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A systematic review of the literature concerning surgical engineering in cranio-maxillofacial surgery was performed. A PubMed search yielded 1721 papers published between 1999 and 2011. Based on the inclusion/exclusion criteria, 1428 articles were excluded after review of titles and abstracts. A total of 292 articles were finally selected covering the following topics: finite element analysis (n = 18), computer-assisted surgery (n = 111), rapid prototyping models (n = 41), preoperative training simulators (n = 4), surgical guides (n = 23), image-guided navigation (n = 58), augmented reality (n = 2), video tracking (n = 1), distraction osteogenesis (n = 19), robotics (n = 8), and minimal invasive surgery (n = 7). The results show that surgical engineering plays a pivotal role in the development and improvement of cranio-maxillofacial surgery. Some technologies, such as computer-assisted surgery, image-guided navigation, and three-dimensional rapid prototyping models, have reached maturity and allow for multiple clinical applications, while augmented reality, robotics, and endoscopy still need to be improved.
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Surgical Engineering in Cranio-Maxillofacial
Surgery:
ALiterature Review
Raphael Olszewski, DDS, MD, PhD
Oral and Maxillofacial Surgery Research Lab
Department of oral and maxillofacial surgery
Cliniques universitaires saint Luc
Université catholique de Louvain, Brussels, Belgium
Submitted March 2011. Accepted for publication August 2011
ABSTRACT
Asystematic review of the literature concerning surgical engineering in cranio-maxillofacial
surgery was performed. APubMed search yielded 1721 papers published between 1999 and 2011.
Based on the inclusion/exclusion criteria, 1428 articles were excluded after review of titles and
abstracts. Atotal of 292 articles were finally selected covering the following topics: finite element
analysis (n = 18), computer-assisted surgery (n = 111), rapid prototyping models (n = 41),
preoperative training simulators (n = 4), surgical guides (n = 23), image-guided navigation (n =
58), augmented reality (n = 2), video tracking (n = 1), distraction osteogenesis (n = 19), robotics
(n = 8), and minimal invasive surgery (n = 7). The results show that surgical engineering plays a
pivotal role in the development and improvement of cranio-maxillofacial surgery. Some
technologies, such as computer-assisted surgery, image-guided navigation, and three-dimensional
rapid prototyping models, have reached maturity and allow for multiple clinical applications,
while augmented reality, robotics, and endoscopy still need to be improved.
Keywords: engineering, maxillofacial, craniofacial, review, surgery
1. INTRODUCTION
Cranio-maxillofacial surgery (CMF) represents a broad range of sub-specialties, such
as maxillofacial oncological surgery (resection of tumors and reconstruction of the site
with different types of grafts), craniofacial corrective surgery of malformative
syndromes (i.e., craniostenoses, or cleft lip palate), orthognathic surgery and distraction
osteogenesis (to correct maxillomandibular dysmorphoses), maxillofacial trauma
surgery and associated reconstructive maxillofacial surgery, and implantology. Surgical
engineering in CMF surgery is present at all levels of the CMF clinical workflow, from
diagnostic tools to preoperative planning, intra-operative guidance and transfer of
preoperative planning to the operative theater. This literature review presents a broad
overview of the implications of surgical engineering in CMF surgery.
Journal of Healthcare Engineering · Vol. 3 · No. 1 · 2012 Page 53–86
53
*Tel: 003227645718, Fax: 003227645876, Email: raphael.olszewski@uclouvain.be
2. METHODS
The literature search was performed on Medline PubMed by one researcher. The
inclusion criteria were as follows: maxillofacial surgery, craniofacial surgery,
implantology, distraction osteogenesis, orthognathic surgery, cleft lip palate surgery,
traumatology, finite elements analysis, technology, robotics, virtual reality, augmented
reality, haptic, computer-assisted surgery, computer-assisted surgical planning,
computer-assisted guides, rapid prototyping, three-dimensional (3D) facial
morphology, maxillofacial simulators, maxillofacial endoscopy, maxillofacial surgical
hardware, cranioplasty, craniotomy, image-guided surgery, CMF navigation,
endoscopy, temporomandibular joint, facial nerve, virtual occlusion, holography, CT
scanner, and MRI. The exclusion criteria consisted of animal studies, in vitro studies,
tissue engineering, prosthetics, orthodontics, dentistry, laser surgery, laser scanner,
piezosurgery, plates, facial protection, jaw tracking, and telemedicine. Articles without
an abstract were also excluded.
We used two main search formulas. The first formula was constructed for a broad
research of articles dealing with surgical engineering and craniofacial surgery. This
formula was formed by association between MeSH Terms (surgical procedures,
operative, engineering, and skull) and the following free text words: surgical
engineering AND cranial (((“surgical procedures, operative”[MeSH Terms] OR
(“surgical”[All Fields] AND “procedures”[All Fields] AND “operative”[All Fields])
OR “operative surgical procedures”[All Fields] OR “surgical”[All Fields]) AND
(“engineering”[MeSH Terms] OR “engineering”[All Fields])) AND (“skull”[MeSH
Terms] OR “skull”[All Fields] OR “cranial”[All Fields]) AND “humans”[MeSH
Terms]). The only limit was human studies. No limits were set on the language or date.
We obtained a total of 334 articles, of which 314 were excluded based on the title and
the abstract. Twenty articles were selected for review.
