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• W2263671871 abstract "Microvascular free tissue transfer has been one of the greatest milestones in reconstruction of the mandible and maxilla after tumor ablative surgery. Although fibula free flap reconstruction allows for immediate bony reconstruction, dental rehabilitation usually requires 6 to 12 months before it is completed. This can have a serious psychological impact on patients because they go without teeth during this timeframe. The “jaw-in-a-day” procedure was previously described by a group at New York University Medical Center. It allowed for tumor removal and full jaw reconstruction and dental rehabilitation in 1 surgery. This report describes 3 patients treated with this novel technique and adds to the 4 cases previously reported in the literature. To their knowledge, the authors are the second group to report on this technique. A series of photographs and videos are referenced in this article to illustrate the different steps used in this procedure. Microvascular free tissue transfer has been one of the greatest milestones in reconstruction of the mandible and maxilla after tumor ablative surgery. Although fibula free flap reconstruction allows for immediate bony reconstruction, dental rehabilitation usually requires 6 to 12 months before it is completed. This can have a serious psychological impact on patients because they go without teeth during this timeframe. The “jaw-in-a-day” procedure was previously described by a group at New York University Medical Center. It allowed for tumor removal and full jaw reconstruction and dental rehabilitation in 1 surgery. This report describes 3 patients treated with this novel technique and adds to the 4 cases previously reported in the literature. To their knowledge, the authors are the second group to report on this technique. A series of photographs and videos are referenced in this article to illustrate the different steps used in this procedure. The microvascular fibula free flap, popularized by Hidalgo,1Hidalgo D.A. Fibula free flap: A new method of mandible reconstruction.Plast Reconstr Surg. 1989; 84: 71Crossref PubMed Scopus (1230) Google Scholar has been one of the greatest advances in reconstruction of the maxillofacial region. Although fibula free flap reconstruction allows for immediate bony reconstruction, the process of dental rehabilitation can be very lengthy. The fibula often is allowed to heal and form a bony union with the adjacent mandible before proceeding with the placement of dental implants, although some investigators have reported immediate implant placement.2Urken M.L. Buchbinder D. Weinberg H. et al.Primary placement of osseointegrated implants in microvascular mandibular reconstruction.Otolaryngol Head Neck Surg. 1989; 101: 56PubMed Google Scholar, 3Chang Y.M. Santamaria E. Wei F.C. et al.Primary insertion of osseointegrated dental implants into fibula osteoseptocutaneous free flap for mandible reconstruction.Plast Reconstr Surg. 1998; 102: 680Crossref PubMed Scopus (109) Google Scholar, 4Chana J.S. Chang Y.M. Wei F.C. et al.Segmental mandibulectomy and immediate free fibula osteoseptocutaneous flap reconstruction with endosteal implants: an ideal treatment method for mandibular ameloblastoma.Plast Reconstr Surg. 2004; 113: 80Crossref PubMed Scopus (126) Google Scholar, 5Shen Y.F. Rodriguez E.D. Wei F.C. et al.Aesthetic and functional mandibular reconstruction with immediate dental implants in a free fibular flap and a low-profile reconstruction plate: Five-year follow-up.Ann Plast Surg. 2015; 74: 442Crossref PubMed Scopus (28) Google Scholar After implant placement, the implants are allowed to undergo osseointegration. Often adjunctive procedures are required, such as vestibuloplasties, flap debulking, and implant uncovering. This process can take 6 to 12 months, which can have a major psychological impact on patients who are suddenly faced with the reality of having to lose a part of their jaw and teeth. Levine et al6Levine J.P. Bae J.S. Soares M. et al.Jaw in a day: Total maxillofacial reconstruction using digital technology.Plast Reconstr Surg. 2013; 131: 1386Crossref PubMed Scopus (114) Google Scholar reported on 4 patients for whom fibula free flap reconstruction with immediate dental implants and full dental rehabilitation was performed in 1 surgery. They coined the term jaw in a day for the procedure. This report describes 3 additional patients who were treated with this fibula jaw-in-a-day procedure. Although some steps are slightly different, the concept is the same, which is occlusion-driven reconstruction. It allows patients to have a new jaw and new teeth in 1 day. In accord