150

Virtual Surgical Planning in Craniofacial Surgery

Harvey Chim, MBBS1

Nicholas Wetjen, MD2

Samir Mardini, MD1

1 Division of Plastic Surgery, Mayo Clinic, Rochester, Minnesota

2 Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota

Address for correspondence Samir Mardini, MD, Division of Plastic

Surgery, Mayo Clinic, 200 1st Street SW, Rochester, MN 55905
(e-mail: [email protected]).

Abstract
Keywords

virtual surgical
planning
craniofacial surgery
craniosynostosis
cranial vault
remodeling
distraction
osteogenesis

The complex three-dimensional anatomy of the craniofacial skeleton creates a formidable challenge for surgical reconstruction. Advances in computer-aided design and
computer-aided manufacturing technology have created increasing applications for
virtual surgical planning in craniofacial surgery, such as preoperative planning, fabrication of cutting guides, and stereolithographic models and fabrication of custom
implants. In this review, the authors describe current and evolving uses of virtual
surgical planning in craniofacial surgery.

The complex three-dimensional (3D) anatomy of the craniofacial skeleton increases the complexity of reconstructing this
region and creates a challenge when attempting to achieve
excellent aesthetic outcomes. Traditionally, reconstructive
surgery for conditions such as craniosynostosis and complex
facial malformations has relied on the surgeons subjective
assessment of form and aesthetics preoperatively and intraoperatively, with intraoperative decision making based on
such factors as the location of bone cuts and the shape of bone
segments for craniofacial reconstruction. Although good outcomes can and are often achieved, the highly subjective
nature of this process results in variable surgeon-specic
outcomes and can also lead to prolonged surgical time.
The advent of virtual surgical planning (VSP) through computer-aided design (CAD) and computer-aided manufacturing
(CAM) techniques has offered an alternative workow13 for
more precise preoperative planning and a decreased necessity
for intraoperative trial and error. Applications include preoperative planning through virtual surgery,4,5 fabrication of
cutting guides and bone models using stereolithography techniques,6,7 and surgical navigation systems to aid in the placement of implants and to guide bone cuts.8,9
Although CAD-CAM technology has been present for
decades, recent developments have made it more relevant
for use in craniofacial surgery. Improvement in resolution and
quality of images as well as decreased slice thickness obtained

Issue Theme Approaches to

Craniosynostosis; Guest Editor, Eric H.
Hubli, MD, FACS, FAAP, FICS

from computed tomography (CT) scans allow generation of

more accurate 3D models for surgical planning and manipulation.6 Advanced surgical simulation tools allow manipulation of the 3D craniofacial model with 6 degrees of
freedom,1012 therefore allowing visualization of simulated
osteotomies from different angles. Advances in rapid prototyping technology allow fabrication of more accurate 3D
models with detailed internal contours through stereolithography techniques as well as fabrication of cutting guides for
osteotomies after preoperative virtual surgery.13,14 However,
there are increased costs related to VSP in some procedures
that are not offset by the savings in valuable surgical time.
In this article, we review current and evolving applications
of virtual surgical planning in craniofacial surgery.

Applications in Craniosynostosis Surgery

Cranial vault remodeling aims to correct abnormal cranial
morphology as much as possible toward age-matched norms.
Understandably, there is signicant subjectivity in what is
ideal or normal. The concept of CAD-CAM technology for
craniosynostosis surgery was rst proposed in 199615 subsequently, the technology was implemented in a patient with
metopic synostosis and another with unicoronal synostosis
by Mommaerts et al in 2001.16 The 3D CAD-CAM planning
was converted to 2D templates that were used to plan

Copyright 2014 by Thieme Medical

Publishers, Inc., 333 Seventh Avenue,
New York, NY 10001, USA.
Tel: +1(212) 584-4662.

DOI http://dx.doi.org/
10.1055/s-0034-1384811.
ISSN 1535-2188.

This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.

Semin Plast Surg 2014;28:150158.

Chim et al.

