Search Results (72)

Computer-assisted surgery (CAS) and virtual surgical planning (VSP) have transformed jaw reconstruction, allowing immediate insertion of dental implants during surgery for better rehabilitation of occlusal function. However, traditional planning for optimal location and angulation of dental implants and fibula relies on experience and can be time-consuming. This study aimed to propose a function-driven workflow and develop an automatic computer program for optimal positioning of simultaneous dental implants and fibula segments. A customized computer program was developed using MATLAB. Computed tomography (CT) of the lower limbs of ninety-one Southern Chinese individuals was retrieved and cross-sections of three-dimensional (3D) fibula models were comprehensively investigated for implant installation. Our research proves that the accuracy of the program in identifying the anatomical orientation of the fibula was 92%. The ideal location, angulation and length of implant could be automatically generated based on any selected implant diameter, with a surgical feasibility of 94%. To the best of our knowledge, this is the first study to develop and validate a customized automatic computer program for osseointegrated implant design in fibula flap surgery. This program can be incorporated into the current workflow of CAS to further the development of reliable and efficient surgical planning for function-driven jaw reconstruction. Full article

Mandibular reconstruction with the fibula free flap is the gold standard for large defects, with virtual surgical planning becoming integral to the process. The localization and dissection of critical vessels, such as the recipient vessels in the neck and the perforating vessels of the fibula flap, are demanding steps that directly impact surgical success. Augmented reality (AR) offers a solution by overlaying three-dimensional virtual models directly onto the surgeon’s view of the operative field. We report the first case in Latin America utilizing a low-cost, commercially available holographic navigation system for complex microsurgical mandibular reconstruction. A 26-year-old female presented with a large, destructive osteoblastoma of the left mandible, requiring wide resection and reconstruction. Preoperative surgical planning was conducted using DICOM data from the patient’s CT scans to generate 3D holographic models with the Medicalholodeck^® software. Intraoperatively, the primary surgeon used the AR system to superimpose the holographic models onto the patient. The system provided real-time, immersive guidance for identifying the facial artery, which was anatomically displaced by the tumor mass, as well as for localizing the peroneal artery perforators for donor flap harvest. A free fibula flap was harvested and transferred. During the early postoperative course and after 3-months of follow-up, the patient presented with an absence of any clinical complications. This case demonstrates the successful application and feasibility of using a low-cost, consumer-grade holographic navigation system. Full article

Jaw in a Day (JIAD) reconstruction provides immediate restoration of mandibular form and function through a single-stage procedure that integrates fibula free flap reconstruction, virtual surgical planning (VSP), immediate dental implant placement, and delivery of a prefabricated prosthesis. Although the technique provides significant benefits in reducing rehabilitation time and improving patient outcomes, its adoption has been limited due to perceived technical complexity and unfamiliarity with dental workflow. This manuscript provides a detailed, step-by-step protocol to guide surgeons through their first JIAD case, from patient selection and data acquisition to VSP execution, intraoperative coordination, and implant positioning. Emphasis is placed on accurate osteotomy design, implant placement using guided protocols, fabrication of patient-specific hardware, and precise prosthesis pickup techniques. This guide also addresses essential OR team preparation and sterile handling of non-sterile components. By breaking down the process into actionable stages and highlighting common pitfalls and technical tips, this resource aims to lower the barrier for early adopters and enhance the success of initial JIAD cases. Full article

Background and Objectives: Reconstructive outcomes following head and neck (H&N) cancer resection in pediatric patients remain understudied, particularly regarding the comparative efficacy of free versus local tissue transfer. Materials and Methods: A retrospective review was conducted on pediatric patients undergoing malignant H&N tumor resection at a tertiary center from 2007 to 2024. Patients were stratified by reconstruction type (free vs. local flap), and outcomes assessed included flap failure, wound complications, revision rates, operative time, hospital stay, and 30-day readmission. Results: A total of 41 patients (mean age: 10.6 years) met inclusion criteria; 18 underwent free flaps and 23 received local flaps. Common diagnoses included osteosarcoma (21.9%) and rhabdomyosarcoma (12.2%). Anterolateral thigh (44.4%) and fibula (33.3%) were the most common free flaps; temporalis (21.7%) and pectoralis (13.0%) were common local flaps. Flap survival was high in both groups (94.4% vs. 100%). However, local flaps had significantly higher rates of hardware exposure (34.7% vs. 5.5%, p = 0.025) and wound dehiscence (39.1% vs. 5.5%, p = 0.045). Free flaps were associated with longer operative times (10.3 vs. 6.5 h, p = 0.011) and hospital stays (29.1 vs. 13.9 days, p = 0.036). Conclusions: While both approaches achieved high flap survival, free flaps may offer more durable reconstruction and reduce wound-related complications in complex pediatric H&N oncologic cases. Full article

