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The accuracy of intra-operative navigation is largely dependent on the intra-operative registration procedure. Next to accuracy, important factors to consider for the registration procedure are invasiveness, time consumption, logistical demands, user-dependency, compatibility and radiation exposure. In this study, a workflow is presented that eliminates the need for a registration procedure altogether: registration-free navigation. In the workflow, the maxillary dental model is fused to the pre-operative imaging data using commercially available virtual planning software. A virtual Dynamic Reference Frame on a splint is designed on the patient’s fused maxillary dentition: during surgery, the splint containing the reference frame is positioned on the patient’s dentition. This alleviates the need for any registration procedure, since the position of the reference frame is known from the design. The accuracy of the workflow was evaluated in a cadaver set-up, and compared to bone-anchored fiducial, virtual splint and surface-based registration. The results showed that accuracy of the workflow was greatly dependent on tracking technique used: the workflow was the most accurate with electromagnetic tracking, but the least accurate with optical tracking. Although this method offers a time-efficient, non-invasive, radiation-free automatic alternative for registration, clinical implementation is hampered by the unexplained differences in accuracy between tracking techniques.

Adequate positioning of an orbital implant during orbital reconstruction surgery is essential for restoration of the pre-traumatised anatomy, but visual appraisal of its position is limited by the keyhole access and protruding soft tissues. A positioning instrument that attaches to the implant was designed to provide feedback outside the orbit. The goal of this study was to evaluate the accuracy of placement with the instrument and compare it with the accuracy of placement by visual appraisal. Ten orbits in five human cadaver heads were reconstructed twice: once using visual appraisal and once using the instrument workflow. No significant improvement was found for the roll (5.8° vs 3.4°, respectively, p=0.16), pitch (2.1° vs 1.5°, p=0.56), or translation (2.9 mm vs 3.3 mm, p=0.77), but the yaw was significantly reduced if the instrument workflow was used (15.3° vs 2.9°, p=0.02). The workflow is associated with low costs and low logistical demands, and may prevent outliers in implant positioning in a clinical setting when intraoperative navigation or patient-specific implants are not available.

Mandibular growth and morphology are important topics in the field of oral and maxillofacial surgery. For diagnostic and planning purposes, a normative database or statistical shape model of the growing mandible can be of great benefit. A collection of 874 cadaveric children’s mandibles with dental age between 1 and 12 years old were digitized using computed tomography scanning and reconstructed to three-dimensional models. Point correspondence was achieved using iterative closest point and coherent point drift algorithms. Principal component analysis (PCA) was applied to find the main modes of variation in the data set. The average mandible was presented, along with the first ten PCA modes. The first mode explained 78% of the total variance; combining the first ten modes accumulated to 95% of the total variance. The first mode was strongly correlated with age and hence, with natural growth. This is the largest study on three-dimensional mandibular shape and development conducted thus far. The main limitation is that the samples lack information such as gender and cause of death. Clinical application of the model first requires validation with contemporary samples.

Contains fulltext : 288339.pdf (Publisher’s version ) (Open Access) Restoration of the orbit is the first and most predictable step in the surgical treatment of orbital fractures. Orbital reconstruction is keyhole surgery performed in a confined space. A technology-supported workflow called computer-assisted surgery (CAS) has become the standard for complex orbital traumatology in many hospitals. CAS technology has catalyzed the incorporation of personalized medicine in orbital reconstruction. The complete workflow consists of diagnostics, planning, surgery and evaluation. Advanced diagnostics and virtual surgical planning are techniques utilized in the preoperative phase to optimally prepare for surgery and adapt the treatment to the patient. Further personalization of the treatment is possible if reconstruction is performed with a patient-specific implant and several design options are available to tailor the implant to individual needs. Intraoperatively, visual appraisal is used to assess the obtained implant position. Surgical navigation, intraoperative imaging, and specific PSI design options are able to enhance feedback in the CAS workflow. Evaluation of the surgical result can be performed both qualitatively and quantitatively. Throughout the entire workflow, the concepts of CAS and personalized medicine are intertwined. A combination of the techniques may be applied in order to achieve the most optimal clinical outcome. The goal of this article is to provide a complete overview of the workflow for post-traumatic orbital reconstruction, with an in-depth description of the available personalization and CAS options.

