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VSP for maxillofacial bony reconstruction is often done in conjunction with imag­ing of related soft tissue structures to obtain adequate coverage of the ablative defect. With respect to soft tissue reconstruction, head and neck surgeons predomi­nantly choose between two approaches: pedicled aps and free aps. The bula and radial forearm regions are among the most common osteomusculocutaneous free ap donor sites to be harvested with a skin island [12]. Adequate perfusion of the tissue is necessary for these aps to be viable. Indeed, perfusion to the donor region should be assessed preoperatively, with methods depending on the chosen site. For example, CT-angiography can be used to conrm the presence of three-vessel run­off in the lower leg for bula free aps. Upon visualizing the perforators from the peroneal artery, bula osteotomies can be planned to obtain a long pedicle and reli­able cutaneous portion [13].

Most procedures in oral and maxillofacial surgery involving bony reconstruction require CT imaging. An image slice thickness of 1mm is an acceptable compromise between high resolution and minimal radiation exposure for the patient [15].

opportunities for error and inaccuracies [18]. Combining different imaging modali­ties and intraoral laser scanning (IOS) for virtual surgical planning has replaced the traditional orthognathic workup and need for dental impressions, and face bow measurements with the added benet of reduced inaccuracies and costs [6, 18]. Jones and colleagues [6] found that the use of patient-specic cutting guides and implants constructed with VSP provide more accurate maxillary repositioning dur­ing bimaxillary surgery than the use of an interim splint constructed by traditional methods. Resnick and colleagues [19] further examined operative time and cost of bimaxillary surgeries of 43 patients to show that operative time and costs were sig­nicantly higher in all the patients with conventional orthognathic workup com­pared with VSP surgeries. These ndings are signicant because prolonged operative time is closely correlated with increased postoperative complications [20]. VSP has made orthognathic surgeries more accurate and efcient when com­pared to conventional surgical planning [21, 22]. A standard orthognathic VSP workow is outlined in Fig.10.2.

Clinically, the margins for surgical resection of lesions can be difcult to discern, such as in osteoradionecrosis (ORN). In these patients, dosimetry-guided VSP has emerged as a new technique that can be used to plan optimal osteotomies, with the goal of obtaining healthy native bone margins. By superimposing previously deliv­ered radiotherapy dosimetry data onto the corresponding virtual mandible, Jenkins and colleagues [24] have been able to use IPS® planning software (KLS Martin IPS Service UK Ltd) to integrate a radiation “heat-map” of the affected mandible with CT data to redene the necessary margins. This additional planning stage is impor­tant where the mandible has received >60Gy of radiation, placing the native bone at higher risk of ORN [25].

with dental laboratories, which resulted in unavoidable delays and patient dissatis­faction. Hutchison and Dawood rst performed immediate loading of dental implants placed in reconstructed microvascular scapula ap in 2007 [35]. This has further evolved to in-house creation of 3D printed dental prosthesis, which has been described and popularized recently with the advent of point-of-care three­dimensional (3D) printing. The in-house 3D printed prosthesis required a shorter time to be constructed, and the cost of fabrication was less compared to laboratory­fabricated prostheses [36]. Case selection is very important to predict the soft-tissue needs for composite defects. VSP revolutionized osteocutaneous vascularized free ap planning in terms of ideal positioning in the maxillofacial skeleton and taking into account the occlusal relationships which subsequently can be used for ideal position of dental implants using the same cutting guides. The digital data required for planning immediate dental implants on bula include: CBCT, CT scan of the bula with 1mm cuts, and digital model of the existing teeth, which can be obtained by intraoral scanner, optical dental scan, or CBCT of polyvinyl siloxane impression. The digital data is then processed and used by commercially available planning software to plan the immediate prosthesis. The plan is then executed and used to 3D print the nal prosthesis using a commercially available 3D printer. Other supplies such as alcohol bath and curing ovens are also required for post-printing processing and nalization of the restoration. The concept of jaw in a day is combining multi­ple advances in planning, accuracy, and the ability to fabricate prosthesis to be avail­able on the day of surgery [37] (Fig.10.8).