Search

Purpose: The purpose of this study was to establish clinical feasibility of our 3-dimensional computer-aided surgical simulation (CASS) for complex craniomaxillofacial surgery., Materials and Methods: Five consecutive patients with complex craniomaxillofacial deformities, including hemifacial microsomia, defects after tumor ablation, and deformity after TMJ reconstruction, were used. The patients' surgical interventions were planned by using the authors' CASS planning method. Computed tomography (CT) was initially obtained. The first step of the planning process was to create a composite skull model, which reproduces both the bony structures and the dentition with a high degree of accuracy. The second step was to quantify the deformity. The third step was to simulate the entire surgery in the computer. The maxillary osteotomy was usually completed first, followed by mandibular and chin surgeries. The shape and size of the bone graft, if needed, was also simulated. If the simulated outcomes were not satisfactory, the surgical plan could be modified and simulation could be started over. The final step was to create surgical splints. Using the authors' computer-aided designing/manufacturing techniques, the surgical splints and templates were designed in the computer and fabricated by a stereolithographic apparatus. To minimize the potential risks to the patients, the surgeries were also planned following the current planning methods, and acrylic surgical splints were created as a backup plan., Results: All 5 patients were successfully planned using our CASS planning method. The computer-generated surgical splints were successfully used on all patients at the time of the surgery. The backup acrylic surgical splints and plans were never used. Six-week postoperative CT scans showed the surgical plans were precisely reproduced in the operating room and the deformities were corrected as planned., Conclusion: The results of this study have shown the clinical feasibility of our CASS planning method. Using our CASS method, we were able to treat patients with significant asymmetries in a single operation that in the past was usually completed in 2 stages. We were also able to simulate different surgical procedures to create the appropriate plan. The computerized surgical plan was then transferred to the patient in the operating room using computer-generated surgical splints.

Purpose: Current surgical planning methods are usually not adequate for the treatment of patients with complex craniomaxillofacial (CMF) deformities. To this end, we have developed a 3-dimensional (3D) computer-aided surgical simulation (CASS) planning method for the treatment of patients with complex CMF deformities. The purpose of this pilot study was to evaluate the accuracy of this technique in the treatment of patients with complex CMF deformities., Patients and Methods: Five patients with complex CMF deformities were enrolled. Surgeries were planned with the CASS planning method. Surgical plans were transferred to patients at the time of surgery via computer-generated splints. After surgery, outcome evaluation was completed by first superimposing the postoperative computed tomography (CT) model onto the planned model, and then measuring the differences between planned and actual outcomes. The criteria used to determine the accuracy of the technique were as follows: a linear difference between planned and actual outcomes of less than 2 mm, and an angular difference of less than 4 degrees ., Results: All patients underwent surgery as planned. With the use of CASS planning, medians of the differences between planned and actual postoperative outcomes were limited to 0.9 mm and 1.7 degrees ., Conclusion: The results of this pilot study are promising. They will be used as the basis of calculations needed to determine the sample size for a larger and more comprehensive study that will be undertaken to assess the accuracy of CASS planning methods.

Purpose: The purpose of this study is to assess the costs and benefits of computer-aided surgical simulation (CASS) and to compare it with the current surgical planning methods for complex cranio-maxillofacial (CMF) surgery., Materials and Methods: The comparison of methods applies to all CMF surgeries where the patient's condition is severe enough to undergo a computed tomography scan and a stereolithographic model is necessary for the surgical planning process. The costs for each method can be divided into time and other costs. The time was estimated based on the authors' experience as well as on a survey of a small group of 6 experienced CMF surgeons in the United States. The other costs were estimated based on the authors' experience., Results: CASS has lower costs in terms of surgeon time, patient time, and material costs. Specifically, total surgeon hours spent in planning are 5.25 hours compared with 9.75 for current standard methods. Material and scanning costs are Dollars 1,900 for CASS compared with about Dollars 3,510 for standard methods. Patient time for planning is reduced from 4.75 hours to 2.25 hours with CASS. The reduction in both time and other costs remains when the fixed fee costs of CASS are added to the variable costs. Amortized across the 600 patients per year (1,800 for the assumed 3-year life of the training and software), this adds only a few dollars and a fraction of an hour per surgery. Even in the case of a small clinic when the cost is amortized for 6 patients per year (18 patients for the assumed 3-year life of the training and software), the per surgery costs (9.65 hours and Dollars 2,456) will still favor CASS., Conclusion: Any great new design should consist of at least 2 of the 3 following features: faster, cheaper, and better outcome. This analysis demonstrates that CASS is faster and less costly than the current standard planning methods for complex CMF surgery. Previous studies have also shown that CASS results in better surgical outcomes. Thus, in all regards, CASS appears to be at least as good as the current methods of surgical planning.