Contains fulltext : 288341.pdf (Publisher’s version ) (Open Access) BACKGROUND: In all giant-cell-rich lesions (GCRL) occurring in bone, a common underlying excessive RANKL expression is held responsible for the osteolytic activity. Apart from giant cell tumour of bone (GCTB), systematic outcome analysis of RANKL inhibition in other GCRL is unavailable. The aim of this study is to assess the efficacy and safety of a 1-year denosumab protocol in giant cell lesions of the jaw (GCLJ). METHODS: A retrospective cohort study was conducted compromising patients treated with a 1-year protocol of monthly subcutaneously administered 120 mg denosumab. Objective tumour response based on histology and imaging was used to calculate objective tumour response rate, progression-free survival (PFS) and time to progression. Type, severity and frequency of adverse events were recorded in a standardised way to assess safety. RESULTS: Twenty patients, predominantly female (90%), were included. Fifty-five per cent of lesions were located in the mandible; most classified as aggressive lesions (90%). Thirty-five per cent (7/20) of cases were either recurrent after prior treatment or progressive, while on other drug treatment. Objective tumour response rate was 100% after 12 months of treatment. Median PFS was 50.4 months (95% CI 38.0-62.8) with a cumulative PFS rate of 22.6% (95% CI 1.8-43.4) at 5 years follow-up. Median time to progression was 38.4 months (95% CI 26.0-50.8). Treatment was well tolerated, and none of the patients had to interrupt therapy for toxicity. CONCLUSION: High-dose denosumab is effective and safe in achieving a complete response in GCLJ within 12 months. The high long-term relapse rate after treatment cessation is the main obstacle for denosumab to become standard treatment for GCLJ.

In orbital reconstruction, a patient-specific implant (PSI) may provide accurate reconstruction in complex cases, since the design can be tailored to the anatomy. Several design options may be embedded, for ease of positioning and precision of reconstruction. This study describes a cohort of 22 patients treated for secondary orbital reconstruction with a PSI; one patient received two PSI. The preoperative clinical characteristics and implant design options used are presented. When compared to preoperative characteristics, the postoperative clinical outcomes showed significant improvements in terms of enophthalmos (P < 0.001), diplopia (P < 0.001), and hypoglobus (P = 0.002). The implant position in all previous reconstructions was considered inadequate. Quantitative analysis after PSI reconstruction showed accurate positioning of the implant, with small median and 90th percentile deviations (roll: median 1.3°, 90th percentile 4.6°; pitch: median 1.4°, 90th percentile 3.9°; yaw: median 1.0°, 90th percentile 4.4°; translation: median 1.4 mm, 90th percentile 2.7 mm). Rim support proved to be a significant predictor of roll and rim extension for yaw. No significant relationship between design options or PSI position and clinical outcomes could be established. The results of this study show the benefits of PSI for the clinical outcomes in a large cohort of secondary post-traumatic orbital reconstructions.

Orbital reconstruction is one of the most complex procedures in maxillofacial surgery. It becomes even more complex when all references to the original anatomy are lost. The purpose of this article is to provide an overview of techniques for complex three- and four-wall orbital reconstructions. Preoperative virtual surgical planning is essential when considering different reconstruction possibilities. The considerations that may lead to different approaches are described, and the advantages and drawbacks of each technique are evaluated. It is recommended to reconstruct solitary three-wall or four-wall orbital defects with multiple patientspecific implants. Optimizations of this treatment protocol are suggested, and their effects on predictability are demonstrated in a case presentation of a four-wall defect reconstruction with multiple patient-specific implants.

Contains fulltext : 237489.pdf (Publisher’s version ) (Closed access) Isolated fractures of the anterior wall of the frontal sinus are most often treated through a coronal approach. Although the coronal approach is a relatively easy procedure, the size of the incision is causing more problems related to patient morbidity and recovery time than smaller approaches. A novel, minimal invasive procedure for reconstruction of the anterior wall fracture of the frontal sinus is presented in this article. An endoscopic assisted approach to camouflage the defect of the anterior wall and restore the contour of the frontal bone with a titanium patient specific implant is described in 2 patients. The aim of this procedure is to evaluate the effect on the operating time, recovery time, length of hospital stay and facial scarring compared to the conventional coronal approach. Postoperative evaluation was performed by superimposing pre and postoperative 3D stereophotographs and computed tomography scans. A distance map demonstrated an accurate reconstruction of the preoperatively planned contour. Postoperative recovery of both patients was quick and uneventful with no complications. The use of endoscopically inserted patient specific implant for contour reconstruction in anterior wall fractures of the frontal sinus seems to offer a predictable and minimal invasive alternative to the conventional approach.

Key points:•The first step in advanced diagnostics and virtual surgical planning is the generation of a virtual patient model.•Information can be added to the virtual patient model through image manipulation for advanced diagnostic purposes.•The virtual surgical planning is used preoperatively, but can also be used intraoperatively and postoperatively.

