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Accuracy of fibular sectioning and insertion into

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reconstruction using CAD-CAM technology
Article in Journal of Cranio-Maxillofacial Surgery October 2014
Impact Factor: 2.93 DOI: 10.1016/j.jcms.2014.10.005

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Manuscript Draft
Manuscript Number: JCMS-D-14-00462R2
Title: Accuracy of fibular sectioning, and insertion into a rapid-prototyped bone plate, for mandibular
reconstruction using CAD-CAM technology
Article Type: Original Paper
Keywords: maxillofacial prosthodontics, CAD-CAM, rapid prototyping
Corresponding Author: Prof. Leonardo Ciocca, DDS, PhD, Researcher of Max-fac Prosth.
Corresponding Author's Institution: University of Bologna
First Author: Leonardo Ciocca, DDS, PhD, Researcher of Max-fac Prosth.
Order of Authors: Leonardo Ciocca, DDS, PhD, Researcher of Max-fac Prosth.; Claudio Marchetti, Full
Professor of Maxillofacial Surgery; Simona Mazzoni, Clinical Assistant; Paolo Baldissara, Researcher;
Maria Rosaria Antonella Gatto, Researcher; Riccardo Cipriani, Chief of Plastic and reconstructive Unit;
Roberto Scotti, Full professor of Prosthodontics; Achille Tarsitano, Researcher
Abstract: Modern techniques of mandibular reconstruction, such as CAD-CAM technology and rapid
prototyping, offer new means by which reconstructive surgery can be planned to optimise aesthetic
outcomes and prosthetic rehabilitation. The high degree of accuracy afforded by these approaches is
principally attributable to high-precision fibular sectioning and insertion of the bone into a customised
bone plate. CAD-CAM mandibular reconstruction procedures using vascularised bone free-flap
transfers were performed on 10 patients with benign or malignant neoplasms. Five were not treated
with the aid of CAD-CAM technology, and served as the control group. Five were scheduled for
maxillofacial surgery using surgical cutting guides and customised bone plates. A Generalized linear
model for linear measures was used to compare the accuracy of reconstruction between the two
groups. A difference, even though not significant, in the lateral shift of the mesial and distal positions of
the fibular units was evident between groups. CAD-CAM-generated fibular surgical guides afford
improved accuracy when used to restore native anatomy, especially in the context of mandibular arch
restoration, and both operating room time and related costs are reduced during fibular sectioning.

*Title Page

Accuracy of fibular sectioning and insertion into a rapid-prototyped bone plate, for
mandibular reconstruction using CAD-CAM technology
a

Ciocca Leonardo , Marchetti Claudio Mazzoni Simona , Baldissara Paolo , Maria Rosaria Antonella Gatto, Cipriani
d
e
f
Riccardo , Scotti Roberto , Tarsitano Achille .
a

Professor of Maxillo-Facial Prosthodontics, Section of Prosthodontics, Department of Biomedical and Neuromotor Sciences, Alma Mater
Studiorum University of Bologna
Via S. Vitale 59
40125 Bologna Italy
Fax: +39 051 225208
E-mail: leonardo.ciocca@unibo.it
b

Professor of Maxillofacial Surgery, School of Medicine, Alma Mater Studiorum University of Bologna
Via S. Vitale 59
40125 Bologna Italy
Fax: +39 051 225208
E-mail: claudio.marchetti@unibo.it
c

Clinical Assistant, PhD, School of Medicine, Alma Mater Studiorum University of Bologna
Via S. Vitale 59
40125 Bologna Italy
Fax: +39 051 6363641
E-mail: simonamazzoni@libero.it
d

Chief of Plastic and reconstructive Unit, S.Orsola-Malpighi Hospital

Via Massarenti 9
40100 Bologna Italy
Fax: +39 051 6363641
E-mail: riccardo.cipriani@aosp.bo.it
e

Professor and Dean of Oral and Maxillo-Facial Rehabilitation, Section of Prosthodontics, Department of Biomedical and Neuromotor
Sciences, Alma Mater Studiorum University of Bologna
Via S. Vitale 59
40125 Bologna Italy
Fax: +39 051 225208
E-mail: roberto.scotti@unibo.it
f

Maxillofacial Surgeon, Reseacher, Maxiollofacial Surgery Unit, S.Orsola-Malpighi Hospital

