Digitally Guided Intraoral Segmental Mandibulectomy and Fibula Flap Reconstruction for Locally Invasive Odontogenic Tumors

Summary

This protocol demonstrates a reproducible digitally guided workflow for intraoral segmental mandibulectomy and mandibular reconstruction using a free vascularized fibula flap. The method integrates virtual surgical planning with patient-specific guides to achieve precise tumor resection and scar-free reconstruction.

Abstract

Radical treatment of ameloblastoma and other benign locally invasive odontogenic tumors frequently requires mandibular segmentectomy followed by functional reconstruction. Conventional reconstruction is typically performed through an extraoral approach to obtain sufficient exposure; however, this technique often results in visible facial scarring, extensive soft-tissue dissection, and potential injury to the marginal mandibular branch of the facial nerve. This protocol describes a reproducible digitally guided workflow for mandibular segmental resection and reconstruction using a free vascularized fibula flap performed entirely through an intraoral approach. Preoperative imaging data are imported into virtual surgical planning software to construct three-dimensional models of the mandible and fibula. Resection margins and fibular osteotomies are simulated digitally, enabling the fabrication of patient-specific osteotomy guides and pre-shaped reconstruction plates. During surgery, the mandibular tumor is exposed and resected via a strictly intraoral incision with the assistance of the customized cutting guide. Simultaneously, a second surgical team harvests and shapes the fibula flap according to the digital plan. The fibular segments are then transferred to the mandibular defect, and microvascular anastomosis is performed through a minimally invasive buccal window, restoring vascular supply and mandibular continuity without external incisions. This technique is particularly suitable for patients with benign or locally aggressive mandibular tumors who prioritize scar-free reconstruction. However, it is not recommended for cases with severe trismus, extensive soft-tissue invasion, or those requiring cervical lymph node dissection. Overall, the protocol provides a reproducible framework for integrating digital surgical planning with minimally invasive intraoral mandibular reconstruction.

Introduction

Benign odontogenic tumors with local invasions usually require mandibular segmentectomy for radical resection^1,2. Successful postoperative reconstruction is crucial for restoring mandibular continuity, facial symmetry, occlusal and chewing functions, and speech functions³. The vascularized free fibular flap is regarded as the "gold standard" for mandibular reconstruction due to its reliable blood supply, sufficient bone mass, and few donor-site complications⁴.

Traditional mandibular reconstruction primarily uses an extraoral ap....

Protocol

This research is approved by the institutional Ethics Board of West China Hospital of Stomatology (protocol approval number: WCHSIRB-D-2022-343). Written informed consent was obtained from the patient. All the materials, softwares or tools used for this study are listed in the Table of Materials.

1. Virtual surgical planning (VSP) and guide design

1. Obtain high-resolution maxillofacial computed tomography (CT) scans with a slice thickness of ≤ 1 mm to evaluate tumor extent and mandibular anatomy accurately.
2. Acquire CT Angiography (CTA) of the lower extremities to assess fibular vas....

Results

The digitally guided intraoral workflow described in this protocol has been successfully performed in 5 patients. While this sample size precludes statistical analysis of long-term outcomes, it is strictly sufficient to demonstrate the technical feasibility and reproducibility of this surgical protocol. The representative case presented herein highlights the standard execution of this procedure. The digitally guided intraoral segmental mandibulectomy and free fibula flap reconstruction were completed without intraoperati.......

Discussion

This protocol outlines a digitally guided workflow for the entire mandibular segmentectomy and free fibular flap reconstruction via a strictly intraoral approach. By integrating virtual surgical planning (VSP) with patient-specific osteotomy guides, this method enables precise tumor resection and functional mandibular reconstruction within the constraints of the intraoral surgical field, while avoiding facial incisions.

Several technical steps are critical for the success of this procedure. Ac.......

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
3-0 antibaterial vicryl absorbable suture	Johnson (Suzhou) Medical Devices Co., Ltd.	VCP1772D	For tissue suturing
8-0 Polypropylene Non-Absorbable Suture	Ethicon,LLC	W2777	For microvascular anastomosis
DSRobot 4K-Station	Digital Vision	-	Surgery video recording
High-Frequency Electrosurgical Unit	Guangdong Baisheng Medical Equipment Co., Ltd.	OBS-350A	Precise tissue cutting and coagulation
Matrix Mandible Reconstruction Plate	Synthes GmbH	04.503.732	Secure the fibular
Matrix Mandible Screw	Synthes GmbH	04.503.440.01C	Secure the fibular
Microvascular Anastomosis Device	Huarong Kechuang Biotechnology Co., Ltd.	KC3500	For microvascular anastomosis
Materialise Mimics software	Materialise	-	For virtual surgical planning
Operating microscope	Zumax	OMS3200Pro	For microvascular anastomosis
Powered Maxillofacial Surgery System	Crown Eagle	DSQ-3L ZD3	For osteotomy
Ultrasonic cutting and hemostasis system	Tianjin Ruiqi Surgical Instrument Company	CSUS6000	For cutting and hemostasis