The implementation of augmented reality (AR) in image-guided surgery (IGS) can improve surgical interventions by presenting the image data directly on the patient at the correct position and in the actual orientation. This approach can resolve the switching focus problem, which occurs in conventional IGS systems when the surgeon has to look away from the operation field to consult the image data on a 2-dimensional screen. The Microsoft HoloLens, a head-mounted AR display, was combined with an optical navigation system to create an AR-based IGS system. Experiments were performed on a phantom model to determine the accuracy of the complete system and to evaluate the effect of adding AR. The results demonstrated a mean Euclidean distance of 2.3 mm with a maximum error of 3.5 mm for the complete system. Adding AR visualization to a conventional system increased the mean error by 1.6 mm. The introduction of AR in IGS was promising. The presented system provided a solution for the switching focus problem and created a more intuitive guidance system. With a further reduction in the error and more research to optimize the visualization, many surgical applications could benefit from the advantages of AR guidance.

Purpose We compared the accuracy of landmark-based and voxel-based 3-dimensional (3D) analysis to quantify the osseous movements of the maxilla and mandible after bimaxillary osteotomy. Materials and Methods Cone beam computed tomography (CBCT) scans of 15 patients who had undergone bimaxillary osteotomy were randomly selected from the database. Before surgery, CBCT scanning was performed and an individualized 3D virtual surgical plan made for all patients. During surgery, the mandibular and maxillary segments were positioned as planned using 3D-milled interocclusal splints. At 1 week after surgery, a postoperative CBCT scan was acquired. All pre- and postoperative CBCT data were rendered in 3 dimensions. The 3D virtual head models were superimposed on the cranial base. The 3D surgical movements of the maxilla and mandible were quantified using conventional landmark-based 3D cephalometric analyses and voxel-based 3D analyses (OrthoGnathicAnalyser). This process was performed by the same observer 3 times. The intraclass correlations and Bland-Altman plots were computed to quantify the measurement errors and reproducibility of both methods. Results High intraclass correlation coefficients were found for both methods. The voxel-based analyses yielded a higher correlation concerning the maxilla and distal mandible (r = 0.98) compared with the landmark-based cephalometric analyses (r = 0.90). Conclusions The use of voxel-based 3D analyses in the quantification of osseous movements was more reliable and reproducible than the use of conventional landmark-based 3D analyses.

Item does not contain fulltext PURPOSE: Unilateral Condylar Hyperplasia (UCH) is an acquired deformity of the mandible, which can highly influence the symmetry of the face due to its progressive nature. It is caused by growth resembling pathology in one of the mandibular condyles. Definition as well as classification is subject to discussion. The aim of this study is to evaluate a large cohort of alleged UCH patients, and to describe the clinical characteristics, demographic features, classification and follow up. Secondly an algorithm is presented, in order to achieve uniformity in diagnosis and treatment. PATIENTS AND METHODS: From 1994 to 2014 a database of consecutive patients from 3 maxillofacial departments (Academic Medical Center, Amsterdam; VU Medical Center, Amsterdam and Spaarne Gasthuis, Haarlem) with suspected UCH was set up. Patients were referred by orthodontists, dentists, general practitioners or maxillofacial surgeons. Demographic features, bonescan outcomes, laterality, classification and follow-up were noted. Secondarily, all patients were retrospectively diagnosed by one surgeon (JWN), using available documentation. Missing data and follow-up were additionally retrieved from orthodontic offices. RESULTS: 394 asymmetric patients were evaluated. In 309 (78%) patients, the diagnosis UCH was justified and SPECT data were available. The mean age at presentation was 20.3 years (SD +/- 7.7, range 9.0-54.5 years). In 48% of the patients, the bonescan was positive. 80% of these patients received surgical treatment, of which 62% were treated with a condylectomy only, 33% were treated with condylectomy plus additive corrective surgery, and 5% underwent corrective surgery only. Of the patient group without positive bonescan 42% of the patients received surgical treatment: 34% condylectomy only, 15% condylectomy plus additive corrective surgery, and 51% corrective surgery only. In total (N = 309) 96 (31%) patients underwent condylectomy as only surgical treatment and 124 (40%) patients received no surgical treatment at all. Treatment could be finalized with orthodontic treatment without further surgery in 64% and 41% respectively. 96 patients were subject to comparison of the classification as noted by the clinician and the author (JWN). In only 72% of the cases, the secondary screening was in agreement with the initial classification. CONCLUSION: Based on this study not all (active) UCH patients require corrective (orthognathic) surgery. A (transoral) partial condylectomy for active patients is recommended, with a postoperative remodeling period of 6 months with or without orthodontic treatment. Second stage correcting surgery may be necessary upon evaluation, using general orthognathic diagnostic and planning procedures. It appears difficult to classify patients reliably using the available clinical and radiological documentation. Objectivity and quantification in the diagnostic process is necessary: uniformity in documentation and parameters. The attached documentation form and UCH treatment algorithm is recommended.

