Advanced Concepts of Orbital Reconstruction

•The use of a cadaver model allows assessment the effect individual steps computer-assisted surgery on orbital implant positioning.•The accuracy and consistency positioning without are low, which enphasizes need for intraoperative control.•3D virtual surgical planning leads to better position through enhanced insight in anatomy fracture details, detailed knowledge ideal position.•Deviations from can be identified with imaging implant’s improved accordingly.•Real-time navigation proves safest, fastest most accurate method reconstruction. In most, if not all, clinical research papers presentations novel techniques reconstruction, combinations different have been used highlight technological progress increased quality outcomes terms predictability reliability.1Gellrich N.-C. Schramm A. Hammer B. et al.Computer-assisted secondary reconstruction unilateral posttraumatic deformity.Plast Reconstr Surg. 2002; 110: 1417-1429Crossref PubMed Scopus (231) Google Scholar, 2Bly R.A. Chang S.-H. Cudejkova M. al.Computer-guided improve outcomes.JAMA Facial Plast 2013; 15: 113-120Crossref (58) 3Rana Chui C.H.K. Wagner al.Increasing selective laser-melted patient-specific implants combined navigation.J Oral Maxillofac 2015; 73: 1113-1118Abstract Full Text PDF 4Zimmerer R.M. Ellis E. Aniceto G.S. al.A prospective multicenter study compare precision internal standard preformed individualized implants.J Craniomaxillofac 2016; 44: 1485-1497Crossref (64) 5Chen C.-T. Pan C.-H. Chen al.Clinical minimally invasive primary using an advanced synergistic combination endoscopy.J Aesthet 2018; 71: 90-100Abstract (10) 6De Cuyper Abeloos J. Swennen G. al.Intraoperative cone beam computed tomography restoring dimensions: single-center experience.Craniomaxillofac Trauma Reconstr. 2020; 13: 84-92Crossref Scholar Amsterdam University Medical Centers, The Netherlands, comprehensive started 2014 development human This was sequence evaluate every single step process article is resume this series investigations publications additive value surgery, including various techniques, has assessed. interventions evaluated were as follows:1.Conventional transconjunctival (baseline)7Dubois L. Jansen Schreurs R. al.Predictability reconstruction: study. Part I: endoscopic-assisted reconstruction.J 43https://doi.org/10.1016/j.jcms.2015.07.019Crossref (17) Scholar2.Reconstruction transsinusoidal endoscopy7Dubois Scholar3.Reconstruction planning8Jansen Dubois al.The advantages diagnostics three-dimensional preoperative https://doi.org/10.1016/j.jcms.2018.02.010Crossref (12) Scholar4.Reconstruction imaging9Jansen how does it affect implant?.Br J 58: 801-806Abstract (1) Scholar5.Reconstruction image-guided navigation10Dubois II: navigation-assisted 43https://doi.org/10.1016/j.jcms.2015.07.020Crossref (29) Scholar6.Reconstruction marker-based navigation11Dubois Essig H. A study, part III: implant-oriented optimized 43: 2050-2056Crossref (25) Scholar7.Reconstruction real-time navigation12Schreurs Ho al.Implant-oriented preclinical study.Int 49: 678-685Abstract (5) Materials methods almost identical all studies. Fixed heads obtained Department Biology, Section Clinical Anatomy Embryology Centers. Computed (CT) scans performed at baseline (with intact orbits, T0) (SOMATOM Sensation 64; Siemens Healthineers, Erlangen, Germany). Scan parameters included collimation 20 × 0.6 mm, 120 kV, 350 mAs, pitch 0.85, field view 30 cm, matrix 512 512, slice thickness 0.75 mm overlapping increments 0.4 bone kernel H70s, window W1600 L400. floor medial wall fully exposed incision retroseptal preparation. Following Jaquiéry classification, complex defects (class III–IV) created piezoelectric (Mectron SpA, Carasco, Italy).13Jaquiéry C. Aeppli Cornelius P. al.Reconstruction defects: critical review 72 patients.Int 2007; 36: 193-199Abstract (94) After creation (T1), postoperatively after placement (T2), consecutive CT acquired aforementioned scanning protocol. T2 acquired, plates removed, screw holes covered dental filling material (DuraLay; Reliance Dental Mfg Co, Worth, IL, USA) make them invisible. studies, titanium mesh (KLS Martin, Tuttlingen, Germany) used; stereolithographic models (STL files) these imported iPlan Cranial software environment (version 3.0.5; Brainlab AG, Munich, optimal virtually planned served target during faces prevent recognition studies carried out time intervals several months years. Validation investigate compared planning. For purpose, reference frame (Fig. 1).14Schreurs Becking