reality model for limb reconstruction in burned patients. Burns 2009;35:1042-6. 3. Gacto-Sánchez P, Sicilia-Castro D, Gómez-Cía T, Lagares A, Collell T, Suárez C, et al. Use of a three-dimensional virtual reality model for preoperative imaging in DIEP flap breast reconstruction. J Surg Res 2010;162:140-7. 4. Gacto-Sánchez P, Sicilia-Castro D, Gómez-Cía T, Lagares A, Collell T, Suárez C, et al. Computerized tomography angiography with VirSSPA 3D-software for perforator navigation improves perioperative outcomes in DIEP flap breast reconstruction. Plast Reconstr Surg 2010;125:24-31.
doi:10.1016/j.oooo.2011.11.033