Advanced Diagnostics and Three-dimensional Virtual Surgical Planning in Orbital Reconstruction

•The first step in advanced diagnostics and virtual surgical planning is the generation of a patient model.•Information can be added to model through image manipulation for diagnostic purposes.•The used preoperatively, but also intraoperatively postoperatively. The principles limitations orbital reconstruction have triggered technological developments past 2 decades. Because complex anatomy orbit limited exposure during surgery, computer-assisted surgery (CAS) great value.1Baumann A. Sinko K. Dorner G. Late with patient-specific implants using computer-aided navigation.J Oral Maxillofac Surg. 2015; 73: S101-S106Abstract Full Text PDF PubMed Scopus (34) Google Scholar, 2Gander T. Essig H. Metzler P. et al.Patient specific (PSI) floor wall fractures.J Cranio-Maxillofacial 43: 126-130Crossref (87) 3Rana M. Chui C.H.K. Wagner al.Increasing accuracy selective laser-melted combined intraoperative 1113-1118Abstract (58) 4Cha J.H. Lee Y.H. Ruy W.C. al.Application rapid prototyping technique navigation system repair fractures.Arch Craniofac 2016; 17: 146Crossref 5Kärkkäinen Wilkman Mesimäki al.Primary fractures titanium milled implants: Helsinki protocol.Br J 2018; 56: 791-796Abstract (16) Scholar Several studies shown that CAS assists surgeon achieving better more predictable treatment outcome.1Baumann Scholar,3Rana Scholar,6Mahoney N.R. Peng M.Y. Merbs S.L. al.Virtual fitting, selection, cutting preformed anatomic implants.Ophthal Plast Reconstr 2017; 33: 196-201Crossref (8) 7Scolozzi Applications 3D (CAS).J Stomatol 118: 217-223Crossref (13) 8Azarmehr I. Stokbro Bell R.B. al.Contemporary techniques reconstruction: review literature report case combining navigation, simulation, implant.J 2020; 78: 594-609Abstract (3) consists several preoperative, intraoperative, postoperative components. Advanced three-dimensional (3D) (VSP) ensure inspection problem possible solutions preoperative phase.9Schreurs R. Dubois L. Becking A.G. al.Quantitative assessment implant position-a proof concept.PLoS One. 11https://doi.org/10.1371/journal.pone.0150162Crossref (15) Scholar,10Jansen J. Schreurs al.The advantages on position reconstruction.J Craniomaxillofac https://doi.org/10.1016/j.jcms.2018.02.010Crossref (12) This article explains preprocessing steps required start VSP, benefits advances diagnostics, tools VSP. modalities may encountered imaging contents: MRI, ultrasonography, two-dimensional (2D) or radiologic (eg, radiographs computed tomography [CT]).11Kubal W.S. Imaging trauma.Radiographics. 2008; 28: 1729-1739Crossref (110) 12Lin K.Y. Ngai Echegoyen J.C. al.Imaging trauma.Saudi Ophthalmol. 2012; 26: 427-432Crossref (25) 13Chazen J.L. Lantos Gupta al.Orbital soft-tissue trauma.Neuroimaging Clin N Am. 2014; 24: 425-437Abstract (7) MRI seldom as primary modality after trauma: soft tissue structures excellently distinguished, sensitivity hard-tissue trauma low.11Kubal contraindicated if metallic foreign bodies present. Ultrasonography provide fast evaluation globe, should not rupture globe suspected because pressure exerted acquisition. lead further acute decompensation eye and/or intraocular content extravasation.11Kubal CT choice traumatology.14Boyette J.R. Pemberton J.D. Bonilla-Velez Management fractures: challenges solutions.Clin 9: 2127Crossref (66) 15Jansen volume analysis: validation semi-automatic software segmentation method.Int Comput Assist Radiol 11https://doi.org/10.1007/s11548-015-1254-6Crossref (29) 16Grob S. Yonkers Tao Orbital fracture repair.in: Seminars plastic surgery. vol. 31. Thieme Medical Publishers, New York2017: 31-39Google has higher detection than plain radiography offers additional possibility internal hemorrhage detection. superimposition 2D radiographic missing information one dimensions overcome by nature data are produced CT: reconstructed built up voxels (3D pixels), each gray-scale value (Hounsfield unit [HU]) corresponding x-ray absorption within voxel. From data, planes reconstructed: typical multiplanar view made axial, coronal, sagittal slices. In order able distinguish