Fig. 1 Virtual surgical planning is used to simulate osteotomies and repositioning of bone segments during cranial vault remodeling for
correction of sagittal synostosis. Normal age matched skull is colored red. Virtual osteotomized segments are shown in blue, green, and purple.
(A) Preoperative lateral view showing planned osteotomies based on overlapping a normal age matched skull onto the patients skull.
(B) Projected postoperative lateral view following re-shaping of the cranial vault to match the normal skull. (C) Preoperative view from the top of
the skull showing planned osteotomies. (D) View following re-shaping of the cranial vault to match as age matched normal.

osteotomies. The process was time-consuming due to the

need to transfer a 3D plan to 2D templates. Burge and
colleagues subsequently described in 201117 the use of
CAD-CAM technology for fabricating age-matched templates
for shaping of the fronto-orbital bandeau. However, these
templates were limited to remodeling of the fronto-orbital
bandeau only.
Nikoo described a mathematically averaged skull based
on CT scan data of 103 infants aged 8 to 12 months.18 Based
on normative data generated from measurements of
radiographs from children,17,19 age-appropriate calvarial
models were generated with the aid of a company specializing in virtual surgical planning, Medical Modeling Inc.
(Golden, CO).
These normative calvarial models are used as an aid during
virtual surgery (Figs. 1 and 2). Data obtained from CT
images of the patient are used to make the rst model,
whereas an age-appropriate normative model is used as
the second model. The two models are overlapped, and
virtual osteotomies are performed to reshape the patients
skull to best t its normative model. With the aid of virtual
surgery, the planned surgical osteotomies are uploaded into
the computer to allow fabrication of templates for use in the
actual surgery. The cutting guides (Fig. 3) show where

osteotomies should be made on the calvarium; the positioning guides (Fig. 4) help to guide placement of individual
bone segments to best approximate an age-appropriate normal calvarial shape.
In cranial vault distraction, virtual surgical planning allows
preoperative determination of the distance and vector of
distraction, as well as the best position for the osteotomies.
Additionally, the bone can be analyzed preoperatively to
determine where solid bone exists for optimal placement of
the distractors. Potential use in some situations is based on
the determination of the thickness of the calvarial bone,
which can aid in determining the length of the screws to be
used.
Virtual surgical planning has been used successfully by our
group7 and others20,21 to aid reconstruction in infants with
craniosynostosis. This technique allows reproducible objective results that improve outcomes. The surgeon begins the
surgery knowing the nal outcome. Other benets include a
better understanding of the pathology and surgical steps by
parents and families through visual 3D images obtained
through the VSP process. While planning the surgery, the
surgeon is able to visualize exactly where the planned cuts
will be made in relation to critical structures around the
brain, therefore avoiding potential complications. In the
Seminars in Plastic Surgery

Vol. 28

No. 3/2014

151

This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.

Virtual Surgical Planning in Craniofacial Surgery

Virtual Surgical Planning in Craniofacial Surgery

Chim et al.

Fig. 2 Virtual surgical planning is used to simulate osteotomies and repositioning of bone segments during cranial vault remodeling for
correction of metopic synostosis. Normal age matched skull is colored red. Virtual osteotomized segments are shown in blue, green, and purple.
(A) Preoperative AP view showing planned osteotomies. (B) Projected postoperative AP view following re-shaping of the cranial vault.
(C) Preoperative overhead view showing planned osteotomies. (D) Projected postoperative overhead view following re-shaping of the cranial vault
shows correction of trigonocephaly.

planning process, the bioengineer shows axial and coronal

cuts that correspond to the 3D model where these cuts will
end up in relation to the structures around the brain and skull
base. The use of VSP requires a CT scan within 1 or 2 months of
the surgery to perform proper planning. The timing is dependent on the age of the patient at the time of surgery. After the
period of rapid cranial growth, an older CT scan may be used.
The craniofacial surgeon must balance the advantage of
increased precision obtained from VSP, with the disadvantage
of possible increased cost and exposure to radiation when
deciding whether to use VSP in their craniosynostosis practice. The use of VSP is illustrated by two case examples below.

Case 1: Metopic Synostosis

A 2-month-old boy presented with abnormal head shape and
was diagnosed with metopic synostosis (Fig. 5). After
virtual surgical planning, he underwent cranial vault remodeling at 12 months of age. Approximately 1 week after
surgery, he bumped his head and developed a subdural uid
collection that required surgical evacuation. He has had good
results 9 months after surgery. To achieve optimal shape, the
Seminars in Plastic Surgery

Vol. 28

No. 3/2014

supraorbital bandeau and frontal bones were segmented into

many pieces. This is not optimal and should be avoided
whenever possible to avoid desorption. Also, plating on the
inside versus outside is dependent on the surgeons preference and on the location of the plates. The planning allows the
surgeon to produce positioning guides that place the bone
segments on the inside with plating on the inside (as seen in
this case), or positioning guides that allow placement of the
bone segments on the outside with plates on the outside.