The second main formula was constructed to find articles about surgical engineering
and maxillofacial surgery. We preferred to use the word “technology” in the second
formula to search specifically for articles aimed at surgical engineering instead of tissue
engineering. We used an association between MeSH Terms (surgery, oral; and
technology) and the following free words: maxillofacial surgery technology ((“surgery,
oral”[MeSH Terms] OR (“surgery”[All Fields] AND “oral”[All Fields]) OR “oral
surgery”[All Fields] OR (“maxillofacial”[All Fields] AND “surgery”[All Fields]) OR
“maxillofacial surgery”[All Fields]) AND (“technology”[MeSH Terms] OR
“technology”[All Fields])) AND (“humans”[MeSH Terms] AND “2001/02/22”[PDat] :
“2011/02/19”[PDat]). The first limit was human studies, and the second limit was to
search over the last ten years. No limits were set on the language. We found a total of
967 articles, and 835 of them were excluded based on title-abstract sifting. The
remaining 131 were selected for review. To complete the general broad search, we
added seven specific formulas based on MeSH terms and free terms:
1. finite element analysis AND maxillofacial surgery ((“finite element
analysis”[MeSH Terms] OR (“finite”[All Fields] AND “element”[All Fields]
AND “analysis”[All Fields]) OR “finite element analysis”[All Fields]) AND
(“surgery, oral”[MeSH Terms] OR (“surgery”[All Fields] AND “oral”[All
Fields]) OR “oral surgery”[All Fields] OR (“maxillofacial”[All Fields] AND
54 Surgical Engineering in Cranio-Maxillofacial Surgery: A Literature Review
“surgery”[All Fields]) OR “maxillofacial surgery”[All Fields])) NOT
plates[All Fields] AND (“humans”[MeSH Terms] AND English[lang] AND
“2008/06/26”[PDat] : “2011/06/25”[PDat]) with 40 articles found, 36 articles
excluded, and 4 articles selected;
2.- haptic AND maxillofacial surgery (haptic[All Fields] AND (“surgery,
oral”[MeSH Terms] OR (“surgery”[All Fields] AND “oral”[All Fields]) OR
“oral surgery”[All Fields] OR (“maxillofacial”[All Fields] AND “surgery”[All
Fields]) OR “maxillofacial surgery”[All Fields])) AND (“humans”[MeSH
Terms] AND English[lang] AND “2008/06/26”[PDat] : “2011/06/25”[PDat])
with 4 articles found, 3 articles excluded, and 1 article selected;
3. computer-assisted surgery AND maxillofacial surgery (computer-assisted[All
Fields] AND “planning”[All Fields] AND (“surgery, oral”[MeSH Terms] OR
(“surgery”[All Fields] AND “oral”[All Fields]) OR “oral surgery”[All Fields]
OR (“maxillofacial”[All Fields] AND “surgery”[All Fields]) OR
“maxillofacial surgery”[All Fields])) AND (“humans”[MeSH Terms] AND
English[lang] AND “2008/06/26”[PDat] : “2011/06/25”[PDat]) with 120
articles found, 111 articles excluded or duplicated, and 9 articles selected;
4. computer-assisted navigation AND maxillofacial surgery computer-
assisted[All Fields] AND navigation[All Fields] AND (“surgery, oral”[MeSH
Terms] OR (“surgery”[All Fields] AND “oral”[All Fields]) OR “oral
surgery”[All Fields] OR (“maxillofacial”[All Fields] AND “surgery”[All
Fields]) OR “maxillofacial surgery”[All Fields])) AND (“humans”[MeSH
Terms] AND English[lang] AND “2008/06/26”[PDat] : “2011/06/25”[PDat])
with 42 articles found, 26 excluded or duplicated, and 16 articles selected;
5. distraction osteogenesis AND maxillofacial surgery ((“osteogenesis,
distraction”[MeSH Terms] OR (“osteogenesis”[All Fields] AND
“distraction”[All Fields]) OR “distraction osteogenesis”[All Fields] OR
(“distraction”[All Fields] AND “osteogenesis”[All Fields])) AND
(“technology”[MeSH Terms] OR “technology”[All Fields]) AND (“surgery,
oral”[MeSH Terms] OR (“surgery”[All Fields] AND “oral”[All Fields]) OR
“oral surgery”[All Fields] OR (“maxillofacial”[All Fields] AND “surgery”[All
Fields]) OR “maxillofacial surgery”[All Fields])) AND (“humans”[MeSH
Terms] AND English[lang]), with 40 articles found, 31 excluded or duplicated,
and 9 articles selected;
6. maxillofacial surgery AND robot ((“surgery, oral”[MeSH Terms] OR
(“surgery”[All Fields] AND “oral”[All Fields]) OR “oral surgery”[All Fields]
OR (“maxillofacial”[All Fields] AND “surgery”[All Fields]) OR
“maxillofacial surgery”[All Fields]) AND robot[All Fields]) AND
(English[lang] AND “2001/07/15”[PDat] : “2011/07/12”[PDat]) 41 articles
found, 41 excluded or duplicated;
7. minimal invasive surgery AND maxillofacial surgery minimal[All Fields]
AND invasive[All Fields] AND (“surgery, oral”[MeSH Terms] OR
(“surgery”[All Fields] AND “oral”[All Fields]) OR “oral surgery”[All Fields]
OR (“maxillofacial”[All Fields] AND “surgery”[All Fields]) OR
“maxillofacial surgery”[All Fields])) AND (“humans”[MeSH Terms] AND
Journal of Healthcare Engineering · Vol. 3 · No. 1 · 2012
55
English[lang] AND “2008/06/27”[PDat] : “2011/06/26”[PDat]) with 37
articles found, 34 articles excluded, and 3 articles selected.
Five of the seven specific formulas had a limit of time (3 years) and of language
(English). One specific formula (robot AND maxillofacial surgery) was limited to 10
years (and to the English language) because of the low number of articles on this topic
during the last 3 years. One formula had no limit of time (distraction osteogenesis)
because there were very few articles searchable in that group. To complete the research,
96 more articles were added after selection by hand search from the US Patent Office,
the European Patent Office, subject related books, and the following journals:
International Journal of Computer Assisted Radiology and Surgery, Revue de
Stomatologie et de Chirurgie Maxillo-faciale, American Journal of Orthodontics,
Journal of Oral and Maxillofacial Surgery, Journal of Cranio-maxillofacial Surgery,
European Journal of Orthodontics, American Journal of Orthodontics and Dentofacial
Orthopedics, International Journal of Oral and Maxillofacial Surgery, Journal of
Clinical Orthodontics, Neuroradiology, Computer Aided Surgery, International Journal
of Adult Orthodontics and Orthognathic Surgery, Studies in Health Technology and
Informatics, Archives of Surgery, International Journal of Oral and Maxillofacial
Implants, Clinical Implant Dentistry and Related Research, Periodontology 2000,
Journal of Prosthetic Dentistry, Oral Surgery, Oral Medicine, Oral Pathology, Oral
Radiology, and Endodontology, Medical Physics, British Journal of Oral and
Maxillofacial Surgery, Clinical Oral Implants Research, and Journal of Orofacial
Orthopedics. Altogether, we found 1721 articles. Most of the articles (1428) were
excluded based on the title and abstract and because of duplications between the nine
search formulas. Finally, 292 articles were selected for the present review.
3. RESULTS
The 292 articles selected were classified into the following groups: finite element
analysis (n = 18), computer-assisted surgery (n = 111), rapid prototyping models (n =
41), preoperative training simulators (n = 4), surgical guides (n = 23), image-guided
navigation (n = 58), augmented reality (n = 2), video tracking (n = 1), distraction
osteogenesis (n = 19), robotics (n = 8), and minimal invasive surgery (n = 7).
3. DISCUSSION
3.1. Preoperative Planning
3.1.1. Finite Element Analysis in CMF Surgery
A3D finite element (3D FE) model of the face can be based on bones, muscles [1], skin,
fat, and superficial musculoaponeurotic system reconstructed from MRI, and modeled
according to anatomical, plastic, and reconstructive surgery literature [2, 3]. The FE
mesh, composed of hexahedron elements, is generated through a semi-automatic
procedure with an effective compromise between the detailed representation of the
anatomical parts and the limitation of the computational time [2]. Nonlinear constitutive
equations can be implemented in the FE model [2]. The corresponding model
parameters are selected according to mechanical measurements on soft facial tissue, or
are based on reasonable assumptions [2]. Model assumptions concerning tissue
geometry, interactions, mechanical properties, and the boundary conditions can be
56 Surgical Engineering in Cranio-Maxillofacial Surgery: A Literature Review
validated through comparison with experiments [2]. The calculated response of facial
tissues to gravity loads, to the application of pressure inside the oral cavity and to the
application of an imposed displacement shows good agreement with the data from the
corresponding MRI and holographic measurements [2]. The goal of the FE models of
the face in CMF surgery is to predict the postoperative facial appearance with respect
to prespecified bone-remodeling plans [3], and to predict the aging process [2].