A.G. al.Quantitative position-a proof concept.PLoS One. 11https://doi.org/10.1371/journal.pone.0150162Crossref (15) made quantification difference between possible: rotational (roll, pitch, yaw, degrees) translational (in millimeters) deviations outcome 1 5, 19 orbits reconstructed by 2 surgeons; 10 surgeon 6, (of another group) surgeons 7. results 5 (study 1). Studies 6 7 because could considered evaluating methods. first session, further additions, approach. Preformed positioned according best judgment fixed osteosynthesis screws. It important know that had no access information planning, but only multiplanar visualization 3-dimensional (3D) scan (T1). available hardware visualized Fig. 2. acted comparison implementation technologies evaluated. reconstructions session additional endoscope. approach again implant. To facilitate inspection endoscope, gingivobuccal 5-mm antrostomy canine fossa concavity Piezotome SpA). sinus mucosa so defect maxillary 30°endoscope (KARL STORZ SE & Co KG, 3, visualized. third 3D computer tools Cranial, such segmentation mirroring. Information implant, help skilled experienced technical physician, 4). challenged put plan. An protocol T0, T1, imaging. verified seen and, required, corrected. procedure repeated until satisfied resulting position. All assistance (Kolibri; AG). plan linked head (registration).15Eggers Mühling Marmulla Image-to-patient registration surgery.Int 2006; 35: 1081-1095Abstract (158) 16Metzger M.C. Hohlweg-Majert Schön al.Verification computer-aided craniomaxillofacial surgery.Oral Surg Med Pathol Radiol Endod. 104: e1-e10Abstract (93) 17Widmann Stoffner Bale Errors error management 2009; 107: 701-715Abstract (83) 18Schramm Suarez-Cunqueiro M.M. Rücker therapy mid-facial reconstructions.Int Robot Comput Assist 5: 111-124Crossref (61) 19Yu Shen S.G. Wang X. indication application oral maxillofacial surgery—Shanghai’s experience based 104 cases.J 41: 770-774Crossref tracked skull marker array (Brainlab stable achieved intraoperatively, pointer moved along result views: trajectory contour shown overlay 6). Results used, feedback indicating orientation markers design. Three embedded design, triangular fashion 7).11Dubois Scholar,20Gander T. Metzler al.Patient specific (PSI) fractures.J 126-130Crossref (87) indicated landmarks allowed current (indicated pointer) both visual, obtain about direction displacement, quantitative, amount displacement (as 8). implant-guided workflow 5).Fig. 8Feedback one points. views, relation landmark guidance. Quantitative deviation also provided.(Courtesy Ruud Schreurs, MSc, Alfred Becking, MD, DMD, PhD, FEBOMS, Jesper Jansen, Leander Dubois, PhD.)View Large Image Figure ViewerDownload Hi-res image Download (PPT) developed used. instrument (Titanium Orbital Positioner) designed attached compatible tracking system. cohesion calculation instrument’s position, even Real-time provided, visually quantitatively, steered correct under attachment 9. presented later discussion same manner; statistical workflows, however, differed some situations design or scientific insights over Implant Positioning Frame (shown 1) translation) provided tables, graphic representation mean each technique position) figures. Table 1. show there minimal control implant: rotation around z-axis (yaw) larger than 15° translation mm. maximum 47.6° yaw. Precision, positioning, large deviations. Visual appraisal average 10) illustrates size quantitative found. These underline reconstruction.Table 1Rotational conventional (baseline)ConventionalMeanSDRoll (deg)−9.89.1Pitch (deg)−1.33.1Yaw (deg)17.810.9Translation (mm)5.02.2The (SD) rotations yaw) given.Abbreviation: deg, degrees. Open table new tab given. Abbreviation: rationale behind bidirectional surgeon: may assessed transconjuctivally aid transsinusoidally.7Dubois positions quantified 11. suggest significant improvement endoscope baseline. Although unrelated regarding exhibition training surgeons,21Bevans S.E. Moe K.S. Advances fractures.Facial Clin. 2017; 25: 513-535Abstract Scholar,22Moe Murr A.H. Wester S.T. 26: 237-251Abstract (2) low.Table 2Quantification positioningConventionalEndoscopeP ValueMeanSDMeanSDRoll (deg)−9.89.1−7.15.6.19Pitch (deg)−1.33.1−0.33.7.24Yaw (deg)17.810.914.511.8.14Translation (mm)5.02.24.22.1.19 With available, able check orbit. study: roll, significantly more smaller well, demonstrating precision. addition superior multi-planar scan. Additional anatomic extent fracture, achieve position).1Gellrich Scholar,23Schmelzeisen Gellrich N.C. Schoen al.Navigation-aided cranio-maxillofacial reconstruction.Injury. 