Reconstruction of a maxillary defect with a fibula graft and titanium mesh using CAD/CAM techniques.

A 25-year-old female was introduced to our department seeking reconstruction of her left maxilla. At the age of 17, an ossifying cementoblastoma was diagnosed, and the patient underwent hemimaxillectomy. The orbital floor next to the maxilla had also been removed, which resulted in an enophthalmus and a collapsed cheek. The open connection between the nasal and oral cavities was treated with a removable prosthesis. The patient complained about the prosthesis size and its heaviness, which made chewing difficult and gave the speech a nasal tone. According to the patient, this was a massive reduction of her quality of life. To reduce the defect and to reconstruct the processus alveolaris, a microvascular fibula flap was selected for transfer. An individually premolded titanium mesh was used to reconstruct the floor of the eye. "Backward" planning was used to find the best position of the bony part. The position of the mandibula was predefined as the ideal position for the implants, which then predefined the ideal position for the transferred bone (Figure 1). A computertomography (CT) scan of both legs was performed, and the necessary bony shape was virtually matched with the patient's left fibula (Figure 2). To achieve the desired lengths and angles at the fibula's resection and split sites, a rapid prototyped template (figure 3) was manufactured by Materialize^© (Leuven, Belgium). To reconstruct the orbital floor, the intact site of the skull was mirrored, and the missing bony part was identified (figure 4). Both parts were produced with rapid prototyping by IDEE^© (Instrument Development Engineering & Evaluation, Maastricht University, Maastricht, The Netherlands). The complete skull was then used to premold a titanium mesh, which was sterilized before surgery.

During the operation, the incision made previously was used to open the site. As planned, the fibula and the individualized titanium mesh were placed in the sites selected preoperatively. Both were fixed with osteosynthesis screws of 2.0 diameter (KLS Martin Tuttlingen, Germany). The fibula was reanastomized to the vena jugularis interna and the arteria carotis externa. Wound healing was uneventful for the following three weeks. A CT scan obtained two days postoperatively demonstrated the accuracy of the fibula insertion (figure 1, 5). The removal of the osteosynthesis material and the placement of dental implants will be performed six months after the operation.