Review
Advances in oncologic head and neck reconstruction: Systematic review and future considerations of virtual surgical planning and computer aided design/computer aided modeling

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Summary

Background

Mastery of craniomaxillofacial reconstruction has been traditionally considered to be learning curve dependent, often with inconsistent results during the skill acquisition phase. Until recently, the overall success in bony oncologic reconstruction of the craniomaxillofacial skeleton has relied mainly on the use of 2D imaging modalities, as well as surgical trial-and-error. Virtual surgical planning (VSP) and computer aided design (CAD)/computer aided modeling (CAM) are gaining traction in oncologic applications and offers opportunity for increased accuracy, improved efficiency, and enhanced outcomes. Its role in oncologic head and neck reconstruction has not been formally evaluated.

Methods

A systematic review of the current literature was conducted by three independent reviewers. Three separate search schemes were utilized to identify cases incorporating VSP-CAD/CAM technology in head and neck reconstruction for an oncologic indication. Inclusion and exclusion criteria were applied; articles that met criteria were evaluated for cohort demographics, osteocutaneous flap type and usage, oncologic indication, recipient bone reconstructed, flap survival, follow up, VSP technology usage, specific reported benefits of the technology, and qualitative and quantitative outcome assessments.

Results

The systematic literature review yielded 87 articles; of these, 33 met inclusion criteria describing a total of 220 cases of oncologic head and neck reconstruction incorporating virtual planning technology. Numerous qualitative benefits of VSP were reported including increased accuracy of the reconstruction (93%), decreased intraoperative time (80%), and ease of use (24%) among others. However, quantitative results using survey data or preoperative/postoperative CT scan comparisons were given for only 33% (3%, 30% respectively) of cases.

Conclusion

VSP represents an evolving technology that ushers oncological craniomaxillofacial reconstruction into a modern era that holds potential to advance the field with increased reconstructive accuracy, expedition of the surgical phase, and improved outcomes. While qualitative improvements from the technology are delineated, specific quantifiable benefits and cost-benefit analysis are limited and need to be further investigated.

Introduction

Virtual surgical planning (VSP) in the area of reconstructive surgery is a new technology that is gaining acceptance due to its many perceived benefits including increased accuracy, improved operative efficiency and enhanced outcomes.1, 2 A number of authors have described using VSP in craniofacial reconstruction, with indications ranging from trauma to oncologic reconstruction.1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36 Refinements in the use of computer aided design (CAD) and computer aided modeling (CAM) for preoperative planning now offers a more facile user interface lending itself to greater draw and adoption in reconstructive applications requiring precise planning and execution.1, 6, 24, 26 In particular, VSP has gained traction for use in reconstruction of the mandible and maxilla, as surgical accuracy is required to restore facial symmetry, appearance, and function; a task complicated by the irregular, unique shapes of the maxillo-mandibular construct and the relative lack of similarly-shaped graft donor sites.11 VSP is an exciting new technology that warrants consideration for use in complex oncologic osseous head and neck reconstruction.

Multi-stage implementation of virtual surgical planning with use of cutting guides, stereolithographic models and pre-fabricated plates offers reconstructive accuracy previously reliant on surgeon experience and intraoperative trial-and-error using 2D imaging modalities. Cited reconstructive benefits of CAD/CAM implementation include increased bone-to-bone contact, better dental alignment, improved esthetic contour, and reduced complication rates.11, 37 As an increasing number of authors are reporting on VSP in oncologic craniomaxillofacial surgery, we sought to investigate the benefits of the technology by performing a systematic review of the literature to identify usage and assess advantages for an oncologic indication. Additionally, to determine the utility of VSP in reconstruction of the head and neck, a comparison of surgical outcomes against those of conventional craniomaxillofacial surgery will be included. This is the first and only systematic review-to-date regarding the utility of virtual surgical planning in oncologic head and neck reconstruction, with a focus on reconstruction of the maxilla and mandible. We will also present sample cases highlighting our experience with VSP in head and neck reconstruction.

Section snippets

Surgical technique

Computer assisted craniomaxillofacial surgery is based on four specific, well-described phases, which are all necessary in order to achieve predictable outcomes: planning, modeling, surgery, and evaluation.3, 17 These steps are detailed as follows:

The first phase, planning, beings with a high-resolution computed tomographic (CT) scan with thin cuts of the craniofacial skeleton and the possible donor sites, (e.g. lower extremities) if considered necessary. A 3D reconstruction of the CT images is

Case 1

A 23 year-old man presented with left lower jaw swelling and after subsequent workup was found to have an ameloblastoma of the left mandible. VSP aided in reconstructive planning given challenges arising from the significant extent of the lesion beyond the normal borders of the mandible, distorting facial contour and symmetry and impairing the ability to bend a reconstructive plate in-situ onto the native mandible. CAM facilitated creation of a stereolithographic model of the reconstruction,

Methods

A systematic review of the current literature was conducted using PubMed and Cochrane Reviews by three independent reviewers. The search terms used were: “computer assisted design”, “reconstruction”, “flap”, “craniomaxillofacial surgery”, “virtual design”, “reconstructive surgery”, and “oncologic”. Three separate search schemes were utilized, providing a total of 82 articles. (Figure 7) Inclusion and exclusion criteria were then applied to the search results as outlined. Additional articles

Results

The systematic literature review yielded 82 articles, and of these, 33 met inclusion criteria. These articles described a total of 220 cases of oncologic head and neck reconstruction incorporating virtual planning technology, of which the majority were for mandibular reconstructions (193 cases, 88%) and the remaining were for maxillary reconstructions (22 cases, 10%). The patients in the series ranged from 13 to 84 years old (average 48 years old) and follow up ranged from 3 weeks to 7 years

Discussion

Virtual surgical planning is an exciting new technology that warrants consideration for complex craniofacial reconstruction, with potential to transform the approach and execution of challenging oncologic head and neck reconstructions.26 Traditional methods of reconstruction typically rely on intraoperative trial-and-error and accumulated surgeon experience, and may engender constraints in achieving consistent, predictable orthognathic and esthetic outcomes.2 Among the reported benefits of

Conclusion

VSP represents an evolving technology that ushers oncological craniofacial reconstruction into a modern era, holding the potential to consistently and predictably advance reconstructive outcomes, both aesthetically and functionally. Implementation of VSP-CAD/CAM into each stage of the reconstruction affords the opportunity to reduce human translational error and facilitates intraoperative decision-making with expedition of the surgical phase. While there are emerging qualitative improvements

Ethical approval

Approval was granted by the University of Illinois Institutional Reveiw Board for the case reports.

Funding

None.

Conflicts/disclosures

The authors have no relevant financial disclosures.

Conflict of interest

None.

References (40)

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