The Reconstruction of Mandible Defects in War Injuries: Systematic Review and Meta-Analysis.

Study Design: Systematic Review and Meta-Analysis. Objective: There has been an increasing trend in maxillofacial injuries associated with combat trauma. Within the maxillofacial complex, the mandible is the most likely structure to be damaged during combat. The structural deficits as a result can be reconstructed with many options. These include vascularised bone grafts (VBGs), non-vascularised bone grafts (NVBGs), alloplastic implants, reconstruction bars and distraction osteogenesis. This study aimed to determine the common modality and efficacy of mandibular reconstruction in combat trauma-related defects. Methods: A literature search was conducted on Pubmed, Prospero, Dynamed, DARE, EMBASE, COCHRANE and BMJ databases. Results: A total of six articles met the inclusion criteria identifying 165 patients requiring mandibular reconstruction. Non-vascularised iliac bone graft (n = 137) was the most common method followed by ileac crest bone chips harvest using Dacron urethran osteomesh tray (n = 24) and frontoparietal grafts (n = 4). Meta-analysis of five out of six trials demonstrated an overall success rate of 85% (95% CI 79-90; I2 = 59%). A total of 13% (n = 22) of reconstructions failed either completely or partially and 21% (n = 34) of patients suffered postoperative complications. Conclusions: NVBGs are a practical, cost-effective and favourable method of war zone management of mandibular defects with success rates comparable to those reported in the civilian literature. However, general trauma principles take precedence to rule out life-threatening injuries. Due consideration of patient factors, surgical factors, and available resources are required in the first-line management of combat-related mandibular defects.

A new concept for mandible reconstruction after oncological resection: Multisegment virtual surgical planning.

PURPOSE: Virtual surgical planning (VSP) is good for three dimensional reconstructions in maxillofacial surgery, but it is not problem-free completely especially when the resection margins cannot be affirmed in preoperative period. We aimed to obtain an ideal reconstruction with elaborating VSP to be prepared for adverse conditions during surgery and to proceed the oncological resections step- by- step with A, B, and C resection planes. PATIENTS AND METHODS: Four patients undergoing multisegment VSP for the primary mandible malignancies were included in the study. The first resection margin was detected as plan A in VSP, and plans of B and C were also prepared considering the tumor- positive result of intraoperative frozen section procedure. RESULTS: Following the tumor resection, margins were extended to the plan B in two patients, and plan C in one patient in accordance with the results of the frozen section procedure.Histogram comparison of the localizations of osteotomies in mandible and fibula, and positions of the implants were calculated at a confidence level of 95 % (p > 0.95) and mean difference was found -0.55 mm, while standard deviation was 1.76 mm. CONCLUSION: Multisegment virtual surgical planning seems to achieve the optimal reconstruction with the staged resection preventing redundant removal of tumor- free structures like bone and teeth.

Personalized lattice-structured prosthesis as a graftless solution for mandible reconstruction and prosthetic restoration: A finite element analysis.

Oral cavity tumors are a prevalent cause of mandible reconstruction surgeries. The mandible is vital for functions like oralization, respiration, mastication, and deglutition. Current mandible reconstruction methods have low success rates due to complications like plate fracture or exposure, infections, and screw loosening. Autogenous bone grafts are commonly used but carry the risk of donor region morbidity. Despite technological advances, an ideal solution for mandible reconstruction remains elusive. Additive manufacturing in medicine offers personalized prosthetics from patient-specific medical images, allowing for the creation of porous structures with tailored mechanical properties that mimic bone properties. This study compared a commercial reconstruction plate with a lattice-structured personalized prosthesis under different biting and osseointegration conditions using Finite Element Analysis. Patient-specific images were obtained from an individual who underwent mandible reconstruction with a commercial plate and suffered from plate fracture by fatigue after 26 months. Compared to the commercial plate, the maximum von Mises equivalent stress was significantly lowered for the personalized prosthesis, hindering a possible fatigue fracture. The equivalent von Mises strains found in bone were within bone maintenance and remodeling intervals. This work introduces a design that doesn't require grafts for large bone defects and allows for dental prosthesis addition without the need for implants.