with the policy of the institutional review board of the University of Mississippi (Jackson, MS), case reports and case series of no more than 3 patients are exempt from institutional review board approval. Appropriate consent forms were obtained from all patients in this study. A 76-year-old man was referred for a biopsy-proved ameloblastoma of the right mandible. His history was notable for pain and discomfort involving the right jaw area with paresthesia of the lower lip. His medical history was notable for well-controlled type 2 diabetes mellitus and hypertension. On physical examination, there was no gross facial asymmetry or any palpable lymphadenopathy. Intra-orally, the patient had bony expansion of the right posterior mandible extending from right mandibular canine posteriorly to the retromolar region. The mucosa overlying this area was intact with no ulcerations (Fig 1). Computed tomography (CT) depicted a 3- × 4-cm multilocular expansile bony lesion involving the right posterior mandible (Fig 2A, B). Perforation of the buccal cortex in several locations was present at imaging. CT angiogram of the lower extremities showed good 3-vessel runoff to the ankles.Figure 2Preoperative computed tomograms showing extent of lesion. A, Axial cut. B, Coronal view.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Virtual planning for surgery was performed using Materialise Pro Plan software (Plymouth, MI; Fig 3). Stone models of the patient's upper and lower dentition were scanned and superimposed on the CT data to produce medical models that were more accurate and to aid in the fabrication of an occlusal splint. Patient-specific data were used for the lower extremities and were obtained from the CT angiogram, which was used to assess the vasculature of the legs. During virtual planning, positioning of the fibular segments and implants in space was driven by the anticipated final occlusion (Fig 3B). If a patient has good occlusion with no displacement of teeth, then the pre-existing occlusion can serve as the guide for the reconstruction. The teeth can be virtually added or subtracted during the planning phase to help with implant positioning. The fibula was positioned roughly 15 mm below the occlusal plane to create adequate occlusal clearance. Similar to the “all-on-4” procedure, this space is required to accommodate the height of prosthesis and maintain a space below the prosthesis for hygiene and tissue closure. If a notable discrepancy results at the inferior border of the mandible from this positioning, then a double-barrel fibula can be used to preserve the facial contour. Alternatively, a reconstruction bar can be placed below the level of the fibula, as was performed for patient 3. Once the virtual plan was completed, medical models were produced and shipped to the authors' dental laboratory. Then, a prosthesis was manually fabricated to fit the medical models and the opposing dentition on the mounted casts (Fig 4). An occlusal splint of the final occlusion was fabricated to help with positioning during surgery. During surgery, resection of the tumor proceeded in the usual fashion. A cutting guide for the mandibular osteotomies was used according to the virtual plan, and the tumor was resected. The cutting guide for the fibula was designed with a built-in dental implant guide allowing for accurate placement of dental implants in the fibula while it was still connected to the vascular pedicle at the leg (Fig 5A). A Nobel replace guided kit (Yorba Linda, CA) was used for placement of the implants. The fibula guide was also used to make osteotomies, therefore shaping the fibular segments exactly as planned for the mandibular reconstruction. The prosthesis was secured to the implants at the leg with the aid of a resected mandible model, and a pre-bent reconstruction bar was used to hold the fibular segments together while luting the prosthesis to the implants. The resulting fibula prosthesis complex was transferred to the head (Fig 5B). This construct was adjusted to fit the adjacent mandible and opposing occlusion using an occlusal splint. The fibula was secured to the adjacent mandible with the pre-bent reconstruction bar. Primary closure over the bone was obtained underneath the prosthesis (Fig 5C, Video 1). A strict puree diet was enforced for 3 months after surgery to decrease chewing forces and allow for bony union without complications. Bony union was confirmed with a CT scan obtained at 4 months (Fig 6). The patient was well 17 months after surgery. His provisional prosthesis was switched out for a final prosthesis at 16 months postoperatively (Fig 7).Figure 7Postoperative photographs 17 months after