Moreover, biomechanical analysis based on FE analysis (FEA) was proposed to better
understand the biomechanical mechanism of rapid maxillary expansion, which is used
in modifying the shape of the maxilla in cleft palate patients [4]. In CMF traumatology,
biomechanical analyses involving FEA [5] were proposed to understand the role of
osteosynthesis fixation [6, 7] and to find the best possible treatment (miniplates, screws,
bioresorbable plates) for different fractured sites in the CMF skeleton such as
mandibular symphysis [8], mandibular angle fracture [9], orbital fractures [10, 11], and
massive midface injuries with bone loss [12]. FEA could also prove useful in the future
to predict the likelihood of iatrogenic fracture of the jaws after surgical removal of
mandibular bone, such as that occurs when the third molar is removed, and this may
allow surgeons to change their approach to tooth removal in certain cases [13]. In
implantology, FEAwas used to choose the best drilling technique in relation to the type
of bone [14, 15]. The results of the FEA imply that the success of a sinus-augmented
dental implant is heavily dependent on the implant design and the rigidity of the bone
grafts [15]. Presurgical FEA was also developed to predict the motion of the
craniofacial skeleton under different constraints due to different types of distractors and
different spatial vectors [16, 17]. Finally, FEA was used to determine the optimum
consolidation period for implant loading under forces of different directions and
amounts after alveolar distraction osteogenesis [18].
3.1.2. Computer Assisted Surgery Planning
Computer-assisted surgery (CAS) planning was implemented in CMF surgery so that
the complex anatomy of the patient can be understood, and that the surgical task can be
improved preoperatively [19-25]. Orthognathic surgery represents an important part of
CMF surgery and allows for correction of different dental and maxillofacial
dysmorphoses, asymmetric faces, or craniofacial syndromes by cutting and moving the
maxilla and/or the mandible according to a treatment plan. Standard orthognathic
surgery planning is shown in Figure 1. This procedure can be divided into the following
four steps [26, 27]:
“A” – Clinical examination, diagnosis and treatment planning.
“B” – Transfer of maxillary and mandibular initial position to the articulator.
“C” – Model surgery.
“D” – Transfer of final relative maxillary-mandibular position to the operating
room (OR).
In the current system, none of these steps require computer assistance. After the
clinical examination [28] (Fig 1.1 - “A1”), standard orthognathic preoperative planning
begins with diagnosis and treatment planning (“A2”). The diagnosis is achieved using
a two-dimensional (2D) cephalometric analysis (“A2”). The treatment is generated by
associating data from the clinical examination (aesthetic aspects, gingival smile, etc),
Journal of Healthcare Engineering · Vol. 3 · No. 1 · 2012
57
and the occlusal examination (on plaster casts), with results from the 2D cephalometric
analysis. 2D cephalometric analysis provides measurements of the maxillary and/or
mandibular movements to perform during model surgery (“C”) and the operative time
in relation to existing normative data or to the individual’s geometrical frame [29].
Registration of the maxillary position in relation to the skull is achieved by using a face
bow (“B1”) [30]. Registration of the mandibular position in relation to the maxilla is
obtained by using an occlusal wax bite positioned between the two dental arches
(“B2”). The face bow is then placed in a semi-adjustable articulator (“C1”). The face
bow transfers the 3D position of the maxilla into a semi-adjustable articulator [31]. A
plaster cast of the maxilla is positioned on the face bow (“C2”) and fixed by plaster to
the upper arm of the articulator. The occlusal bite registration is used for positioning the
mandibular plaster cast relative to the maxilla. Horizontal and vertical reference lines
are traced for both plaster casts (“C3”). The plaster casts are then separated from the
articulator by sawing. The casts are subsequently moved by the surgeon to their final
positions (“C4, c”). The amount of movement imposed to the plaster casts should
theoretically correspond to that planned with the 2D cephalometric analysis. This
movement may create a gap between the reference lines. The gap is measured with a
manual caliper [32]. The intercuspidation plate (or splint) (“D”) represents the
impression (in resin) of teeth contacts between the two dental arches. The intermediary
and final maxillary positioning in relation to the mandibular plaster cast requires the
manufacturing of two splints [33-35], which represent the unique element of transfer
between model surgery (“C4”) and OR (“D”).
Figure 1. Standard orthognathic surgery planning.
58 Surgical Engineering in Cranio-Maxillofacial Surgery: A Literature Review
CAS [45] was introduced in orthognathic surgery as one of the technologies (Table 2)
to resolve multiple weaknesses and pitfalls of standard procedures (Table 1) [46]. The
stages of the CAS workflow process for routine 3D virtual treatment planning of
orthognathic surgery are the following: (1) image acquisition for 3D virtual
orthognathic surgery, (2) processing of the acquired image data to construct a 3D virtual
augmented model of the patient’s head [47], (3) 3D virtual diagnosis of the patient [48],
(4) 3D virtual treatment planning for the orthognathic surgery, (5) 3D virtual treatment
planning communication, (6) 3D splint manufacturing, (7) 3D virtual treatment
planning transfer to the OR, and (8) 3D virtual treatment outcome evaluation [49]. The
image acquisition and processing of data for the 3D virtual treatment planning can
merge information from bone (computed tomography (CT) scan, cone beam CT) [50,
51], soft tissues [24, 52], external facial appearance [53-59], 3D photographic system
[57], and dental occlusion [47, 60-63] to provide the most complete 3D virtual model
of each patient [64]. Figure 2 exhibits an example of CAS planning in orthognathic
surgery.
Journal of Healthcare Engineering · Vol. 3 · No. 1 · 2012
59
2D radiological
planning (A2)
[29, 36-40]
Face-bow (B1) [26,
30, 31, 40]
Model surgery (C2-C4)
[26, 40-44]
Splint (D) [33, 40]
Insufficient distance
between the source
and the target
Inaccuracy in the 3D
positioning of the
device
Hand-drawn reference lines Resin may be deformed if
heating is not achieved within
the articulator
Inadequate filter
application
Two clinicians
required for
manipulation
No standards for horizontal
or vertical reference lines
High risk of destruction of the
occlusal part of the models
when resin is not correctly
separated from the plaster casts
Superimpositions of
anatomical
structures
Long time for
manipulation
The reference lines do not
correspond to any lines from
the 2D cephalometry
Splint does not transfer any
absolute position of the maxilla
and/or mandible in relation to
the skull
Impossible to
quantify right-left
asymmetry
The reference lines do not
correspond to any of the
osteotomy lines
No standard for movement
(translation or rotation) to
perform first during
manipulations of the plaster
casts
No quantifiable control
during the rotations of the
plaster casts
Table 1. The pitfalls and limitations of a standard orthognathic surgical procedure.
Figure 2. CAS planning in orthognathic surgery. (A) Pre-operative profile with soft
and hard tissue superimposition. (B) Virtual planning with 3D
cephalometric analysis and double advancement of the chin. (C) Post-
operative visualisation of soft and hard tissues modification.
60 Surgical Engineering in Cranio-Maxillofacial Surgery: A Literature Review
Task Means
Analyze 2D X-Rays
manual
cephalometry
[72-81]
2D X-Rays
digital
cephalometry
[82]
3D cephalometry
CT [83-86 ]
Simulate
bone
movements
Articulator and
plaster casts [72,
87-91]
Robot arm for
model surgery
[92]
3D RP
model
[73, 93]
CAS planning
[84, 85, 94-98]
Simulate soft
tissues
CAS planning (CT,
laser scan)
[99-102]
Check
occlusion
Plaster casts [72,
84, 85, 87, 92]
3D CT
reconstr-
uction
[63]
Laser scanned
virtual model [82]
Combinat-
ion 3D CT
—laser scan
virtual
model
[103]
Transfer Acrylic splint
[72]
Surgical
guide
[73, 85]
Image-guided
surgery [82, 84,
104-107]
Augmented
reality
[108]
Robotics
[92, 109, 110]
Table 2. Different technologies used in orthognathic surgery for the analysis, planning, and transfer of
preoperative planning to OR.
