Increasing the accuracy of orbital reconstruction with selective laser-melted patient-specific implants combined with intraoperative navigation

Novel CAD/CAM-splint-based navigation protocol enhances intraoperative maxillary position control in orthognathic surgery: a case control study

BACKGROUND

Virtual surgical planning for orthognathic surgery typically relies on two methods for intraoperative plan transfer: CAD/CAM occlusal splints and patient-specific implants (PSI). While CAD/CAM splints may offer limited accuracy, particularly in the vertical dimension, PSIs are constrained by higher costs and extended preparation times. Surgical navigation has emerged as a potential alternative, but existing protocols often involve invasive registration or lack transparent evaluation. This study introduces a novel protocol for point-based optical navigation using modified CAD/CAM splints for non-invasive registration and transparent intraoperative evaluation, assessing its effectiveness in maxillary positioning.

METHODS

This prospective case-control study included 20 patients undergoing bimaxillary orthognathic surgery. The experimental group employed surgical navigation with modified CAD/CAM splints, while the control group used standard CAD/CAM splints. Surgical accuracy was evaluated by measuring translational and rotational discrepancies between the planned and achieved maxillary positions. A mixed ANOVA was conducted to assess other factors, aside from surgical navigation, that might influence surgical accuracy.

RESULTS

Surgical navigation significantly improved accuracy in translational movements along the x-axis (right-left: -0.81 mm; p = 0.021) and z-axis (down-up: -0.82 mm; p = 0.014), as well as in yaw rotation (-0.45°; p = 0.045). Other movements also showed improved precision in the navigated group, though not statistically significant; y-axis (back-front): -0.60 mm (p = 0.094); pitch rotation: -0.70° (p = 0.071); roll rotation: -0.04° (p = 0.428). Besides the use of surgical navigation, the amount of planned movement significantly impacted surgical accuracy, although no specific factors could be identified to predict which cases would particularly benefit from surgical navigation.

CONCLUSIONS

Surgical navigation with modified CAD/CAM splints enhances surgical accuracy without requiring invasive procedures, offering a straightforward and transparent protocol suitable for routine clinical practice that allows intraoperative evaluation of maxillary positioning. However, the clinical significance and cost-effectiveness compared to PSI need further investigation. These findings suggest new directions for future developments, especially with advancements in mixed reality technologies, which could broaden the application of surgical navigation.

TRIAL REGISTRATION

Retrospectively registered with the German Clinical Trials Register (DRKS00034795).

Assessment of the Correlation Between Types of Orbital Fractures and Ocular Symptoms, and the Effect of Manual Preformed and Patient-Specific Mesh Implants: A Retrospective Study

OBJECTIVE

Although certain orbital fractures are associated with specific clinical symptoms, these relationships should be reviewed comprehensively. The optimal choice between manual preformed mesh implants (MPIs) and patient-specific mesh implants (PSIs) for orbital reconstruction remains undetermined due to inconclusive evidence regarding their effectiveness.

METHODS

This retrospective study investigated 280 patients with unilateral orbital fractures to explore the correlation between clinical ocular symptoms, including diplopia, enophthalmos, limitation of ocular movement, blindness, and the specific type of orbital fracture. The effects on orbital volume (OV) and orbital volume ratio (OVR) of MPI and PSI with and without the use of navigation were also evaluated in this study. Patients were categorized into 4 groups: MPI, PSI, navigation-assisted MPI, and navigation-assisted PSI. After this categorization, alterations in OV and OVR were analyzed before and after surgical intervention.

RESULTS

Significant correlations were observed between the orbital fracture type and diplopia, enophthalmos, and limitation of ocular movement ( P < 0.05). Patients in the MPI group exhibited a notable difference in the postoperative OV between the injured and normal sides ( P < 0.05), but no statistically significant difference was found in the postoperative OV between the injured and normal sides among the patients in the other 3 groups ( P > 0.05). Moreover, the MPI group demonstrated significantly higher postoperative OVR than the other groups ( P < 0.05). Notably, PSI remained effective with or without navigation, MPI combined with navigation technology achieved a reconstruction quality similar to that of PSI by rectifying positioning errors during surgery.

CONCLUSION

The authors found significant correlations ( P < 0.05) between orbital fracture type and diplopia, enophthalmos, and limitations of ocular movement. Patient-specific mesh implant plays an important role in orbital reconstruction. It is also a good method for reconstructing orbital fractures using MPI assisted by navigation technology.

Utilization of Computer-Assisted Navigation Technology Within Craniomaxillofacial Fracture Surgery: A Systematic Review

BACKGROUND

Use of intraoperative computer-assisted navigation (iCAN) has been well-established in otolaryngology and neurosurgery; however, its use in surgical management of facial fractures is yet to be reported on a large scale. This study aimed to review the existing literature to determine the outcomes, limitations, risks, and benefits of iCAN use in facial fracture management.

METHODS

A systematic review of iCAN use in craniomaxillofacial fracture surgery was performed by 2 authors in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The search was conducted on 3 databases, PubMed, Cochrane Library, and Embase, using the search terms "navigation," "intraoperative," and "brain lab" in combination with "facial fractures" or "facial reconstruction." Study type, demographics, fracture characteristics, surgery characteristics, iCAN devices, intraoperative fracture fixation accuracy, postoperative outcomes, complications, navigation limitations, and risks and benefits were analyzed.

RESULTS

There were 909 studies identified in the initial search, of which 42 were chosen for final use. iCAN use was most commonly reported in unilateral (57.1%) and complex (50%) facial fracture cases. Surgical accuracy ranged from 0.7 to 4 mm and postoperative discrepancy ranged from 0.05 to 8 mm. Benefits included improved intraoperative surgical accuracy (95.2%), improved postoperative surgical discrepancy (52.4%), and decreased total surgical time (35.7%). Limitations reported with iCAN device use included operative technical difficulties (23.8%) and persistent systematic errors during device registration (21.4%). None of the studies discussed cost analysis or risks compared to conventional fixation methods.

CONCLUSIONS

Advancements in and increasing familiarity with iCAN technology have preliminarily shown favorable surgical outcomes in facial fracture fixation, which include improved operative accuracy and discrepancy and decreased surgical time.

PSI: Planner-specific, physician-specific, or patient-specific implant for orbital reconstruction?

This study aimed to identify and quantify the variations in PSI designs intended for an identical patient. Records from 10 patients with an orbital fracture involving two walls, for which a primary orbital reconstruction was indicated, were retrospectively included. Clinical engineers from two centers independently generated proposal designs for all patients. Following web meeting(s) with the surgeon from the same institute, the PSI designs were finalized by the engineer. A cross-over of the engineer with the surgeon of the other center created two new design teams. In total, 20 proposal and 40 final PSI designs were produced. A three-dimensional comparison between different PSI designs for the same patient was performed by computing a difference score. Initially, the design proposals of the two engineers showed a median difference score of 37%, which was significantly reduced to a median difference score of 26% for the final designs with different engineers. The median difference score of 22% between surgeons demonstrated that both parties introduced notable user variations to the final designs. Evidence supporting the advantages of an experienced design team was found, with significantly fewer modifications, fewer meetings, and less time required to complete the design (up to 40% time reduction). The findings of the study underline the dependency of PSI design on the surgeon and engineer, and support the need for a more evidence-based protocol for PSI design.