A Novel Method for Secondary Mandible Reconstruction to Re-Achieve a Native Condyle Position Comprising a New Design for Cutting Guides and New Positioning Devices.

Secondary mandibular reconstruction using fibular free flaps (FFF) is a technical challenge for surgeons. Appropriate operation planning is crucial for postoperative quality control and is notably necessary for the (re-) achievement of a physiological condylar position, and the sensible expansion and shaping of the transplant. Computer-assisted planning may help to reconstruct mandibular defects in a patient-specific and precise manner. Herein, we present a newly-developed workflow for secondary mandibular reconstruction using FFF; it comprises digital planning and in-house manufacturing to perform precise secondary mandible reconstruction. This method utilizes a newly designed positioning device to ensure the precise positioning of the fibula segments in relation to each other and the mandibular stumps. The presented in-house-printed positioning device made it possible to achieve digital planning with high precision during surgery.

Use of reconstruction plates prebent on three-dimensional models to reduce the complications of mandibular reconstruction.

Background/purpose: Though the gold standard method for mandible reconstruction of the defect from segmental mandibulectomy is by osseous flap or graft, using reconstruction plates is still indicated in some cases. Traditionally, the plate is bended immediately after the segmental mandibulectomy by freehand. However, it's difficult to fit well to the original position of mandible, which may result in more complications. This study therefore aimed to investigate whether using prebent plates on computer-aided 3D printing models could reduce the complication rate. Materials and methods: Patients who received mandible reconstruction by reconstruction plate from 2018 to 2022 were enrolled and evaluated in this study. The data, including demographics, indications for surgery, pre-existed preoperative and postoperative therapies, classification of defects, and postoperative outcomes were collected and analyzed. Results: A total of 52 patients were enrolled in our study. The prebent group exhibited a significantly lower complication rate than that of the immediately bent group (P = 0.012). Other risk factors of plate complications included postoperative adjuvant radiotherapy (P = 0.017) and previous surgery (P = 0.047). The complication-free survival rate was also better in the prebent group in a 3-year follow-up period (P = 0.012). Conclusion: Prebent plates on computer-aided printing models proved to be an effective approach to reduce the complications for mandibular reconstruction in segmental mandibulectomy.

Soft-tissue, non-osteogenic distraction of the mandible and lower face in bilateral hemifacial microsomia-technical report.

The aim of this study is to present a sequential strategy of soft-tissue, non-osteogenic distraction with a novel device, followed by microvascular bony reconstruction for severe cases of mandibular hypoplasia. The case of a 21-year-old woman with Goldenhar syndrome is presented, whose mandible remained severely hypoplastic despite previous attempts at distraction and was not suitable for further osteogenic distraction. Soft tissue deficiency and pin track scarring prevented free fibular transfers. A personalized distractor, anchored to the cranium and the mandibular symphysis, was designed to expand the soft tissues while allowing for physiological temporomandibular joint (TMJ) movement without compression forces. Internal distractors were placed along the osteotomies to prevent condylar luxation. After completion of the soft tissue distraction, the native mandible was resected except for the condyles and reconstructed with two free fibula flaps. This report represents the proof of concept of a sequential approach to severe lower face soft-tissue and bone deficiency, which preserves TMJ function and avoids the transfer of poorly matched skin to the face.

Influence of microvascular mandibular bony reconstruction on the posterior airway space: A retrospective cohort study.