Three-dimensional virtual diagnosis and treatment planning enable us to simulate
and quantify osteotomies [65] and bone movements, to try to predict postoperative soft
tissues appearance with a photorealistic quality [66, 67], and to verify the achievement
of good postoperative virtual dental occlusion by means of collision detection
algorithms [63, 68]. The movements of the mandible can be added to the 3D virtual
model of the patient to provide dynamic/functional data and to predict surgical
outcomes [69, 70]. In 3D virtual planning, a precise knowledge of the location of the
mid-facial plane is important for the assessment of asymmetric deformities and for the
planning of reconstructive procedures [69]. Automatic extraction of the mid-facial
plane was proposed by De Momi et al. [71] based on matching homologous surface
areas selected by the user on the left and right facial sides through iterative closest point
optimization. Soft tissue prediction of the patient’s final appearance after orthognathic
surgery still needs some improvements [66, 67].
CAS planning in implantology allows obtaining highly precise implant positioning,
taking advantage of the maximum amount of bone available, and facilitating minimally
invasive surgery [111]. The workflow consists of the following steps: (1) CT/cone beam
CT data acquisition [112], (2) 3D reconstruction, and (3) 3D implant planning
(Implametric, Simplant [113], NobelGuide [115, 116], med 3D [117, 118]). These
software allows for axial cuts and panoramic cuts with multiple bucolingual cuts. Bony
and soft tissues structures can be easily visualized [114]. The tendency is toward
prosthodontic-driven implant placement (Figure 3), taking into account the later
prosthetic restoration [111], and to achieve integration of anatomical, biomechanical,
and aesthetic factors [119]. To incorporate the information from the prosthodontic wax-
up, a template is prepared and introduced into the workflow. First, a template with
radioopaque position markers (gutta-percha or calibrated balls of known diameter) or a
special radioopaque template (with barium sulfate coating) is made for the patient [114,
120] (Figure 3). Then the patient without the template and the template itself are
separately CT scanned (Nobel guide procedure). Using the chosen software, a treatment
is planned based on the implant position in the axial, sagittal and panoramic sections.
The functional and aesthetic outcome will be satisfactory if the template is made based
on the final shape of the tooth (shape, emergency profile, occlusion, and contact areas)
and not based on bone quality alone [113]. The template can also be modified to serve
as a surgical guide. If the modification of tamplate is not possible, a new surgical guide
is manufactured [113]. A different template can be used for a different supporting
surface. The templates can be supported by teeth or both teeth and mucosa, or they can
be directly fixed to the maxilla bone [114, 121]. The template can be stabilized by
placing pins directly into the bone through soft tissue [114], raising a flap and placing
the template into the bone, using wires as a guide and support [113], using transitional
implants [122], or placing the template over soft tissues [114, 120]. 3D CT
reconstruction enables determining the implant number, location, angle and
characteristics [114]. CAS in implantology is appropriate for situations with anatomical
limitations, such as an inferior alveolar nerve [120], nasal fossae or maxillary sinus
[117, 123], or atrophic maxilla [119]. CAS allows visualization of the amount of
available bone in each area, which is important for choosing the ideal donor site for the
osseous grafts. CAS also enables choosing the best graft location as well as the shape
and volume of the graft [119, 123]. In complex procedures, such as zygomatic implants
Journal of Healthcare Engineering · Vol. 3 · No. 1 · 2012
61
[124], 3D CAS implantology planning helps to follow the critical anatomical structures
along the implant trajectory [125, 126].
Figure 3. CAS planning in implantology. Virtual planning of 8 implants positioning
in the upper maxilla after a double sinus lift, with the help of the
prosthodontic-driven template (in blue).
In reconstructive oncological CMF surgery, virtual bending of the mandibular
reconstructive plate [127] or shaping of the fibular graft to reconstruct the mandible
after oncological resectioning can be performed by means of computer-aided
design/computer-aided manufacturing (CAD/CAM) procedures [128]. CAS planning
has also been used for the evaluation of the presurgical mandibular anatomy, by which
3D models of the fibula graft are obtained [128, 129].
3.1.3. Rapid Prototyping 3D Models
Rapid prototyping (RP) was introduced in the 1980’s as a techniques for manufacturing
of physical models from CAD/-CAM. In RP, a medical model is built layer by layer,
reproducing almost every shape of the external and the internal anatomical structures
(Table 3). RP models are different from the physical models manufactured by drilling
[130]. The medical models or bio-models represent a part of the human anatomy at a
1:1 scale obtained from 3D medical imaging (CT scan, MRI). Fabrication of the
medical models consists of four main steps: (1) 3D imaging (3D CT, MRI), (2) image
processing including segmentation of the zone of interest, (3) image data optimization,
and (4) construction of the medical model with RP.
Different methods have been proposed, such as stereolithography [131-135], selective
laser sintering (SLS) [136, 137], PolyJet [138], fused deposition modeling [139], and 3D
printing [140] (Table 3). Artifacts in 3D RP models are due to data import, computed
tomography gantry distortion, metal, motion, surface roughness due to removal of
support structure or surface modeling, and image data thresholding [139]. The source of
the artifact can be related to the patient, to the imaging modality performance, or to the
modeling technology [139]. RP medical modeling in CMF surgery involves multiple
indications for diagnosis [143], instruction for residents [133], and patient information
62 Surgical Engineering in Cranio-Maxillofacial Surgery: A Literature Review
tool when obtaining consent for surgery [134]. A specific application of RP technology
is the diagnosis and treatment planning for facial fractures (i.e., titanium mesh prebent
on 3D RP models to correct orbital fractures) (Figures 4, 5) [144-148].
Table 3. Different techniques of RP modeling for craniomaxillofacial surgery
Figure 4. Rapid prototyping (RP) applied to the diagnosis and treatment planning
for orbital fractures. (A) Pre-operative soft-tissue appearance for late left
inferior orbital wall fracture with enophthalmos and accentuated upper
palpebral fold on the left side. (B) Preoperative low-dose CT scan,
coronal view, fracture of the left orbit floor. (C) Postoperative appearance
of left eye; correction of the left palpebral fold. (D) Postoperative low-
dose CT scan, coronal view, restoratio ad integrum of the left inferior
orbital wall with the pre-shaped titanium mesh.
Name Technical
principle
Dimensional error
Stereolithography Photopolymer
cured layer by layer
with UV laser
2.2% [141] to 2.7% [142]
Selective laser
sintering
CO2 laser beam
heats powder
particles and fuses
them together
1.79% [138] to 2.1% [136, 138]
Fused deposition
modeling
Extrusion of heated
thermoplastic
material layer by
layer
Not found
Polyjet Jetting a state-of- 2.14% [138]
the-art
photopolymer in
ultrathin layers
(16�m) onto a build
tray
3D printing Selective dispersion
of binder onto
powder layers
3.14% [138]
Journal of Healthcare Engineering · Vol. 3 · No. 1 · 2012
63
Figure 5. Rapid prototyping (RP) applied to the surgery for orbital fractures (same
patient as in Figure 4). (A) Pre-bent titanium mesh on the 3D RP model.
The holes for the screws and the size of the guide are marked with black
pencil (arrow). (B) The acrylic surgical guide for the positioning of the
holes for the screws on the 3D RP model; positioning of the drill at 90°
to the bone surface. (C) Intra-operative drilling of the holes through the
surgical guide. (D) Intra-operative view of the positioning of the pre-bent
titanium mesh on the left orbital floor.