Via Massarenti 9
40100 Bologna Italy
Fax: +39 051 6363641
E-mail: achilletarsitano@gmail.com
g

Aggregate Professor of Dental Materials, Section of Prosthodontics, Department of Biomedical and Neuromotor Sciences, Alma Mater
Studiorum University of Bologna
Via S. Vitale 59
40125 Bologna Italy
Fax: +39 051 225208
E-mail: paolo.baldissara@unibo.it
h

Aggregate Professor of Statistics, Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum University of Bologna
Via S. Vitale 59
40125 Bologna Italy
Fax: +39 051 225208
E-mail: mariarosaria.gatto@unibo.it
Corresponding author:
Dr. Leonardo Ciocca
Via S. Vitale 59
40125 Bologna Italy
Fax: +39 051 225208
E-mail: leonardo.ciocca@unibo.it

*Manuscript
Click here to view linked References

Accuracy of fibular sectioning and insertion into a rapid-prototyped bone plate, for
mandibular reconstruction using CAD-CAM technology

Abstract
Modern techniques of mandibular reconstruction, such as CAD-CAM technology and rapid prototyping, offer new
means by which reconstructive surgery can be planned to optimise aesthetic outcomes and prosthetic
rehabilitation. The high degree of accuracy afforded by these approaches is principally attributable to highprecision fibular sectioning and insertion of the bone into a customised bone plate. CAD-CAM mandibular
reconstruction procedures using vascularised bone free-flap transfers were performed on 10 patients with
benign or malignant neoplasms. Five were not treated with the aid of CAD-CAM technology, and served as the
control group. Five were scheduled for maxillofacial surgery using surgical cutting guides and customised bone
plates. Students t-test was used to compare the accuracy of reconstruction between the two groups. A
statistically significant difference in the lateral shift of the mesial positions of the fibular units was evident
between groups (p = 0.013) and, even though without significant difference, this was also true of the distal
positions of the fibular units (p =0.132). CAD-CAM-generated fibular surgical guides afford improved accuracy
when used to restore native anatomy, especially in the context of mandibular arch restoration, and both
operating room time and related costs are reduced during fibular sectioning.

Keywords: maxillofacial prosthodontics, CAD-CAM, rapid prototyping

Introduction
Free flaps are considered the gold standard for reconstruction of tissues lost during oncological surgery. A high
success rate is combined with low donor site morbidity. Currently, microvascular free-flap reconstruction using
bone transfer is the best choice for mandibular reconstruction (Bak et al., 2010). The use of bone microvascular
tissue allows the surgeon to address the aesthetic and functional aspects of mandibular reconstruction, because
a wide range of donor sites is available (Urken et al., 1998; Hidalgo, 1989).
Bone segments should be fixed using reconstructive plates. Such plates are commercially available in standard
formats and are manually bent by the surgeon during surgery, eventually being used for pre-plating using the
native mandible as a template (Marchetti et al., 2006). Modern techniques, such as CAD-CAM and rapid
prototyping, offer new routes toward the planning of reconstructive maxillofacial surgery, allowing aesthetic
outcomes to be optimised, and ensuring ultimate prosthetic and functional rehabilitation (Ciocca et al., 2009;
Hou et al., 2014; Tarsitano et al., 2014). However, although many applications have been reported in the
literature (Antony et al. 2011; Zhou et al., 2010; Markiewicz et al., 2011; Lethaus et al., 2012; Wang et al., 2013),
no study to date has evaluated the accuracy of fibular cutting and insertion into a customized bone plate. In a
previous article, Ciocca et al. described restoration of mandibular anatomy after microvascular surgical
reconstruction; the cited authors evaluated the positions of four anatomical reference points (Ciocca et al. 2010;
Mazzoni et al. 2013). In the present study, the accuracy of fibular sectioning using rapid-prototyped (RP) cutting
guides, and the accuracy of insertion of fibular units in the RP bone plate, were evaluated in comparison with the
outcomes of the conventional pre-plating technique.