INTRODUCTION: The posterior airway space (PAS) is a common site of passive obstructions with high morbidity. Surgical changes to the craniomandibular system may affect the PAS. Data regarding the effects of mandibular reconstruction using vascularized bone flaps on PAS are insufficient. This retrospective cohort study aimed to investigate changes in PAS after mandibular reconstruction. MATERIALS AND METHODS: Pre- and post-reconstructive computed tomography scans of 40 patients undergoing segmental mandibulectomy and mandibular reconstruction with deep circumflex iliac artery or fibula flaps were analyzed. Absolute differences in PAS geometry and relative trends of PAS volume changes were compared within the study population and between subgroups formed according to the extent of resection, timing and type of reconstruction, and presence of pre-reconstructive radiotherapy. RESULTS: Irradiated patients were characterized by an increase in PAS volume after reconstruction. Absolute differences in total PAS volume after reconstruction were significantly different (p = 0.024) compared to non-irradiated patients. Reconstruction of central mandible segments resulted in decrease of the cross-sectional PAS areas. Absolute differences in middle cross-sectional PAS area after reconstruction were significantly different (p = 0.039) compared to non-central reconstructions. Patients who received radiotherapy were less likely to show a total PAS volume reduction after reconstruction (OR: 0.147; p = 0.007), with values adjusted for gender, age, body mass index, timing and type of reconstruction, and transplant length. CONCLUSIONS: Mandibular reconstruction causes changes in PAS geometry. Specifically, reconstructions of central mandibular segments can lead to a reduction in the cross-sectional areas of PAS, and mandibular reconstructions in irradiated sites may cause an increase in PAS volume.

Application of digital guide plate with drill-hole sharing technique in the mandible reconstruction.

Background/purpose: With the development of computer-assisted surgery, digital guide plate was widely used in vascularized bone flap grafts for mandibular reconstruction. The purpose of this study was to design and manufacture a digital guide plate with drill-hole sharing for mandibular reconstruction and assess for surgical accuracy. Materials and methods: 17 patients that required mandibular reconstruction using fibula free flap or iliac crest free flap were included in the study. The computed tomography (CT) data of the patient's mandible and pelvis or fibula were acquired preoperatively. A surgical simulation was then performed using computer-aided surgical simulation (CASS) technology based on above date, which allowed the design of two cutting guide and a repositioning guide for mandibular reconstruction. After surgery, the accuracy of reconstruction was evaluated by superimposing the postoperative image onto the preoperative image of mandible, recording the linear and angular deviation of landmarks, measuring the differences between the planned and actual outcomes. Results: The osteotomy and repositioning of fibula or iliac crest segments were successfully performed as planned using surgical guides. The digital guide plate with drill-hole sharing showed excellent accuracy, When the iliac crest or the fibula free flap were used for mandibular reconstruction, the largest mean differences between the preoperative and postoperative were 1.11 mm and 2.8° or 1.3 mm and 3.87°. Conclusion: The digital guide plate with drill-hole sharing designed preoperatively provides a reliable method of for the mandibular reconstruction. This can assist surgeons in accurately performing osteotomy and repositioning fibula or iliac crest segments during the mandibular reconstruction.

Three-dimensional printed titanium mesh combined with iliac cancellous bone in the reconstruction of mandibular defects secondary to ameloblastoma resection.

BACKGROUND: The reconstruction of large mandibular defects is a challenge, and free vascularized bone flaps are most commonly used. However, the precision and symmetry of this repair are deficient, and patients have a risk of vascular embolism, flap necrosis, and donor site complications. Therefore, to explore an ideal alternative in mandibular reconstruction with high surgical accuracy and low complications is indispensable. METHODS: Seven patients with recurrent or large-scope ameloblastoma were enrolled in this study. All patients were provided with a fully digital treatment plan, including the design of osteotomy lines, surgical guides, and three-dimensional printed titanium mesh for implantation. With the assistance of surgical guide, ameloblastomas were resected, and custom 3D printed titanium mesh combined with posterior iliac bone harvest was used in mandibular reconstruction. A comparison was made between the discrepant surgical outcomes and the intended surgical plan, as well as the average three-dimensional deviation of the mandible before and after the surgery. At the same time, the resorption rate of the implanted bone was evaluated. RESULTS: All patients completed the fully digital treatment process successfully without severe complications. Image fusion showed that the postoperative contour of the mandible was basically consistent with surgical planning, except for a slight increase in the inferior border of the affected side. The mean three-dimensional deviation of the mandible between the preoperative and postoperative periods was 0.78 ± 0.41 mm. The mean error between the intraoperative bone volume and the digital planning bone volume was 2.44%±2.10%. Furthermore, the bone resorption rates of the harvested graft 6 months later were 32.15%±6.95%. CONCLUSIONS: The use of digital surgical planning and 3D-printed templates can assist surgeons in performing surgery precisely, and the 3D-printed titanium mesh implant can improve the patient's facial symmetry. 3D printed titanium mesh combined with posterior iliac cancellous bone graft can be regarded as an ideal alternative in extensive mandibular reconstruction.

