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Grewal et al. Plast Aesthet Res 2021;8:37 https://dx.doi.org/10.20517/2347-9264.2021.43 Page 5 of 14

Figure 2. Virtual surgical planning representation of digital provisional and occlusion. In this case, a full wax-up was not needed since
the patient had existing dentition, which was suitable and used as a reference.

Definitive prosthesis fabrication
A definitive prosthesis will be fabricated and delivered once osseointegration of the DIs and soft tissue
healing/maturation is confirmed. A definitive prosthesis can be made from zirconia or titanium
superstructure with porcelain. Hygienic design is of utmost importance.

Virtual surgical planning
In the VSP, the surgeons will collaborate and design the osteotomies to excise the disease. This plan will also
include the specific design of the cuts on the fibula. Further, the team will plan the location of the DIs to
which the dental prosthesis will be attached. The selected locations need to be appropriately spaced
throughout each fibular segment. More specifically, the locations of the DIs cannot interfere with planned
sites for fixation screws from the reconstruction plate [Figure 3]. It is imperative to ensure the height and
width of the fibula can accommodate the implant without fenestration for optimal placement. Ideally, there
should be at least 1-2 mm of surrounding bone on either side of the fixture. The sizes of DIs vary between
manufactures, but in general range from 3-6 mm in width and 6-16 mm in length. DIs are cylindrical in
nature and can be parallel or tapered requiring the shape of the fibula triangle (in cross section), to be
rotated such that a broad flat side is cephalad to accommodate the width of the implants.

The surgeons and prosthodontist work backwards from where the proper occlusion of the reconstructed
jaw needs to be. For example, if the plan is to resect a portion of the right mandible, then the teeth for that
segment will be designed (and limited) to appropriately function against the opposing maxillary dentition.
Based on the entire surgical simulation using an extensive VSP, maxillary or mandibular and fibular cutting
guides, a titanium reconstruction plate, as well as a surgical guide for the DIs are manufactured uniquely for
the patient’s surgery.

Surgical workflow
Instrumentation and equipment
The VSP session, as described above, provide the maxillomandibular and fibula cutting guides and direct
the creation of the provisional dental prosthesis. A dental implant system chosen by the OMS and
prosthodontist will be required and used to prepare the osteotomies for the DIs that will support the
provisional and definitive prostheses. The DI drills follow a protocol of three to five successively larger drills
starting from 2.0 mm up to 5.0 mm at a speed of 600-1200 rpm (per manufacture guidelines). Copious
irrigation throughout this sequence is critical to prevent overheating of the fibula, local necrosis and failure
of DI osseointegration. The fibula cutting guides can be designed to include a surgical guide for DI