RP models afford manufacturing of surgical guides and splints [149] for transfer of
preoperative planning (osteotomy lines, bone movements, facial asymmetry) to the
operating theater in orthognathic surgery [150-152], implantology [153], and
distraction osteogenesis [154-155]. In reconstructive oncological CMF surgery, 3D RP
models of the fibula graft allow for choosing the best titanium plates, allow for the
bending of the plates preoperatively (reducing the time spent in the operating theater
[156]), and help in preoperatively planning the osteotomies and bone movements [156-
160]. The 3D RP models also serve for prosthetic implant design in cranioplasty [161-
166], prosthodontic rehabilitation of the midface after malignant tumor resection [167,
168] and the preparation for temporomandibular joint replacement [169, 170].
64 Surgical Engineering in Cranio-Maxillofacial Surgery: A Literature Review
3.1.4. Preoperative Training
Very few simulators have been developed for CMF surgery, except the physical [171]
or virtual [172] simulators for facial cleft palate repair and mandibular reconstruction
[173]. Haptic models were added to simulate routine oral surgery procedures, such as
bone drilling [174].
3.2. Intraoperative Guidance
3.2.1. Surgical Guides
In orthognathic surgery, virtual planning can be transferred to the OR with a surgical occlusal
splint prepared by CAD-CAM procedures [175-177]. Olszewski et al. [178] proposed using
an acrylic guide based on a 3D RP printed model for the transfer of the osteotomy lines and
the screw holes for the osteosynthesis titanium plates from the preoperative orthognathic
surgery planning (genioplasty) to the operating theater (Figures 6-8).
Figure 6. Surgical guide based on 3D RP printed model for the transfer from the
preoperative orthognathic surgery planning to the operating theater. (A)
3D RP model, pre-operative initial position. (B) 3D RP model,
postoperative final position. Black dots indicate the position of holes for
the screws [178].
Figure 7. The acrylic guide is positioned on the osseous chin of the patient. The
holes for the screws are drilled through the surgical guide. Solid arrows
indicate the transfer lines for osteotomy paths. The broken arrow marks
the midline indicator of the acrylic guide. The acrylic guide is fabricated
on the 3D RP model based on the initial position [178].
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65
Figure 8. (A) Prebent plate on the 3D RP model in the final position. (B)
Positioning and screwing of the pre-bent plates intraoperatively [178].
For CMF skull reconstruction, Clijmans et al. [179] described thin metallic templates
to transfer preoperative planning of the new shape of the dysmorphic skull to the OR.
In reconstructive CMF surgery, a surgical guide based on a 3D RP model is used for
resectioning of the fibula and for its insertion into the resected defect on the mandible
[158-160, 180, 181]. The length of the resected mandibular bone, the mandibular
curvature, and the width of the basal bone can also be transferred to the fibula flap with
a surgical guide [158].
In CAS implantology [191, 194], surgical guides are used to facilitate procedures
such as maxillary sinus lift elevation (bone grafting of the maxillary sinus before
implant placement in the maxilla) (Figure 3) [195], zygomatic implants [124] or
pterygoid implant positioning [196], and placement of orbit prosthesis after orbital
exenteration [197]. The advantages and disadvantages of surgical guides in
implantology are summarized in Table 4.
3.2.2. Image-Guided Navigation
Image-guided navigation leads to an improvement in surgical accuracy with the aid of
software that uses the images captured from CT or MRI and a tracking system for the
surgical instruments [126]. The accuracy of image-guided navigation in CMF [198]
66 Surgical Engineering in Cranio-Maxillofacial Surgery: A Literature Review
Advantages Disadvantages
Transfer of the diagnostic wax-up for a prosthodontic
restoration into actual implant planning [182]
Not allowed for alveolar ridge expansion [126]
Increased precision of implant positioning [113, 183] Conditions of mucosa not considered [184]
Increased directional precision of drilling [185, 187] Tactile reference lost [189]
Reduced operating time [113, 188] Precise milling depth not given [126]
Reduced surgical errors [113, 190] Bone interference [193]
Bone and tooth support possible [114, 191, 192]
Table 4. The advantages and disadvantages of surgical guides in implantology.
depends on the imaging modalities [199], patient-to-image registration procedures, the
navigation system used [200-202], data acquisition [94], interaction of the surgeon with
the system [200], technical errors [200], and instrument tracking [203-205]. The
technical accuracy and the navigation procedures seem to be of minor influence [198].
Image-guided navigation requires a means of registering anatomical points in the
medical image (CT or MRI) and a software program to locate the surgical instruments
[198, 206-210]. Knowing the exact position of the instrument is the key to the success
of the surgical intervention. CT/MRI images are used as a map to provide the surgeon
with a real-time representation of the surgical instruments in relation to the images of
the patient. This real time representation allows for tracking the instrument position
during the surgery and their visualization on the computer [211]. During the surgical
phase, the surgeon is given interactive support with guidance in order to better control
potential dangers and avoid complex anatomical regions [94, 212]. Navigation is
possible through a series of sensors attached to the rotator instruments, the surgical
template and a cap fixed on the patient’s head, and the data are captured by different
systems. The obtained data are transferred immediately to the computer and enable the
surgeon to view the real situation [94].
The systems used in image-guided navigation evolved from stereotactic
neurosurgical systems (mechanical) [94, 211], ultrasound-based (connected to satellite)
[94], and electromagnetic systems (based on the localization of the instruments by
measuring the changes produced in the magnetic field intensity) [211, 212], to optical
navigation systems based on infrared light (localization of infrared light emitting diodes
on the instruments captured through cameras mounted in the operation room) [211, 213-
215]. StealthStation is the most accurate optical navigation system (mean [SD] target
registration error: 1.00 [0.04] mm), followed by VectorVision (1.13 [0.05] mm), and
then Voxim (1.34 [0.04] mm) (P < .05) [202].
Traumatic CMF injuries often present difficult reconstructive challenges for CMF
surgeons [216, 217]. Reconstruction is often complicated by significant soft tissue loss,
comminuted bone fragments, tenuous blood supply, and wound contamination [217]. For
panfacial injuries, restoration of normal facial width, facial height, and sagittal projection
may be difficult to achieve [217]. Marked swelling may limit the surgeon’s ability to
palpate and recognize subtle bony defects and malunion [217]. Furthermore, a true 3D
assessment of bony alignment may not be possible with traditional surgical exposures to
the craniofacial skeleton [217]. Image-guided navigation affords precise treatment of old
fractured zygoma in the appropriate position and orientation [218, 219]. Intraoperative
navigation can reconstruct a complex post-traumatic orbital anatomy, restore the
midfacial symmetry and optimize the treatment outcome [220-222].
The association of CAS with stereolithographic models and with intraoperative
navigation was applied to the planning and repair of zygomatico-orbito-maxillary
complex fractures [223-225]. Intraoperative navigation in maxillofacial fracture repair
facilitates reconstruction in unilateral defects through mirroring techniques, and
reconstruction in bilateral defects by importing virtual models from standard CT
datasets and by improving the software tools needed for maxillofacial surgical
reconstruction [226-228].
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67
Navigation can make tumor surgery more reliable by specifying the correct safety
margins, protecting vital structures, and facilitating the reconstruction process [229].
