Utility of Custom Plates in Bimaxillary Orthognathic Surgery: For the Mandible, Stick With Tradition
Victory C. Eze, BS1, Nia E. R. James, BA1, Karina Charipova, MD2, Paige K. Dekker, BA3, Salma A. Abdou, MD2, Christopher M. Fleury, MD2, Stephen B. Baker, MD, DDS2
1Howard University College of Medicine, Washington, DC, 2Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC, 3Georgetown University School of Medicine, Washington, DC
Background: Virtual surgical planning (VSP) optimizes the accuracy, precision, and efficiency of craniomaxillofacial reconstruction. This study aims to determine whether the use of customized surgical guides with fixation plates alongside VSP improves surgical accuracy and efficiency while eliminating the need for maxillomandibular fixation (MMF) with intermediate splints.
Methods: Surgical plans from 3D Systems (Littleton, CO) for all patients undergoing orthognathic surgery using VSP and custom plates by the senior author between December 2019 and February 2021 were retrospectively reviewed. Data collected included operative details and required corrections specified by VSP including midline/cant correction, maxillary segmentation, and occlusal equilibration. Intraoperative technique modifications, the success rate of splintless surgery, and postoperative complications were documented.
Results: A total of 15 patients (8 female, 7 male) with mean age 21.8±5.7 years underwent bimaxillary orthognathic surgery (8 maxilla-first, 7 mandible-first) using custom plates. Of the maxillary osteotomies, 14 were single-piece and 1 was multi-piece. A total of 8 genioplasties were performed. Modifications in technique were made to accommodate the use of cutting guides: (1) a periosteal release was employed in the mandibular incision to facilitate lateral retraction for access for plating, (2) the vertical cut of the bilateral sagittal split osteotomy (BSSO) was made more anteriorly; and (3) ultrasonic saws were used to reduce fragmentation of the anterior maxilla. Four patients successfully underwent splintless surgery; accuracy of the custom maxillary plate was confirmed using intermediate and final splints for all patients. In 4 patients inaccuracy of the custom mandibular plate necessitated traditional plating. While time required for application of maxillary plates was consistently less than that of traditional maxillary fixation, application time for custom mandibular plates exceeded traditional plating time in all cases. The last 7 cases were performed using a custom maxillary plate and traditional, non-custom mandibular plating. Two patients required custom mandibular plate removal within 6 months of surgery.
Conclusions: Our early experience using custom plates in orthognathic surgery and the technique modifications required to incorporate this new technology into practice are described. While maxillary custom plates are accurate and efficient, the additional time and inaccuracy in our experience with custom mandibular plate application do not justify their routine use. While we acknowledge that the technology continues to improve, our practice currently uses maxillary custom plates but plates the mandible with conventional plate fixation. We recommend the above modifications in technique are employed to ease the application of all custom plates.
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