Intraoperative navigation is frequently used to assess the position of the implant in orbital reconstruction. Interpretation of the feedback from the navigation system to a three-dimensional position of the implant needs to be done by the surgeon, and feedback is only gathered after the implant has been positioned. An implant-oriented navigation approach is proposed, with real-time intuitive feedback during insertion. A technical framework was set up for implant-oriented navigation, with requirements for planning, implant tracking, and feedback. A dedicated navigation instrument was designed and a software tool was developed in order to meet the technical requirements. An accuracy study was performed to investigate the accuracy of the method in comparison to the regular navigation pointer. A proof of concept was provided. The results showed a translation error of 1.12–1.15 mm for implant-oriented navigation with regular registration (pointer 0.71–0.98 mm) and 0.81 mm with accurate registration (pointer 0.54 mm). Rotational error was found to be small (

Purpose: Mirroring has been used as a diagnostic tool in orbital wall fractures for many years, but limited research is available proving the assumed symmetry of orbits. The purpose of this study was to evaluate volume and contour differences between orbital cavities in healthy humans. Materials and Methods: In this cross-sectional study, the left and right orbital cavities of a consecutive sample of patients' computed tomograms were measured. Inclusion criteria were patients with no sign of orbital or sinus pathology or fracture. Outcome variables were differences in volume and contour. Descriptive statistics and Student paired t test were used for data analysis of orbital volume and distance maps were used for analysis of orbital contour. Results: The sample was composed of 100 patients with a mean age of 57; 50% were men. The total mean orbital volume was 27.53 +/- 3.11 mL. Mean difference between cavities was 0.44 +/- 0.31 mL or 1.59% (standard deviation [SD], 1.10%). The orbital contour showed high similarity, with an absolute mean left-versus-right difference of 0.82 mm (SD, 0.23 mm). Conclusion: The authors hypothesize that the measured differences between right and left orbital volumes and contours are clinically minor. In consequence, the use of mirroring tools as part of preoperative planning in orbital reconstruction is legitimate with the aim of simulating the pre-traumatized anatomy. (C) 2017 American Association of Oral and Maxillofacial Surgeons

A novel surgical treatment sequence for secondary orbitozygomatic complex (OZC) reconstruction is described. Orbital reconstruction is performed before OZC repositioning. A surgical plan is made: the affected OZC is virtually osteotomized and aligned with a mirrored model of the unaffected OZC. A patient-specific implant (PSI) is designed for orbital reconstruction. Screw holes from the primary reconstruction are used for fixation. Primary screw hole positions at the repositioned OZC are embedded in the design, to guide OZC repositioning. A second patient-specific design is made for guidance at the zygomaticomaxillary buttress. The workflow was utilized in two patients. The PSI was positioned using navigation feedback. After repositioning of the zygomatic complex, the screw hole positions at the infraorbital rim and zygomaticomaxillary buttress seemed to align perfectly: no screw hole adjustments were necessary. Minor deviations were seen between planned and acquired PSI position; the mean errors between planned and acquired OZC position were 1.5 and 1.2 mm. Orbital reconstruction with a PSI before OZC repositioning ensures true-to-original orbital reconstruction. The use of old screw hole positions enables the PSI to be used as a static guide for ON repositioning. The combination of static and dynamic guidance increases predictability in secondary OZC reconstruction. (C) 2017 Published by Elsevier Ltd on behalf of European Association for Cranio-Maiillo-Facial Surgery

In orbital reconstruction, the acquired position of an orbital implant can be evaluated with the aid of intraoperative navigation. Feedback of the navigation system is only obtained after positioning of the implant: the implant's position is not tracked in real time during positioning. The surgeon has to interpret the navigation feedback and translate it to desired adjustments of the implant's position. In a previous study, a real-time implant-oriented navigation approach was introduced and the system's accuracy was evaluated. In this study, this real-time navigation approach was compared to a marker-based navigation approach in a preclinical set-up. Ten cadavers (20 orbital defects) were reconstructed twice, by two surgeons (total: 80 reconstructions). Implant positioning was significantly improved in the real-time implant-oriented approach in terms of roll (2.0° vs. 3.2°, P = 0.03), yaw (2.2° vs. 3.4°, P = 0.01) and translation (1.3 mm vs. 1.8 mm, P = 0.005). Duration of the real-time navigation procedure was reduced (median 4.5 min vs. 7.5 min). Subjective appreciation of the navigation technique was higher for real-time implant-oriented navigation (mean 7.5 vs. 9.0). Real-time implant-oriented navigation feedback provides real-time, intuitive feedback to the surgeon, which leads to improved implant positioning and shortens duration of the navigation procedure.