Case 2: Coronal Synostosis

A 3-month-old girl with Crouzon syndrome presented with
bicoronal synostosis and hydrocephalus (Fig. 6). She underwent posterior cranial vault distraction at 14 months of
age. Postoperative photos were obtained 3 months after
completion of distraction; they show a good surgical result.

Applications in Maxillofacial Reconstruction

Virtual surgical planning has proven to be very useful in
complex maxillofacial reconstruction. In the area of

This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.

152

Fig. 3 Cutting template allows exact placement of osteotomies and

labeling of individual bone segments in a patient with sagittal synostosis. (A) Placement of the template on the calvarium after elevation of
the scalp aps. (B) Marking of planned osteotomies on the calvarium.

Chim et al.

mandibular reconstruction, VSP has been used in the shaping

of free bular aps.22,23 With data obtained from highresolution CT scans of the maxillofacial skeleton and lower
extremity, stereolithographic models can be fabricated,
whereas virtual surgery allows fabrication of mandible and
bular cutting guides and a plate-bending template for
shaping the bula to best approximate the desired shape of
the reconstructed mandible. With VSP, intraoperative time is
decreased as bending and shaping of the plate and bula can
now be done with precision to match the dimensions of the
defect,24 and not freehand as is the traditional technique. This
is extremely valuable in decreasing ischemia time; the accuracy of the bular osteotomies allows better shape and
optimizes the position of the bones for eventual dental
rehabilitation.
The use of VSP in mandibular reconstruction consists of a
planning phase, modeling phase, and surgical phase.25 Highresolution CT scans of the craniofacial skeleton and lower
extremities are obtained. These images are forwarded to a
company specializing in VSP. After an online meeting to
discuss the case, a virtual resection of the mandible is
performed. The 3D image of the bula is superimposed on
the defect and virtual osteotomies are performed. In the
modeling phase, a stereolithographic model is fabricated, as
well as cutting guides for the mandible and bula. Finally, in
the surgical phase, the mandible cutting guides are used to
guide resection of the lesion. A temporary external xator
may be placed to ensure that the remaining segments are kept
in proper position. Otherwise, more commonly, a reconstruction plate and drilling of holes at appropriate locations on the

Fig. 4 Positioning guides used for placement of individual bone segments to best achieve an age-matched normal calvarial morphology in a
patient with metopic synostosis. (A) In this case, bone segments are placed on the internal surface of the template and secured with resorbable
plates internally. This can be performed with the bone segments placed on the outside of a positioning guide and plating on the outside. This
depends on the preference of the surgeon and the planning of each particular surgery. (B) The reconstructed calvarium is transferred to the
patient and further secured with resorbable plates on the external aspect.
Seminars in Plastic Surgery

Vol. 28

No. 3/2014

153

This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.

Virtual Surgical Planning in Craniofacial Surgery

Virtual Surgical Planning in Craniofacial Surgery

Chim et al.

Fig. 5 Virtual surgical planning for cranial vault remodeling in a patient with metopic synostosis. (A,B) Preoperative frontal and lateral view of a
child with metopic synostosis. (C,D) Oblique views of cutting guides based on VSP of this patients surgery. (E) Cutting guide in place after
elevation of the anterior scalp ap. (F) Marking of planned osteotomies on the calvarium. (G) Positioning guide used to reshape bone segments on
the back table. (H) Reconstructed anterior cranial vault and supraorbital bar in place. (I,J) Postoperative frontal and lateral view.

remaining mandible are placed prior to performing the

osteotomies. The reconstruction plate is removed and the
cutting guides are placed in preparation for the osteotomies.
The bula is shaped using the bular cutting guide, prior to or
after division of the pedicle. The shaped bula is used to
reconstruct the mandible.
Virtual surgical planning with stereotactic navigation has
been used for midface reconstruction with free bular aps.26
Physical models are created using rapid prototyping techniques. Titanium plates are then bent to match the contours of
the bular ap and facial skeleton. In addition, custom cutting
guides are fabricated for the bular osteotomies. Navigation is
performed with ducial markers on the patients forehead,
subsequently replaced by a navigation array xed to the
patients calvaria at the time of surgery. Virtual surgical
planning has also been used for complex reconstruction of
the midface and mandible with two separate free bular
aps.27 In extensive defects, where the native anatomy of the
face is distorted by trauma or irradiation, the amount of bone
Seminars in Plastic Surgery