Alloplastic reconstruction of the mandible after subtotal mandibulectomy for medication-related osteonecrosis of the jaw: An update of the method.

BACKGROUND: Reconstruction of continuity defects following osteonecrosis in multimorbid patients is challenging. In all cases of the predescribed palliative treatment method for alloplastic mandible reconstruction, plate fractures were detected in follow-up. We hypothesized that a modification could avoid these fractures, leading to stable long-term results. METHODS: This retrospective study compares the original method with a modification using single, laser-sintered CAD-CAM plates instead of manually bent miniplates. The predescribed shuttering technique was used to reconstruct the mandible in its original shape with bone cement. RESULTS: Uneventful wound healing was observed in 86% of the cases after modification of the method. No implant or plate fracture occurred. CONCLUSIONS: The presented method should be considered as a treatment option for mandible reconstruction in elderly, multimorbid patients in palliative situations. The results of this study suggest that the modification of the method leads to significantly improved long-term stability. Donor site morbidity is avoided with this method of palliative surgery.

Feasibility analysis of bone density evaluation with Hounsfield unit value after fibula flap reconstruction of jaw defect.

BACKGROUND: Implant-supported dentures have become an essential means of restoring occlusal function after jaw reconstruction. Bone mineral density (BMD) may influence the success rate of implant denture restorations. This study aimed to explore whether the Hounsfield unit (HU) value can be used to monitor the changing trend of fibular BMD after jaw reconstruction. RESULTS: A total of 54 patients who underwent maxillar/mandibular reconstruction with a fibula flap were included in this study. There was a significant correlation between the HU value and BMD at 1 week, 3 months, and 6 months after surgery, and both were significantly correlated with follow-up time. The difference between each pair of absorption rates (DAR) was less than 10% in 66.7% and 75.9% of patients at 3 and 6 months; however, the DAR was more than 20% in 12% and 13.8% of patients at 3 and 6 months, respectively. CONCLUSIONS: There is a significant correlation between HU value and BMD. The HU value can be used to roughly reflect the fibular BMD changing trend in a group of patients as opposed to an individual, and the HU value is not equivalent to BMD. TRIAL REGISTRATION: ChiCTR, ChiCTR2300069661, retrospectively registered on 22 March 2023. Retrospectively registered, https://www.chictr.org.cn/showproj.html?proj=188953 .

Long-Term Follow-Up of a Novel Surgical Option Combining Fibula Free Flap and 3D-Bioprinted, Patient-Specific Polycaprolactone (PCL) Implant for Mandible Reconstruction.

As the fibula free flap became the gold standard in mandibular reconstruction that required both hard tissue and soft tissue, various methods have been sought to solve the height discrepancy between the mandible and fibula. The purpose of this paper was to propose a surgical option that combined the microvascular fibula free flap with a 3D-bioprinted, patient-specific polycaprolactone (PCL) implant as a safe and simple novel method that achieved the best functional and aesthetic results in mandibular reconstruction surgery for young patients with malignant tumors. The patient's reconstructed mandible maintained volume symmetry without any deformation or complications for over 6 years. Computer-aided design/computer-aided manufacturing (CAD/CAM) and 3D printing technology enabled accurate and safe surgical results.

Cutting-edge patient-specific surgical plates for computer-assisted mandibular reconstruction: The art of matching structures and holes in precise surgery.