Image-guided navigation is especially useful in tumor resection involving complex
anatomy areas modified by tumor growth [230-232] (such as the orbit), in the proximity
of cerebral structures, and when cranial nerves could be injured [233, 234]. Image-
guided navigation allows for the immediate reconstruction of the unilateral resected
area with an autologous graft designed and positioned under navigation with a
preoperative plan based on the mirrored healthy side [235]. CAS navigation in CMF
tumor resection can also be combined with new imaging modalities, such as positron
emission tomography [236, 237]. In this combination, the surgeon is simultaneously
provided with anatomical and functional (metabolic) details. The resulting fused images
offer improved localization of malignant lesions and improve the targeting of the
biopsy, especially for small lesions [236]. Reisner et al. [238] proposed the integration
of spectroscopy-based biosensors with an image-guided surgery system. Their system
can simultaneously provide the surgeon with information about the diagnosis of the
tissue and its 3D localization. This information could help to increase the safety during
surgery for malignant tumor resections [238].
In implantology, the accuracy achieved with manual implantation is sufficient [200].
However, some situations exist where a very precise navigation-guided implantation
[239] is required, such as those due to anatomical limitations (inferior alveolar canal,
nasopalatine canal, maxillary sinus, pterygoid region), limited space, atrophic maxillae
[240-246], sinus lift, and trans-zygomatic implants [200, 247, 248]. Image-guided
navigation in orthognathic surgery enables transfer of individualized 3D virtual
planning and drilled screws holes for plating the osteotomy lines [249] to improve the
reproducibility of the preoperative simulation [250, 251]. Intraoperative navigation has
also been used in the resection of the ankylotic bone in temporomandibular joint (TMJ)
gap arthroplasty [252] and for TMJ arthroscopy using optoelectronic tracking
technology [253, 254].
The most difficult clinical situations for image-guided navigation in the CMF region
are related to edentulous patients and to the mandible [255]. In edentulous patients, the
registration depends on the required level of accuracy, the prospective region for
surgical navigation, and the status of the patient’s prosthesis [255]. The mobility of the
mandible makes it difficult to accurately synchronize with preoperative imaging data
[233]. However, a teeth-mounted sensor frame and teeth-supported fiducial markers can
afford more accurate navigation for surgery of the lower jaw [233].
3.2.3. Augmented Reality
Augmented reality provides the surgeon with real-time intraoperative information from
preoperative planning by see-through glasses or video projectors to directly visualize
the planning data in the surgeon’s field of view [256]. Mischkowski et al. [257]
introduced the augmented reality tool (X-Scope) based on the visual tracking of real
anatomic structures in superposition with volume-rendered CT or MRI for controlling
the intraoperative translocation of the maxilla.
68 Surgical Engineering in Cranio-Maxillofacial Surgery: A Literature Review
3.2.4. Video-tracking
Intra-operative facial nerve monitoring, which is imperative in facial nerve dissection
(resection of parotid glands tumors), is based on electromyography and video-tracks the
ipsilateral oral commissure displacement in relation to different levels of current
administered to the nerve during surgical procedures [258].
3.2.5. Distraction Osteogenesis
Distraction osteogenesis (DO) consists of sectioning and elongating a bone at a specific
rate with a distractor to create bone by osseous distraction (Figure 9). Different types of
DO devices are described in Table 5. DO can reconstruct a deformed skull, a midface
complex, a mandible or an alveolar ridge [259-261].
The main issue in DO is the accurate positioning of the distractor on the
maxillofacial skeleton (mandible, maxilla, and cranium) [267] and the choice of the
best suitable distraction vector for 3D moving and shaping of the newly created bone
and soft tissues. CAS planning has been employed for individual positioning of the
distractor, performing virtual osteotomies, visualizing the displacement of newly
created bone in 3D space, and correcting facial asymmetries [264, 268]. Curvilinear
distractors require more precise positioning and individualized patient planning based
on CAS. Yeshwant et al. [269] proposed quantifying the 3D curvilinear movement to
elongate the mandible by 4 parameters of movement: radius of curvature, elongation,
pitch, and handedness (left- or right-turning helix). Based on these parameters, a
distraction device was constructed to execute a computer-assisted plan for skeletal
correction [269]. 3D CAS simulation and model surgery provide accurate orientation of
the distraction vectors [131]. A combination of virtual surgical simulations and
stereolithographic models can be validated as an effective method of preoperative
planning for complicated maxillofacial surgery cases [170, 155, 259, 262, 270-274].
Moreover, preoperative bending of distractors on RP models [273] prevents significant
loss of operation time. In DO, the 3D positioning of pins and screws affects the global
movement vector and eventually affects the treatment outcome (insufficient correction
of symmetry, insufficient amount of movement performed through the device) [275].
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69
Degree of freedom (DOF) Intraoral Extraoral
1 DOF Internal trans-sinusoidal maxillary
distractor [262], alveolar ridge
distractor (KLS Martin Track
distractor [263], smile distractor
Titamed (maxillary transverse
expansion), Zurich pediatric ramus
distractor (KLS Martin)
Rigid external distractor (RED),
Mono-block distractor (KLS
Martin)
2 DOF V2-Alveolar Distraction System;
Medartis AG [264]
3 DOF Multiaxis mandibular DO [265] Leibinger [266]
Table 5. Different types of distraction osteogenesis devices
Therefore, Kofod et al. [275] proposed transferring vector planning from 3D RP models
to the operating theater through a guiding splint, while Lübbers et al. [276, 277]
introduced image-guided navigation for positioning the screws during fixation of the
distractor. Without navigation, the mean deviation from the planned position was 4.9
mm (varying from 0.9 to 10.7 mm), with a clear tendency to position the screws in the
easy-to-access regions. With navigation, the mean deviation was significantly reduced
to 1.5 mm (varying from 0.1 to 3.4 mm).
Figure 9. Internal distraction osteogenesis (DO) device with (A) 1 DOF for vertical
ramus elongation, and (B) 3 DOF for horizontal ramus elongation [265].
3.2.6. Robotics in CMF
The use of robotics in CMF surgery is still limited to research institutions or large
clinics, because it is difficult to implement the necessary technical and logistic
measures in routine surgical work [110, 278]. The robotic system RoboDent can
transfer the virtual preoperative plan for positioning the oral implants to the OR [279,
280]. This system is based on CAS navigation of the drilling system, control of the
orientation of the drilling system in space, and control of the depth of drilling, through
a computer-assisted interface. The absolute implant position accuracy was
approximately 0.5 ± 0.4 mm, the relative accuracy between the implants was
approximately 0.2 ± 0.5 mm, and the deviation from the parallel position was
approximately 0.6 ± 0.5 degrees [281]. Da Vinci Surgical Robot (transoral approach)
was employed in CMF surgery for the resection of the base of the tongue neoplasm in
only 3 patients [282]. The application of robotics for craniotomy is confined to phantom
and animal studies [283-285]. A passive robot arm was proposed by Theodossy et al.
[92] to improve the model surgery phase during preoperative planning of orthognathic
surgery.
70 Surgical Engineering in Cranio-Maxillofacial Surgery: A Literature Review
3.2.7. Minimally Invasive Surgery: Endoscopic Surgery
Endoscopic surgery in CMF oncological surgery is limited to the resection of osseous
tumors [286]. In orthognathic surgery, endoscopically assisted mandibular lengthening
with bilateral sagittal split osteotomies and transoral osteosynthesis reduces periosteal
degloving and consequent edema. However, the minimal surface available for screw
osteosynthesis increases the difficulty of the procedure [287].