Guidelines for Orbital Defect Assessment and Patient-Specific Implant Design: Introducing OA2 (Orbital Assessment Algorithm)

Study Design

This study presents a review of the evolutionary development in reconstructive orbital surgery over the past 3 decades. Additionally, it proposes the Orbital Assessment Algorithm (OA2) to enhance decision-making for intraorbital reconstruction of post-traumatic orbital deformities.

Objective

The objective of this paper is to provide insights into modern post-traumatic orbital reconstruction from a surgeon's perspective, with a specific focus on adult patients. It aims to highlight the advancements in computer-aided design and manufacturing techniques, particularly in the field of reconstructive orbital surgery, and to introduce the OA2 as a tool for improved decision-making in this context.

Methods

The study conducts a comprehensive review of the evolution of reconstructive orbital surgery, focusing on the integration of 3D technology into surgical practices. It also outlines the development and rationale behind the proposed OA2, emphasizing its potential to enhance the accuracy and efficacy of intraorbital reconstruction procedures for post-traumatic deformities.

Results

The review demonstrates the significant progress made in reconstructive orbital surgery, particularly in leveraging 3D technology for virtual modeling, navigation, and the design and manufacturing of patient-specific implants. The introduction of the OA2 provides a structured approach to assessing and addressing post-traumatic orbital deformities, offering potential benefits in decision-making and surgical outcomes.

Conclusions

In conclusion, this paper underscores the pivotal role of computer-aided design and manufacturing in advancing reconstructive orbital surgery. It highlights the importance of integrating innovative design concepts into implant manufacturing processes and emphasizes the potential of the OA2 to guide surgeons in the management of post-traumatic orbital deformities, ultimately contributing to improved patient outcomes.

The impact of polydioxanone (PDS) foil thickness on reconstruction of the orbital geometry after isolated orbital floor fractures

PURPOSE

The orbital floor is frequently involved in head trauma. Current evidence on the use of reconstruction materials for orbital floor repair is inconclusive. Accordingly, this study aimed to compare the impact of polydioxanone (PDS) foil thickness on reconstruction of the orbital geometry after isolated orbital floor fractures.

METHODS

Standardized isolated orbital floor fractures were symmetrically created in 11 cadaver heads that provided 22 orbits. PDS foils with thicknesses of 0.25-0.5 mm were inserted. Computed tomography (CT) scans of the native, fractured, and reconstructed orbits were obtained, and orbital volume, orbital height, and foil bending were measured.

RESULTS

Orbital volume and height significantly (p < 0.01) increased after the creation of isolated orbital floor fractures and significantly (p = 0.001) decreased with overcorrection of the orbital geometry after orbital floor reconstruction with PDS 0.25 mm or PDS 0.5 mm. The orbital geometry reconstruction rate did not differ significantly with respect to foil thickness. However, compared to PDS 0.5 mm, the use of PDS 0.25 mm resulted in quantitatively higher reconstructive accuracy and a restored orbital volume that did not significantly differ from the initial volume.

CONCLUSION

Orbital floors subjected to isolated fractures were successfully reconstructed using PDS regardless of foil thickness, with overcorrection of the orbital geometry. Due to its lower flexural stiffness, PDS 0.25 mm appeared to provide more accurate orbital geometry reconstruction than PDS 0.5 mm, although no significant difference in reconstructive accuracy between PDS 0.25 mm and PDS 0.5 mm was observed in this cadaveric study.

Does Integration of Technology and Customization of Implants Produce Better Outcomes in Post-Traumatic Orbital Reconstruction? A Systematic Review and Meta-Analysis

PURPOSE

This review aims to compare and evaluate the outcomes achieved by integrating technological aids and the influence of different implant designs in the reconstruction of post-traumatic orbital defects.

METHODS

Electronic searches of the MEDLINE, Embase, Cochrane Library, and Google Scholar databases until March 2023 were conducted. Clinical controlled trials, observational studies, cohort studies, and retrospective studies were identified and included. The predictor variables were the integration of technological aids namely, computer-assisted surgical planning, mirror image overlay, and intraoperative navigation with the utilization of different orbital implant designs (standard orbital meshes, preformed implants, prebent implants, and patient-specific implant [PSI]) during post-traumatic orbital reconstruction. The primary outcome variables were orbital volume, diplopia, and enophthalmos. Weighted or mean difference and risk ratios at 95% confidence intervals were calculated, where P ＜ .05 was considered significant and a random effects model was adopted.

RESULTS

This review included 7 studies with 560 participants. The results indicate that the difference in postoperative orbital volume between affected and nonaffected eye showed no statistically significant difference between PSI and prebent group (mean difference, -0.41 P = .28, I2 = 46%). PSI group resulted in diplopia 0.71-fold less than that of the standard orbital mesh group but was not statistically significant (P = .15). Standard orbital mesh group is 0.30 times at higher risk of developing enophthalmos as compared to PSI group (P = .010). The literature suggests PSIs are preferred for patients with large defects (Jaquiéry's III-IV), whereas prebent implants are equally effective as PSIs in patients with preserved infraorbital buttress and retrobulbar bulge.

CONCLUSION

PSIs are associated with improved outcomes, especially for correcting enophthalmos. The data suggests the potential efficacy of prebent implants and PSIs in orbital volume corrections. There is a lack of randomized studies. This review should serve as a recommendation for further studies to contribute to the existing literature.

Presurgical Virtual Planning and Intraoperative Navigation with 3D-Preformed Mesh: A New Protocol for Primary Orbital Fracture Reconstruction

PURPOSE

This pilot study aims to evaluate the feasibility and effectiveness of computer-assisted surgery protocol with 3D-preformed orbital titanium mesh (3D-POTM), using presurgical virtual planning and intraoperative navigation in primary inferomedial orbital fracture reconstruction.

METHODS

Between March 2021 and March 2023, perioperative data of patients undergoing surgery for unilateral inferomedial orbital fracture treated with 3D-POTM were analyzed. Presurgical virtual planning with a Standard Triangle Language file of preformed mesh was conducted using the mirrored unaffected contralateral side as a reference, and intraoperative navigation was used. The reconstruction accuracy was determined by: correspondence between postoperative reconstruction mesh position with presurgical virtual planning and difference among the reconstructed and the unaffected orbital volume. Pre- and postoperative diplopia and enophthalmos were assessed.

RESULTS

Twenty-six patients were included. Isolated orbital floor fracture was reported in 14 (53.8%) patients, meanwhile medial wall and floor one in 12 (46.1%) cases. The mean difference between final plate position and ideal digital plan was 0.692 mm (95% CI: 0.601-0.783). The mean volume difference between reconstructed and unaffected orbit was 1.02 mL (95% CI: 0.451-1.589). Preoperative diplopia was settled out in all cases and enophthalmos in 19 (76.2%) of 21 patients.

CONCLUSION

The proposed protocol is an adaptable and reliable workflow for the early treatment of inferomedial orbital fractures. It enables precise preoperative planning and intraoperative procedures, mitigating pitfalls and complications, and delivering excellent reconstruction, all while maintaining reasonable costs and commitment times.