Background/Objectives: Medication-related osteonecrosis of the jaw (MRONJ) is a serious complication in patients treated with antiresorptive or antiangiogenic agents, particularly those with cancer-related comorbidities. This systematic review and meta-analysis aimed to estimate the prevalence of free flap failure in patients undergoing microvascular reconstruction for MRONJ. Methods: A comprehensive literature search was conducted across Medline/PubMed, Scopus, and Web of Science up to 30 January 2025. Inclusion criteria were observational studies involving MRONJ patients treated with free flap reconstruction. Risk of bias was assessed using the Newcastle–Ottawa Scale. The pooled prevalence of free flap failure was calculated using a random-effects model with Freeman–Tukey double arcsine transformation. Results: Twelve studies were included in the quantitative analysis. The fibula free flap was the most frequently used flap. The pooled prevalence of free flap failure was 0.1% (95% CI: 0–2.3%), with no significant associations observed in meta-regression analyses for publication year, patient age, or sex. All included studies were of moderate methodological quality. Conclusions: These findings suggest that free flap reconstruction is a reliable and effective surgical option for managing advanced MRONJ in well-resourced and specialized healthcare settings; however, limitations such as small sample sizes and heterogeneity in protocols must be considered. Further high-quality, multicenter studies are needed to evaluate long-term outcomes and refine perioperative management strategies. Full article

Objectives: Ameloblastoma is a locally aggressive odontogenic tumor of the jaws characterized by a high recurrence rate. This work aims to present our clinical experience in managing patient oral rehabilitation following an extensive mandibular ameloblastoma, with a specific focus on mandibular reconstruction using a fibula free flap, followed by dental implant placement and prosthetic rehabilitation in a female patient. Additionally, we provide a comprehensive review of the current evidence on surgical management, reconstruction techniques, and long-term outcomes in ameloblastoma treatment. Methods: A 44-year-old female patient presented with a painless swelling in the left mandible. Orthopantomography (OPG) and computed tomography (CT) demonstrated a well-defined radiolucent lesion extending from the canine to the second premolar. An incisional biopsy was performed, and histopathological examination confirmed the diagnosis of mandibular ameloblastoma. The patient underwent segmental resection of the left mandibular body, followed by immediate reconstruction using a vascularized fibular free flap. Eighteen months postoperatively, four dental implants were placed. One implant failed during the osseointegration phase and was removed. Due to residual hard and soft tissue deficiency, prosthetic rehabilitation was achieved with a metal-reinforced resin overdenture, restoring both function and aesthetics. Results: At the three-year follow-up, clinical and radiographic examinations revealed no evidence of tumor recurrence. The patient remained asymptomatic, reporting neither pain nor functional discomfort. Prosthetic rehabilitation with the metal-reinforced resin overdenture was successfully completed, achieving satisfactory masticatory function and aesthetics. Conclusions: The use of the fibula free flap for mandibular reconstruction after ameloblastoma resection provides excellent flexibility, enabling effective bone integration of dental implants. Full article

Background/Objectives: Oral cancer resection often leads to maxillofacial defects and dentition loss, compromising patients’ quality of life. Implant-supported prosthetic rehabilitation offers a reliable solution to restore function, though factors such as bone reconstruction, radiotherapy, and timing of implant placement (immediate vs. delayed) may influence outcomes. This study aimed to evaluate long-term implant survival and rehabilitation timelines in oncologic patients, comparing two cohorts (2005–2014 and 2015–2024) to assess the impact of evolving clinical practices. Methods: A retrospective cohort study was conducted at Hospital General Universitario Gregorio Marañón (Madrid, Spain), including 304 patients who underwent ablative oral cancer surgery and subsequent implant-based rehabilitation between 2005 and 2024. Data on demographics, oncologic treatment, reconstruction, implant timing, and prosthetic rehabilitation were collected. Outcomes were compared using Kaplan–Meier analysis and appropriate statistical tests between the 2005–2014 (n = 122) and 2015–2024 (n = 182) cohorts. Results: A total of 2341 Ticare Implants^® were placed, supporting 281 prostheses. Implant placement during primary surgery increased from 41% to 71% (p < 0.001). The median time from surgery to prosthesis significantly decreased from 24 to 15 months (p < 0.001). Five-year implant survival was 95% in the early cohort versus 97% in the later cohort. Implant survival was comparable between irradiated and non-irradiated patients (~94–96%). Fixed prostheses became more frequent (92% vs. 79%, p = 0.002). Conclusions: Implant-supported rehabilitation in oncologic patients is highly feasible and durable, with improved timelines and functional outcomes associated with early implant placement and modern digital planning strategies. Full article