Objectives: Cutting-edge patient-specific surgical plates (PSSPs) are supposed to improve the efficiency, precision, and functional outcomes of mandibular reconstruction. This study characterized the premium role of PSSPs in precise surgery and explored their working principles in computer-assisted mandibular reconstruction (CAMR). Methods: The PSSPs-enhanced surgical precision was investigated through the model surgery and representative cases. Spatial deviations of reconstruction were characterized by comparing the reconstructed mandible with the virtually designed mandible. Working principles of PSSPs were distinguished by a review of evolving surgical techniques in CAMR. Results: In the model surgery, spatial deviations between the virtually planned mandible and the reconstructed mandible were 1.03 ± 0.43 mm in absolute distance deviation, 1.70 ± 1.26 mm in intercondylar length, and 1.86 ± 0.91 mm in intergonial length in the study group of PSSPs, significantly smaller than in the control group of conventional prebent surgical plates. Meanwhile, in the study group, distance deviations were 0.51 ± 0.19 mm in bone-plate distance and 0.56 ± 0.28 mm in drilled screw holes, indicating the art of matching structures and holes. The PSSPs-enhanced CAMR was further demonstrated in three representative cases of mandibular reconstruction. Finally, four primary techniques of CAMR were summarized based on a review of 8,672 articles. The premium role of PSSPs was distinguished by the benefits of matching structures and holes. Conclusions: The PSSPs-enhanced surgical precision was verified through the model surgery and demonstrated in human surgery. Compared to other surgical techniques of CAMR, PSSPs contributed to the precise surgery by the art of matching structures and holes.

Reconstruction of the mandible from partial inputs for virtual surgery planning.

Statistical Shape Models (SSMs) and Sparse Prediction Models (SPMs) based on regressions between cephalometric measurements were compared against standard practice in virtual surgery planning for reconstruction of mandibular defects. Emphasis was placed on the ability of the models to reproduce clinically relevant metrics. CT scans of 50 men and 50 women were collected and split into training and testing datasets according to an 80:20 ratio. The scans were segmented, and anatomical landmarks were identified. SPMs were constructed based on direct regressions between measurements derived from the anatomical landmarks. SSMs were developed by establishing correspondence between the segmented meshes, performing alignment, and principal component analysis. Anterior and bilateral defects were simulated by removing sections of the mandibles in the testing set. Measurement errors after reconstruction ranged from 1.07˚ to 2.2˚ and 0.66 mm to 2.02 mm for mirroring, from 0.45˚ to 3.67˚ and 0.66 mm to 2.54 mm for the SSMs, and from 1.74˚ to 5.01˚ and 0.64 mm to 2.89 mm for the SPMs. Surface-to-surface errors ranged from 1.01 mm to 1.29 mm and 1.06 mm to 1.33 mm for mirroring and SSMs, respectively. Based on the results, SSMs are recommended for VSP in the absence of normal patient anatomy.

Donor site morbidity after computer assisted surgical reconstruction of the mandible using deep circumflex iliac artery grafts: a cross sectional study.

BACKGROUND: Computer Assisted Design and Computer Assisted Manufacturing (CAD/CAM) have revolutionized oncologic surgery of the head and neck. A multitude of benefits of this technique has been described, but there are only few reports of donor site comorbidity following CAD/CAM surgery. METHODS: This study investigated comorbidity of the hip following deep circumflex iliac artery (DCIA) graft raising using CAD/CAM techniques. A cross-sectional examination was performed to determine range of motion, muscle strength and nerve disturbances. Furthermore, correlations between graft volume and skin incision length with postoperative donor site morbidity were assessed using Spearman's rank correlation, linear regression and analysis of variance (ANOVA). RESULTS: Fifteen patients with a mean graft volume of 21.2 ± 5.7 cm3 and a mean incision length of 228.0 ± 30.0 mm were included. Patients reported of noticeable physical limitations in daily life activities (12.3 ± 11.9 weeks) and athletic activities (38.4 ± 40.0 weeks in mean) following surgery. Graft volume significantly correlated with the duration of the use of walking aids (R = 0.57; p = 0.033) and impairment in daily life activities (R = 0.65; p = 0.012). The length of the scar of the donor-site showed a statistically significant association with postoperative iliohypogastric nerve deficits (F = 4.4, p = 0.037). Patients with anaesthaesia of a peripheral cutaneous nerve had a larger mean scar length (280 ± 30.0 mm) than subjects with hypaesthesia (245 ± 10.1 mm) or no complaints (216 ± 27.7 mm). CONCLUSIONS: Despite sophisticated planning options in modern CAD/CAM surgery, comorbidity of the donor site following  iliac graft harvesting is still a problem. This study is the first to investigate comorbidity after DCIA graft raising in a patient group treated exclusively with CAD/CAM techniques. The results indicate that a minimal invasive approach in terms of small graft volumes and small skin incisions could help to reduce postoperative symptomatology. Trial registration Retrospectively registered at the German Clinical Trials Register (DRKS-ID: DRKS00029066); registration date: 23/05/2022.