Titanium Implants Coated with Hydroxyapatite Used in Orbital Wall Reconstruction-A Literature Review

With the increasing incidences of orbital wall injuries, effective reconstruction materials and techniques are imperative for optimal clinical outcomes. In this literature review, we delve into the efficacy and potential advantages of using titanium implants coated with nanostructured hydroxyapatite for the reconstruction of the orbital wall. Titanium implants, recognized for their durability and mechanical strength, when combined with the osteoconductive properties of hydroxyapatite, present a potentially synergistic solution. The purpose of this review was to critically analyze the recent literature and present the state of the art in orbital wall reconstruction using titanium implants coated with nanostructured hydroxyapatite. This review offers clinicians detailed insight into the benefits and potential drawbacks of using titanium implants coated with nanostructured hydroxyapatite for orbital wall reconstruction. The highlighted results advocate for its benefits in terms of osseointegration and provide a novel strategy for orbital reconstruction, though further studies are essential to establish long-term efficacy and address concerns.

Customized orbital implant versus 3D preformed titanium mesh for orbital fracture repair: A retrospective comparative analysis of orbital reconstruction accuracy

This study aimed to compare the accuracy of inferomedial orbital fracture restoration using customized orbital implant versus 3D preformed titanium mesh. Patients were divided into two groups. Group 1 underwent surgery with customized orbital implants and intraoperative navigation, while group 2 was treated using 3D preformed titanium meshes with preoperative virtual surgical planning (VSP) and intraoperative navigation. Reconstruction accuracy was assessed by: (1) comparing the postoperative reconstruction mesh position with the preoperative VSP; and (2) measuring the difference between the reconstructed and unaffected orbital volume. Pre- and postoperative diplopia and enophthalmos were also evaluated. Fifty-two patients were enrolled (25 in group 1 vs 27 in group 2). The mean difference between final plate position and ideal digital plan was 0.62 mm (SD = 0.235) in group 1 and 0.69 mm (SD = 0.246) in group 2, with no statistical difference between the groups (p = 0.282). The mean volume differences between the reconstructed and unaffected orbits were 0.95 ml and 1.02 ml in group 1 and group 2, respectively, with no significant difference between the groups (p = 0.860). Overall clinical improvements, as well as complications, were similar. 3D preformed titanium meshes can reconstruct inferomedial fractures with the same accuracy as customized implants. Therefore, in clinical practice, it is recommended to use 3D preformed meshes for this type of fracture due to their excellent results and the potential for reducing time and costs.

Applications of Preoperative and Intraoperative Technologies for Complex Primary and Secondary Facial Trauma Reconstruction

This article provides a review of the current technologies available in the preoperative and intraoperative management of complex and secondary maxillofacial trauma reconstruction. These patients present a unique challenge for which the advancement of imaging technologies, patient-specific modeling and implants, and intraoperative imaging and navigation can play an important role to improve their post-treatment outcomes.

Modified individualized titanium mesh in orbital floor reconstruction for preventing exposure

Objective

To describe a novel method of medial fixation of titanium mesh with a right-angled screwdriver for orbital floor and maxillary reconstruction and to compare the reconstruction outcome of orbital floor reconstruction with modified and traditional methods.

Methods

The data of 23 patients who underwent maxillectomy and orbital floor defect reconstruction by individualized titanium mesh in Peking University School and Hospital of Stomatology between 2018 and 2021 were retrospectively reviewed. While eight patients received modified orbital floor reconstruction with titanium mesh and angled screwdriver (group A), 15 patients received traditional orbital floor reconstruction (group B). The contact area with buccal flap for titanium mesh in groups A and B was calculated. Titanium mesh deformation, fracture or exposure was recorded. Postoperative ophthalmic function and success of esthetic restoration were assessed.

Results

Mean follow-up was for 15.7 months (range, 9-22 months). The contact area with buccal flap for the modified titanium mesh in group A (13.11 ± 1.41 cm2) was significantly less than that of the traditional titanium mesh in group B (21.83 ± 1.23 cm2; p < .05). The exposure of titanium mesh occurred in two patients in group B. The self-evaluation of facial symmetry for 23 patients showed no significant difference between group A (7.75 ± 0.71) and group B (6.68 ± 1.30; p > .05). No specific complications were reported.

Conclusion

We propose a novel method of zygomatic medial fixation of titanium mesh with a right-angled screwdriver for orbital floor and maxillary reconstruction, which has the potential to prevent the postoperative exposure of titanium mesh.

Level of Evidence

Level III (Retrospective comparative study).

The Use of Patient-Specific Orbital Reconstruction Implants During Maxillectomy Reconstruction

Background: Reconstruction of the orbital floor after maxillectomy can result in significant functional and aesthetic morbidity. Study Objective: To measure eyelid position, self-reported visual outcomes, and complications in patients undergoing concurrent maxillectomy and reconstruction with a patient-specific orbital reconstruction implant (PSORI). Design Type: Case series. Materials and Methods: Case series including 12 patients who received PSORI for orbital floor reconstruction after tumor extirpation. Primary outcomes gathered were diplopia, ectropion, and wound healing complications. Results: The majority of patients were men (75%) and the mean age was 53.3 years. Ten patients underwent free flap reconstruction with the majority receiving fibula free flaps (n = 6). Median follow-up was 415.5 days. Three patients (25%) experienced long-term complications, including diplopia (n = 1) and hardware extrusion (n = 3). Each of these occurred in the context of total maxillectomy and radiation. This prompted subsequent use of a modified implant design for the final six patients and the preferential use of a midface-degloving approach. These interventions eliminated extrusions in subsequent patients. Conclusion: PSORIs can be used for orbital floor reconstruction following maxillectomy in combination with free tissue transfer. Implant design is critical to reduce complications. The use of a midface degloving approach and a modified low-profile design was associated with a low rate of complications.

Usage of Object Matching Algorithms Combined with Mixed Reality for Enhanced Decision Making in Orbital Reconstruction-A Technical Note

This technical note describes the usage of object matching to virtually compare different modes of reconstruction in orbital trauma and display the results to the surgeon and the patient pre-operatively via mixed reality devices for enhanced surgical decision making and immersive patient education. A case of an orbital floor fracture is presented for which surface and volume matching were implemented to compare orbital reconstruction utilizing pre-fabricated titanium meshes versus patient-specific implants. The results could be visualized by mixed reality devices to further enhance surgical decision-making. The data sets were demonstrated to the patient in mixed reality for immersive patient education and enhanced shared decision making. The advantages of the new technologies are discussed in view of the new possibilities of improved patient education and informed consent processes, as well as new ways of teaching medical trainees.

Skull-Base Surgery-A Narrative Review on Current Approaches and Future Developments in Surgical Navigation

Surgical navigation technology combines patient imaging studies with intraoperative real-time data to improve surgical precision and patient outcomes. The navigation workflow can also include preoperative planning, which can reliably simulate the intended resection and reconstruction. The advantage of this approach in skull-base surgery is that it guides access into a complex three-dimensional area and orients tumors intraoperatively with regard to critical structures, such as the orbit, carotid artery and brain. This enhances a surgeon's capabilities to preserve normal anatomy while resecting tumors with adequate margins. The aim of this narrative review is to outline the state of the art and the future directions of surgical navigation in the skull base, focusing on the advantages and pitfalls of this technique. We will also present our group experience in this field, within the frame of the current research trends.