Vol. 28

No. 3/2014

required for reconstruction can be underestimated. Virtual

surgical planning obviates this problem by allowing the
visualization of the preinjury 3D anatomy to aid planning
of osteotomies preoperatively, saving valuable surgical time.
Another application of VSP allows immediate prosthodontic rehabilitation in mandibular reconstruction.28,29 Dental
implants are placed in the bula in the rst stage to allow for
osseointegration, followed by free bular transfer in the
second stage, allowing immediate implant-supported prosthetic rehabilitation with dentures.
In addition to midface reconstruction using free bular
aps, a group used VSPs cutting guides to aid in their
completion of osteotomies in vascularized iliac crest bone
grafts for zygoma reconstruction.30 The same group used VSP
for preoperative planning and fabrication of cutting guides
for vascularized iliac crest bone grafts in mandibular reconstruction, and found that surgical time was decreased and the
iliac crest donor site defect was downsized when VSP was
used.31

This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.

154

Chim et al.

Fig. 6 Virtual surgical planning for posterior cranial vault distraction in a syndromic patient with bilateral coronal synostosis. (A,B) Preoperative
anteroposterior and lateral view. (C) Overlap of patients skull with normal age-matched skull (red). (D) Distracted segment (in blue) positioned
where it needs to be to achieve normal morphology. (E) Distractors in place in positions that allow for distracting in the planned vector. (F) Cutting
guide placed over a three-dimensional model of the patients abnormal skull. (G) Distractors in placed after osteotomy is performed. (H,I,J)
Postoperative views of the patient after 30 mm of distraction performed and prior to removal of distractors.

Other Applications of Virtual Surgical

Planning
Virtual surgical planning has been used in planning mandibular distraction osteogenesis in a neonate32 with Pierre Robin
syndrome. Three-dimensional models are fabricated based
on CT scan data of the craniofacial skeleton and distractors.
Virtual surgery is performed to ensure that the planned
osteotomies would allow achievement of the planned distraction vector. Cutting guides for the mandible are then
fabricated to allow accurate cuts intraoperatively. Virtual
surgical planning also allows preplanning of screw position
and lengths to ensure bicortical screw placement, away from
the inferior alveolar nerve. The cutting guides allow sliding of
the actual distractors over K wires to improve efciency and
accuracy of placement of the distractors.
Custom alloplastic total joint replacement implants of the
temporomandibular joint (TMJ) have been used for treatment
of TMJ ankylosis33 in a single-stage surgery. Similar to the
workow for other applications in VSP, ne-cut CT scans of
the TMJ and maxillomandibular complex are obtained, followed by the creation of 3D models by a company experienced in VSP. Through an interactive online meeting, virtual

surgery is performed, consisting of the resection of the

ankylosed segment. The joint replacement is then designed,
rst with planning of the fossa component with a custommade ange to t the patients zygomatic arch, followed by
design of the mandibular ramus component. Accurate visualization of the 3D anatomy of the mandible ensures that the
prosthesis and xation avoid the inferior alveolar nerve and
tooth roots. Finally, a virtual 3D prosthesis is designed. Screw
holes can be placed away from vital structures such as the
inferior alveolar nerve and maxillary artery and over the best
bone thickness for xation. In addition, measurement of
screw depth is obtained to ensure that screw placement is
bicortical for all holes. Bone-cutting guides are also fabricated
to t the posterior border of the mandible and/ or glenoid
fossa and aid the resection phase of the surgery.
Virtual surgical planning in surgery for TMJ ankylosis
allows performance of the surgery in a single stage, compared
with traditional multiple-stage surgeries that involve resection of the ankylosis, followed by reconstruction. The accuracy of implant fabrication and placement is increased, with
decreased micro-movement under loading compared with
standard implants, while morbidity related to multiple surgeries is avoided.
Seminars in Plastic Surgery

Vol. 28

No. 3/2014

155

This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.

Virtual Surgical Planning in Craniofacial Surgery

Virtual Surgical Planning in Craniofacial Surgery

Chim et al.

Virtual surgical planning has also been used for singlestage resection and reconstruction of the TMJ using stock
prostheses from Biomet.34 In these cases, cutting guides aid in
the performance of osteotomies intraoperatively, while stereolithographic models allow the selection of appropriately
sized prosthesis components prior to surgery to ensure the
best t. In these situations, where the complex bony anatomy
of the TMJ prevents easy selection of prosthesis size and
placement, VSP has a role in preoperative visualization and
planning to decrease surgical time.
Virtual surgical planning has a clear role in facial transplantation where bone is a necessary component in the
completion of the reconstruction.35,36 If a Lefort III segment
is planned, cutting guides and templates are fabricated for the
recipient and for the donor at the appropriate times. Additionally, VSP can be used in surgical navigation. The use of VSP
for this indication ensures a more accurate outcome while
minimizing ischemia time.

