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Pediatric free fibula reconstruction of the mandible utilizing virtual surgical planning
Tomer Avraham, MD, Peter Franco, DMD., Lawrence Brecht, DDs., David Hirsch, DDs, MD, Jamie Levine, MD.
NYU Langone Medical Center, New York, NY, USA.

Purpose: The use of free osteocutaneous fibula flaps has become the gold standard for reconstruction of complex mandibular defects. As use of this modality has become more commonplace, indications have been expanded such that it is routinely used in the pediatric population. The use of this reconstructive method creates unique challenges related to precision, planning, and future growth. We have attempted to optimize both the procedure and outcomes through the use of virtual planning and pre-fabricated cutting jigs.
Methods: All cases of mandibular reconstruction with a free fibula osteocutaneous flap in children aged less than 18 between 2009 and 2012 were identified. These cases were then reviewed retrospectively for a variety of outcomes and variables. Prior to surgery all patients underwent CT scanning of the face and bilateral lower extremities. These images were then transmitted to an outside vendor. In consultation with both the oral-maxillofacial and reconstructive teams, a surgical plan was devised, cutting jigs for both creation of the mandibular defect and for fibular osteotomies were fabricated, and a streolithic model that allows for precise reconstruction plate bending was created.
Results: Our cohort included 8 patients average age 13.9 years with a range of 10 to 17 years. Indications for procedure were 4 cases of hemifacial microsomia, 3 cases of ameloblastoma, and one of stage 4 squamous cell carcinoma. There was one major complication in our series which was flap loss in a patient with ameloblastoma. This patient was subsequently reconstructed with a second fibula flap. The patients with hemifacial microsomia underwent augmentation of hemi-mandibular length with vascularized bone as well as concomitant orthognathic procedures to optimize occlusion and chin point positioning. All these patients achieved significant improvement in their occlusal relationships. Three patients underwent immediate placement of osteointegrated dental implants. All patients achieved placement of dental implants within six months of flap placement. Seven of eight patients have achieved dentition of their fibula flap, with one patient who underwent surgery in late 2012 awaiting denture placement.
Conclusions: Pre-operative virtual planning along with use of prefabricated cutting jigs allows for precise complex fibula reconstruction of the mandible in the pediatric population. Additionally, virtual planning facilitated concomitant orthognathic procedures in patients with hemifacial microsomia. All patients in our series were able to have dental implants placed into their mandibular reconstruction. Improvement of long-term dental function in this population suggests superiority of virtual planning techniques to previous modalities.


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