Primary reconstruction of combined orbital and zygomatic complex fractures with patient-specific milled titanium implants - A retrospective study

The aim of this retrospective study was to compare mid-facial symmetry and clinical outcomes between patients treated with patient-specific and standard implants in primary fracture reconstructions of combined orbital and zygomaticomaxillary complex fractures. Patients who underwent primary reconstruction of orbital and zygomaticomaxillary complex fractures during the study period were identified and background and clinical variables and computed tomography images were collected from patient records. Zygomaticomaxillary complex dislocation and orbital volume were measured from pre- and postoperative images and compared between groups. Out of 165 primary orbital reconstructions, eight patients treated with patient-specific and 12 patients treated with standard implants were identified with mean follow-up time of was 110 days and 121 days, respectively. Postoperative orbital volume difference was similar between groups (0.2 ml for patient-specific vs 0.3 ml for standard implants, p = 0.942) despite larger preoperative difference in patient-specific implant group (2.1 ml vs 1,5 ml, p = 0.428), although no statistical differences were obtained in symmetricity or accuracy between the reconstruction groups. Within the limitations of the study it seems that patient-specific implants are a viable option for primary reconstructions of combined zygomaticomaxillary complex and orbital fractures, because with patient-specific implants at least as symmetrical results as with standard implants can be obtained in a single surgery.

Prospective Evaluation of Two Wall Orbital Fractures Involving the Medial Orbital Wall: PSI Reconstruction versus PDS Repair—Worth the Effort?

Proper treatment of the two-wall fractured orbit is still controversial. Specifically, there is no consensus on the issue of the necessity of medial orbital wall repair. With anatomically critical structures at risk during the surgical approach, surgeons’ view on the necessity of medial orbital wall repair often is restricted and an aesthetically disturbing enophthalmos is more likely to be accepted. Therefore, treatment options range from leaving the medial wall without repair to reconstruction with autogenous tissue or alloplastic materials, which can lead to moderate to severe side effects. However, emerging technologies such as patient-specific implants (PSI) offer a reliable and anatomically correct reconstruction of the bony orbit. This study aimed to evaluate the outcome of full orbital reconstruction using PSIs compared to only orbital floor repair using PDS (bioresorbable polydioxanone) foils leaving the medial orbital wall untouched in traumatic two-wall orbital fractures. Of all patients treated at the University Hospital of Düsseldorf between 2017 and 2019 who suffered from traumatic orbital fracture, only patients with a two-wall orbital fracture involving both the orbital floor and the medial wall (n = 68) were included. Patients were treated either with a PSI (n = 35) or a PDS foil (n = 33). Primary outcome parameters were ophthalmological disturbances analyzed via clinical investigation and intra-orbital angles, volumes and implant position analyzed with radiological 3D-datasets. While a two-wall reconstruction using PSIs led to a significant improvement of the enophthalmos, the rate of postoperative enophthalmos was significantly increased in cases of only orbital floor repair with PDS foils. Radiologically, a significant reconstruction of the three-dimensional bony orbit succeeded with the simple use of PSIs leading to a significant reduction in the traumatically enlarged orbital volume. PSI also led to a significant reduction in the traumatically enlarged medial angle of the orbit. This was not the case for single-floor repair with PDS foil. The results of this study suggest that complex orbital fractures can be reconstructed at an even higher degree of accuracy with selective laser-melted PSIs than PDS foils. In order to achieve a true to original reconstruction of the bony orbit, surgical treatment of the medial orbital wall can be advocated for in the long term depending on the indication.

Personalized Medicine Workflow in Post-Traumatic Orbital Reconstruction

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.

Prospective Evaluation of Intraorbital Soft Tissue Atrophy after Posttraumatic Bone Reconstruction: A Risk Factor for Enophthalmos

Orbital fractures are a common finding in facial trauma, and serious complications may arise when orbital reconstruction is not performed properly. The virtual planning can be used to print stereolithographic models or to manufacture patient-specific titanium orbital implants (PSIs) through the process of selective laser melting. This method is currently considered the most accurate technique for orbital reconstruction. Even with the most accurate techniques of bone reconstruction, there are still situations where enophthalmos is present postoperatively, and it may be produced by intraorbital soft tissue atrophy. The aim of this paper was to evaluate the orbital soft tissue after posttraumatic reconstruction of the orbital walls’ fractures. Ten patients diagnosed and treated for unilateral orbital fractures were included in this prospective study. A postoperative CT scan of the head region with thin slices (0.6 mm) and soft and bone tissue windows was performed after at least 6 months. After data processing, the STL files were exported, and the bony volume, intraorbital fat tissue volume, and the muscular tissue volume were measured. The volumes of the reconstructed orbit tissues were compared with the volumes of the healthy orbit tissues for each patient. Our findings conclude that a higher or a lower grade of fat and muscular tissue loss is present in all cases of reconstructed orbital fractures. This can stand as a guide for primary or secondary soft tissue augmentation in orbital reconstruction.

Primary Orbital Reconstruction with Selective Laser Melting (SLM) of Patient-Specific Implants (PSIs): An Overview of 96 Surgically Treated Patients

Contemporary advances in technology have allowed the transfer of knowledge from industrial laser melting systems to surgery; such an approach could increase the degree of accuracy in orbital restoration. The aim of this study was to examine the accuracy of selective laser melted PSIs (patient-specific implants) and navigation in primary orbital reconstruction. Ninety-six patients with orbital fractures were included in this study. Planned vs. achieved orbital volumes (a) and angles (b) were compared to the unaffected side (n = 96). The analysis included the overlay of post-treatment on planned images (iPlan 3.0.5, Brainlab®, Feldkirchen, Germany). The mean difference in orbital volume between the digitally planned orbit and the postoperative orbit was 29.16 cm3 (SD 3.54, presurgical) to 28.33 cm3 (SD 3.64, postsurgical, t = 5.00, df = 95.00; p < 0.001), resulting in a mean volume difference (planned vs. postop) of less than 1 cm3. A 3D analysis of the color mapping showed minor deviations compared to the mirrored unaffected side. The results suggested that primary reconstruction in complex orbital wall fractures can be routinely achieved with a high degree of accuracy by using selective laser melted orbital PSIs.

Customised products for orbital wall reconstruction: a systematic review

The purpose of this systematic review was to critically analyse the recent literature and present the state of the art in customised reconstruction of orbital fractures. Three electronic databases and manual search approaches were used to identify relevant articles. Only controlled clinical studies were included. Primary outcome was defined as the status of recovery (complete/partial functional, and aesthetic disturbances). The benefit of intrasurgical navigation should be described. The secondary outcome was defined as the time of surgery, post-surgical events, and hospitalisation. Of the 552 records identified, eight met the inclusion criteria. Post-surgical results regarding recovery were superior in the customised group, and were comparable to the control group in five studies. The time of surgery was shorter in the customised groups, and liquid infusion and time of hospitalisation were reduced. Four studies documented more accurate reconstruction with the use of navigation. All the studies presented at least one bias, and considerable heterogeneity was evaluated. This review found that the use of customised meshes in combination with surgical navigation resulted in more accurate reconstruction. A significant reduction in surgical time was revealed.