Intraoperative imaging enables the surgeon to control the position of the implant during orbital reconstruction. Although it might improve surgical outcome and avoid the need for revision surgery, it may also increase the duration of the operation and the exposure to radiation. The goal of this study was to find out whether intraoperative imaging improves the position of the implant in reconstructions of the orbital floor and medial wall. Two surgeons reconstructed complex orbital fractures in 10 cadavers. After the reconstruction a computed tomographic scan was made to confirm the position of the implant and, if required, to make any adjustments. Scans were repeated until the surgeon was satisfied. The ideal position was ascertained by scans that were obtained before and after creation of the fractures. The position of the implant achieved was compared with that of the ideal position of the implant, and improved significantly for yaw (p = 0.04) and roll (p = 0.03). A mean of 1.6 scans was required for each reconstruction (maximum n = 3). The main reason for alteration was the rotation roll. Intraoperative imaging significantly improves the position of the implant in fractures of the orbital floor and medial wall. The surgeon has quality control of its position during the reconstruction to restore the anatomical boundaries.

Purpose: To quantify the postoperative condylar remodelling and its role in skeletal relapse after bimaxillary surgery. Materials and methods: 50 patients with mandibular hypoplasia who underwent bimaxillary surgery were analyzed. CBCT scans were acquired preoperatively, one week postoperatively and two years postoperatively. 3D cephalometric analysis was carried out for each CBCT scan, after which the condylar volume analysis was performed. Results: The maxilla was advanced by a mean of 2.1 mm with a corresponding mean relapse of 0.3 mm. The maxilla was impacted in 23 and extruded in 27 patients. The mean mandibular advancement was 7.8 mm. Two years after surgery a mean mandibular skeletal relapse of 1.3 mm was observed. 78% of condyles exhibited a postoperative reduction in volume of 179 mm(3) (mean), equivalent to 12.5 volume%. Postoperative condylar volume loss was correlated with mandibular skeletal relapse (r = 0.42, p

Item does not contain fulltext PURPOSE: The aim of this study was to evaluate the usefulness of intra-operative visualisation, endoscopic assistance, and CT measurements for estimating the orbital fracture size and complexity. METHODS: Ten human cadaver heads were subjected to thin-slice computed tomography (CT). Standardised fractures were created using piezoelectric surgery in accordance with the Jaquiery classification system. Four surgeons and one anatomist used six different observation methods to visualise and describe the orbital defects. RESULTS: The intraclass correlation coefficients (ICCs) for the fracture length measurements were relatively low for all observation methods (range, 0.666-0.883). CT measurements of width showed high consistency (ICC, 0.910). The surface area of the defect was highly overestimated by all methods (range, 121-184%). None of the observers was able to accurately estimate the length or width of 95% of the defects within an error range of +/-0.75 cm. CONCLUSION: CT measurements are the most consistent and accurate tool for estimating the critical size of orbital factures. In daily practice, a measurement tool in a DICOM viewer could be used, although software packages that allow manual adjustments are advisable. Direct intraoperative visualisation and surgeon experience are of limited value in the estimation of fracture size and complexity, and endoscopy provides no additional advantages.

The current standard of care in alveolar cleft repair is timing the procedure in the mixed dentition stage and making use of autologous bone to restore the maxillary defect. Using a synthetic bone substitute bypasses the risk of donor site morbidity and reduces the operation time. In this study, the outcome of alveolar cleft repair using microporous beta-tricalcium phosphate (β-TCP) was investigated in patients with unilateral cleft lip and palate. Twenty patients were enrolled prospectively in this study, divided between two centres. Continuity of the alveolar process, recurrence of oronasal fistulas, and eruption of teeth into the repaired cleft were evaluated at 1year postoperative. Also, cone beam computed tomography scans were analyzed using a volume-based semi-automatic segmentation protocol. No adverse events were reported. The mean residual bone volume in the repaired cleft at 1year postoperative was 65%. There was no recurrence of oronasal fistula. Furthermore, 90% of the teeth adjacent to the cleft erupted spontaneously and all patients showed a continuous alveolar process. Secondary alveolar grafting using microporous β-TCP can safely be used in the clinical situation. Residual calcified tissue, canine eruption, and complication rates at the recipient site are comparable to those with autologous grafts.