surgery. A, Frontal. B, Intra-oral views.View Large Image Figure ViewerDownload Hi-res image Download (PPT) A 23-year-old man was referred for biopsy-proved ameloblastoma of the right mandible. The lesion was incidentally found by the referring provider, and the patient was asymptomatic (Fig 8A, B). CT scan showed a 2.5- × 2-cm expansile lytic lesion involving the right mandibular body with buccal expansion and cortical perforation.Figure 8A, B, Preoperative photographs. C, D, Virtual plan showing the mandible, fibula cutting guides, and planned osteotomies. E, Planned reconstruction with single-segment fibula with 4 dental implants. F, Positioning of the fibula and implants in relation to the anticipated occlusion. G, Virtual placement of screw holes between implants to avoid interferences. H, Predictive holes in the mandibular cutting guide used to secure the reconstruction bar.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Virtual planning was performed in a similar fashion as for case 1. 3D Systems (Denver, CO) was used for the planning in this case. The plan consisted of surgical resection of the tumor with a 1-cm margin leading to loss of the right mandibular canine through the second molar as part of the surgical specimen (Fig 8C, D). The reconstruction was driven by the patient's existing occlusion; a single fibular segment with 4 implants was used to reconstruct the defect (Fig 8E). The implants and fibula were positioned in space by adding and subtracting the patient's teeth during the virtual planning (Fig 8F). Similar to case1, cutting guides for the mandible and fibula were designed, with the fibular guide containing guides for the osteotomies and dental implant placement (Fig 8D). In contrast to case1, a custom milled bar was used (Stryker, Portage, MI). This allowed virtual placement of the screw holes in any desired position and thus avoided interference between the dental implants and fixation screws (Fig 8E). Furthermore, the use of a custom plate allowed for the use of predictive holes in the mandible and fibula cutting guides. Predictive holes are strategically planned screw holes that are used to secure the cutting guides in place and are designed to line up with the holes on the custom plate (Fig 8F). These holes can considerably simplify the positioning of all components 3-dimensionally in space and help with the inset of the fibula-and-prosthesis construct at the head. During surgery, the fibula flap was harvested in the usual fashion. The fibula guide was secured in place using predictive holes, and implant placement proceeded in the standard sequential manner using the Nobel guided kit (Fig 9A). Osteotomies were made and the proximal fibula bone was dissected off to free up the vascular pedicle. Then, 5-mm straight multiunit abutments and temporary copings were placed over the implants in the standard fashion (Fig 9B, C). The prosthesis was placed over the implants. Once positioning of the fibula and prosthesis was confirmed against a resected model, the prosthesis was luted to the implants (Fig 9D). This fibula-and-prosthesis complex was ready to be passed off to the head for inset and anastomosis. The use of the mandible-resected model at the leg allows for adjustments at the leg and thus shortening ischemia time by facilitating the inset process. The fibula-and-prosthesis complex was moved to the head and adjusted to fit the adjacent mandible and teeth and the opposing dentition. This positioning was aided by the use of the predictive holes made in the mandible and a final occlusal splint. Figure 10 shows the occlusion of this patient 3 weeks after surgery. Notice how well the prosthesis complements the adjacent and opposing dentition. CT scan obtained at 4 months showed good bony union (Fig 11). Thirteen months after the initial surgery, the patient was well. His provisional prosthesis was been switched out to a milled zirconium prosthesis at 12 months (Fig 12). The tissue around the implants appeared healthy at 1 year at the insertion of the final prosthesis because of preservation of the attached gingiva at the time of resection (Fig 12C). If hyperplastic tissue or loose mobile tissues surround the implants, then a skin grafting procedure might be feasible using the actual prosthesis as a stent.Figure 10Occlusion 3 weeks after surgery.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 11Computed tomogram at 4 months after surgery showing good bony union.