existing bony ledges thin walls phase, it recommended use maximum slice thickness 1 1.5 mm.17Cai E.Z. Koh Y.P. Hing E.C.H. al.Computer-assisted navigational improves outcomes reconstructive surgery.J 23: 1567-1573Crossref (43) 18Wagner M.E.H. Lichtenstein J.T. Winkelmann al.Development clinical application automated unilateral midface defects.J 1340-1347Crossref (18) 19He Y. Zhang Yu G.Y. al.Expert consensus navigation-guided techniques.Chin Dent Res. 51-55PubMed An important preparation create from basic Typically, rendering overview. original fractured easily visualized. For purposes, render sufficient cannot manipulated; surface needs created this. Surface generates this model: belonging same anatomical structure selected (segmentation) object generated based selection made. models modified manipulated therefore Typical include at least (Fig. 1) exterior. overview renders accurately represent patient’s disorder. If required, images different time points intraoral scans, cone-beam CT, stereophotogrammetry) (multimodality) registration techniques.20TJJ Maal Plooij J.M. Rangel F.A. matching photographs skin surfaces derived tomography.Int 37: 641-646Abstract (97) Scholar,21Baan F. Bruggink Nijsink al.Fusion intra-oral scans scans.Clin Investig. https://doi.org/10.1007/s00784-020-03336-yCrossref way, base augmented complete detailed representation patient: 2). integration accurate dental an scan might, example, useful splint guidance After creation model, VSP performed. dedicated environment, analysis expansion readily available data. obtained manipulation. Segmentation, mentioned earlier relation such technique: type annotated volume. process done manually (coloring set) thresholding, which greater certain (HU) selected. thresholding is, instance, differentiating tissues before these generated. paper-thin medial hamper threshold segmentation: elaborate algorithms acquire its contents 3). One example atlas-based segmentation, atlas consisting presegmented registered current 4).6Mahoney Scholar,15Jansen Scholar,18Wagner Atlas-based reliable even when quality suboptimal. Small manual adjustments might needed optimize result 5), especially deviating disorder.2Gander prerequisite many processes, much research been performed improvement user-friendliness anatomy.15Jansen Scholar,22Wagner Gellrich N.-C. Friese K.-I. al.Model-based measurement cone beam against concepts.Int 11: 1-9Crossref 23Hsung T.-C. Lo Chong M.-M. al.Orbit automatic sliced vertex screening.IEEE Trans Biomed Eng. 65: 828-838Crossref (4) 24Kim Son al.Three-dimensional modeling paranasal sinus segmentation.J 2019; 47: 959-967Crossref ScholarFig. 4Atlas-based unaffected contralateral (patient 1). was Brainlab iPlan Cranial (Brainlab AG, Munich, Germany).(Courtesy Ruud Schreurs, MSc, Cornelis Klop, Thomas Maal, PhD.)View Large Image Figure ViewerDownload Hi-res Download (PPT)Fig. 5Small resulting segmentation. These small necessary number cases, differs greatly template.(Courtesy (PPT) A segmented similar generate Of particular interest bilateral orbits, contents, and, orbitozygomatic fracture, zygomatic complex. shape analyzed, measured software. method enables comparison between affected orbits thus quantification enlargement orbit. subsequently environment ongoing adding model. fractures, mirroring provides exact insight into displacement 6).3Rana Scholar,5Kärkkäinen 6Mahoney 7), structures, workflows, obtain template side 8). floor, arch, prominence (relative side) seen mirrored 9).6Mahoney Scholar,25Susarla S.M. Duncan Mahoney reconstruction.Middle East Afr 22: 442Crossref Scholar,26Ho J.-P.T.F. Milstein D.M.J. al.Measuring zygomaticomaxillary symmetry three-dimensionally techniques.J 44https://doi.org/10.1016/j.jcms.2016.07.034Crossref (10) 7Hard-tissue views 2. naso-orbitoethmoid I comminuted seen.(Courtesy 8Threshold bone (yellow) (green), 2).