Reconstruction of maxillofacial bone defects using patient-specific long-lasting titanium implants

The objective of this retrospective study is to verify the effectiveness and safety of patient-specific titanium implants on maxillofacial bones, with a long-term follow-up. Total 16 patients with various maxillofacial defects underwent reconstruction using patient-specific titanium implants. Titanium implants, manufactured by electron beam melting, selective laser sintering, or milling, were inserted into the maxilla, mandible, or zygoma. Long-term follow‐up (36.7 ± 20.1 months) was conducted after the surgery. Bone fusion of the titanium implant body, postoperative infection, implant malunion, functional results, patient satisfaction, subsidence, osteolysis around the implants, and complications were recorded and analyzed at the last follow-up. Of the 28 implants, only one failed to unite with the bone; therefore, revision surgery was performed. No osteolysis or subsidence around the titanium implants nor adverse events were observed; the mean VAS score for satisfaction was 9. All patients enrolled in this trial were esthetically and functionally satisfied with their surgical results, and fixation failure and esthetic dissatisfaction complications were well resolved. Patient-specific titanium showed satisfactory outcomes when used to treat various oral and maxillofacial defects. A 3D printed titanium implant can be effectively used in the reconstruction of the zygoma and mandible instead of autogenous bone without donor site morbidity.

Anatomical Engineering and 3D Printing for Surgery and Medical Devices: International Review and Future Exponential Innovations

Three-dimensional printing (3DP) has recently gained importance in the medical industry, especially in surgical specialties. It uses different techniques and materials based on patients' needs, which allows bioprofessionals to design and develop unique pieces using medical imaging provided by computed tomography (CT) and magnetic resonance imaging (MRI). Therefore, the Department of Biology and Medicine and the Department of Physics and Engineering, at the Bioastronautics and Space Mechatronics Research Group, have managed and supervised an international cooperation study, in order to present a general review of the innovative surgical applications, focused on anatomical systems, such as the nervous and craniofacial system, cardiovascular system, digestive system, genitourinary system, and musculoskeletal system. Finally, the integration with augmented, mixed, virtual reality is analyzed to show the advantages of personalized treatments, taking into account the improvements for preoperative, intraoperative planning, and medical training. Also, this article explores the creation of devices and tools for space surgery to get better outcomes under changing gravity conditions.

"6 Anatomical Landmarks" Technique for Satisfactory Free-Hand Orbital Reconstruction With Standard Preformed Titanium Mesh

Study Design

Retrospective study.

Objective

Resolution of clinical signs and symptoms following orbital fractures depends on the accurate restoration of the orbital volume. Computer-Assisted procedures and Patient Specific Implants represent modern solutions, but they require additional resources. A more reproducible option is the use of standard preformed titanium meshes, widely available and cheaper; with their use quality of results is proportional to the accuracy with which they are positioned. This work identifies 6 reproducible and constant anatomical landmarks, as an intraoperative guide for the precise positioning of titanium preformed meshes.

Methods

90 patients treated at the Maxillofacial Surgery Department, Niguarda Trauma Center, Milan, for unilateral orbital reconstruction (January 2012 to December 2018), were studied. In all cases reconstruction was performed respecting the 6 proposed anatomical landmarks. The outcomes analyzed are: post-operative CT adherence to the 6 anatomical markers and symmetry achieved respect to controlateral orbit; number/year of re-interventions and duration of surgery; resolution of clinical defects (at least 12-months follow-up); incidence of complications.

Results

Satisfactory results were obtained in terms of restoration of orbital size, shape and volume. Clinical defects early recovered with a low incidence of complications and re-interventions. Operating times and radiological accuracy have shown a progressive improvement during years of application of this technique.

Conclusions

The proposed "6 anatomical landmarks" is an easy free-hand technique that allows everyone to obtain high levels of reconstructive accuracy and it should be a skill of all surgeons who deal with orbital reconstruction in daily clinical activity.

Digital planning and individual implants for secondary reconstruction of midfacial deformities: A pilot study

Objective

To evaluate the feasibility and accuracy of implementing three‐dimensional virtual surgical planning (VSP) and subsequent transfer by additive manufactured tools in the secondary reconstruction of residual post‐traumatic deformities in the midface.

Methods

Patients after secondary reconstruction of post‐traumatic midfacial deformities were included in this case series. The metrical deviation between the virtually planned and postoperative position of patient‐specific implants (PSI) and bone segments was measured at corresponding reference points. Further information collected included demographic data, post‐traumatic symptoms, and type of transfer tools.

Results

Eight consecutive patients were enrolled in the study. In five patients, VSP with subsequent manufacturing of combined predrilling/osteotomy guides and PSI was performed. In three patients, osteotomy guides, repositioning guides, and individually prebent plates were used following VSP. The median distances between the virtually planned and the postoperative position of the PSI were 2.01 mm (n = 18) compared to a median distance concerning the bone segments of 3.05 mm (n = 12). In patients where PSI were used, the median displacement of the bone segments was lower (n = 7, median 2.77 mm) than in the group with prebent plates (n = 5, 3.28 mm).

Conclusion

This study demonstrated the feasibility of VSP and transfer by additive manufactured tools for the secondary reconstruction of complex residual post‐traumatic deformities in the midface. However, the median deviations observed in this case series were unexpectedly high. The use of navigational systems may further improve the level of accuracy.

To evaluate the feasibility and accuracy of implementing three‐dimensional virtual surgical planning (VSP) and subsequent transfer by additive manufactured tools in the secondary reconstruction of residual post‐traumatic deformities in the midface. This study demonstrated the feasibility of VSP and transfer by additive manufactured tools for the secondary reconstruction of complex residual post‐traumatic deformities in the midface. However, the median deviations observed in this case series were unexpectedly high. The use of navigational systems may further improve the level of accuracy.

Is the Mirroring Technology Reliable in the Use of Computer-Aided Design for Orbital Reconstruction? Three-Dimensional Analysis of Asymmetry in the Orbits

BACKGROUND

Reconstruction of the orbital area remains a challenge in many cases. The recently introduced mirroring technology provides surgeons with patient-specific information for accurate orbital reconstruction; its premise is that the three-dimensional anatomy of craniofacial bone is symmetric. The purpose of this study was to verify this premise of the mirroring technology by assessing three-dimensional asymmetry.

METHODS

Facial computed tomographic data of 104 patients were imported into iPlan software. Four reference points (i.e., zygomaticofrontal suture, frontomaxillary suture, infraorbital foramen, and optic canal) were set, and the three-dimensional distances from these points to the anterior nasal spine on the mirroring plane were calculated. In addition, the orbital cavity volume and the three-dimensional distances from point optic canal to the other reference points were calculated for the assessment of the orbit anatomy. Three plastic surgeons performed these processes independently.

RESULTS

No statistically significant difference was found in the three-dimensional distances between anterior nasal spine and the four reference points bilaterally. Also, no statistically significant difference in the three-dimensional distances between the point representing the optic canal and other reference points was detected bilaterally. Orbital cavity volume showed a mild asymmetry, but the discrepancy was acceptable for computer-aided design applications. For all reference points, the maximum value of the 95 percent CI was less than 1.4 mm.