Objective: Advanced three-dimensional (3D) diagnostics and preoperative planning are the first steps in computer-assisted surgery (CAS). They are an integral part of the workflow, and allow the surgeon to adequately assess the fracture and to perform virtual surgery to find the optimal implant position. The goal of this study was to evaluate the accuracy and predictability of 3D diagnostics and preoperative virtual planning without intraoperative navigation in orbital reconstruction. Methods: In 10 cadaveric heads, 19 complex orbital fractures were created. First, all fractures were reconstructed without preoperative planning (control group) and at a later stage the reconstructions were repeated with the help of preoperative planning. Preformed titanium mesh plates were used for the reconstructions by two experienced oral and maxillofacial surgeons. The preoperative virtual planning was easily accessible for the surgeon during the reconstruction. Computed tomographic scans were obtained before and after creation of the orbital fractures and postoperatively. Using a paired t-test, implant positioning accuracy (translation and rotations) of both groups were evaluated by comparing the planned implant position with the position of the implant on the postoperative scan. Results: Implant position improved significantly (P < 0.05) for translation, yaw and roll in the group with preoperative planning (Table 1). Pitch did not improve significantly (P = 0.78). Conclusion: The use of 3D diagnostics and preoperative planning without navigation in complex orbital wall fractures has a positive effect on implant position. This is due to a better assessment of the fracture, the possibility of virtual surgery and because the planning can be used as a virtual guide intraoperatively. The surgeon has more control in positioning the implant in relation to the rim and other bony landmarks.

Item does not contain fulltext The aim of this study was to evaluate the accuracy of three-dimensional (3D) soft tissue simulation of nose width changes following bimaxillary osteotomies and to identify patient- and surgery-related factors that may affect the accuracy of simulation. Sixty patients (mean age 26 years) who underwent bimaxillary osteotomies participated in this study. Cone beam computed tomography scans were acquired preoperatively and at 1-year postoperative. The 3D hard and soft tissue rendered preoperative and postoperative virtual head models were superimposed, after which the maxilla and mandible were segmented and aligned to the postoperative position. The postoperative changes in alar width were simulated using a mass tensor model (MTM)-based algorithm and compared with the postoperative outcome. 3D cephalometric analyses were used to quantify the simulation error. The postoperative alar width was increased by 1.6+/-1.1mm and the mean error between the 3D simulation and the actual postoperative alar width was 1.0+/-0.9mm. The predictability was not correlated to factors such as age, sex, alar cinch suture, VY closure, maxillary advancement, or a history of surgically assisted rapid maxillary expansion. The MTM-based simulation model of postoperative alar width change was found to be reasonably accurate, although there is room for further improvement.

Item does not contain fulltext Navigation-assisted orbital reconstruction remains a challenge, because the surgeon focuses on a two-dimensional multiplanar view in relation to the preoperative planning. This study explored the addition of navigation markers in the implant design for three-dimensional (3D) orientation of the actual implant position relative to the preoperative planning for more fail-safe and consistent results. Pre-injury computed tomography (CT) was performed for 10 orbits in human cadavers, and complex orbital fractures (Class III/IV) were created. The orbits were reconstructed using preformed orbital mesh through a transconjunctival approach under image-guided navigation and navigation by referencing orientating markers in the implant design. Ideal implant positions were planned using preoperative CT scans. Implant placement accuracy was evaluated by comparing the planned and realized implant positions. Significantly better translation (3.53 mm vs. 1.44 mm, p = 0.001) and rotation (pitch: -1.7 degrees vs. -2.2 degrees , P = 0.52; yaw: 10.9 degrees vs. 5.9 degrees , P = 0.02; roll: -2.2 degrees vs. -0.5 degrees , P = 0.16) of the placed implant relative to the planned position were obtained by implant-oriented navigation. Navigation-assisted surgery can be improved by using navigational markers on the orbital implant for orientation, resulting in fail-safe reconstruction of complex orbital defects and consistent implant positioning.

Objective: The study aim was to investigate variations in the symmetry of the zygomaticomaxillary complex (ZMC) in normal individuals. Method: Computed tomography datasets of 200 individuals without facial fractures were analyzed using a validated three-dimensional analysis technique. The absolute average distance (AD) and 90th percentile distance (NPD) were calculated, representing respectively the overall and maximum symmetry between bilateral ZMCs. Results: The mean AD and NPD of the total study group was 0.9 +/- 0.3 mm(95% CI 0.3-2.3) and 1.7 +/- 0.5 mm (95% CI 0.5-3.9), respectively. The mean AD and NPD in males were 1.0 +/- 0.3 mm (95% CI 0.28-2.34) and 1.9 +/- 0.5 mm (95% CI 0.5-3.9) versus 0.8 +/- 0.3 mm (95% CI 0.4-1.7) and 1.6 +/- 0.5 mm (95% CI 0.8-2.9), respectively, for females. A statistically significant difference between male and female was found for both AD and NPD (p 40 years. Conclusion: The naturally occurring anatomic variation in ZMC symmetry described in this study is proposed as a benchmark for evaluating the amount of preoperative displacement and postoperative reduction of ZMC in trauma cases. (C) 2017 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved

