Paradigm Shift from Conventional to Virtual Surgery Using Three-dimensional Model of Fibula as Preoperative Planning and Guide Technique in Mandibular Reconstruction in Oral Carcinoma: A Prospective Multicentric Comparative Study
Authors: Roy Nilanjan , Chaterjee Pallab , Hari J P , Wadhwa Sumedha , Jaffri Haris , Kumar Satish , Rao Pankaj P 
Published: January 2025

Abstract

Background:
Mandibular reconstruction using a free fibula osseocutaneous flap is a commonly performed and well-established technique accepted worldwide, as the postoperative restoration of form and function of the oral cavity and facial features is superior compared to pedicled flaps. However, this requires precise preoperative planning, followed by execution to correctly restore the loss caused by the complex defect created after the surgical extirpation. With the incorporation of virtual surgical planning (VSP) and computer-assisted design and manufacturing (CAD/CAM) techniques in medical science, their incorporation as preoperative tools holds a lot of promise for a better surgical outcome.

Aim:
The aim of study was to assess the utility and benefits of VSP using CAD/CAM techniques over preexisting preoperative planning methods for mandibular reconstruction using a free fibular flap.

Materials and Methods:
A multicentric prospective comparative study was carried out at two tertiary care hospitals of the Armed Forces. Two-year data were collected from October 2020 to October 2022. A total of 39 consecutive cases of oral carcinoma requiring mandibular reconstruction using a free fibular flap were included in the study. Nineteen cases underwent free fibula flap reconstruction using already established preoperative planning in one center, whereas 20 cases underwent VSP as a preoperative tool in another center. The primary objectives assessed were the operative time and intraoperative blood loss in each arm. The secondary objectives assessed were the incidence of flap loss, the presence of oral incompetence postsurgery, the total hospital stay, and the presence of facial symmetry.

Results:
The total flap harvest time in the VSP group (68 min ± 13 standard deviation [SD]) was lower than that in the control group (88 min ± 14 SD), which was statistically significant (P < 0.001). There was no statistical difference in total operative time (P = 0.06), although in the VSP group, the mean was 10.6 h ± 1.5 SD as opposed to 11.5 h ± 1.6 SD in the control group. Nearly 26.3% of cases in the control group, as compared to 10.5% in the VSP group, had flap-related complications. In the early postoperative period, oral competence was achieved in 94.7% of cases (18/20) in the VSP group as opposed to 68.4% (13/19) in the conventional arm, which was statistically significant (P = 0.04). The mean overall hospital stay was higher in the VSP group (7.1 weeks ± SD) compared to the conventional group (4.4 weeks ± 0.9 SD), which was statistically significant (P < 0.001). Nearly 73.7% (14/20) of cases in the VSP group were satisfied with their facial symmetry, compared to 63.2% (12/19) in the conventional group in the postoperative rehabilitation phase. However, this was not statistically significant (P < 0.48).

Conclusions:
This index multicentric study carried out in two tertiary care hospitals of the Armed Forces Medical Services, where this emerging technology was adopted as its test arm to prove a better postoperative outcome, may have exhibited equivocal results so far, but it is encouraging results, although not proven statistically significant, hold lots of promises for the future.