Frontal sinus fractures account for 5 to 15% of all maxillofacial injuries [288].The
majority of these fractures are the result of high-impact injuries such as motor vehicle
accidents, assaults, and sporting events [288]. The treatment algorithm for complex
frontal sinus fractures is controversial due to the associated risks of brain injury,
meningitis, cerebrospinal fluid fistula, and mucocele formation [288]. However, mild to
moderately displaced anterior table fractures have a relatively low risk of long-term
morbidity and are generally treated as esthetic deformities [288]. Unfortunately, the
coronal approach for the repair of these injuries is associated with significant sequelae
including large scars, alopecia, paresthesias, and, uncommonly, facial nerve injuries
[288]. These sequelae may result in greater cosmetic deformities than the initial injury.
Consequently, an endoscopic approach to these injuries has recently been proposed
[288]. The advantages of endoscopic surgery include limited incisions, reduced soft
tissue dissection, reduced risk of alopecia, minimal risk of postoperative paresthesias,
reduced hospital stay, and improved patient selection [288]. However, its disadvantages
include a moderate learning curve, narrow field of view, lack of depth perception, and
the fact that the surgeon cannot operate bimanually without an assistant [288].
Owing to the risk of facial nerve damage and the creation of visible scars, surgical
treatment of condylar mandible fractures using an extraoral approach remains
controversial [289]. The transoral endoscopically assisted approach for condylar fractures
has been reported to avoid these complications [289]. Endoscope-assisted treatment has
proved to be more time-consuming but may offer advantages for selected cases,
particularly in reducing the occurrence of facial nerve damage [290]. The advancements
in miniaturization afford new applications of endoscopy in implantology for
intraoperative observations, the assessment of implant sites, and active assistance during
implant placement procedures [291]. The major ducts of salivary glands have been
explored with a miniaturized sialendoscope, providing a minimally invasive approach for
the diagnosis and treatment of obstructive diseases and chronic infections [292].
4. CONCLUSIONS
Surgical engineering plays a fundament role in the development and improvement of
CMF surgery. The growth in importance of different technologies varies with time.
Some technologies have reached maturity and have multiple clinical applications, such
as CAS, image-guided navigation, and 3D RP models. Other technologies, such as
augmented reality, robotics, and endoscopy require further improvements. Preoperative
CAS training has been poorly developed. The existing surgical CMF simulators are in
their infancy and are behind advanced pilot simulators. Joint efforts between the
surgical and engineering communities should be directed toward integrated surgical
simulators for training surgeons for complex surgeries, based on simulations of
maxillofacial anatomy, image fusion modalities, and the haptic interface. The most
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71
pressing issue is to establish effective communication between surgeons and engineers,
so that clinical problem encountered by surgeons can be communicated to the engineers
and resolved through joint efforts [293].
CONFLICT OF INTEREST: The author declares no conflict of interst.
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86 Surgical Engineering in Cranio-Maxillofacial Surgery: A Literature Review
... The worldwide demand for improving healthcare standards in cranio-maxillofacial (CMF) surgery has steered many scientists to suggest feasible solutions for clinical problems. To improve conventional surgery methods and to achieve an increased success rate, CMF surgeons ask for multidisciplinary studies with the biomechanical engineers (Olszewski 2012), some of which can be listed as patient-specific surgery planning, computer-assisted prediction, customdesigned implants and finite element analysis (FEA)based studies (Gladilin and Ivanov 2009;Ouyang et al. 2017;Kraeima et al. 2018;Yang et al. 2018). These multidisciplinary approaches not only provide increased accuracy for CMF operations but also improve patient comfort. ...
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The aim of this study was to optimize and experimentally validate the certain parameters affecting the operation success of mandibular distraction osteogenesis (MDO). For this purpose, a novel MDO protocol suggested was comparatively evaluated with the conventional approaches. Moreover, in order to compare the sensitivity of MDO parameters on callus stability, three different protocols were considered. The samples of the protocols were prepared in accordance with the Finite Element models, and the experiments were conducted by simulating the finite element analysis (FEA) boundary conditions. According to FEA results, the displacement of the samples showed 28.5% reduction as only the osteotomy line was separately optimized, and 64.2% less displacement was determined when the osteotomy line and the screw configuration were optimized together. In consistent with the FEA results, the experimental findings for the same loading condition, the samples showed 62% and 84.5% fewer displacement values, respectively. As a result, the MDO protocol suggested, which is validated by both numerical and experimental studies, offers promising outcomes for operation success.
... 30 The development of RP technique has been facilitated by improvements in medical imaging technology, computer hardware, 3D image processing software and the technology transfer of engineering methods into the field of surgical medicine. 30 Since first described in the 1990s, RP as a technique for manufacture of physical models from CAD/computer aided manufacturing (CAM), 32 has now been applied in a wide range of medical specialties. RP contains the following techniques: stereolithography, selective laser sintering, fused deposition, polyjet, etc. ...
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Patients suffering from zygomatic complex fractures always present facial deformity and dysfunctions, and thereafter develop psychological and physiological problems. It is really hard to get an ideal prognosis for the zygomatic complex fractures because of the complicated anatomical structures. Computer-assisted surgery techniques, as the new emerging auxiliary methods, can optimize the surgical protocol, predict operation outcomes, and improve the accuracy and quality of the operation. Meanwhile the postoperative complications can be reduced effectively. This review aims to provide a comprehensive overview of the application of computer-assisted surgery techniques in the management of zygomatic complex fractures. © 2018 Daping Hospital and the Research Institute of Surgery of the Third Military Medical University
... Oral and Maxillofacial Surgery covers several areas considered sub-specialties, such as maxillofacial oncology, maxillofacial traumatology, orthognathic surgery, implantology, among others, in which the advancement of technologies with a combination of medicine and en-gineering have a very important role in the diagnosis and treatment of each patient in order to obtain a better postoperative and rehabilitation (1). Mandibular reconstructions have been a great challenge for the oral and maxillofacial surgeon. ...
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Background: Stereolithography, which consists of computer-aided designed/computer-aided manufactured (CAD-CAM) and computer simulations, is a manufacturing technologies used for the production of definitive models and prototypes printed in three dimensions, and is widely used in Oral and Maxillofacial Surgery. Surgical procedures using models made by these technologies offer several advantages. Materials and methods: This article describes three clinical cases of our experiences with patients diagnosed with squamous cell carcinoma and mandibular osteosarcoma, who underwent surgical removal of the lesions and subsequent mandibular reconstruction with a free fibula graft using surgical guides. Results: In all three clinical cases, surgical guides were used for the mandibular osteotomy, fibula osteotomy, and graft placement in the recipient area. Discussion: Surgical guidelines are useful for improving the accuracy of surgical interventions and are appropriate for many types of resection and mandibular reconstruction.
... In order to reduce the trauma of cranio-maxillofacial surgery for patients, the minimally invasive treatment is often adopted. And the cranio-maxillofacial puncture manually by surgeons is typical of minimally invasive treatment [1]. ...
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In view of the characteristics of high risk and high accuracy in cranio-maxillofacial surgery, we present a novel surgical robot system that can be used in a variety of surgeries. The surgical robot system can assist surgeons in completing biopsy of skull base lesions, radiofrequency thermocoagulation of the trigeminal ganglion, and radioactive particle implantation of skull base malignant tumors. This paper focuses on modelling and experimental analyses of the robot system based on navigation technology. Firstly, the transformation relationship between the subsystems is realized based on the quaternion and the iterative closest point registration algorithm. The hand-eye coordination model based on optical navigation is established to control the end effector of the robot moving to the target position along the planning path. The closed-loop control method, “kinematics + optics” hybrid motion control method, is presented to improve the positioning accuracy of the system. Secondly, the accuracy of the system model was tested by model experiments. And the feasibility of the closed-loop control method was verified by comparing the positioning accuracy before and after the application of the method. Finally, the skull model experiments were performed to evaluate the function of the surgical robot system. The results validate its feasibility and are consistent with the preoperative surgical planning.
