Angle-to-Angle Mandibular Defect Reconstruction With Fibula Flap by Using a Mandibular Fixation Device and Surgical Navigation.

Purpose: Although free fibula flaps are widely used for mandibular reconstruction, 3-dimensional (3D) position is difficult to control in angle-to-angle mandibular defects. The present study describes a revised approach for angle-to-angle mandibular reconstruction with fibula flaps by using mandibular fixation device and surgical navigation. Methods: Preoperative maxillofacial and fibular computed tomography (CT) scans were acquired, and CT data were imported into ProPlan CMF software. Virtual mandibulectomy was performed, and 3D fibula image was superimposed on the mandibular defect. The fibula flap was shaped according to virtual parameters and the stereo model. Surgical navigation was used to check and correct shaped segments. Position of the osteotomy lines and relevant parameters regarding the shape of the fibula flap were provided to the surgeon. A mandibular fixation device (Cibei, China) was fixed to bilateral mandibular ramus before mandibulectomy, which maintained normal mandibular width. Under computer navigation guidance, the fibula flap was accurately positioned in 3D direction, and the defect could be precisely reconstructed despite the lack of stable occlusal relationship after osteotomy. Results: Postoperative CT and 3D error analysis revealed that osteotomy lines and reconstruction contour matched well with preoperative planning. Using our method, we precisely recovered the original configuration of the mandible. Bilateral condyles were located in the temporomandibular joint fossae, and normal mandibular width was maintained. Compared with preoperative positions, the average shift on the remaining mandible was 0.803 +/- 0.502 mm (largest, 1.886 mm). Average shift in the reconstructed mandible was 0.281 +/- 0.300 mm, largest being 2.441 mm. Conclusions: We describe a novel method for angle-to-angle mandibular reconstruction with free fibula flap. A mandibular fixation device combined with computer-assisted techniques involving surgical navigation improved clinical outcomes of this procedure. (C) 2017 by Mutaz B. Habal, MD.

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