11

12

13

14

15

16

17

18

Conclusion
The use of VSP can lead to increased accuracy in reconstructing the craniofacial skeleton. Its applications and practicality
continue to be explored as new technology becomes available
and as experience with the current technology increases.

19

20

21

References
1 Bly RA, Chang SH, Cudejkova M, Liu JJ, Moe KS. Computer-guided

10

orbital reconstruction to improve outcomes. JAMA Facial Plast

Surg 2013;15(2):113120
Foley BD, Thayer WP, Honeybrook A, McKenna S, Press S. Mandibular reconstruction using computer-aided design and computeraided manufacturing: an analysis of surgical results. J Oral Maxillofac Surg 2013;71(2):e111e119
Hierl T, Arnold S, Kruber D, Schulze FP, Hmpfner-Hierl H. CADCAM-assisted esthetic facial surgery. J Oral Maxillofac Surg 2013;
71(1):e15e23
Nikkhah D, Ponniah A, Ruff C, Dunaway D. Planning surgical
reconstruction in Treacher-Collins syndrome using virtual simulation. Plast Reconstr Surg 2013;132(5):790e805e
Tepper OM, Sorice S, Hershman GN, Saadeh P, Levine JP, Hirsch D.
Use of virtual 3-dimensional surgery in post-traumatic craniomaxillofacial reconstruction. J Oral Maxillofac Surg 2011;69(3):
733741
Zhao L, Patel PK, Cohen M. Application of virtual surgical planning
with computer assisted design and manufacturing technology
to cranio-maxillofacial surgery. Arch Plast Surg 2012;39(4):
309316
Mardini S, Alsubaie S, Cayci C, Chim H, Wetjen N. Three-dimensional preoperative virtual planning and template use for surgical
correction of craniosynostosis. J Plast Reconstr Aesthet Surg 2014;
67(3):336343
Verma SN, Schow SR, Stone BH, Triplett RG. Applications of surgical
navigational systems for craniofacial bone-anchored implant
placement. Int J Oral Maxillofac Implants 2010;25(3):582588
Nowinski D, Messo E, Hedlund A, Hirsch JM. Computer-navigated
contouring of craniofacial brous dysplasia involving the orbit.
J Craniofac Surg 2011;22(2):469472
Cynthia DB, Steven S, Anil M, et al. A survey of interactive meshcutting techniques and a new method for implementing general-