CONCLUSIONS

The three-dimensional location of the orbits and the three-dimensional anatomy of the orbit were symmetric. Thus, the mirroring technology could be a reliable first step in computer-aided design, computer-assisted surgery, and navigation-assisted surgery.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, V.

Do Patient-Specific Implants Decrease Complications and Increase Orbital Volume Reconstruction Accuracy in Primary Orbital Fracture Reconstruction?

PURPOSE

Patient-specific titanium implants are increasingly used in orbital trauma as a means of achieving improved surgical outcomes as well as decreasing postoperative complications; however, the data to support their use remain limited. The purpose of this study is to compare the complication rates and accuracy of orbital reconstruction using preformed titanium mesh implants and patient-specific implants.

METHODS

The authors conducted a retrospective cohort study consisting of patients with orbital floor and/or medial wall fractures treated by reconstruction with either preformed or patient-specific implants from August 1, 2015 to December 31, 2020. The primary predictor variable was the implant type. Outcome variables were the percent volume difference between the reconstructed and uninjured orbital volume and complications. Statistical analysis was performed using Fisher exact test and Wilcoxon rank-sum test.

RESULTS

Of the 85 patients in the study, 73% were male and the average age was 38.7 ± 16.6 years. Sixty-one patients (72%) were treated with preformed implants and 24 (28%) with patient-specific implants. Complications occurred in 8.3% of the patient-specific implant group and 26.2% of the preformed implant group (P = .08). Percent volume difference between the reconstructed and nontraumatized orbit was 4.2% and 6.8% in the patient-specific and preformed implant group, respectively (P = .03).

CONCLUSIONS

Patient-specific implants improved orbital volume reconstruction accuracy but did not decrease complications when compared to preformed implants.

Pitfalls of Surgeon-Engineer Communication and the Effect of In-House Engineer Training During Digital Planning of Patient-Specific Implants for Orbital Reconstruction

PURPOSE

The use of patient-specific implants for reconstruction of complex orbital floor defects is increasing and requires communication with an industry partner, which warrants investigation. Therefore, the aim of this study was to evaluate the effects of in-house training of engineers on such communication as well as to identify frequent sources of problems and their solutions for improvement of the implant-planning workflow.

METHODS

We conducted a retrospective cross-sectional study and enrolled a sample of patients who had undergone orbital reconstruction with patient-specific implants between 2017 and 2020. The predictor variables were in-house training (additional training completed in hospital or not) and implant complexity (complex [multiwalled implants] vs less complex [isolated orbital floor reconstructions]). The outcome variables were duration of communication, message length, and need for synchronous communication or modifications to the original design. Descriptive, univariate, and multivariate statistics were computed, and statistical significance was set at a P value of < 0.05.

RESULTS

This study included the data of 66 patients (48 men and 18 women, average age: 42.27 years). The complexity of the implant statistically significantly increased the duration of the communication (8.76 vs 16.03 days; P = .004). In 72.73%, the initial design had to be changed. Engineers trained in house required less communication to plan less-complex implants and generally needed fewer corrections to the original design (P = .020 and P = .036, respectively). Problems during planning were observed in 25.76% of the cases, with an insufficient diagnostic 3-dimensional data set being the most common (15.15%).

CONCLUSIONS

In-house training of engineers is time-saving while planning the workflow for patient-specific implants, especially in less-complex cases, given that design changes are not needed often. The high rate of data sets that were insufficient for planning patient-specific implants suggests that diagnostic 3-dimensional data sets should already meet the requirements for such planning.

3D Printing in Eye Care

Three-dimensional printing enables precise modeling of anatomical structures and has been employed in a broad range of applications across medicine. Its earliest use in eye care included orbital models for training and surgical planning, which have subsequently enabled the design of custom-fit prostheses in oculoplastic surgery. It has evolved to include the production of surgical instruments, diagnostic tools, spectacles, and devices for delivery of drug and radiation therapy. During the COVID-19 pandemic, increased demand for personal protective equipment and supply chain shortages inspired many institutions to 3D-print their own eye protection. Cataract surgery, the most common procedure performed worldwide, may someday make use of custom-printed intraocular lenses. Perhaps its most alluring potential resides in the possibility of printing tissues at a cellular level to address unmet needs in the world of corneal and retinal diseases. Early models toward this end have shown promise for engineering tissues which, while not quite ready for transplantation, can serve as a useful model for in vitro disease and therapeutic research. As more institutions incorporate in-house or outsourced 3D printing for research models and clinical care, ethical and regulatory concerns will become a greater consideration. This report highlights the uses of 3D printing in eye care by subspecialty and clinical modality, with an aim to provide a useful entry point for anyone seeking to engage with the technology in their area of interest.

Technical Note on Three- and Four-Wall Orbital Reconstructions with Patient-Specific Implants

ABSTRACT

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 patient-specific 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.

Critical appraisal of patient-specific implants for secondary post-traumatic orbital reconstruction

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.

Advances in the Resection and Reconstruction of Midfacial Tumors Through Computer Assisted Surgery

Curatively intended oncologic surgery is based on a residual-free tumor excision. Since decades, the surgeon’s goal of R0-resection has led to radical resections in the anatomical region of the midface because of the three-dimensionally complex anatomy where aesthetically and functionally crucial structures are in close relation. In some cases, this implied aggressive overtreatment with loss of the eye globe. In contrast, undertreatment followed by repeated re-resections can also not be an option. Therefore, the evaluation of the true three-dimensional tumor extent and the intraoperative availability of this information seem critical for a precise, yet substance-sparing tumor removal. Computer assisted surgery (CAS) can provide the framework in this context. The present study evaluated the beneficial use of CAS in the treatment of midfacial tumors with special regard to tumor resection and reconstruction. Therefore, 60 patients diagnosed with a malignancy of the upper jaw has been treated, 31 with the use of CAS and 29 conventionally. Comparison of the two groups showed a higher rate of residual-free resections in cases of CAS application. Furthermore, we demonstrate the use of navigated specimen taking called tumor mapping. This procedure enables the transparent, yet precise documentation of three-dimensional tumor borders which paves the way to a more feasible interdisciplinary exchange leading e.g. to a much more focused radiation therapy. Moreover, we evaluated the possibilities of primary midface reconstructions seizing CAS, especially in cases of infiltrated orbital floors. These cases needed reduction of intra-orbital volume due to the tissue loss after resection which could be precisely achieved by CAS. These benefits of CAS in midface reconstruction found expression in positive changes in quality of life. The present work was able to demonstrate that the area of oncological surgery of the midface is a prime example of interface optimization based on the sensible use of computer assistance. The fact that the system makes the patient transparent for the surgeon and the procedure controllable facilitates a more precise and safer treatment oriented to a better outcome.

