Case 1
A 57-year-old female was diagnosed with ameloblastoma in the mandible on the right side. A radiolucent lesion of the right mandible was observed on a panoramic radiograph (Fig. 1a) and a computed tomography (CT) image (Fig. 1b, c), and segmental resection of the mandible without the surrounding soft tissue was scheduled.
As the first step, a three-dimensional (3D) model of the mandible was created by a 3D printer using DICOM data of CT. The extent of segmental resection with an approximately 10-mm safety margin was determined, and the resection lines were marked on the 3D model (Fig. 2a, b). Next, a surgical guide made from an autopolymer resin was prepared to control the position and direction of osteotomy. The autopolymer resin in a soft state was pressed against the lower border of the mandible and buccal and lingual sides of the 3D model. After hardening, it was shaved with a carbide bar to make the proximal and distal parts parallel to the resected surface in order to determine the direction of mandibular resection (Fig. 2c, d). Then, a titanium reconstruction plate was bent to conform closely to the form of the 3D model.
Segmental mandibular resection was performed via submandibular approach. The periosteum was separated from the bone, and the surgical device was attached (Fig. 3a). The osteotomy was performed only on the proximal and distal buccal cortical bone using a sagittal saw along the proximal and distal edges of the device (Fig. 3b). After that, the pre-bent titanium reconstruction plate was provisionally fixed to the mandible (Fig. 3c). After detaching the titanium reconstruction plate, the device was reinstalled again and segmental resection of the mandible was completely performed (Fig. 3d). The titanium reconstruction plate was fixed at the previous temporarily fixed position, and free iliac bone was transplanted (Fig. 3e). Both the occlusion and position of condylar heads in the temporomandibular fossae could be restored to the preoperative position (Fig. 4).
Case 2
The patient was a 61-year-old female who had recurrent lower gingival squamous cell carcinoma in the right side of the mandible (Fig. 5). Segmental resection of the mandible including the surrounding soft tissue with a 10-mm safety margin was scheduled.
Surgical simulation and preparation of the surgical device were performed using a 3D model. First, the right and left mandibular rami of the 3D model were connected by the autopolymer resin to keep the preoperative position between the proximal and distal segments (Fig. 6a). Based on the findings in a CT image, segmental resection was performed on the 3D model with a safety margin of at least 10 mm from the tumor (Fig. 6b). Since it was necessary to extensively resect not only the mandibular bone but also the soft tissue surrounding the mandible, it was impossible to provisionally fix the reconstruction plate on the mandible before mandibular resection. Therefore, a surgical device that not only guides the direction of bone cutting but also restores the preoperative condylar head positioning in the temporomandibular fossa was needed. The device was made to fit the lower border of the anterior mandible and the posterior border of the mandibular ramus. The surgical device to guide the direction of mandibular resection had a U-shaped handle so that adaptation of the device would not interfere with the soft tissue to be removed and had holes to be fixed on the mandible with screws (Fig. 6c). A titanium reconstruction plate was bent so as to be inside at the area of resection in the 3D model.
Segmental mandibular resection was performed via a submandibular approach. The surgical device was fixed on the mandible with two screws each at the proximal segment and distal segment (Fig. 7a). The mandibular resection was performed along the proximal and distal edges of the device fixed to the mandible (Fig. 7b). After the pre-bent titanium reconstruction plate had been fixed on the proximal and distal segments with screws, the screws used to fix the surgical device were removed (Fig. 7c). A panoramic radiograph showed that the mandible had been successfully reconstructed with the reconstruction plate since the preoperative relation between the proximal and distal segments and the position of the condylar heads in the temporomandibular fossae were maintained (Fig. 8).