Methods and Materials

The study was approved by the S. Orsola Hospital Ethics Committee in September 2011 (approval no.
57/2011/O/Disp).
Two groups of patients were assembled. The test group (five patients) underwent CAD-CAM-assisted
maxillofacial surgery and the control group conventional maxillofacial surgery featuring pre-plating. Group
assignment was based exclusively on the date of surgery. Thus, the control group was assembled in a
retrospective manner from patients who underwent maxillofacial surgery before the advent of CAD-CAM
technology-assisted techniques. The test group was composed of cases treated, between 2011 and 2013, with
CAD-CAM-based mandibular reconstruction procedures using vascularised composite free flap transfers

(Table 1). All reconstructions were performed at the time of primary tumour ablation. Histological classifications
of the control group are shown in Table 2. Three patients in the control group and two in the test group received
adjuvant radiotherapy after reconstruction. One patient in the test group received both neoadjuvant and adjuvant
chemotherapy to treat a high-grade osteosarcoma. No microvascular complications, in terms of partial or total
flap loss, were observed in any patient in either the control or the test group.
In the test group, virtual planning and CAD procedures were performed as described previously by Mazzoni
(Mazzoni et al., 2013). Surgical planning involved the design and manufacture of customised surgical devices
(mandibular cutting guides, fibular cutting guides, and reconstructive plates). Also, final prosthetic rehabilitation
was carefully considered. The technique has been termed Prosthetically Guided Maxillofacial Surgery. Fibular
osteotomy guides were used to ensure that the free flaps accurately fitted the defects, in the way that was
preoperatively planned in a virtual manner. The reconstructive plates were manufactured using a direct metal
laser sintering approach, as described previously, and a laser melting technique was employed for metal printing
(Leiggener et al., 2009). In the control group, the pre-plating technique with freehand plate cutting was used to
insert the fibular free flap into the standard bone plate.
In the test group, we calculated the difference between the virtually planned and the postoperative position of
each fibular unit (as revealed by CT). The pre-op CT data set used for the virtual planning, were superimposed
to the post-op one, in the portion of the mandible that were not involved in the resection: a best fit algorithm of
the software GOM mbH (Braunschweig, Germany) allowed overlapping the rami or condyles of each patient to
give the exact deviations of each fibula units.

In the control group, we compared the positions of the fibular

units with the preoperative positions of the mandibles, ideally sectioned along the section lines of the
postoperative fibular units. Measurements were taken from each fibular unit at two points located in the section
lines of the mesial and distal sections. These were the lower mesial point and the lower distal point (using the
dental definitions of mesial as the nearest point to the mandible midline, and distal as the farthest point from
the mandible midline). After superimposing the preoperative virtual CT images of the condyles and the rami on
the postoperative positions, using the best-fit tool option of GOM Inspect Professional (GOM mbH,
Braunschweig, Germany), the extent of overlapping between each fibular unit was measured (Table 3). Each
lateral shift (the shift in the horizontal plane passing through the long axis of each fibular unit; (Fig. 1) and
vertical shift (the up/down shift calculated on the vertical plane passing through the long axis of each fibular unit)

(Fig. 2) was measured. The lateral and vertical shifts were compared by statistical means. Thus, the mean
mesial and distal shifts were compared between the control and test group using Students t-test.

Results
In the control group, the mean values of the lateral shifts with respect to the planned positions were 4.111 mm
(from the mesial cutting lines of the fibular units) and 4.069 mm (from the distal cutting lines of the fibular units).
The mean vertical shift values were 2.170 mm (from the mesial cutting lines of the fibular units) and 2.105 mm
(from the distal cutting lines of the fibular units). In the test group, the mean value of the lateral shift with respect
to the planned position was 1.369 mm (from the mesial cutting lines of the fibular units) and 2.223 mm (from the
distal cutting lines of the fibular units); the vertical shift mean values were 2.932 mm (from the mesial cutting
lines of the fibular units) and 2.902 mm (from the distal cutting lines of the fibular units) (Table 3).
Statistical analysis of the lateral shifts showed that the mean values of the mesial positions of the fibular units
differed significantly between the groups (p = 0.013, t = 2.661), but this was not true of the distal positions (p =
0.132, t = 1.551), although the value was importantly lower in the test than the control group. Turning to vertical
shift, T-student values were negative in the comparison between control and test groups, indicating that the
mean values of the test group (mesial and distal vertical shift) were better in the control group than in the test
group. No difference was statistically significant between the groups, even if the absolute t-mean values (1.126
of the mesial shift and 1.137 of the distal shift) were similar. (Table 4)

