Background:
Maxillary reconstruction is challenging due to the complex anatomy of the maxilla. Virtual surgical planning (VSP) allows surgeons to pre-plan the reconstruction and generate 3D-printed cutting guides and models for intraoperative use. In the literature, VSP for maxillary reconstruction typically utilize commercial services which can be cost prohibitive, and in house solutions are challenging due to the complexity involved in cutting guide design. The authors have developed an in-house VSP platform for planning of mandibular and maxillary reconstruction surgeries. The goal of this study is to assess maxillary reconstruction with the scapular free flap utilizing this in-house VSP with a simple cutting guide design compared to a historical control cohort undergoing freehand surgery without preplanning.

Methods: Ten maxillary reconstruction cases were planned with VSP using an in-house software. Models of the reconstruction and scapular resection were 3D printed and used intraoperatively for visualization and estimation of the size and position of the flap (Figure 1). Clinical outcomes, functional outcomes as measured by the Disabilities of the Arm, Shoulder and Hand and the Oral Health Impact Profile-14 questionnaires, cephalometric measurements, and dental implantability of the VSP cohort were compared to 18 consecutive historical control cases not utilizing VSP.

Results: Patients in the VSP cohort were more likely to undergo surgeries with a two-team approach (80% vs 0%, p<0.01) and had a significantly lower tracheotomy rate (20% vs 72%, p<0.01). VSP resulted in significantly lower operating time (256 ± 69 minutes vs. 448 ± 108 minutes, p<0.01) and lower average deviation between the reconstruction and pre-operative maxillary cephalometrics, measured as a combination of variables including malar height, maxilla height, maxilla width, premaxilla height, and anterior-posterior projection (7.5±3.4 mm vs 11.7±7.6 mm, p=0.048). There was no significant difference in length of hospital stay, complication rates, dental implantability rates, or functional outcomes.

Conclusions: In house VSP with a simple cutting guide design has allowed for a two-team simultaneous oncologic resection and reconstruction harvest with improved ability to reconstruct maxillary cephalometrics. This is associated with decreased operating time, lower tracheotomy rate and potential for cost-reduction. The VSP method introduced in this study is open-source, inexpensive and can be reproduced at other centres.

Figure 1: Preoperative plan of a maxillary reconstruction case utilizing VSP (left) and corresponding postoperative model (right).