[Complex reconstructions in the facial and cranial regions]

Posttraumatic reconstruction of the neurocranium and viscerocranium is an essential part of modern oral and maxillofacial surgery, in addition to oncological surgery, surgery of congenital craniofacial deformities and dental surgery. Due to the complex anatomy of the facial skull and significant esthetic and functional demands on its reconstruction, reconstructive trauma surgery in this area places the highest demands on the surgeon. This is all the more true if definitive craniomaxillofacial surgical treatment can sometimes only be performed with considerable delays for the benefit of other life-threatening injuries. In order to take these prerequisites into account, achievements of modern biomedical technology, such as intraoperative real-time navigation, computer-assisted planning and computer-assisted manufacturing (CAD/CAM) of patient-specific biomodels and implants, came up early for use in oral and maxillofacial surgery. In combination with intraoperative three-dimensional imaging, these methods result in a treatment pathway tailored to the individual patient, which is directly checked for quality at every step and thus ensures the best possible result for the patient. The use of these technologies extends far beyond the original indications in the area of orbital reconstruction and restoration of bony defects with simple geometry, such as skull defects. Nowadays, even the most complex pan-facial fractures can be restored esthetically and functionally by means of digitalized preliminary planning and individualized skull, orbital and zygomatic implants as well as total temporomandibular joint prostheses.

Accuracy of free-hand positioned patient specific implants (PSI) in primary reconstruction after inferior and/or medial orbital wall fractures

BACKGROUND

To assess the accuracy with which CAD/CAM-fabricated patient-specific titanium implants (PSI) are positioned for inferior and/or medial orbital wall reconstruction without the use of intraoperative navigation.

METHODS

Patients who underwent a primary reconstruction of the orbital walls with PSI due to fractures were enrolled in this retrospective cohort analysis. The primary outcome variables were the mean surface distances (MSD) between virtually planned and postoperative PSI position and single linear deviations in the x-, y- and z-axis at corresponding reference points. Secondary outcome variables included demographic data, classification of orbital wall defects and clinical outcomes.

RESULTS

A total of 33 PSI (orbital floor n = 22; medial wall, n = 11) were examined in 27 patients. MSD was on a comparable level for the orbital floor and medial wall (median 0.39 mm, range 0.22-1.53 mm vs. median 0.42 mm, range 0.21-0.98 mm; p = 0.56). Single linear deviations were lower for reconstructions of the orbital floor compared to the medial wall (median 0.45 vs. 0.79 mm; p < 0.05). There was no association between the occurrence of diplopia and the accuracy level (p = 0.418).

CONCLUSIONS

Free-hand positioning of PSI reaches a clinically appropriate level of accuracy, limiting the necessity of navigational systems to selected cases.

A Multi-Criteria Assessment Strategy for 3D Printed Porous Polyetheretherketone (PEEK) Patient-Specific Implants for Orbital Wall Reconstruction

Pure orbital blowout fractures occur within the confines of the internal orbital wall. Restoration of orbital form and volume is paramount to prevent functional and esthetic impairment. The anatomical peculiarity of the orbit has encouraged surgeons to develop implants with customized features to restore its architecture. This has resulted in worldwide clinical demand for patient-specific implants (PSIs) designed to fit precisely in the patient's unique anatomy. Material extrusion or Fused filament fabrication (FFF) three-dimensional (3D) printing technology has enabled the fabrication of implant-grade polymers such as Polyetheretherketone (PEEK), paving the way for a more sophisticated generation of biomaterials. This study evaluates the FFF 3D printed PEEK orbital mesh customized implants with a metric considering the relevant design, biomechanical, and morphological parameters. The performance of the implants is studied as a function of varying thicknesses and porous design constructs through a finite element (FE) based computational model and a decision matrix based statistical approach. The maximum stress values achieved in our results predict the high durability of the implants, and the maximum deformation values were under one-tenth of a millimeter (mm) domain in all the implant profile configurations. The circular patterned implant (0.9 mm) had the best performance score. The study demonstrates that compounding multi-design computational analysis with 3D printing can be beneficial for the optimal restoration of the orbital floor.

Patient-Specific Implants in Oculofacial Plastic Surgery

PURPOSE

To investigate how patient-specific implants (PSIs) are being utilized for periocular facial skeletal reconstruction. Specifically, to characterize indications for custom implants, areas of reconstruction, intraoperative variables impacting implant placement, as well as to report on postoperative outcomes.

MATERIALS AND METHODS

A retrospective chart review was performed for patients who received a PSI for periocular skeletal reconstruction between 2015 and 2019. Three independent academic centers were included in this study, which encompassed 4 different primary surgeons. Medical records, radiographic imaging, and operative reports were reviewed.

RESULTS

Eleven patients, 8 females and 3 males, ages ranging from 15 to 63 years old received PSIs. The average duration of follow up was 16 months ± 6.6 months (range: 9-30 months). The most common underlying etiology for reconstruction was prior trauma (54.5%) followed by benign tumor resection (18.2%). The most frequent area of reconstruction involved the inferior orbital rim and adjacent maxilla (63.6%). Implant materials included porous polyethylene, polyetheretherketone, and titanium. Six implants required intraoperative modification, most commonly accommodate critical neurovascular structures (66.6%) or improve contour (33.3%). Two postoperative complications were noted, both in the form of infection with 1 implant requiring removal.

CONCLUSIONS

Reconstruction of complex facial skeletal defects can be achieved by utilizing computer-assisted design software and 3D printing techniques to create PSIs. These implants represent the most customizable option for symmetric restoration of the facial skeleton by not only addressing structural deficits but also volumetric loss. This was particularly apparent in reconstruction of the orbital rim and midface. PSIs were found to be of most benefit in patients with prior trauma or complex skeletal defects after tumor resection.

Surgical instrument to improve implant positioning in orbital reconstruction: a feasibility study

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.

Intraoperative real-time navigation and intraoperative three-dimensional imaging for patient-specific total temporomandibular joint replacement

Customized solutions for replacement of the temporomandibular joint (TMJ) along with surgical guides enable precise and fast transfer of the virtual plan to the patient. However, these guides lack information on screw vectors and length, and well-defined borders for bony resections towards the medial skull base. This retrospective study was performed to investigate the feasibility and benefit of real-time navigation and intraoperative three-dimensional imaging during total TMJ replacement (TJR), as well as patient clinical outcomes. Between 2016 and 2020, 26 customized prostheses were implanted in 21 patients either with or without real-time navigation and instrument tracking. The clinical, surgical, radiological, and navigational data were analysed. The accuracy of navigation registration with instrument tracking, precision of screw insertion, and implant and screw positions were analysed by fusion of the virtual plan and surgical outcome. Real-time navigation aided orientation during lateral skull base dissection and resection. However, the results of real-time navigation-aided drilling were inconclusive regarding vector and length control. At a mean 15.3±3.0 months of follow-up, average mouth opening had improved from 21.69±2.80mm to 36.40±1.25mm; the average pain score decreased from 6.18±0.74 to 1.06±0.52. Thus, intraoperative real-time navigation for TJR assists lateral skull base dissection and resection.

CAD/CAM-based referencing aids to reduce preoperative radiation exposure for intraoperative navigation

BACKGROUND

All intraoperative navigation systems need a referencing procedure prior to utilization, usually requiring an additional computed tomography (CT) or cone beam computed tomograph (CBCT) scan. As new techniques in the field of Computer-aided design / Computer-aided manufacturing (CAD/CAM) have evolved, it seemed favourable to develop a new referencing method not relying on additional CT or CBCT scans.