Discussion
CAD/CAM technologies have been introduced into the field of maxillofacial bony reconstruction to increase
precision and to reduce both morbidity and operation time (Liu et al., 2009). In the present study, we focused on
the accuracy of fibular unit repositioning. Two principal measurements were performed; these were the lateral
and vertical shifts of each fibular unit with respect to the native mandibular contour. Lateral malpositioning was
evaluated to determine the accuracy of the CAD-CAM technology used to reconstruct the mandibular arch.
Vertical shifting was calculated to evaluate the accuracy of the use of the surgical guides. We chose to make
these vertical measurements to determine if the fixation screw holes system (the same holes used to both fix the
surgical guide and insert the bone plate) was useful and functional during actual surgery. In the ideal planning
protocol, the screw holes system would be used to position the fibular units at the inner margin of the bone plate,

exactly as virtually projected. To determine landmark points useful to evaluate lateral/vertical shifts, each fibular
unit was virtually isolated and oriented in terms of the lower margin of the mandible. The line of this margin
intersects the cut plane mesially and distally, thus pinpointing the exact point of interest. In the test group, this
point was easily identified both in the CAD project and in the postoperative 3D reconstruction of the CT dataset.
In the control group, the absence of a CAD plan meant that each comparison was made between the native
anatomy and the postoperative result. In detail, the two CT scans (preoperative/postoperative) were
superimposed and the native anatomy was sectioned where the cutting lines of single fibular units met (Fig. 3 a,
b). Thus, the CAD engineer could compare two volumes, one from the native mandible and one from the
postoperatively reconstructed mandible. The difference between the two volumes, reflecting malpositioning of
the mesial and distal landmark points, was measured.
The first parameter (the lateral shift) reflected the accuracy of reproduction of the mandibular arch from the
perspective of the native anatomy. The mesial points differed significantly between the two groups, and an
important (but not statistically significant) difference (p = 0.132) was noted when the distal points were
compared. These data confirmed a previous report by Mazzoni et al.

10

on the angular deviation of the

mandibular arch, explaining completely why the native anatomy is preserved when the CAD-CAM technique is
used. Precise insertion of fibular units into the CAD-CAM-generated bone plate affords better results than
insertion into a standard commercial bone plate, even when the pre-plating technique is used. This parameter
directly influences an important clinical featurefacial disfigurement. Use of the CAD-CAM protocol allows the
native anatomy to be restored to that prior to illness. Even the distortion of facial lineaments caused by cancer
can be remedied.
The second parameter (vertical shift) measured whether the surgeon had executed the protocol correctly when
utilising fixing screws system. The screws seek to optimise fibular unit positioning as virtually projected. The
holes used to fix the fibular surgical guide should be the same as used to fix the screws to the bone plate.
Unfortunately, during surgery, limitations imposed by compression of the vascular peduncle (a constraint on
blood supply) and the learning curves of surgeons meant that it was often necessary to reposition the screw
holes in positions different to those used to fix the fibular surgical guide (Fig. 4). In turn, this meant that the
fibular units were incorrectly positioned in the vertical plane. The negative t-test values (-1.126 for the mesial
vertical shift and -1.137 for the distal vertical shift) indicated that the control group fared a little better in terms of
vertical positioning (measured in the vertical plane, see Fig. 2). However, in terms of clinical significance, when

