Clinical context and challenges of mandibular reconstruction

Mandibular reconstruction after segmental resection — whether motivated by tumor pathology, trauma, or osteonecrosis — represents a major surgical challenge. While the fibula free flap (FFF) has established itself as the gold standard since 1989, conventional techniques still rely heavily on manual intraoperative modeling and empirical plate bending. This traditional approach, although proven, is technically demanding and presents significant variability in terms of facial symmetry and functional predictability (breathing, swallowing, speech).

Study objective and hypotheses

This retrospective study, conducted at the University of Turin on patients operated on between 2016 and 2023, aims to compare two distinct approaches: the conventional model-assisted technique (Group A) and virtual surgical planning (VSP) with computer-aided design and manufacturing (CAD/CAM) for cutting guides and specific plates (Group B). The precise objective is to evaluate the impact of these technologies on long-term results (minimum 12-month follow-up) reported by patients and surgeons.

The central hypothesis is based on the fact that the integration of the digital workflow allows for increased precision and efficiency. The authors seek to demonstrate that CAD/CAM significantly optimizes aesthetic results (chin projection, mandibular contour) and overall quality of life compared to the classic manual approach, thanks to better predictability of the reconstructed volumes.

Study methodology

This retrospective study, conducted at the University of Turin, analyzes data from patients who underwent mandibular reconstruction using a fibula free flap (FFF) between January 1, 2016, and December 31, 2023. The design aims to compare the long-term efficacy of the digital approach versus the traditional method.

La sélection des participants a respecté des critères stricts pour garantir la fiabilité des mesures :

• Inclusion criteria: Adult patients (≥ 18 years) treated with primary or secondary reconstruction after segmental resection, with a minimum postoperative follow-up of 12 months.
• Exclusion criteria: Concomitant lingual resections or flap failures (partial or total loss), in order to eliminate major confounding variables on functional outcomes.

Patients were divided into two groups according to the surgical modality:

• Group A: Conventional model-assisted technique.
• Group B: Virtual Surgical Planning (VSP) assisted surgery and CAD/CAM protocols.

The analysis protocol was based on the extraction of specific variables: age, gender, lesion pathology, and resection type according to the Brown classification. The final evaluation integrated a complete physical clinical examination as well as a set of validated instruments to measure morpho-functional outcomes and quality of life, cross-referencing subjective assessments from both patients and surgeons.

Comparative Analysis of Mandibular Reconstruction Protocols

The study focused on a cohort of patients who underwent fibula free flap (FFF) reconstruction between January 1, 2016, and December 31, 2023. Patients were divided into two distinct groups: Group A (conventional model-assisted technique) and Group B (virtual surgical planning VSP with CAD/CAM).

Clinical analysis: digital precision facing the anatomical challenge

The results of this retrospective study, conducted at the University of Turin, highlight a major technological pivot in mandibular reconstruction. The use of CAD/CAM (Group B) is not limited to simple technical assistance; it redefines aesthetic and functional predictability compared to conventional model-assisted methods (Group A). Based on the Katsuragi scale, the study shows that virtual surgical planning (VSP) allows for a more faithful restoration of the contour, projection, width, and length of the mandible. In the practice, this translates into a reduction of the uncertainty associated with manual intraoperative plate bending.

A critical point emerges from the analysis: the systematic exclusion of patients who had undergone lingual resection or flap failure. While this methodological choice allows for isolating the efficacy of bone reconstruction without major functional bias (swallowing, speech related to the tongue), it limits the interpretation of results to cases of "ideal" morphological reconstruction. For the practitioner, this means that while CAD/CAM optimizes symmetry, soft tissue management remains the limiting factor unresolved by digital technology.

Compared to conventional data, this study confirms that VSP potentially reduces operative time and complications, while improving patient psychological well-being (measured via FACE-Q Aesthetics© modules). However, the steep learning curve of conventional techniques, mentioned by the authors, serves as a reminder that digital technology compensates for inter-operator variability that manual modeling can no longer ignore in 2024.

Summary of study parameters

The study analyzes the long-term morpho-functional results of patients who underwent segmental mandibular resection, with inclusion based on a postoperative follow-up of at least 12 months. The protocol rigorously compares the accuracy of chin projection and mandibular symmetry between the traditional manual technique and the use of customized cutting guides combined with pre-bent plates.

In concrete terms, for the practitioner:

• Secure anatomical precision: Prioritize virtual surgical planning (VSP) to ensure more predictable chin projection and mandibular contouring, thereby reducing the risks of asymmetry associated with intraoperative manual bending.
• Optimize the operative flow: The use of cutting guides and CAD/CAM plates allows for a reduction in surgical time, a critical factor for flap viability and patient recovery.
• Adopt an objective evaluation: Integrate tools such as the Katsuragi scale (symmetry/scars) and the FACE-Q questionnaire to quantify aesthetic satisfaction and psychological well-being post-reconstruction for your patients.

Technical lexicon of mandibular reconstruction using a fibula flap

Fibula Free Flap (FFF): A true "gold standard" for mandibular reconstruction, this fibula flap is highly regarded for its robust bone quality and the comfortable length of its vascular pedicle, facilitating anastomoses.

Virtual Surgical Planning (VSP): Virtual surgical planning allows for the simulation of the procedure beforehand. It is the key step for designing precise cutting guides and anticipating aesthetic and functional results.

CAD/CAM: The duo of computer-aided design and manufacturing. This technology transforms virtual planning into clinical reality via 3D printing of patient-specific implants and reconstruction plates.

Brown Classification: The anatomical reference used in this study to categorize the extent of mandibular defects following surgical excision, essential for standardizing the reconstructive approach.

Osteocutaneous flap: A variant of the graft combining fibular bone with a skin paddle. Essential when the loss of substance affects both the bone architecture and the epithelial lining.

Segmental mandibular resection: The surgical procedure of excision (oncological or traumatic) that interrupts the continuity of the mandibular arch, creating the complex defect that the FFF technique restores.

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