Contains fulltext : 175044.pdf (Publisher’s version ) (Closed access) A novel protocol for volumetric assessment of alveolar cleft grafting procedures is presented. Eleven cone-beam computed tomography (CBCT) datasets of patients who underwent secondary alveolar cleft reconstructive surgery for a unilateral alveolar cleft were evaluated by two investigators. Residual bone volumes 1 year after surgery were analysed using a semi-automated technique in which preoperative CBCT datasets were superimposed on the postoperative scans using voxel-based registration. To define the correct boundaries of the alveolar cleft defect in the preoperative CBCT dataset, a mirror image of the preoperative CBCT dataset was superimposed on the preoperative CBCT dataset. For the difference in residual bone volume between the two observers, an intraclass correlation of 0.98 and a Dice coefficient of 0.89 were found. This study describes a reliable segmentation protocol for volumetric analysis of the alveolar cleft defect in patients with a unilateral alveolar cleft. 01 mei 2017

Contains fulltext : 165275.PDF (Publisher’s version ) (Open Access) AIM: The purpose of this study was to present and validate an innovative semi-automatic approach to quantify the accuracy of the surgical outcome in relation to 3D virtual orthognathic planning among patients who underwent bimaxillary surgery. MATERIAL AND METHOD: For the validation of this new semi-automatic approach, CBCT scans of ten patients who underwent bimaxillary surgery were acquired pre-operatively. Individualized 3D virtual operation plans were made for all patients prior to surgery. During surgery, the maxillary and mandibular segments were positioned as planned by using 3D milled interocclusal wafers. Consequently, post-operative CBCT scan were acquired. The 3D rendered pre- and postoperative virtual head models were aligned by voxel-based registration upon the anterior cranial base. To calculate the discrepancies between the 3D planning and the actual surgical outcome, the 3D planned maxillary and mandibular segments were segmented and superimposed upon the postoperative maxillary and mandibular segments. The translation matrices obtained from this registration process were translated into translational and rotational discrepancies between the 3D planning and the surgical outcome, by using the newly developed tool, the OrthoGnathicAnalyser. To evaluate the reproducibility of this method, the process was performed by two independent observers multiple times. RESULTS: Low intra-observer and inter-observer variations in measurement error (mean error < 0.25 mm) and high intraclass correlation coefficients (> 0.97) were found, supportive of the observer independent character of the OrthoGnathicAnalyser. The pitch of the maxilla and mandible showed the highest discrepancy between the 3D planning and the postoperative results, 2.72 degrees and 2.75 degrees respectively. CONCLUSION: This novel method provides a reproducible tool for the evaluation of bimaxillary surgery, making it possible to compare larger patient groups in an objective and time-efficient manner in order to optimize the current workflow in orthognathic surgery.

Objective Since reconstruction of composite defects in the head and neck region is a challenging and demanding problem for head and neck surgeons, surgical aids have been sought for decades. The purpose of this study was to evaluate the accuracy of prefabricated surgical resection templates used in mandibular segmental resections in comparison to the virtual surgical plan. Materials and methods A prospective study was performed in 11 consecutive patients, with a primary T4 oral squamous cell carcinoma or osteoradionecrosis of the mandible. Preoperatively, a CBCT scan was acquired to delineate the size and extension of tumor invasion; a virtual patient-specific resection template was designed based on this information. Intraoperatively, the resection template was positioned on the mandible and secured using four fixation screws. Postoperatively, a CBCT scan was acquired. This scan was superimposed on the preoperative scan. Positioning of the resection template and inclination of the resection planes were evaluated on the virtual head model. In order to test the interobserver reliability of these new measurement methods, two different observers executed all measurements. Results The mean shift of the proximal resection templates was 3.76 mm (standard deviation [SD] 3.10 mm). For the distal resection templates, the mean shift was 3.06 mm (SD 1.57 mm) with no significant interobserver difference (ICC = 0.99). An absolute mean deviation of 8.5° (SD 5.3°) was found for the proximal resection angle and 10.4° (SD 5.0°) for the distal resection angle. Again, no significant interobserver differences were found (ICC = 0.98). Conclusion The resection templates used in this study proved reasonably accurate. Although the concept of virtual surgical planning aids significantly in mandibular reconstruction with microvascular free flaps, further improvement of resection accuracy is necessary for further improvement of reconstruction accuracy.