Purpose: The purpose of this study was to compare the accuracy of 4 methods for cephalometric tracing superimposition. They are the FH@Porion method, S-N@Sella method, least-squared averaged 5 landmarks (LS-5) method, and manual geometric method., Materials and Methods: Eight lateral cephalometric radiographs were used. Cephalometric tracing was performed by 2 examiners. One had extensive experience in landmark digitization while the other had minimal experience. The radiographs were scanned and the reference landmarks ANS, Point A, Point B, and Pogonion were digitized, creating 8 master tracings. Then 6 digital copies of each master tracing were made, 3 for each examiner. Subsequently, the examiners were asked to digitize and trace predetermined cranial base landmarks and structures. Tracings occurred at 1-month intervals. As a result, 3 separate tracings of each set were obtained from each examiner. The tracings of each set were superimposed using 4 different methods in the CASSOS software (SoftEnable Technology Ltd, Hong Kong SAR, China). For each method of superimposition, the coordinates of ANS, Point A, Point B, and Pogonion were recorded. Their means and variances were calculated. The variance represents the variability of the superimposition method. A general linear model for repeated measures was computed to test whether there were statistically significant differences among the 4 superimposition methods, 2 examiners, 4 reference landmarks, and 2 directions. Because the distribution of the variances was skewed, they were transformed to log variances. Finally, the errors of the superimposition in millimeters for each given examiner, superimposition method, reference landmark, and direction (X, Y) were calculated., Results: There was a statistically significant difference in measurement variability among the 4 superimposition methods (P < .001). For both examiners, the variability of the different superimposition methods from the highest to the lowest was: Frankfort Plane registered at Porion method, Sella-Nasion registered at Sella method, least-square averaged 5 landmarks method, and the manual geometric method. In addition, there was a statistically significant difference in the magnitude of superimposition errors between the 2 examiners (P < .001). The experienced examiner was consistently more precise than the inexperienced examiner across all methods. Moreover, there was a statistically significant difference among 4 reference landmarks (P < .001). For both examiners, the recorded variability of each given reference landmark from the lowest to the highest was: ANS, Point A, Point B, and Pogonion. Furthermore, the variability differences between horizontal and vertical directions did not reach a conventional level of significance (P = .123). Finally, the recorded errors in millimeters for each superimposition method were summarized. A smaller error in millimeters represented a higher accuracy in superimposition. The error of using manual geometric or LS-5 methods for both examiners was less than 0.50 mm, while the error of using the other 2 methods was up to 0.99 mm for the experienced examiner and 2.88 mm for the inexperienced examiner., Conclusion: The error of both manual and LS-5 methods was within 0.5 mm. The LS-5 method had its advantage because it could be automated by the computer.

This study focused on the assessment of radiography, microcomputed tomography, and histology for the evaluation of bone formation in a 15.0-mm defect in the rabbit radius after the implantation of a tissue-engineered construct. Radiography was found to be useful as a noninvasive method for obtaining images of calcified tissue throughout the time course of the experiment. With this method, however, image quality was low, making it difficult to obtain precise information about the location and quantity of the bone formed. Microcomputed tomography was used to create three-dimensional reconstructions of the bone (25-microm resolution). These reconstructions allowed for greater spatial resolution than the radiography, but did not allow for imaging of the implanted scaffold material or the surrounding, nonmineralized tissue. To visualize all materials within the defect area at the cellular level, histology was used. Histological analysis, however, is a destructive technique that did not allow for any further analysis of the samples. Each technique examined here has its own advantages and limitations, but each yields unique information regarding bone regeneration. It is only through the use of all three techniques that complete characterization of the bone growth and tissue/construct responses after implantation in vivo.