Background: Surgical care in conflict regions like Tigray, Ethiopia, faces severe challenges due to limited resources, infrastructural deficiencies, and high trauma burden. From 2019 to 2023, a multidisciplinary team conducted five humanitarian missions focusing on orthoplastic reconstruction of extremity and mandibular injuries from high-energy gunshot trauma. Methods: A retrospective analysis was performed on 98 patients who underwent free or pedicled flap reconstruction. Data included demographics, flap type, technique, complications, follow-up, and early clinical outcomes score as well as mobility scores. Flaps were harvested using loupes anastomosis performed using microscopes, depending on availability. Results: Among 98 patients (25.5% female, 74.5% male), 69 free flaps and 38 pedicled flaps were performed. Free fibula flaps (n = 54) included 33 mandibular and 21 extremity reconstructions. Additional flaps included ALT, gracilis, and LD flaps. Pedicled flaps included 18 fibula and 20 ALT/LD flaps. Mean age was 35.5 years; mean operative time was 429.5 min, with mandibular fibula transfers being longest. Microsurgical techniques were used in 34% of cases. Median follow-up was 10 months. Microsurgical complications occurred in 18.4%, mainly in fibula transfers (25.9%). Non-microsurgical issues included wound infections (n = 15), graft loss (n = 3), and bleeding (n = 5). Flap loss occurred in 16.3% overall. Early clinical outcome results were good (30.6%), acceptable (28.6%), and moderate (24.5%). Conclusions: Orthoplastic reconstruction using both free and pedicled flaps is feasible in low-resource, conflict settings. Despite infrastructural challenges, functional outcomes were achievable, supporting the value of adaptable microsurgical strategies in humanitarian surgery. Full article

Background: Primary malignant bone tumors among adolescent patients are most commonly associated with burdensome surgeries that can severely affect young patients’ early life. To this day, despite available autologous tissue donor sites, cement spacers or endoprostheses are still most commonly used as a form of reconstruction of post-resection defects. Methods: The study group includes 20 adolescent patients diagnosed with Osteosarcoma or Ewing Sarcoma involving the upper limbs. The inclusion criteria were as follows: primary malignant bone tumors sensitive to neoadjuvant chemotherapy, tumors not infiltrating major blood vessels and nerves, and the appliance of the microsurgical free flap as a reconstructive method. Poor tumor response to neodajuvant chemotherapy or patients with incomplete follow-up were excluded from this study. To achieve the functional reconstruction of post-resection defects, fibula free flaps were applied. In cases of resection, including the metaphysis of a long bone, a modification of the flap harvest was applied in order to prevent arthrodesis. The MSTS (Musculoskeletal Tumor Society Scoring System) scale was used as a functional outcome measurement tool. Results: The reported outcomes of this study prove the efficiency of the treatment’s approach of combining the resection of the tumor with subsequent microsurgical restoration with the use of autologous tissues. The average score on the MSTS scale, which assesses the functional outcome, was 26.8/30 points, which indicates great motor outcomes. There were no reports of local recurrence during follow-up. Conclusions: Patients with primary malignant bone tumors in the upper limbs can benefit from microsurgical techniques, which are highly customized; effective; and give sufficient functionality following extensive resection. Full article