Straight-segment mandibulectomy: a reproducible porcine mandibular critical-size defect model.

Porcine mandibular defect models are commonly used for the preclinical evaluation of reconstruction techniques. Existing studies vary in technique, complexity, and postoperative outcomes. The procedures are complex and often described without sufficient detail. We describe in detail a simple and reproducible method for creating a critical-size mandibular defect in a porcine model. Seven hemimandibular critical size defects were created in five male Yorkshire-Landrace pigs, three with unilateral defects and two with bilateral defects. A transverse incision was made over the mandibular body. Periosteum was incised and elevated to expose the mandibular body and a critical-size defect of 30 × 20 mm created using an oscillating saw. The implant was inserted and fixed with a titanium reconstruction plate and bicortical locking screws, and the wound closed in layers with resorbable sutures. Intraoral contamination was avoided. Dentition was retained and the mental nerve and its branches preserved. The marginal mandibular nerve was not encountered during dissection. All pigs retained normal masticatory function, and there were no cases of infection, wound breakdown, haematoma, salivary leak, or implant-related complications. The procedure can be performed bilaterally on both hemimandibles without affecting load-bearing function. All pigs survived until the end point of three months. Postoperative computed tomographic scans and histology showed new bone formation, and a three-point bend test showed the restoration of biomechanical strength. Straight-segment mandibulectomy is a simple and reproducible method for the creation of critical-size mandibular defects in a porcine model, simulating a load-bearing situation.

Augmented reality guided in reconstruction of mandibular defect with fibular flap: A cadaver study.

BACKGROUND: Augmented reality (AR) navigation has been developed in recent years and can overcome some limitations of existing technologies. This study aimed to investigate a novel method of fibula free flap (FFF) osteotomy based on AR technology through a cadaver study. METHODS: One mandible, seven fibulas, and seven lower limb specimens underwent computed tomography (CT) examination. We used the professional software Proplan CMF 3.0 to design a defective mandible model and created fourteen virtual reconstruction plans using the fibulas and lower limb specimens. The AR-based intraoperative guidance software prototype was developed using the Unity Real-Time Development Platform, and virtual plans were transferred into this software prototype. We used AR-based surgical navigation to guide the FFF osteotomy and used these fibular segments to reconstruct the defective mandible model. After reconstruction, all segments were scanned by CT. Osteotomy accuracy was evaluated by measuring the length and angular deviation between the virtual plan and the final result. The reconstruction precision was reflected by the volume overlap rate and average surface distance between the planned and obtained reconstruction. RESULTS: The length difference, angular deviation, volume overlap rate and average surface distance of the in vitro group were 1.03±0.68 mm, 5.04±2.61°, 95.35±1.81%, and 1.02±0.27 mm, respectively. Those of the in vivo group were 1.18±0.84 mm, 5.45±1.47°, 95.31±2.09%, and 1.22±0.12 mm. CONCLUSIONS: Due to the ideal result of cadaver experiments, an AR-based FFF osteotomy guided system may become a novel approach to assist FFF osteotomy for the reconstruction of defective mandibles.