Item does not contain fulltext OBJECTIVE: The study aim was to validate a new method for measuring zygomaticomaxillary complex (ZMC) symmetry, which can be helpful in analyzing ZMC fractures. METHODS: Three-dimensional virtual hard-tissue models were reconstructed from computed tomography (CT) datasets of 26 healthy individuals. Models were mirrored and superimposed. Absolute average distance (AD) and 90th percentile distance (NPD) were used to measure overall and maximal symmetry. The Intraclass Correlation Coefficient (ICC) was calculated to measure interobserver consistency. In order to determine whether this technique is applicable in ZMC fracture cases, 10 CT datasets of individuals with a unilateral ZMC fracture were analyzed. RESULTS: For the unaffected group the mean AD was 0.84 +/- 0.29 mm (95% CI 0.72-0.96) and the mean NPD was 1.58 +/- 0.43 mm (95% CI 1.41-1.76). The ICC was 0.97 (0.94-0.98 as 95% CI), indicating almost perfect interobserver agreement. In the affected group the mean AD was 2.97 +/- 1.76 mm (95% CI 1.71-4.23) and the mean NPD was 6.12 +/- 3.42 mm (95% CI 3.67-8.57). The affected group showed near-perfect interobserver agreement with an ICC of 0.996 (0.983-0.999 as 95% CI). CONCLUSIONS: The method presented is an accurate instrument for evaluation of ZMC symmetry, which can be helpful for advanced diagnostics and treatment evaluation.

Item does not contain fulltext OBJECTIVE: To compare the validity and reproducibility of four different methods for the quantification of soft tissue facial asymmetry. MATERIAL AND METHODS: Twenty 3D-photographs were randomly selected from the healthy control database. To assess the validity of the one landmark-based and three surface-based methods for measuring asymmetry, artificial facial asymmetry was created on two 3D photographs. The discrepancy between the artificial facial asymmetry and the asymmetry quantified by different methods was calculated. To evaluate the reproducibility of the methods, they were applied three times by two independent observers. The intraobserver and interobserver variations were calculated. RESULTS: The mean absolute differences between the measured asymmetry and the artificial asymmetry for the landmark-based method, forehead method, 5 mm method and 1 mm method were 1.4 mm, 0.3 mm, 0.09 mm and 0.06 mm respectively. The intraobserver and interobserver variations for the forehead, 5 mm and 1 mm methods were between 0.18 mm and 0.34 mm. CONCLUSION: The surface-based methods were valid and highly reproducible in comparison to the landmark-based method for the quantification of soft tissue facial asymmetry. The 1 mm surface-based method can be implemented in a clinical and research setting to quantify facial asymmetry.

Item does not contain fulltext The aim of this study was to analyse changes in the volume of the chin after harvest of a bone graft for secondary reconstruction of an alveolar cleft. Cone-beam computed tomographic (CT) scans of 27 patients taken preoperatively, and immediately and one year postoperatively, were analysed, and 3-dimensional hard-tissue reconstructions made. The hard-tissue segmentation of the scan taken one year postoperatively was subtracted from the segmentation of the preoperative scan to calculate the alteration in the volume of bone at the donor site (chin). A centrally-orientated persistent concavity at the buccal side of the chin was found (mean (range) 160 (0-500) mm(3)). At the lingual side of the chin, a central concavity remained (mean (range) volume 20 (0-80) mm(3)). Remarkably, at the periphery of this concavity there was overgrowth of new bone (mean (range) volume 350 (0-1600) mm(3)). Re-attachment of the muscles of the tongue resulted in a significantly larger central lingual defect one year postoperatively (p=0.01). We also measured minor alterations in volume of the chin at one year. Whether these alterations influence facial appearance and long term bony quality is to be the subject of further research.

Item does not contain fulltext Preformed orbital reconstruction plates are useful for treating orbital defects. However, intraoperative errors can lead to misplaced implants and poor outcomes. Navigation-assisted surgery may help optimize orbital reconstruction. We aimed to explore whether navigation-assisted surgery is more predictable than traditional orbital reconstruction for optimal implant placement. Pre-injury computed tomography scans were obtained for 10 cadaver heads (20 orbits). Complex orbital fractures (Class III-IV) were created in all orbits, which were reconstructed using a transconjunctival approach with and without navigation. The best possible fit of the stereolithographic file of a preformed orbital mesh plate was used as the optimal position for reconstruction. The accuracy of the implant positions was evaluated using iPlan software. The consistency of orbital reconstruction was lower in the traditional reconstructions than in the navigation group in the parameters of translation and rotation. Implant position also differed significantly in the parameters of translation (p = 0.002) and rotation (pitch: p = 0.77; yaw: p < 0.001; roll: p = 0.001). Compared with traditional orbital reconstruction, navigation-assisted reconstruction provides more predictable anatomical reconstruction of complex orbital defects and significantly improves orbital implant position.