the test group mean values were compared to those control group, the absolute mean values differed by 0.172
mm for mesial vertical shift and 0.797 mm for distal vertical shift. Such values do not materially affect correct
restoration of the mandibular contour. The surgeon may accurately conserve the inferior border contour and the
form of the native mandibular arch. These results indicated that surgical guides are essential to ensure rapid and
precise sectioning of the fibula, and may also be useful for insertion of fibular units into the bone plate, but only if
the fixing screw protocol is carefully followed. An accurate determination of vascular peduncle volumes during
surgery, and training prior to surgery, are of fundamental importance for best using this protocol.
However, in our experience, this method affords surgical advantages. Fibular bone segmentation, using a cutting
guide and a piezoelectric saw, can be safely performed without removal of the periosteum. In fact, each segment
can be readily osteotomised because both the length and the cutting angle are precisely indicated by the guide.
This consistently reduces sectioning time and allows the surgeon to section the fibula into units less than 3.0 cm
long, affording a better morphological result upon reconstruction. Our microvascular success rate was 100%,
confirming the safety of the procedure.
Last but not least, an advantage of the CAD-CAM protocol is that it can be used to educate maxillofacial surgery
fellows. The availability of precise cutting guides for bone sectioning (the fibula and mandible), and use of prebent, RP bone plates, make performance of good surgery possible even by surgeons at the beginning of their
learning curves. In other words, the new techniques facilitate all steps that, in the past, required highly skilled
operators to restore the correct anatomy by manually sectioning the fibula and inserting bone using a manually
bent standard bone plate.
The potential disadvantages of the technique include the costs of designing and prototyping the device, and
difficulties associated with adapting to situations requiring an intra-operative change in the surgical plan (e.g.
when positive margins are found on frozen section examination). For this reason, the time between surgical
planning and surgery must be minimised to avoid any amplification of tumour margins.
Conclusion
To summarise our experience, if two or more fibular angulated reconstructive segments are required to repair a
mandibular defect, the CAD-CAM approach is the most useful by which to ensure the native morphology of the
reconstructed mandible. Turning to the fibular cutting guide, the tool allows perfect bone segmentation and very
precise insertion of bone segments into the reconstructive plate, if all rules are carefully followed (i.e. if the screw
hole system is used as intended).

Further studies on CAD-CAM-driven reconstructions are needed to better define the types of defects for which
the technology affords advantages compared to conventional procedures.

Financial Disclosures: None.

Acknowledgments
The authors thank Dr. Andrea Sandi (Sintac, Rovereto, Italy) for his valuable work in CAD and in the rapid
prototyping.

The English in this document has been checked by at least two professional editors, both native
speakers of English. For a certificate, please see:

http://www.textcheck.com/certificate/AoMWSu

Figures legend:
Fig. 1. Lateral shift: a. control; b. test.
Fig. 2. Vertical shift: a. control; b. test.
Fig. 3. Determination of the points (mesial and distal) at which the positions of the fibular units were measured:
(left) vertical shift; (right) horizontal shift.
Fig. 4. Deviations of the projected and actual holes.

References
Antony AK, Chen WF, Kolokythas A, Weimer KA, Cohen MN. Use of virtual surgery and stereolithographyguided osteotomy for mandibular reconstruction with the free fibula. Plast Reconstr Surg Nov;128:1080 1084,
2011.
Bak M, Jacobson AS, Buchbinder D, Urken ML. Contemporary reconstruction of the mandible. Oral Oncol 46:71
76, 2010. Review.
Ciocca L, Crescenzio FD, Fantini M, Scotti R. CAD-CAM and rapid prototyped scaffold construction for bone
regenerative medicine and surgical transfer of virtual planning: a pilot study. Comput Med Imaging Graph 33:58
62, 2009.
Ciocca L, Mazzoni S, Fantini M, Persiani F, Baldissara P, Marchetti C, Scotti R. A CAD/CAM-prototyped
anatomical condylar prosthesis connected to a custom-made bone plate to support a fibula free flap. Med Biol
Eng Comput 50:743 749, 2012.
Hidalgo DA: Fibula free flap: a new method of mandible reconstruction. Plast Reconstr Surg 84:71 79, 1989.
Hou JS, Chen M, Pan CB, Wang M, Wang JG, Zhang B, Tao Q, Wang C, Huang HZ. Application of CAD/CAMassisted technique with surgical treatment in reconstruction of the mandible. J Craniomaxillofac Surg. 2012
Dec;40(8):e432-7. doi: 10.1016/j.jcms.2012.02.022. Epub 2012 Apr 4.
Leiggener C, Messo E, Thor A, Zeilhofer HF, Hirsc JM. A selective laser sintering guide for transferring a virtual
plan to real time surgery in composite mandibular reconstruction with free fibula osseous flaps. Int J Oral
Maxillofac Surg 38:187-192, 2009.
Lethaus B, Poort L, Bckmann R, Smeets R, Tolba R, Kessler P. Additive manufacturing for microvascular
reconstruction of the mandible in 20 patients. J Craniomaxillofac Surg. 2012 Jan;40(1):43-6. doi:
10.1016/j.jcms.2011.01.007. Epub 2011 Feb 5.
Liu X, Gui L, Mao C, Peng X, Yu GY. Appling computer techniques in maxillofacial reconstruction using fibula
free flap: messenger and evaluation method. J Craniofac Surg 20:372 377, 2009.
Marchetti C, Bianchi A, Mazzoni S, Cipriani R, Campobassi A. Oromandibular reconstruction using a fibula
osteocutaneous free flap: four different preplating techniques. Plast Reconstr Surg 118:643 651, 2006.
Markiewicz MR, Bell RB. Modern concepts in computer-assisted craniomaxillofacial reconstruction. Curr Opin
Otolaryngol Head Neck Surg 19:295 301, 2011. Review.
Mazzoni S, Marchetti C, Sgarzani R, Cipriani R, Scotti R, Ciocca L. Prosthetically guided maxillofacial surgery:
evaluation of the accuracy of a surgical guide and custom-made bone plate in oncology patients after
mandibular reconstruction. Plast Reconstr Surg 131:1376 1385, 2013.
Tarsitano A, Mazzoni S, Cipriani R, Scotti R, Marchetti C, Ciocca L. The CAD-CAM technique for mandibular
reconstruction: An 18 patients oncological case-series. J Craniomaxillofac Surg. 2014 May 2. pii: S10105182(14)00134-6. doi: 10.1016/j.jcms.2014.04.011. [Epub ahead of print]

