PMC9309430_01
Clinical examination revealing a significant bulge of the right mandibular: cone beam computerized tomography (CBCT) demonstrating that (A) there was a bone mineral density reducing area of nabout 4.8 cm x 4.6 cm x 4.9 cm in the right mandible from 47 to the mandibular ramus region and (B) Buccolingual bulge was obvious.
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F1
After admission, clinical examination revealed a significant bulge of the right mandible (Figure 1A). Cone beam computerized tomography (CBCT) demonstrated that there was a bone mineral density reducing area of about 4.8 cm x 4.6 cm x4.9 cm in the right mandible from 47 to the mandibular ramus region, and a buccolingual bulge was obvious (Figure 1B).
Virtual model created by computer-aided design (CAD); the osteotomy line and surgical cutting guides for the mandible were designed first (A); the model of the defect region was used to look for the most matching region in the Iliac bone model, and we found that the most matching region was on the left iliac bone. The anterior superior iliac spine would be used to reconstruct the angle of the mandible, the iliac crest would be used to reconstruct the posterior border of the mandible ramus, and the anterior border of the iliac wing would be used to reconstruct the inferior border of the mandible; the natural curvature of left Iliac bone could complement the curve of the mandible perfectly and can be placed accordingly to fill the defect (B); then, the virtual iliac bone graft model was obtained (C), which was used to design the bone graft cutting guide (D), shaping guide (E), and fixation guide (F).
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F2
The osteotomy line and surgical cutting guide for the mandible were designed first (Figure 2A). The anterior superior iliac spine could be used to reconstruct the angle of the mandible, the iliac crest would be used to reconstruct the posterior border of the mandible ramus, and the anterior border of the iliac wing would be used to reconstruct the inferior border of mandible; the natural curvature of left iliac bone could complement the curve of the mandible perfectly and can be placed accordingly to fill the defect (Figure 2B). Then, we obtained the virtual iliac bone graft model (Figure 2C), which was used to design the bone graft cutting guide (Figure 2D), shaping guide (Figure 2E), and fixation guide (Figure 2F).
All models and guides were printed on a three-dimensional (3D) printer: original mandible model and cutting guide (A); iliac model and cutting guide (B); shaping guide (C); and reconstructed mandible model and fixation guide (D).
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F3
All the models and guides were printed by a three-dimensional (3D) printer (Figures 3A-D).
According to the surgical cutting guide, the right mandible from 47 to the condylar neck was resected (A,B); and the vascularized iliac flap was harvested and prepared (C-E). The prepared vascularized iliac flap was fixed to the mandible to reconstruct the mandible defect by a titanium plate according to the fixation guide, and the deep circumflex iliac artery (DICA) and the deep circumflex iliac vein (DICV) were anastomosed with facial artery and external jugular vein; the arrow shows that the vessel pedicle was in a line when the iliac bone flap was transferred to the mandible defect area (F).
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F4
According to the preoperative planning and the surgical cutting guide, the right mandible from 47 to the condylar neck was resected (Figures 4A,B), and the vascularized iliac flap was harvested and prepared (Figures 4C-E). Additionally, the deep circumflex iliac artery (DICA) and the deep circumflex iliac vein (DICV) were anastomosed with the facial artery and external jugular vein, respectively (Figure 4F).
Postoperative anterior view showing that the mandible is symmetrical for 3 months after operation (A); postoperative CBCT demonstrating that both the shape of the mandible and the height and width of the alveolar crest are satisfactory (B). L stands for the left side, R stands for the right side, both sides are ruler.
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F5
The postoperative anterior view showed that the mandible is symmetrical (Figure 5A). Postoperative CBCT demonstrated that the grafted iliac bone matched the shape of the mandible satisfactorily (Figure 5B).
Lateral views showing that the facial incision healed well: (A-C) postoperative, 1 week, and 7 years after operation; postoperative function and facial appearance recovered well (D,E).
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F6
The patient was satisfied with the function, facial appearance, and local scar recovery after the operation (Figure 6).