METHODS

A digital maxillary dental scan was used to create a referencing splint by CAD/CAM containing four reference points. By matching scanned dental model and initial trauma-CT, the splints position and thus the reference points were digitally simulated. These splints data were imported into the navigation system in Standard Tessellation Language (STL) format. These data were also 3D printed and the resulting piece was placed on the anatomical models' teeth. The methods accuracy was then assessed in vitro.

CONCLUSION

Our method for referencing of intraoperative navigation can be feasible to avoid an additional CT or CBCT prior to navigation.

Self-centering second-generation patient-specific functionalized implants for deep orbital reconstruction

Deep and complete reconstruction of the orbital cavity has been shown to be essential for preventing enophthalmos and hypoglobus in patients with orbital defects or deformities. Additively manufactured patient-specific titanium implants provide unlimited options in design. However, implant malpositioning can still occur, even when intraoperative imaging and navigation are used. In this study, we investigated novel orbital implants containing features facilitating self-centering. Accuracy of implant placement and reconstruction of the orbital dimensions were compared retrospectively between self-centering second-generation patient-specific functionalized orbital implants (study group) and CAD-based individualized implants (control group). Design features of implants in the study group included functionalization with navigation tracks, a preventive design, and flanges - so called stabilizers - towards opposite orbital walls. Implant position was evaluated by fusion of preoperative virtual plans and the post-therapeutic imaging. Aberrances were quantified by 3D heatmap analysis. 31 patients were assigned to the study group and 50 to the control group, respectively. In the study group, most implants were designed with either one (n = 18, 58.06%) or two (n = 10, 32.26%) stabilizers. Twice (6.45%), one stabilizer had to be shortened intraoperatively. Implant fit analysis revealed a significantly more precise (p < 0.001) positioning in the study group (n = 22/31) than in the control group (n = 42/50). Self-centering second-generation patient-specific functionalized orbital implants showed significantly more accurate implant positioning, facilitating the transformation of virtual plans into patient's anatomy. The presented design provides an additional instrument for intraoperative quality control besides intraoperative imaging and navigation.

Surgical Outcomes of Orbital Fracture Reconstruction Using Patient-Specific Implants

PURPOSE

Patient-specific implants (PSIs) are known to yield reliable outcomes in orbital wall fracture reconstruction (high precision, smoother operating techniques, and shorter surgical duration). This study analyzed the surgical error and clinical and esthetic outcomes of orbital reconstructions with PSIs.

METHODS

This ambispective cohort study enrolled patients who underwent orbital reconstruction using PSIs between October 2016 and January 2018. The study end points were surgical error, indication and duration of surgery, long-term sequelae, revision surgeries, and surgical complications. Surgical error was analyzed by superimposing the postoperative implant position onto the preoperative virtual plan. Both qualitative (heat map) and quantitative (distance) measurements were obtained.

RESULTS

Three patients were enrolled prospectively, and 23 were enrolled retrospectively. Indications for surgery were defect size (25 patients), diplopia (10 patients), impaired eye motility (4 patients), and significant enophthalmos (6 patients). At the last patient visit, there were 5 cases of diplopia, 1 case of exophthalmos, and 6 cases of slight enophthalmos of incremental degree. In terms of surgical error, a mean distance of 0.6 mm (95% confidence interval, 0.49 to 0.76), with a mean maximal distance of 3.4 mm (95% confidence interval, 2.79 to 4.02), was noted. No revision surgery was necessary. Lid malposition complications were not observed. However, 1 case each of symblepharon and scleral show were observed. No time-saving component was observed.

CONCLUSIONS

PSI use in orbital reconstruction guarantees a preplanned 3-dimensional anatomical shape with a mean surgical error of just 0.6 mm. Our clinical results were similar to those of other protocols; however, warranting a complex 3-dimensional anatomical shape also in large orbital fractures with a low mean surgical error is feasible by using PSIs.

Patient-Specific Mandibular Reconstruction Plates Increase Accuracy and Long-Term Stability in Immediate Alloplastic Reconstruction of Segmental Mandibular Defects

OBJECTIVES

The aim of the current study was to evaluate potential differences in the accuracy of mandibular reconstruction and long-term stability, with respect to different reconstructive procedures.

METHODS

In total, 42 patients who had undergone primary segmental mandibular resection with immediate alloplastic reconstruction, with either manually pre-bent or patient-specific mandibular reconstruction plates (PSMRP), were included in this study. Mandibular dimensions, in terms of six clinically relevant distances (capitulum [most lateral points], capitulum [most medial points], incisura [most caudal points], mandibular foramina, coronoid process [most cranial points], dorsal tip of the mandible closest to the gonion point) determined from tomographic images, were compared prior to, and after surgery.

RESULTS

Dimensional alterations were significantly more often found when conventionally bent titanium reconstruction plates were used. These occurred in the area of the coronoid process (p = 0.014). Plate fractures were significantly (p = 0.022) more often found within the manually pre-bent group than within the PSMRP group (17%/0%).

CONCLUSION

The results suggest that the use of PSMRP may prevent rotation of the proximal mandibular segment, thus avoiding functional impairment. In addition, the use of PSMRP may potentially enhance the long-term stability of alloplastic reconstructions.

Overview of tools for the measurement of the orbital volume and their applications to orbital surgery

There are numerous applications in craniofacial surgery with orbital volume (OV) modification. The careful management of the OV is fundamental to obtain good esthetic and functional results in orbital surgery. With the growth of computer-aided design - computer-aided manufacturing (CAD-CAM) technologies, patient-specific implants and custom-made reconstruction are being used increasingly. The precise measurement of the OV before surgery is becoming a necessity for craniofacial surgeons. There is no consensus on orbital volume measurements (OVMs). Manual segmentation of computed tomography (CT) images is the most used method to determine the OV, but it is time-consuming and very sensitive to operator errors. Here, we describe the various methods of orbital volumetry validated in the literature that can be used by surgeons in preoperative planning of orbital surgery. We also describe the leading software employed for these methods and discuss clinical use (posttraumatic enophthalmos prediction and orbital reconstruction) in which OVMs are important.

Computer-Assisted Secondary Orbital Reconstruction

Study Design

This study presents a case-control study of 33 patients who underwent secondary orbital reconstruction, evaluating techniques and outcome.

Objective

Adequate functional and aesthetical appearance are main goals for secondary orbital reconstruction. Insufficient premorbid orbital reconstruction can result in hypoglobus, enophthalmos, and diplopia. Computer-assisted surgery and the use of patient-specific implants (PSIs) is widely described in the literature. The authors evaluate the use of selective laser-melted PSIs and hypothesize that PSIs are an excellent option for secondary orbital reconstruction.

Methods

The sample was composed of 33 patients, previously treated with primary orbital reconstruction, presenting themselves with indications for secondary reconstruction (i.e. enophthalmos, diplopia, or limited eye motility). Computed tomography and/or cone beam data sets were assessed before and after secondary reconstruction comparing intraorbital volumes, infraorbital angles, and clinical symptoms. Clinical outcomes were assessed using a standardized protocol.

Results

Results show a significant change in intraorbital volumes and a reduction of clinical symptoms after secondary reconstruction.

Conclusions

Outcomes of this study suggest that secondary orbital reconstruction can be performed routinely using selective laser-melted PSIs and titanium spacers.