Seminars in Plastic Surgery

Vol. 28

No. 3/2014

22

23

24

25

26

27

28

29

ized interactive mesh cutting using virtual tools. J Visual Comput

Animat 2002;13:2142
Zachow S, Gladilina E, Saderb R, et al. Draw and cut: intuitive 3D
osteotomy planning on polygonal bone models. Int Congr Ser
2003;1256:362369
Westermark A, Zachow S, Eppley BL. Three-dimensional osteotomy planning in maxillofacial surgery including soft tissue prediction. J Craniofac Surg 2005;16(1):100104
McGurk M, Amis AA, Potamianos P, Goodger NM. Rapid prototyping techniques for anatomical modelling in medicine. Ann R Coll
Surg Engl 1997;79(3):169174
Joffe JM, McDermott PJ, Linney AD, Mosse CA, Harris M. Computergenerated titanium cranioplasty: report of a new technique for
repairing skull defects. Br J Neurosurg 1992;6(4):343350
Vander Sloten J, Degryse K, Gobin R, Van der Perre G, Mommaerts
MY. Interactive simulation of cranial surgery in a computer aided
design environment. J Craniomaxillofac Surg 1996;24(2):122129
Mommaerts MY, Jans G, Vander Sloten J, Staels PF, Van der Perre G,
Gobin R. On the assets of CAD planning for craniosynostosis
surgery. J Craniofac Surg 2001;12(6):547554
Burge J, Saber NR, Looi T, et al. Application of CAD/CAM prefabricated age-matched templates in cranio-orbital remodeling in
craniosynostosis. J Craniofac Surg 2011;22(5):18101813
Saber NR, Phillips J, Looi T, et al. Generation of normative pediatric
skull models for use in cranial vault remodeling procedures. Childs
Nerv Syst 2012;28(3):405410
Pereira IMR, Filho AAB, Alvares BR, Palomari ET, Nanni L. Radiological determination of cranial size and index by measurement of
skull diameters in a population of children in Brazil. Radiol Bras
2008;41:229234
Seruya M, Borsuk DE, Khalian S, Carson BS, Dalesio NM, Dorafshar
AH. Computer-aided design and manufacturing in craniosynostosis surgery. J Craniofac Surg 2013;24(4):11001105
Khechoyan DY, Saber NR, Burge J, et al. Surgical outcomes in
craniosynostosis reconstruction: the use of prefabricated templates in cranial vault remodelling. J Plast Reconstr Aesthet Surg
2014;67(1):916
Moro A, Cannas R, Boniello R, Gasparini G, Pelo S. Techniques on
modeling the vascularized free bula ap in mandibular reconstruction. J Craniofac Surg 2009;20(5):15711573
Antony AK, Chen WF, Kolokythas A, Weimer KA, Cohen MN. Use of
virtual surgery and stereolithography-guided osteotomy for mandibular reconstruction with the free bula. Plast Reconstr Surg
2011;128(5):10801084
Roser SM, Ramachandra S, Blair H, et al. The accuracy of virtual
surgical planning in free bula mandibular reconstruction: comparison of planned and nal results. J Oral Maxillofac Surg 2010;
68(11):28242832
Hirsch DL, Garfein ES, Christensen AM, Weimer KA, Saddeh PB,
Levine JP. Use of computer-aided design and computer-aided
manufacturing to produce orthognathically ideal surgical outcomes: a paradigm shift in head and neck reconstruction. J Oral
Maxillofac Surg 2009;67(10):21152122
Hanasono MM, Jacob RF, Bidaut L, Robb GL, Skoracki RJ. Midfacial
reconstruction using virtual planning, rapid prototype modeling,
and stereotactic navigation. Plast Reconstr Surg 2010;126(6):
20022006
Saad A, Winters R, Wise MW, Dupin CL, St Hilaire H. Virtual
surgical planning in complex composite maxillofacial reconstruction. Plast Reconstr Surg 2013;132(3):626633
Rohner D, Jaquiry C, Kunz C, Bucher P, Maas H, Hammer B.
Maxillofacial reconstruction with prefabricated osseous free aps:
a 3-year experience with 24 patients. Plast Reconstr Surg 2003;
112(3):748757
Schepers RH, Raghoebar GM, Vissink A, et al. Fully 3-dimensional
digitally planned reconstruction of a mandible with a free vascularized bula and immediate placement of an implant-supported
prosthetic construction. Head Neck 2013;35(4):E109E114

This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.

156

Virtual Surgical Planning in Craniofacial Surgery

zygoma reconstruction with vascularized iliac crest bone graft.

Int J Med Robot 2013;9(4):497502
31 Ayoub N, Ghassemi A, Rana M, et al. Evaluation of computerassisted mandibular reconstruction with vascularized iliac crest
bone graft compared to conventional surgery: a randomized
prospective clinical trial. Trials 2014;15:114
32 Doscher ME, Garfein ES, Bent J, Tepper OM. Neonatal mandibular
distraction osteogenesis: converting virtual surgical planning into
an operative reality. Int J Pediatr Otorhinolaryngol 2014;78(2):
381384
33 Haq J, Patel N, Weimer K, Matthews NS. Single stage treatment of
ankylosis of the temporomandibular joint using patient-specic

157

total joint replacement and virtual surgical planning. Br J Oral

Maxillofac Surg 2014;52(4):350355
34 Chandran R, Keeler GD, Christensen AM, Weimer KA, Caloss R.
Application of virtual surgical planning for total joint reconstruction with a stock alloplast system. J Oral Maxillofac Surg 2011;
69(1):285294
35 Brown EN, Dorafshar AH, Bojovic B, et al. Total face, double jaw,
and tongue transplant simulation: a cadaveric study using computer-assisted techniques. Plast Reconstr Surg 2012;130(4):
815823
36 Chim H, Amer H, Mardini S, Moran SL. Vascularized composite
allotransplantation in the realm of regenerative plastic surgery.
Mayo Clin Proc 2014;89(7):10091020

This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.

30 Modabber A, Gerressen M, Ayoub N, et al. Computer-assisted

Chim et al.

Seminars in Plastic Surgery

Vol. 28

No. 3/2014