Formatted: Italian (Italy)

Urken ML, Buchbinder D, Costantino PD, et al. Oromandibular reconstruction using microvascular composite
flaps: report of 210 cases. Arch Otolaryngol Head Neck Surg 124:46 55, 1998.

Wang WH, Zhu J, Deng JY, Xia B, Xu B. Three-dimensional virtual technology in reconstruction of mandibular
defect including condyle using double-barrel vascularized fibula flap. J Craniomaxillofac Surg. 2013
Jul;41(5):417-22. doi: 10.1016/j.jcms.2012.11.008. Epub 2012 Dec 5.
Zhou LB, Shang HT, He LS, Bo B, Liu GC, Liu YP, Zhao JL. Accurate reconstruction of discontinuous mandible
using a reverse engineering/computer-aided design/rapid prototyping technique: a preliminary clinical study. J
Oral Maxillofac Surg 68:2115 2121, 2010.

10

Fig. 1a
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Fig. 1b
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Fig. 2a
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Fig. 2b
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Fig. 3
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Fig. 4
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Highlights (for review)

Highlights
1. Better results were obtained when using the surgical guide for sectioning the fibula
than conventional technique (free-hand
2. The evaluation of the accuracy generated by the surgical guides was compared with
the accuracy of conventional (pre-plating) techniques, in relation to the restoration of
pre-op/native anatomy. No other parameter was statistically evaluated.
3. Time and cost saving was also observed when using the surgical guides

Detailed Response to Reviewers

ANSWERS TO REVIEWERS
Reviewer #1:
1) The authors revealed a statistically significant difference in the lateral shift of the mesial positions of the
fibular units (p=0.013). However, due the small sample size of 5 patients in each group and the relatively
high standard deviation, we could not confirm this significance using unpaired t-test (p=0.1630). We
therefore would recommend a more detailed description of the statistical method used. In addition, we would
recommend increasing the sample size of both groups to strengthen the statistical power.
The statistical analysis has been revised and the mathematical errors corrected by a specialized statistician
(who has been inserted between the article authors). Missing measurements were substituted by estimated
values obtained by using linear regression (independent values were sequentially codified in categorical
way1,2,3 and dependent variable was represented by the measurements performed). A generalized model
for repeated measures was used for comparisons between test and control group taking into account lateral
or vertical shift, mesial or distal. - level was a priori set at 0.05.

Reviewer #2
How high is the change of pre- and postoperative condylar and ramus dimensions in both groups, is there a
significant differrence in the resulting dimension changes of the remaining mandible,due to more accuracy
provided by the CAD-CAM-reconplate? Meaning, how does the plate influence theese dimensions. This is
separate from fibular units dimensions, which can preoperativle intentionally be differently planned due to
prosthodontic needs. Please discuss e.g. (Wilde et al. 2012 and 2014) in this respect.
A sentence was added in the discussion, and the two articles were discussed.

