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away the periosteum. After further exposure of the mandible is completed, the prefabricated cutting guide is
fixated to the exposed mandible with screws, and the predictive holes drilled. Finally, the mandible is cut
and resected along the predictive cutting lines with a reciprocating saw. If applicable - care should be taken
to protect the inferior alveolar nerve and the lingual soft tissue. In certain instances, it is necessary to
separate the temporalis tendon from the coronoid process to fully free the specimen. Once the resected
mandible has cleared the field, spot hemostasis can be achieved with electrocautery to prep the field for the
microvascular anastomosis. Alternatively, an intra oral approach with occlusal based guides can be chosen.

While the ablative team carries out the mandibulectomy, the reconstructive team harvests the fibular flap:
The surgeon draws a line from the head of the fibular to the lateral malleolus and incises and dissects down
to the fascia of the peroneal muscles. Upon encountering the lateral compartment musculature, dissect it off
the fibula from distal to proximal, and then enter the anterior compartment and dissect down to the
interosseus membrane, dividing it with electrocautery. This allows enough visibility to make the
osteotomies, leaving 7 cm both distally and proximally to preserve ankle stability and protect the common
peroneal nerve respectively. The fibula is then distracted by dissection through the deep posterior muscle
compartment, and the peroneal vessels are traced to their origins and transected. Then the surgeon secures
the custom cutting guide 7 cm from the lateral malleolus on the fibular graft and drills the respective
predictive holes.

The OMS now uses the selected implant system to carefully complete guided successive osteotomies
required for the pre-planned and selected implant sizes according to appropriate manufacture guidelines.
Once the DIs have been placed, the fibula osteotomies are completed to create the necessary fibular
segments that are then affixed to the custom reconstruction plate to orient the flap into the shape of the
reconstructed jaw. At this time, the prosthodontist selects and places appropriate IAs onto the DIs which
come in various heights and angle degrees (as described earlier) to correct for skew and create a path of
draw for the provisional dental prosthesis. This part is critical, technique sensitive and cumbersome.

After insertion of all the IAs, the prosthodontist secures the provisional abutments to each IA and lutes the
provisional prosthesis to the provisional abutments with dual cure composite resin, using a dental dam to
maintain a clean surgical field. The prosthodontist utilizes the model of the patient’s skull to ensure proper
occlusion and delivery of the prosthesis. Once this is verified, the prosthesis is removed and polished for
delivery.

The reconstructive surgeon now moves to the head and neck region and completes preparation of the
vessels, typically the facial artery and vein for microvascular anastomosis. The fibular pedicle is divided, and
the flap is brought to the head and neck region. The graft is then plated to the native mandible with the
custom reconstruction plate. Then microvascular anastomosis is performed with 9-0 Nylon for the artery
and venous coupler for venous anastomoses. After ensuring adequate flap reperfusion, the head and neck
wounds are closed with 3-0 Vicryl for platysma, 4-0 Vicryl for deep dermal, and a 5-0 Prolene stitch for the
skin. Intra-orally the excess gingiva is trimmed, and the prosthodontist delivers the provisional prosthesis
onto the implants and makes any necessary final adjustments. The soft tissue is sutured closed under the
prosthesis to prevent oro-cervical communication.

Post-operative care
The patient must be closely monitored for several days (typically 5-7) for adequate flap perfusion. Patients
will ambulate with physical therapy on post-operative day (POD) 1, and trial a clear liquid diet on POD 3-5.
They are discharged on POD 5-7 on a pureed diet, which can be advanced to a mechanical soft diet in 3