Aging induces several types of architectural changes in trabecular bone including thinning, increased levels of anisotropy, and perforation. It has been determined, on the basis of analysis of mathematical models, that reduction in fracture load caused by perforation is significantly higher than those due to equivalent levels of thinning or anisotropy. The analysis has also provided an expression which relates the fractional reduction of strength tau to the fraction of elements nu that have been removed from a network. Further, it was proposed that the ratio Gamma of the elastic constant of a sample and its linear response at resonance can be used as a surrogate for tau. Experimental validation of these predictions requires following architectural changes in a given sample of trabecular bone; techniques to study such changes using microcomputed tomography are only beginning to be available. In the present study, we use anatomically accurate computer models constructed from digitized images of bone samples for the purpose. Images of healthy bone are subjected to successive levels of synthetic degradation via surface erosion. Computer models constructed from these images are used to calculate their fracture load and other mechanical properties. Results from these computations are shown to be consistent with predictions derived from the analysis of mathematical models. Although the form of tau(nu) is known, parameters in the expression are expected to be sample-specific, and hence nu is not a reliable predictor of strength. We provide an example to demonstrate this. In contrast, analysis of model networks shows that the linear part of tau(Gamma) depends only on the structure of trabecular bone. Computations on models constructed from samples of iliac crest trabecular bone are shown to be in agreement with this assertion. Since Gamma can be computed from a vibrational assessment of bone, we argue that the latter can be used to introduce new surrogates for bone strength and hence diagnostic tools for osteoporosis.

Purpose: This study incorporated 3 objectives: 1 ) to evaluate the physical location of the center of rotation as determined by a custom mathematical algorithm, 2 ) to identify and compare the geometric center of the condylar head in radiographs with the calculated center of rotation, and 3 ) to determine whether a correlation exists between jaw motion characteristics and the mandibular geometry of the subject., Materials and Methods: Lateral cephalometric radiographs of 9 subjects who underwent motion path analysis were obtained. The determined center of rotation of each mandible was calculated through a custom algorithm and recorded on the radiograph. Circular templates were used to determine the geometric center of the condyle for comparisons. Finally, measurements of 4 geometric jaw parameters were made and compared with motion characteristics to investigate whether mandibular geometry can be correlated to motion parameters., Results: All calculated centers of rotation were found to lie in the condylar head of the mandible. The average difference between the calculated center of rotation and geometric center of the condylar head was 2.87 mm (SD, 1.69 mm). In addition, correlations were found linking the length of the mandibular rotational arm to the rotational and translational motions. However, there was no correlation found with the other geometric mandibular parameters., Conclusions: Analysis of mandibular motion allows for an accurate determination of the center of rotation. Previously identified characteristic motion exists in terms of primary rotation, followed by translation of the mandible with rotation. The magnitude of each phase differs between subjects. This study points to a natural mechanism of mandibular opening as the amount of rotation increased for longer rotational arms and amount of translation increased for shorter ones, serving to lessen the disparity in the opening amounts among individuals.

This study investigated the in vitro degradation of porous poly(propylene fumarate) (PPF-based) composites incorporating microparticles of blends of poly(DL-lactic-co-glycolic acid) (PLGA) and poly(ethylene glycol) (PEG) during a 26-week period in pH 7.4 phosphate-buffered saline at 37 degrees C. Using a fractional factorial design, four formulations of composite scaffolds were fabricated with varying PEG content of the microparticles, microparticle mass fraction of the composite material, and initial leachable porogen content of the scaffold formulations. PPF scaffolds without microparticles were fabricated with varying leachable porogen content for use as controls. The effects of including PLGA/PEG microparticles in PPF scaffolds and the influence of alterations in the composite formulation on scaffold mass, geometry, water absorption, mechanical properties and porosity were examined for cylindrical specimens with lengths of 13 mm and diameters of 6.5 mm. The composite scaffold composition affected the extent of loss of polymer mass, scaffold length, and diameter, with the greatest loss of polymer mass equal to 15+/-5% over 26 weeks. No formulation, however, exhibited any variation in compressive modulus or peak compressive strength over time. Additionally, sample porosity, as determined by both mercury porosimetry and micro-computed tomography did not change during the period of this study. These results demonstrate that microparticle carriers can be incorporated into PPF scaffolds for localized delivery of bioactive molecules without altering scaffold mechanical or structural properties up to 26 weeks in vitro.

Osteoporosis-related bone damage causes major socioeconomic problems. For efficient use of therapeutic agents, it is necessary to be able to reliably identify patients with high propensity for nontraumatic fracture. Age-related bone loss imposes several architectural changes in bone; one of the few ways to estimate damage due to individual changes, and hence determine the most serious types of damage, is via the analysis of suitable mathematical models. Anatomical sites such as the vertebral body, proximal femur, and distal radius are locations where most age-related fractures occur. The inner porous (or trabecular) bone from these sites, which resemble disordered cubic networks, play a significant role in load transmission at these sites. Analysis of a mathematical model of porous bone is used to show that perforation of elements of the network is the most damaging architectural change to a bone. We also show that an expression for bone strength, derived on this basis, can capture changes in strength caused by the inclusion of other features like thinning of trabecular bone and the anisotropy of the network. We finally argue that bone density, which is currently the most routinely used diagnostic, cannot be a reliable surrogate for bone strength.