2004; 955-962Abstract (129) Scholar,24Mahoney N.R. Peng M.Y. Merbs S.L. al.Virtual fitting, selection, cutting implants.Ophthal 33: 196-201Crossref (8) 12.Table 3Results versus planningConventionalVirtual PlanningP (deg)−9.89.1−4.53.5.01Pitch (deg)−1.33.1−1.12.2.78Yaw (deg)17.810.95.26.8<.01Translation (mm)5.02.22.61.7<.01 imaging, major altered avoid second potential complications.13Jaquiéry Scholar,25Stuck B.A. Hülse Barth T.J. Intraoperative facial fractures.Int 2012; 1171-1175Abstract (34) Scholar,26Wilde F. midface reconstruction.Facial 2014; 30: 545-553Crossref (27) improves (Table 4), showing advantageous 13, yielded shown. Significant parameter largest deviation, recorded reconstructive attempt final 5), learning guidance provides.Table 4Quantification imagingConventionalIntraoperative ImagingP (deg)−9.89.1−2.54.2.01Pitch (deg)−1.33.1−1.83.7.37Yaw (deg)17.810.96.87.8<.01Translation (mm)5.02.23.01.4<.01Compared improvements seen. 5Comparison group adjustments imageFirst CTFinal CTP (deg)−2.18.2−1.53.6.78Pitch (deg)−1.22.9−1.94.5.48Yaw (deg)10.213.25.610.1.02Translation (mm)3.61.42.91.0.16 Compared Image-guided generated immediately positioned. From pointer’s adjustment implant.1Gellrich Scholar,2Bly Scholar,18Schramm made, their directly afterward. short loop yields Roll, navigation. 14 demonstrates implant.Table 6The positionConventionalImage-Guided NavigationP (deg)−9.89.1−2.34.8<.01Pitch (deg)−1.33.1−1.12.2.77Yaw (deg)17.810.98.88.1<.01Translation (mm)5.02.23.31.6<.01The results, comparison. provides direct itself improved: moving probe means needs interpretation continuously shifting views.27Schreurs 1: 47https://doi.org/10.1016/j.ijom.2017.09.009Abstract (14) thought static, positions; makes feasible. Marker-based 5) yaw 15, 7). navigation, handling thus becomes intuitive.Table 7The positionImage-Guided NavigationMarker-Based (deg)−2.34.8−2.33.1.16Pitch (deg)−1.12.2−2.22.8.52Yaw (deg)8.88.16.08.1.02Translation (mm)3.31.61.40.7<.01The very small 16, approach, translation, explained nature feedback.12Schreurs either adjust switch processes. possible Feedback true fashion. Next reduced higher.Table 8Linear mixed estimates parametersMarker-Based NavigationReal-Time ValueModel EstimateModel EstimateRoll (deg)3.22.0.03Pitch (deg)1.51.3.53Yaw (deg)3.42.2.01Translation (mm)1.81.3<.01The P values Likelihood Ratio tests executed assess relevance parts modern technologic advancements instead grouped (3D navigation). reliability introducing gain local anatomy, size, complexity. turn generates helpful landmarks, leading positioning.1Gellrich traditional CT, hoped, decreases procedures.25Stuck reconstruction; increases brings within calibration error. Using Advanced Concepts Reconstruction protocol, user-friendly fastest, way place into clinically introduced yet: concept development. goal discriminative seems achieved, restrictions materials methods: series, few surgeons, circumstances (human models). one-on-one comparisons Care taken comparable, instance, repeating Still, setting warrant caution. focus article, many other positioning.4Zimmerer Scholar,16Metzger Scholar,28Essig Dressel Rana al.Precision individually bent navigation: retrospective study.Head Face Med. 9: 1-7Crossref (60) Scholar,29Rana Holtmann Kanatas A.N. al.Primary laser melted core implants: overview 100 patients.Br 2019; 57: 782-787Abstract (6) Outcome evaluation presentation lead believe will tremendously technologies. Of course, overarching life patients fractures. Surgery trauma orbit its contents should well balanced anticipated nonsurgical less-invasive treatment options.30Zimmerer von Bülow S. al.Is inferior walls surface contouring? identify predictors outcome.J 46: 578-587Crossref Scholar,31Jansen Maal T.J.J. orthoptic justified blow-out Crossref (9) distinct When indicated, accurately precisely possible, bulb ocular movements, volumes, esthetic outcome.13Jaquiéry Scholar,32Cai E.Z. Koh Y.P. Hing E.C.H. navigational surgery.J Craniofac 23: 1567-1573Crossref (43) Scholar,33Schlittler Schmidli al.What incidence malpositioning revision repair?.J 76: 146-153Abstract (11) •Significant introduction techniques. optimize reconstruction.•The providing intuitive user friendly presented, positioned.•Translation always warrants caution.•The However, main patient. Accurate viewed goal, rather itself. submission process, kind funding declared. equipment kind, while KLS Martin kind. Additionally, IGT link license sub-project supported S.O.R.G. Research Grant Award 2017.