Objective: Reconstructing the anterior mandible in patients with irradiated and contracted soft tissues remains challenging despite advances in computer-assisted design and three-dimensional printing. Unpredictable soft-tissue changes reduce the effectiveness of these technologies. This paper explores an alternative using a single-adjustable-osteotomy fibula flap technique. Methods: A retrospective study was performed on patients with anterior segmental mandibular defects due to recurrent tumors, secondary reconstruction, or osteoradionecrosis and previously received radiotherapy who represented the highest risk of soft tissue complexity while limiting the utility of computer technology. All patients underwent mandible reconstruction using the adjustable, single-osteotomy fibula method, which eliminated the need for computer-assisted design. We evaluated the effectiveness and outcome. Results: From 2016 to 2023, 11 patients were included in this study. The median patient age was 58 (ranging 49–65) years. Included patients had either recurrent tumors (n = 6), secondary reconstruction needs (n = 3), or mandibular osteoradionecrosis (n = 2). No complete flap failures occurred. Five of six patients with recurrent cancer required two skin island fibular flaps for intraoral and external defect repair. One patient experienced partial skin paddle loss requiring an additional free flap, and another had plate exposure requiring removal after bone union was achieved. Conclusions: The adjustable single-osteotomy fibula flap technique offers a reliable alternative for anterior mandibular reconstruction in complex cases. This approach demonstrates advantages in surgical simplicity and flexibility while maintaining acceptable outcomes. However, careful patient selection and consideration of defect extent remain crucial for success. Full article

Background: Mandibular reconstruction has evolved significantly since its inception in the early 1900s. Currently, the fibula free flap (FFF) is considered the gold standard for mandibular and maxillary reconstructions, particularly for extensive defects, and the introduction of Extended Reality (XR) and virtual surgical planning (VSP) is revolutionizing maxillofacial surgery. Methods: This study focuses on evaluating the accuracy of using in-house cutting guides for mandibular reconstruction with FFF supported by virtual surgical planning (VSP). Planned and intraoperative osteotomies obtained from postoperative CT scans were compared in 17 patients who met the inclusion criteria. The proposed analysis included measurements of deviation angles, thickness at the centre of gravity, and the maximum thickness of the deviation volume. Additionally, a mandibular resection coding including 12 configurations was defined to classify and analyze the precision of mandibular osteotomies and investigate systematic errors. Preoperative, planned, and postoperative models have been inserted in an interactive VR environment, VieweR, to enhance surgical planning and outcome analysis. Results: The results proved the efficiency of adopting customized cutting guides and highlighted the critical role of advanced technologies such as CAD/CAM and VR in modern maxillofacial surgery. A novel coding system including 12 possible configurations was developed to classify and analyze the precision of mandibular osteotomies. This system considers (1) the position of the cutting blade relative to the cutting plane of the mandibular guide; (2) the position of the intersection axis between the planned and intraoperative osteotomy relative to the mandible; (3) the direction of rotation of the intraoperative osteotomy plane around the intersection axis from the upper view of the model. Conclusions: This study demonstrates the accuracy and reliability of in-house cutting guides for mandibular reconstruction using fibula free flaps (FFF) supported by virtual surgical planning (VSP). The comparison between planned and intraoperative osteotomies confirmed the precision of this approach, with minimal deviations observed. These findings highlight the critical role of CAD/CAM and XR technologies in modern maxillofacial surgery, offering improved surgical precision and optimizing patient outcomes. Full article

Background: Mandibular reconstruction poses challenges in achieving functional and aesthetic outcomes. Effective oral rehabilitation is crucial for restoring function and improving quality of life; however, the altered neomandibular anatomy complicates oral hygiene, increasing the risk of peri-implant complications and making successful rehabilitation more difficult. This study introduces a novel approach combining vestibuloplasty with patient-specific implant-retained splints to enhance oral health and improve rehabilitation outcomes. Methods: Three patients underwent mandibular reconstruction with a free vascularized fibula flap (FFF). After 6 months of osseointegration, vestibuloplasty and soft tissue refinement were performed, with a split-thickness skin graft placed on the FFF periosteum. An implant-retained splint was secured to the abutments for two weeks to support soft tissue healing. Implant survival, bone loss, and peri-implant health were evaluated over a 2-year follow-up. Results: A total of 12 implants were placed, primarily in the neomandible (83.3%), with a 100% survival rate. Implant survival was assessed. Implant survival was assessed based on established criteria for clinical success, including stability, presence of pain, bleeding on probing (BOP), pocketdepth, bone loss and lack of peri-implant radiolucency. Functional outcomes included normal mouth opening, laterotrusion, and protrusion. Pocket depths ranged from 3 to 4 mm, except for one implant in cases 1 and 2. The mean BOP was 51.7%. Conclusions: This case series introduces a surgical technique that combines CAD/CAM and vestibuloplasty to optimize dental rehabilitation in mandibular FFF reconstructions, demonstrating safe thinning of soft tissues for improved oral hygiene and survival. Full article