Purpose: Our goal was to establish whether the pins of an external distractor were capable of overcoming tissue resistance to distraction., Materials and Methods: The study was carried out in 2 parts. The first part of the study determined the bending rigidity of the distractors pins. To accomplish this, the distractor was installed on the mandible of a stereolithographic model using 4 regular 2.0-mm steel pins. An osteotomy was not performed. The distractor was activated using a torque gauge, and the bending rigidity of the pins was recorded. The second part of the study determined the tissue resistance to mandibular distraction using fresh cadavers. Six cadavers were divided into 2 groups to determine tissue resistance to angular and linear distraction, respectively. The devices used to measure tissue resistance were a modified external multiplanar distractor and a torque gauge., Results: In the anteroposterior direction, the tissue resistance to linear distraction clearly exceeded the bending rigidity of the pins for the first 7.5 mm of activation. After this, the opposite was true. In the vertical direction, the tissue resistance clearly exceeded the bending rigidity of the pins for the first 8.0 mm of activation. After this, the opposite was true. For the first 15.0 degrees of angular distraction in the sagittal plane, the tissue resistance was almost identical to the bending rigidity of the pins. After this, the tissue resistance significantly exceeded the bending rigidity of the pins. For the first 7.0 degrees of angular distraction in the transverse plane, the tissue resistance was marginally greater than the bending rigidity of the pins. After this, the bending rigidity of the pins increased significantly., Conclusion: The 2.0-mm steel pins used in most external multiplanar distractors are not capable of overcoming the tissue resistance to linear or angular distraction.

Tissue engineering combines the aspects of cell biology, engineering, material science, and surgery to generate new functional tissue, and provides an important approach to the repair of segmental defects and in restoring biomechanical function. The development of tissue-engineering strategies into clinical therapeutic protocols requires extensive, preclinical experimentation in appropriate animal models. The ultimate success of any treatment strategy must be established in these animal models before clinical application. It is clear that the demands of the biological and mechanical environment in the clinical repair of critical size defects with tissue-engineered materials is significantly different from those existing in experimental animals. The major considerations facing any tissue-engineering testing logic include the choice of the defect, the animal, the age of the animal, the anatomic site, the size of the lesion, and most importantly, the micro-mechanical environment. With respect to biomechanical considerations when selecting animals for tissue- engineering of bone, it is evident that no common criteria have been reported. While in smaller animals due to size constraint only structural properties of whole bones can be measured, in larger animals and humans both material properties and structural properties are of interest. Based on reported results, comparison between the tissue-engineered bone across species may be of importance in establishing better model selection criteria. It has already been found that the deformation of long bones is fairly constant across species, and that stress levels during gait are dependent on the weight of the animal and the material properties of the bone tissue. Future research should therefore be geared towards developing better biomechanical testing systems and then finding the right animal model for the existing equipment.

Purpose: The purpose of this study was to determine whether the position of the mandibular condyle in patients with anterior disc displacement (ADD) is different from that of a control group with normal joints using a novel method to quantify the irregular shape of the temporomandibular joint (TMJ)., Materials and Methods: Twenty-six magnetic resonance images of TMJs with ADD were evaluated and compared with 14 normal joints. The position of the condyle was determined by using 2 different methods: 1) measuring the horizontal and vertical normalized distances in millimeters between the geometric centers of the glenoid fossa and the condyle and 2) calculating the anteroposterior joint space ratio., Results: Using the first method, the horizontal distance between the centers of the condyle and the glenoid fossa was 14.0 +/- 11.1 in the ADD group and 5.3 +/- 10.9 in the control group (P <.001). The vertical distance was 64.7 +/- 22.7 in the ADD group and 68.3 +/- 32.9 in the control group (P =.015). The ratio of the horizontal and the vertical condylar displacement in the ADD group was 2.4. Using the second method, the anteroposterior joint space ratios in the ADD group and in the control group were 1.7 +/- 0.5 and 1.2 +/- 0.4, respectively (P =.001)., Conclusion: This study found that condyles of patients with ADD were situated more posterior and superior in the fossa than those in the control group. Moreover, in the ADD group, the posterior condylar displacement was noted to be 2.4 times greater than the superior condylar displacement.