Background

A hemimaxillectomy or total maxillectomy causes complex defects in the maxilla, the zygomatic bone, palate, orbital floor, maxillary sinus, alveolar bone and gingiva. These defects can have severe functional and cosmetic consequences. The main aims of reconstructing complex midfacial defects should be: (1) to recreate facial aesthetic appearance and symmetry; (2) to recreate and improve mastication; and (3) to obliterate any communication between the orbit, oral cavity and nasopharynx. Defects have traditionally been managed using a large dental obturative prosthesis, which can be an excellent and definitive treatment for some patients. However for the patient in the present case, the prosthesis was unsatisfactory due to reduced masticatory function, poor aesthetic appearance and poor oral hygiene.

Bone from numerous osseous donor sites, such as the scapula, radius, iliac crest, rib and fibula, has been used for reconstruction of maxillary defects. The free vascularised fibula flap has become the most popular because of its length and acceptance of dental implants.1–6

The use of virtual planning and rapid prototyping is increasingly popular in reconstructive surgery,7 particularly in complex anatomical reconstructions. Rapid prototyping facilitates the manufacture of three-dimensional (3D) models and templates that allow the surgeon to plan the procedure before surgery, thereby closing the gap between preoperative planning and execution.8 ,9

This article describes the case of a 15-year-old girl in whom maxillary reconstructive surgery was performed using virtual planning, rapid prototyping, a free fibula graft and dental implants.

Case presentation

A 15-year-old girl was referred to the Department of Plastic and Reconstructive Surgery and the Department of Oral and Maxillofacial Surgery, Odense University Hospital, Denmark, in 2011 for reconstructive surgery of her right maxilla (figure 1A). In 2007, at the age of 11 the patient had been diagnosed with a large arteriovenous malformation in her right maxilla and had undergone hemimaxillectomy at the Royal Liverpool Children's Hospital NHS Trust, UK. The orbital floor was reconstructed in the same procedure with a calvarial bone graft. The intraoral defect was treated with a removable obturative prosthesis (figure 2A). The patient's main complaints were related to the function and appearance of the prosthesis because of reduced masticatory function and poor oral hygiene. This resulted in a reduced quality of life for the patient.

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Figure 1

(A) Three-dimensional CT reconstruction visualising the large defect of the right maxilla. (B) Stereo-lithography model with the surgical template for the fibula osteotomies and guided dental implant placement.

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Figure 2

(A) Presurgical obturator prosthesis. (B,C) Oral rehabilitation was carried out using an implant-retained fixed dental prosthesis on three dental implants and coupled to tooth 21 and tooth 22. (D) Facial appearance 12 months after surgery.

Treatment

An osseomyocutaneous fibula free flap was planned on the basis of CT of the head and of both legs. A stereo-lithography (SLA) model was constructed in order to visualise the large defect of the right maxilla and to plan the length and osteotomies of the fibula (figure 1B). A reconstruction plate was made based on the SLA model. The right fibula was found to be the best match for the planned reconstruction. Backward planning was used identify the best position for the free fibula graft: the mandible predefined the ideal position of the implants, which indicated the ideal position of the free fibula graft.

Before surgery, a rapid prototyped template was manufactured (1) to help determine the planned lengths and angles of the fibula osteotomies and (2) to guide the insertion of four dental implants (NobelActive) which were placed in the free fibula graft prior to resection and the planned osteotomies. In addition, a Medpor premanufactured infraorbital implant was planned for insertion to compensate for the patient’s infraorbital and zygomatic bony deficiency.

The modified Weber-Ferguson incision was employed during facial surgery. The standard lateral approach as originally described by Gilbert10 was used on the right fibula. One sufficiently sized perforator perfusing a skin flap was identified and dissected.

The surgical template was fixed to the fibula using osteosynthesis screws after which the dental implants were inserted. One of the planned implants was abandoned because it was too close to the skin perforator. Finally, the angled osteotomies of the fibula were carried out (figure 3A,B).

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Figure 3

(A) Placement of dental implants using the surgical template. (B) Fibula osteotomies guided by the surgical template.

The osseomyocutaneous flap was fixed to the premanufactured reconstruction plate and placed in the exact preplanned position at the recipient site and fixed with osteosynthesis screws (figure 4A). The Medpor implant was fixed with two osteosynthesis screws. A vascular pedicle length of 6.5 cm was insufficient to reach the neck. We did not wish to use the temporal vessels as a temporoparietal flap as had been done in the initial operation because angiography showed insufficient perfusion of the temporal vessels. Therefore, a graft from the great saphenous vein was used for both the artery and the vein which were anastomosed to the facial vessels. Ischaemia time was 138 min. The flap was well perfused, and there were no postoperative problems. The entire skin flap survived completely, but a small necrosis of the scarred mucosa of the palate occurred. The fistula was treated successfully with a small buccal fat pad flap and by mobilising the skin flap.

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Figure 4

(A) Peroperative placement of the osseomyocutaneous flap fixed to the premanufactured reconstruction plate and placed in the exact preplanned position at the recipient site. (B) The virtual preplanned position of the fibula graft. (C) Postoperative cone beam CT showing the accuracy of the fibula placement in accordance with the virtually preplanned position.

Prosthodontic treatment was carried out 12 months after surgery, when a fixed dental reconstruction was carried out (figure 2B,C). Orthodontic alignment was also performed in the lower jaw to stabilise the resulting occlusion.

The result was aesthetically refined with fat grafting 10 and 16 months after surgery.

Outcome and follow-up

Transfer of the free fibula graft was successful and uneventful without necrosis, local infections or vessel thrombosis. Donor site morbidity was normal, with only a few complications following surgery. All complications resolved spontaneously over 12 months. The patient did have a small oroantral fistula, which was treated and closed at the time of abutment surgery 10 months postoperatively.

Cone beam CT was performed 1 week after surgery to determine if the fibula has been correctly placed in accordance with the virtually preplanned position (figure 4B,C).There was no evidence of late complications such as plate fracture, implant failure, or loosening of osteosynthesis screws 12 months after surgery.

Oral rehabilitation was carried 12 months postoperatively using an implant-retained fixed dental prosthesis on three dental implants which was coupled to tooth 21 and tooth 22 (figure 2B–D).