... Medical RP models are physical hard copies of a patient's specific anatomy, visualized by three-dimensional scanning techniques. These medical models provide visual and tactile information for diagnosis and operational planning [33,34]. In the proposed research, RP is employed to build a set of prototype mockups of the tumors. ...
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Most of the current radiation therapy planning systems, which are based on pre-treatment Computer Tomography (CT) images, assume that the tumor geometry does not change during the course of treatment. However, tumor geometry is shown to be changing over time. We propose a methodology to monitor and predict daily size changes of head and neck cancer tumors during the entire radiation therapy period. Using collected patients' CT scan data, MATLAB routines are developed to quantify the progressive geometric changes occurring in patients during radiation therapy. Regression analysis is implemented to develop predictive models for tumor size changes through entire period. The generated models are validated using leave-one-out cross validation. The proposed method will increase the accuracy of therapy and improve patient's safety and quality of life by reducing the number of harmful unnecessary CT scans.
Chapter
Cranio-maxillofacial surgery (CMF) represents a broad range of sub-specialties, such as maxillofacial oncological surgery (resection of tumors and reconstruction of the site with different types of grafts), craniofacial corrective surgery of malformations associated to syndromes (i.e., craniosynostoses, or cleft lip palate), orthognathic surgery and distraction osteogenesis (to correct craniofacial deformities), cranio-maxillofacial trauma surgery and associated reconstructive maxillofacial surgery, and implantology. Surgical engineering in CMF surgery is present at all levels of the CMF clinical workflow, from diagnostic tools to preoperative planning, intraoperative guidance, and transfer of preoperative planning to the operative theater.
Thesis
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This PhD research focused on the area of Maxillofacial Additive Manufactured Surgical Guides. A mix of qualitative and quantitative research was undertaken to develop new knowledge about how guides are used, the cleanliness and surface roughness characteristics of the materials and the accuracy of procedures. The PhD thesis covers the research results from the above topics, summarising and highlighting specific advantages & limitations from the planning, designing, fabrication and use of maxillofacial surgical guides. The discussion will highlight how the work has challenged some common assumptions; conclude the clinical implications of this and the need for further research.
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Surgical guides have been used widely in maxillofacial surgery. Details of the types of digital surgical guide used in mandibular resection and reconstruction with fibula flaps at the authors’ institution are presented in this article. Three patients diagnosed with mandibular ameloblastoma underwent mandibular resection and reconstruction with fibula flaps using surgical guides for assistance. These digital surgical guides included a mandibular osteotomy guide, a fibular osteotomy guide, and a mandibular fixation guide. Surgical guides are helpful in improving the accuracy of operations and are appropriate for many types of mandibular resection and reconstruction.
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An analysis method for the tolerance problem of the mechanism of remote center of motion used in surgical robot was conducted, which incorporated the identification and definition of the mechanical tolerance. An error propagation model was established using the direct linearization method. Besides, the absolute accuracy and repeat accuracy of the mechanism were analyzed using the probabilistic method and the deterministic method. In addition, sensitivity analysis of each error factor was conducted. The result shows that the mechanism can achieve a relatively high accuracy when using the IT6 standard designing level, and sensitivity analysis can find out the key factor that affects the mechanism accuracy.
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Recent technological advances in 3D printing have resulted in increased use of this technology in human medicine, and decreasing cost is making it more affordable for veterinary use. Rapid prototyping is at its early stage in veterinary medicine but clinical, educational, and experimental possibilities exist. Techniques and applications, both current and future, are explored and illustrated in this article.
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Distraction osteogenesis of the craniofacial skeleton with the use of several different types of distraction devices (i.e., extraoral, intraoral, unidirectional, multidirectional, and customized) have been documented. However, the details of treatment planning and the method of predicting the distraction of the mandible in patients with hemifacial microsomia have not been published previously. This paper presents a technique for (1) three-dimensional treatment planning for mandibular distraction, (2) three-dimensional prediction tracings with conventional radiographs (panoramic, lateral, and posterior-anterior cephalometric), and (3) correlating the treatment planning and clinical applications. Lastly, 2 patients with hemifacial microsomia planned and treated with this approach are reported.
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Complex maxillofacial malformations continue to present challenges in analysis and correction beyond modern technology. The purpose of this paper is to present a virtual-reality workbench for surgeons to perform virtual orthognathic surgical planning and soft-tissue prediction in three dimensions. A resulting surgical planning system, i.e., three-dimensional virtual-reality surgical-planning and soft-tissue prediction for orthognathic surgery, consists of four major stages: computed tomography(CT) data post-processing and reconstruction, three-dimensional (3-D) color facial soft-tissue model generation, virtual surgical planning and simulation, soft;tissue-change preoperative prediction. The surgical planning and simulation are based on a 3-D CT reconstructed bone model, whereas the soft-tissue prediction is based on color texture-mapped and individualized facial soft-tissue model. Our approach is able to provide a quantitative osteotomy-sinulated bone model and prediction of postoperative appearance with photorealistic quality. The prediction appearance can be visualized from any arbitrary viewing point using a low-cost personal-computer-based system. This cost-effective solution can be easily adopted in any hospital for daily use.
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The purpose of this study was to assess the reliability of the planning software of an image-guided implant placement system based on a mechanical device coupled with a template stabilized on soft tissue during surgery.
Article
Objective: In recent years, three-dimensional (3D) CT-based planning methods have increasingly been implemented in oral and maxillofacial surgery. Alveolar ridge distraction is accomplished by unidirectional distraction devices which in turn must be positioned optimally in all three dimensions. It is the aim of this study to demonstrate 3D planning of alveolar ridge distraction by means of distraction implants. Patients and Methods: 1997, nine patients were treated with distraction implants for a deficient alveolar ridge. A CT-scan-based 3D milled model of the facial skull was prepared for each patient to enable preoperative diagnosis and operative planning. Results: Exact preoperative diagnosis of the alveolar ridge defect and atrophy was enabled by the 3D polyurethane model. Correct positioning of the distraction implants and predictability of the course of distraction was facilitated by preoperative planning according to the 3D model. Conclusion: Three-dimensional planning according to a milled model is an indispensable aid to positioning of distraction implants and therefore to directed augmentation of the alveolar ridge. Correct distractor positioning is vital for optimal subsequent prosthetic treatment.
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Recently, surgeons have begun to treat serious congenital craniofacial deformities including craniosynostoses with mechanical devices that gradually distract the skull. As a prospective means of treatment planning for such complex deformities, FE models derived from routine preoperative CT scans (CT/FEA) would provide ideal patient specific engineering analyses. The purpose of this study was to assess the dimensional and predictive accuracy of the CT/FEA process through the development of a D model of a dry human calvarium subjected to two-point distraction ex vivo. Comparative skull measurements revealed that CT/FEA construction error did not exceed 1% for transcranial dimensions, and the thickness error did not exceed 8.66% or 0.31 mm. CT/FEA strain predictions for the central region of the skull, between the distraction posts, were not statistically different from homologous gage values at P