Delayed Maxillary Reconstruction with Free Osteocutaneous Fibula Flap Using CAD-CAM Technology

Background  Maxillary reconstruction poses unique challenges for the reconstructive surgeon because of the complex three-dimensional (3D) anatomy of the maxilla. Undertaking this endeavor on secondary reconstruction makes it more difficult due to problems in recreating the true defect. This study is an attempt to demonstrate the role of virtual surgical planning (VSP), 3D printing, and mock surgery in reconstructing such defects using free fibula flaps. Materials and Methods  This was a prospective study involving 10 patients of maxillary defects who underwent delayed reconstruction with a free fibula flap. The planning was done preoperatively using computer-aided design and computer-aided manufacturing (CAD-CAM) technology. A mock surgery with 3D printed models was done before the surgery. After the surgery, the accuracy results were obtained by overlapping and measuring fixed point distances between preoperative virtual planning and postoperative computed tomography (CT) scan data. Results and Discussion  Nine patients underwent successful reconstruction and were satisfied with the outcome. One patient had flap loss. The mean shift along the horizontal, vertical, and 3D axes was less than 5 mm between the preoperative virtual planning and postoperative CT scan data, indicating accurate reconstruction. We also suggest strategies for soft-tissue and bony inset including inferolateral pedicle origin, anteriorly facing lateral fibular surface, and two bony struts for the alveolus. Conclusion  VSP and CAD-CAM technology in maxillary reconstructions help achieve an anatomically accurate neo-maxilla. The addition of mock surgery to the routine and the use of cutting guide avoid unpredictability and reduce the need for adaptation activities on the operating table. CAD-CAM technology despite its limitations is invaluable in maxillary reconstruction and is an important tool for a reconstructive plastic surgeon.