Approach for Mandibular Reconstruction Using Vascularized Free Fibula Flap: A Review of the Literature.

Mandible reconstruction is one of the major challenges that face any maxillofacial surgeon worldwide. Different approaches and methods are used for mandible reconstruction, including pedicle flaps, titanium reconstruction plates, and bone grafts. A free fibular flap is used commonly and is considered the gold standard in mandibular reconstruction with a good success rate. Advantages of the free fibula flap include the long pedicle, flexible skin island, good length of dense cortical bone, consistent bone shape, minimal donor site morbidity, superior union rate, anti-collapse effectiveness, segmental blood supply, the potential for two skin paddles, and ease of harvest with a flap survival rate up to 95%. This current review aims to illustrate the approach for mandibular reconstruction using a vascularized free fibula flap.

Introduction of 3D Printing in a German Municipal Hospital-Practice Guide for CMF Surgery.

Study Design: This study aimed to introduce 3D printing in a municipal hospital to improve the treatment of craniomaxillofacial patients and optimize costs and operating time. Thus we describe the implementation of low-cost in-house 3D printing to facilitate orbital- and mandible reconstruction in CMF surgery. Moreover, we address legal requirements, safety at work, fire- and data protection. Finally, we want to share our experiences using 3D printing and point out its advantages in providing better patient care. Methods: We outline the setup of in-house 3D printing and focus on obeying German health care regulations. We based our approach on a fused deposition modeling 3D printer and free software. As proof of concept, we treated 4 cases of severe orbital trauma and 1 case of mandibular reconstruction. We printed a 3D patient-specific model for each case and adapted a titanium mesh implant, respectively, a titanium reconstruction plate before performing the surgery. Results: Our approach reduced costs, duration of anesthesia, operating time, recovery time, and postoperative swelling and increased the revenue. Functional outcome in orbital reconstruction like eye movement and double vision, was improved compared to the conventional technique. No severe complications like loss-of-vision or surgical revision occurred. Likewise, mandibular reconstruction showed no plate loosening or plate fracture. Conclusion: The implementation of cost-efficient 3D printing resulted in successful patient treatment with excellent outcomes. Our practice guide offers a 3D printing workflow and could be adapted to fit the needs of other specialties like neurosurgery, orthopedic surgery as well.

Intraoral versus transcervical approaches in mandibular reconstruction with free flaps: A retrospective study.

This study aims to investigate the clinical and functional differences between intraoral and transcervical approaches for segmental mandible resection and reconstruction with free flaps. Patients diagnosed as benign and low-grade mandibular malignant tumors without neck dissections were retrospectively reviewed and divided into intraoral and transcervical groups. Patients of intraoral group underwent intraoral mandibulectomy and vascular anastomosis was performed through a 2-cm submandibular incision, while traditional submandibular approach was used in transcervical group. Clinical characteristics of two groups were assessed including body mass index (BMI), defect types and number of fibular segments, as well as perioperative variables such as operation time, blood loss, drainage volume. The score of appearance, swallowing and speech using the University of Washington Quality of Life Questionnaire (UW-QOL) was recorded and analyzed 6-month postoperatively. A total of 14 patients in intraoral group and 21 patients in transcervical group was collected, respectively. In intraoral group, intraoperative blood loss and postoperative drainage volume were significantly reduced in comparison with transcervical group (p = 0.0146, p = 0.0017; respectively). The score of appearance was 87.50 ± 12.97 in intraoral group, which was significantly higher than 64.29 ± 12.68 in transcervical group (p < 0.0001). Similar results were found in patients of subtype Class II mandibular defect between two groups. However, patients of intraoral group had a significant increase in operative time and a comparable amount of intraoperative blood loss (p = 0.0472, p = 0.1434; respectively). Within the limitations of the study it seems that an intraoral approach combined with a 2-cm submandibular incision should be preferred over a transcervical approach for segmental mandibulectomy and free flap reconstruction whenever appropriate.