How accurate was the overlay of the virtually reconstruction and the postoperative result in the test group?
These parameters would demonstrate the accuracy of thie specific CAD-CAM-method, since different other
methods are in use, e.g. (prebended standard recon plates individually sized from anatomic mandible
models of the patient, CAD-CAM-milled recon plates).
A sentence was added in the M&M section to better explain how accurate the overlap was.

Please also discuss the use of piezoelectric osteotomies in respect to temperature during osteotomy. Have
you used only Piezoosteotomes or have you also used drill,saw,chissel before and finally to save the vessel
the Piezo? I think that the readers may benefit from your exsperience even more,when you describe it a little
bit more specific.
A sentence was added in the discussion.

Editor-in-Chief:
The Conclusion part is missing.
The Conclusion was added at the end of the manuscript

Table

Table 1. Histological classification. type of defect. and virtual resections planned for test group patients.

Patient
Pt. #1

Tumour
Ameloblastoma

Resection
B+S

Pt. #2

Squamous cell
carcinoma

B+R

Pt. #3

Osteogenic
sarcoma

S+B+R

Pt. #4

Ameloblastoma

B+S+B

Pt. #5

Squamous cell
carcinoma

B+S+R

Virtual resection

Legend: B: mandibular body; S: mandibular symphysis; R: mandibular ramus.

Table 2. Histological classification and type of defect in control patients.

Patient
Pt. #1
Pt. #2
Pt. #3
Pt. #4
Pt. #5

Tumour
Squamous cell carcinoma
Ameloblastoma
Squamous cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma

Resection
B+R
B+R
S+B
B+R
B+R

Table 3. Measurements from the control group.

Lateral shift (mm)
mesial
distal

Vertical shift (mm)

mesial
distal

V1

+5.187

+2.803

+4.539

+2.278

V2
V3
Patient 2
V1

+2.683
+4.547

+5.168
+3.122

+1.953
+1.039

+1.741
+2.494

+0.593

+2.514

+4.119

V2
V3
Patient 3
V1
V2
V3
V4
Patient 4
V1
V2
Patient 5
V1
V2
V3
MEAN
(absolute value)
SD
(standard
deviation)

0
+1.179

+1.179
+13.196

+4.119
+1.988

+1.988
+0.768

+12.042
+6.813
+6.097
+0.684

+1.155
+11.498
+0.945
+1.482

+6.673
+2.149
+2.153
+0.990

+1.112
+2.297
+1.487
+2.813

0
+1.540

+1.540
+0.819

0
+1.376

+1.376
+4.5448

+3.326
+5.811
+11.177

+5.811
+11.177
+1.661

+0.439
+1.311
+1.311

+2.485
+0.439
+1.641

4.112

4.104

2.170

2.105

3.818

4.378

1.740

1.124

Patient 1

Measurements from the test group.

Patient 1

Lateral shift

Vertical shift

Mesial

Distal

Mesia Dist
l
al
3.690 0.45
9
3.383 3.36
5
3.647 +1.6
59

V1

1.344

0.371

V2

1.695

V3

+0.775

+1.26
7
2.173

V1

+1.770

0.731

0.798

V2

+ 0.758

+
3.250

+2.67
5

Patient 2

3.45
6
+3.8
18

V3

+5.141

+4.51
5

+
6.791

0.87
1

V1

+ 0.770

0.749

0.716

V2

+ 0.392

V3

+ 0.998

+0.73
6
3.381

V4

0.818

+0.67
5
+1.67
6
3.160

+3.0
37
3.39
5
3.99
4
0.38
7

0.093

Patient 3

3.651

Patient 4
V1

+ 0.980

V2

0.963

+2.50
5
1.269

V3

1.130

4.335

0.528

V1

0.602

3.351

4.531

V2

2.392

3.286

+
4.594

+5.1
46
+7.2
68

1,368

2.221

2.932

2,902

1,164

1,375

1.960

1,902

4.764

2.24
0
+3.7
02
0.73
0

Patient 5

MEAN
(absolute
value)

(standard
deviation)

Table 4 Results of Generalized Linear Model for repeated measures

Source
Type III
Degree Square F+test
p
5quare sum freedom mean

1546

1546

10.40

10.40

87.21 .0.00
1
0.587 0.449

Shift lateral/vertical

4.36

4.36

0.246 0.623

Section
mesial/distal

4.79

4.79

0.270 0.607

Intercept
Group