Study Design: Retrospective cohort study. Objective: To (1) assess post-operative quality of life (QOL) and functional outcomes of fibula free flap (FFF) donor sites, (2) examine the incidence of post-operative claw toe deformities (CTDs) following FFF harvest, and (3) assess the effect of flexor hallicus longus (FHL) muscle preservation on the incidence of post-operative CTDs. Methods: Patients aged 18 years or older and at least 6 months from FFF reconstructive surgery completed the Manchester–Oxford Foot Questionnaire (MOXFQ)and the Short-form 36 (SF-36) Questionnaire. The incidence of post-operative CTDs reported by respondents was calculated. We assessed the associations between FHL preservation at time of surgery and QOL and functional outcomes, including the development of post-operative CTDs. Results: Sixty patients completed questionnaires at a mean of 38.3 months from surgery. The cohort consisted of 28 patients in whom the FHL muscle and nerve were preserved and 32 patients in whom they were not. Among respondents, 23.3% (14/60) reported post-operative CTDs. FHL status was not associated with post-operative CTDs or with worse scores in the domains of pain (p = 0.612), walking/standing (p = 0.431), or social functioning (p = 0.400). Overall, majority reported high post-operative QOL. Conclusions: While majority of patients who undergo FFF reconstruction can expect good long-term donor site QOL and functional outcomes, there are risks of functional impairment, including post-operative CTDs. Preservation of FHL muscle did not affect post-operative QOL outcomes or the incidence of CTDs. These data can inform patient QOL expectations following FFF harvest. Full article

Study Design: This is an experimental feasibility study. Objective: The objective was to analyze the potential of open-source freeware (OSF) to train residents in virtual surgical planning (VSP) and compare this workflow with commercially available software (CAS). Methods: A workflow for mandibular reconstruction with a fibular free flap (FFF) was developed in 3D-Slicer^® and Blender^® and compared to our clinical workflow in Materialise Mimics Innovation Suite version 25 (Materialise InPrint^®, ProPlan CMF^® and 3-Matic^®). Five CMF residents, inexperienced in VSP, were trained to use both the OSF and CAS workflows and then performed four planning sessions on OSF and CAS. The duration (minutes) and the amount of mouse clicks (MCs) of every step in the workflow were recorded. Afterwards, the experience with VSP was investigated with the System Usability Scale (SUS) and a self-developed questionnaire. Results: The total VSP time with CAS took 91 ± 15 min and needed 2325 ± 86 MCs compared to 111 ± 26 min and 1876 ± 632 MCs for OSF, respectively. The questionnaire had an 80% response rate. The SUS for CAS was 67.5 compared to 50 for OSF. The participants believe it is extremely valuable to learn VSP during their training and to be able to perform VSP as a surgeon. Conclusion: We believe OSF can be a cost-effective alternative compared to CAS for the training of surgical residents to gain insight in complex surgeries and to better understand CAD limitations and possibilities. Full article

Introduction: The fibula free flap (FFF) is regarded as the workhorse for lower jaw reconstruction in maxillofacial surgery. Imitating the preexisting shape of the mandible by an FFF while meeting various clinical and geometric aspects can be challenging, even for an experienced surgeon. To enhance the quality and reproducibility of the reconstruction process, several tools are available, mainly based on CAD/CAM techniques and the KLS L1 Mandible ReconGuide. The objective of this study was to examine the clinical use of the KLS L1^® Mandible ReconGuide compared to CAD/CAM templates. Material and Methods: In this study, we compared 25 patients who underwent mandibular reconstruction by a FFF with either the KLS L1^® Mandible ReconGuide (G1, n = 17) or personalized CAD/CAM-based cutting guides (G2, n = 8). We performed a pre- and postoperative 3D image reconstruction using standard triangle language (STL) to quantify the anatomical results in terms of volume deviations, intercondylar distance, and gonial angle, as well as clinical criteria such as surgery time, function, and postoperative complications. Results: The analysis of pre- and postoperative clinical outcomes in 25 patients revealed no statistically significant differences between the groups. However, it was observed that longer surgery time was group-independent, associated with a 5.63% increase in the length of hospital stays (p = 0.0002). In terms of geometric criteria, the only significant difference referred to the postoperative length of the symphysis, which measured 34.32 mm in G2 versus 34.78 mm in G1 (p = 0.046). Conclusions: Both the KLS L1^® Mandible ReconGuide and CAD/CAM templates seem equivalent, effective devices for standardized mandibular reconstruction, with their suitability depending on the specific indications and the segments involved. Full article