(Courtesy 9Template segmentations Fig. 8 purple template, (cyan) about indication established findings, possibly supported findings process. goal reconstruct pretraumatized closely possible.27Wilde Schramm Intraoperative reconstruction.Facial 30: 545-553Crossref (27) 28Bittermann Metzger M.C. Schlager prefabricated implants, transfer, revision surgery.Facial 554-560Crossref (19) 29Rana Holtmann Kanatas A.N. laser melted core 100 patients.Br 57: 782-787Abstract (6) continues acquired itself comprise planning: premorbid structure. adequate well, reduction dislocated parts infeasible: alloplastic materials frequently wall. alone: optimal material implant) planned. used, stereolithographic (STL) imported environment. find 10, 11 11).6Mahoney Scholar,30Doerfler H.-M. Huempfner-Hierl Kruber D. al.Template-based statistical analysis.J 75: 1475-e1Abstract Scholar,31Hierl Doerfler al.Computer-aided versus conventional traumatology meshes: development new workflow.J 77: 1663-1672Abstract parameters taken account positioning process: covering defect, support dorsal ledge, fixation rim, prevention interference reconstructing contour orbit, tip 12). perform evaluate outcome Multiple positions evaluated coming decision desired position. necessary, sizes other manufacturers, compare their fit size individual 13).6Mahoney Scholar,28Bittermann 11VSP virtually positioned 6 keeping details 12 mind.(Courtesy 12Positioning Support ledge (top) rim (bottom) coronal views.(Courtesy 13Small (red) large (blue) extension interferes wall, without implant. follows adequately 11) does interfere case.(Courtesy suboptimal (and/or surgeon’s preference) premolded 14, 18; see 18). basis design again, extended all preliminary phase 15; 19). Information extracted additive manufacturing printing) 16, 17 17).3Rana Scholar,32Kim Y.C. Jeong Park prebented 3D-printed prototype 45: 928-936Crossref 33Schreurs first! novel protocol secondary 45https://doi.org/10.1016/j.jcms.2017.03.026Crossref 34Kang Kwon Ahn C.J. al.Generation customized templates 3-dimensional printing reconstruction.Eye. 32: 1864-1870Crossref premolding implant, mirrored, printed mold before, during, Additional embedded print, separate prints; defect boundaries Generation PSI exported case, generating implant’s rather physical: serves digital PSI. beforehand; overcorrection designated area (see 20).5Kärkkäinen STL PSI, design, check meets positioning, whether will unique 21). Possible screw-hole well. reconstruction, osteosynthesis indicated 22). designed overlap screw feedback positioning.33Schreurs 15Desired 3).(Courtesy 16Orbital 15 173D bending 3), visualized 16 (left). indicating contour, (middle). Based templates, (right).(Courtesy first, arguably most important, workflow reconstruction. stage ensures decision-making feasibility intervention assessed beforehand rules out preventable mismanagement unsuited 18, 19, 20, 21, 22 23). simulated times anatomy. advantage simulations familiarized training surgeons, enhanced learning experience, whereas experienced surgeons anticipate difficulties plan.Fig. 19Unaffected 4).(Courtesy 20Possibility 4). cyan cm3 overcorrected orbit.(Courtesy 21Design 22Segmentation incorporated positioning.(Courtesy 23Feasibility chosen followed, no ledge. were sought, enlarged would corrected properly.(Courtesy entails plan sets target surgeon, operation beyond just visualization workflow. guide planned system, dynamic mechanisms aid result.8Azarmehr Scholar,17Cai Scholar,27Wilde Scholar,35Hsieh T.-Y. Vong Strong E.B. reconstruction.Curr Opin Otolaryngol Head Neck 388-392Crossref 36Dubois Jansen al.Predictability human cadaver study. Part II: navigation-assisted 2042-2049Crossref 37Dubois study, part III: implant-oriented optimized 2050-2056Crossref Both discussed detail colleagues’ article, “Intraoperative Feedback Quality Control Reconstruction: Past, Present Future,” issue. fusion position.2Gander Scholar,9Schreurs Scholar,19He final 24, 25, 26, 27, 28, 29), yield improvements any stages next who treated workflow.Fig. 25Computer-assisted necessary.(Courtesy 26Postoperative 2.(Courtesy 27Computer-assisted repositioned according plan, deviates position.(Courtesy 28Postoperative 4.(Courtesy 29Computer-assisted obtained.(Courtesy •An model.•The planning, phase.•Virtual valuable tool setting, utilized feedback, postoperatively evaluation.•Postoperative meaningful future cases. authors nothing disclose.