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 12A, B, Photographs 12 months after surgery. C, Condition of the tissues around the implants at the time of final prosthesis insertion at 1 year.View Large Image Figure ViewerDownload Hi-res image Download (PPT) A 34-year-old woman had biopsy-proved ameloblastoma of the anterior mandible extending from canine to canine on imaging. (Fig 13A-C). The patient was treated with a fibula jaw-in-a-day procedure in a similar fashion as in case 2. Figures 13D and E further illustrate the utility of the predictive holes in helping position all the involved segments 3-dimensionally in space. Figures 14A and B show the resected specimen and underscore the importance of this technique in reconstructing this critical area of the mandible and its impact on the patient's psychology and quality of life. The fibula-and-prosthesis complex is shown in Figure 14C and Video 2. Figure 14D and Video 3 show the occlusion at the conclusion of the procedure. Figure 15A shows the patient 3 weeks after surgery, and Figures 15B and C show the patient at 3 months after surgery. Figure 15D shows good bony union at 4 months postoperatively at CT imaging.Figure 14A, B, Resected mandibular specimen. C, Assembled fibula-and-prosthesis complex ready for transfer to the head. D, Fibula-and-prosthesis complex in occlusion after flap inset.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 15A, Postoperative photographs 3 weeks after surgery. B, C, Extraoral and intraoral photographs 3 months after surgery. D, Computed tomogram at 4 months showing good bony union between the bony segments.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 15A, Postoperative photographs 3 weeks after surgery. B, C, Extraoral and intraoral photographs 3 months after surgery. D, Computed tomogram at 4 months showing good bony union between the bony segments.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Dental rehabilitation after bony microvascular reconstruction often takes 6 to 12 months to complete.2Urken M.L. Buchbinder D. Weinberg H. et al.Primary placement of osseointegrated implants in microvascular mandibular reconstruction.Otolaryngol Head Neck Surg. 1989; 101: 56PubMed Google Scholar, 5Shen Y.F. Rodriguez E.D. Wei F.C. et al.Aesthetic and functional mandibular reconstruction with immediate dental implants in a free fibular flap and a low-profile reconstruction plate: Five-year follow-up.Ann Plast Surg. 2015; 74: 442Crossref PubMed Scopus (28) Google Scholar In the traditional approach, implants are placed 3 to 6 months after the free flap procedure to allow for adequate bony consolidation. After the implants are placed, they are allowed to undergo osseointegration before fabrication of the prosthesis. Any preprosthetic surgery that is required, including vestibuloplasties, flap debulking, and or skin grafting, also can be performed during this timeframe, if feasible.7Wu Y.Q. Huang W. Zhang Z.Y. et al.Clinical outcome of dental implants placed in fibula-free flaps for orofacial reconstruction.Chin Med J (Engl). 2008; 121: 1861PubMed Google Scholar, 8Kramer F.J. Dempf R. Bremer B. Efficacy of dental implants placed into fibula-free flaps for orofacial reconstruction.Clin Oral Implants Res. 2005; 16: 80Crossref PubMed Google Scholar The time-proven success of the all-on-4 procedure with immediate provisionalization for the edentulous mandible has increased interest in applying these same principles to the patient undergoing fibular reconstruction.9Maló P. de Araújo Nobre M. Lopes A. et al.“All-on-4” immediate-function concept for completely edentulous maxillae: A clinical report on the medium (3 years) and long-term (5 years) outcomes.Clin Implant Dent Relat Res. 2012; 14: e139Crossref PubMed Scopus (156) Google Scholar Chiapasco and Gatti10Chiapasco M. Gatti C. Immediate loading of dental implants placed in revascularized fibula free flaps: A clinical report on 2 consecutive patients.Int J Oral Maxillofac Implants. 2004; 19: 906PubMed Google Scholar and Okay et al11Okay D.J. Buchbinder D. Urken M. et al.Computer-assisted implant rehabilitation of maxillomandibular defects reconstructed with vascularized bone free flaps.JAMA Otolaryngol Head Neck Surg. 2013; 139: 371Crossref PubMed Scopus (40) Google Scholar reported on cases in which implant placement with immediate provisionalization was performed using the fibula free flap 3 months after the initial surgery, essentially treating the fibula-reconstructed mandible the same way as an edentulous mandible. Rohner et al12Rohner D. Bucher P. Hammer B. Prefabricated fibular flaps for reconstruction of defects of the maxillofacial skeleton: Planning, technique, and long-term experience.Int J Oral Maxillofac Implants. 