Recent advances in virtual surgical planning in maxillomandibular reconstruction

Abstract

Innovations in microvascular free flap reconstruction of the maxilla and mandible aim to improve accuracy and functional outcomes. However, heterogeneity in accuracy analysis and the unclear clinical relevance of increased accuracy limit meaningful evaluation of these advancements, including virtual surgical planning (VSP), adjunctive procedures and new surgical techniques including zygomatic implant perforated (ZIP) flaps. This thesis explores accuracy measurement in VSP jaw reconstruction to assess recent advances and ascertain their impact on aesthetics, function and health-related quality of life (HRQOL).

A literature review including 28 studies with 889 patients demonstrated diverse accuracy measures by comparator (digital plan, preoperative imaging or mirror contralateral side), and quantitative measures (distance, angle, global measures), limiting interpretation and comparison between studies.

Adjunctive procedures, including autologous fat grafting and surgical debulking, can optimise facial contour post-reconstruction, as demonstrated in 2 cases with objective improvements in facial contour and HRQOL.

A cohort study (n=22) examined bone and soft tissue accuracy as a predictor of HRQOL. While soft tissue accuracy was associated with better function and HRQOL, bone accuracy was associated with worse eating and drinking, oral competence and eating distress in mandibular reconstructions, suggesting prioritising dental rehabilitation could compromise aesthetics.

A case-control study (n=20) assessed the new ZIP flap technique, compared to VSP fibula free flap maxillary reconstruction, finding no significant difference in facial contour or HRQOL between groups.

This thesis provides insights into how advances in technology and surgical techniques can expand reconstruction options. Further studies with standardised accuracy measures, are required to clarify the link between accuracy and aesthetic, functional and HRQOL outcomes for the optimal jaw reconstruction.