2013; 28: e221Crossref PubMed Scopus (27) Google Scholar and Freudlsperger et al13Freudlsperger C. Bodem J.P. Engel E. et al.Mandibular reconstruction with a prefabricated free vascularized fibula and implant-supported prosthesis based on fully three-dimensional virtual planning.J Craniofac Surg. 2014; 25: 980Crossref PubMed Scopus (26) Google Scholar shared their experience with prefabricated free flaps, which helped pave the way for the fibula jaw-in-a-day procedure. In this technique, implants and skin graft are placed on the fibula in situ and left there for 3 months for osseointegration. In a second-stage surgery, the fibula is harvested with the osseointegrated implants and an immediate provisional prosthesis is inserted. Although this technique is remarkable and shares some similarities with the present technique, the drawbacks are obvious: it requires 2 surgical procedures and patients would go without a reconstruction for several months. Odin et al14Odin G. Balaguer T. Savoldelli C. et al.Immediate functional loading of an implant-supported fixed prosthesis at the time of ablative surgery and mandibular reconstruction for squamous cell carcinoma.J Oral Implantol. 2010; 36: 225Crossref PubMed Scopus (0) Google Scholar reported on a case in which the provisional prosthesis was inserted 48 hours after the fibula free flap procedure during the same hospitalization. Implants were placed into the fibula after the completion of flap inset and anastomosis. Then, an impression was taken for fabrication of a prosthesis. With the advances and increased accuracy of virtual planning, impressions are no longer necessary and these procedures are performed in a stepwise manner. The technology has advanced to the point where implants can be placed at the leg and the position of each implant can be exactly predicted 3-dimensionally in space when transferred to the head.15Hirsch D.L. Garfein E.S. Christensen A.M. et al.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: 2115Abstract Full Text Full Text PDF PubMed Scopus (248) Google Scholar Using an occlusion-driven approach, the implants are ideally positioned to support the prosthesis. This allows the prosthesis to be placed and luted to the implants with minimal adjustments. The use of “resected medical models” at the leg can confirm the fit of the prosthesis and simulate the inset process, thus allowing for inset of the fibula-and-prosthesis construct at the head with minimal, if any, adjustments. An occlusal splint is used to position the fibula-and-prosthesis complex in relation to the adjacent mandible and opposing dentition. A maxillofacial prosthodontist is present during surgery to check final occlusion with articulating paper to ensure there are no detrimental occlusal interferences in maximum intercuspation and in function. The first group to perform this jaw-in-a-day procedure successfully is a multidisciplinary group at New York University led by Levine et al.6Levine J.P. Bae J.S. Soares M. et al.Jaw in a day: Total maxillofacial reconstruction using digital technology.Plast Reconstr Surg. 2013; 131: 1386Crossref PubMed Scopus (114) Google Scholar The present authors are the first group to perform this procedure solely within the department of oral and maxillofacial surgery. The use of a digital dental laboratory in conjunction with a virtual planning company allows the prosthesis to be milled or created with computer-aided design and computer-aided manufacturing technology. The authors' department has an in-house laboratory, which substantially lowers costs for the department and patients. Therefore, these provisional prostheses were fabricated in house. One might note from the figures that a skin paddle was harvested with the fibula in all 3 cases. This was performed as a precautionary measure in case primary closure over the fibula intraorally was not attainable. The authors could obtain primary closure around the implants in all 3 cases with the patients' native mucosa. Therefore, the skin paddles were trimmed and used as small external skin monitors in cases 1 and 2, which were excised 3 to 4 weeks after surgery (not shown). In case 3, the authors elected to bury the flap and not use the skin paddle for esthetic reasons. The flap was monitored with a Synovis flow coupler (Birmingham, AL). The advantages of the fibula jaw-in-a-day technique become apparent when one looks at Figure 14A and considers patients who are suddenly faced with the reality that they are going to lose a substantial portion of their jaw because of tumor surgery. This can have a serious psychological impact on patients and affect their quality of life. This technique allows for early restoration of form and function, giving patients a sense of normalcy. Another advantage is the decrease in the number of procedures and general anesthetics required to obtain the final result.16Hanasono M.M. Chang D.W. Discussion: Jaw in a day: Total maxillofacial reconstruction using digital technology.Plast Reconstr Surg. 2013; 131: 1392Crossref PubMed Scopus (7) Google Scholar This can yield some cost savings and needs to be investigated further. Moreover, the excellent access to the fibula at the time of harvest combined with guided implant placement is likely to provide the surgeon the best opportunity to position these implants in the proper position and optimal angulation. The disadvantage of this technique is that it is a new technique and therefore has a learning curve. Furthermore, the impact of this procedure on free flap survival and implant success rates is not known because of the small number of cases reported thus far, although the early findings have been favorable. The success of immediate implants without immediate loading has been documented by previous studies even in the setting of malignant disease with postoperative radiation.2Urken M.L. Buchbinder D. Weinberg H. et al.Primary placement of osseointegrated implants in microvascular mandibular reconstruction.Otolaryngol Head Neck Surg. 1989; 101: 56PubMed Google Scholar, 3Chang Y.M. Santamaria E. Wei F.C. et al.Primary insertion of osseointegrated dental implants into fibula osteoseptocutaneous free flap for mandible reconstruction.Plast Reconstr Surg. 1998; 102: 680Crossref PubMed Scopus (109) Google Scholar, 4Chana J.S. Chang Y.M. Wei F.C. et al.Segmental mandibulectomy and immediate free fibula osteoseptocutaneous flap reconstruction with endosteal implants: an ideal treatment method for mandibular ameloblastoma.Plast Reconstr Surg. 2004; 113: 80Crossref PubMed Scopus (126) Google Scholar, 5Shen Y.F. Rodriguez E.D. Wei F.C. et al.Aesthetic and functional mandibular reconstruction with immediate dental implants in a free fibular flap and a low-profile reconstruction plate: Five-year follow-up.Ann Plast Surg. 2015; 74: 442Crossref PubMed Scopus (28) Google Scholar Although further studies are needed to validate these findings, immediately placed implants appear to be safe at this time and serve as the rationale for the jaw-in-a-day procedure. The greatest and most obvious disadvantage of this technique is the loss of the investment in dental implants and the prosthesis should a flap failure occur. This occlusion-driven technique requires close collaboration among the oral and maxillofacial surgeon, microvascular surgeon, prosthodontist, and dental laboratory technician in the same way for the all-on-4 procedure. Furthermore, this technique underscores why oral and maxillofacial surgeons are well suited to reconstruct the maxillofacial region using conventional or microvascular techniques. For years, oral & maxillofacial surgeons stood out in the fields of facial trauma, orthognathic, and tempromandibular joint surgery, because of their dental background and understanding of occlusion and the tempromandibular joints. In conclusion, according to the early available data, the fibula jaw-in-a-day procedure seems a viable option for the immediate reconstruction of the mandible and associated dentition after resection of benign tumors. Levine et al6Levine J.P. Bae J.S. Soares M. et al.Jaw in a day: Total maxillofacial reconstruction using digital technology.Plast Reconstr Surg. 2013; 131: 1386Crossref PubMed Scopus (114) Google Scholar also have been successful in reconstructing a case of the maxilla using this technique. Long-term follow-up data are needed to validate the success of this technique and its impact on flap and implant success rates. The role of this technique in treatment of patients with malignancies will need to be investigated. This technique is likely to become more prevalent in the future as more surgeons become familiar with it. https://www.joms.org/cms/asset/911fc046-45c5-4f94-9715-f2b72cfede92/mmc1.mp4Loading ... Download .mp4 (25.78 MB) Help with .mp4 files Video 1Final occlusion at the conclusion of the case.https://www.joms.org/cms/asset/44dc43df-7fc0-46ea-8d5f-7bba6f4b75a6/mmc2.mp4Loading ... Download .mp4 (12.02 MB) Help with .mp4 files Video 2Fibula-and-prosthesis complex before transfer to the head.https://www.joms.org/cms/asset/52bd243a-5811-40f4-a220-7e587a2ca586/mmc3.mp4Loading ... Download .mp4 (30.04 MB) Help with .mp4 files Video 3Occlusion at the conclusion of the procedure. Supplementary data associated with this article can be found, in the online version at, http://dx.doi.org/10.1016/j.joms.2016.01.047." @default.
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• W2263671871 title "Fibula Jaw in a Day: State of the Art in Maxillofacial Reconstruction" @default.
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