Intraoperative Feedback and Quality Control in Orbital Reconstruction

•The development and implementation of medical technology in orbital reconstructive surgery is a logical consequence the philosophy to optimize treatment procedure before, during, after terms maximum control for surgeon aim optimal outcome individual patient.•During surgical procedure, virtual planning must be transferred site as accurately possible; this purpose, variety different methods devices may used even combined, depending on complexity task.•The adage that “the best way predict future invent it” (Alan Kay) has proved true reconstruction past will key innovations. Over last 20 years, rapid changes digital have occurred if it comes “making invisible visible.” Especially craniomaxillofacial surgery, complex procedures primary or secondary cases always been challenge remain such future. Patients view their pathology than has: patient an outside-oriented perspective, which relates outer appearance appropriate function. The take tissue envelope into consideration focus inside-oriented craniofacial skeleton, associated soft tissues analyze amount deformity, modify these, finally achieve esthetic result combined with adequate Detailed knowledge anatomic structures fundamental surgery: inadequate reconstructions potentially lead unsatisfactory results.1Schramm A. Gellrich N.C. Intraoperative navigation und computerassistierte Chirurgie. Schwenzer N Und Ehrenfeld M Zahn-Mund-Kieferheilkunde.Mund Kiefer Gesichtschir. 2011; 4: 479-499Google Scholar For reason, clinical assessment, imaging techniques diagnosis planning, meet highest standards. It only then possible answer most important question fracture management: do we explore defect? This ongoing debate further discussed Leander Dubois colleagues’ article,”Ongoing Debate Clinical Decision Making Orbital Fractures: Indications, Timing, Biomaterials,” issue. If indicated, task minimize risk result, brings following questions: plan our intended result? Is achievable? adequate? available during surgery? Can feedback obtained intraoperatively? Did These questions led introduction computer-assisted surgery. From all phases (before, procedure) should optimized patient. Medical turned out cornerstone idea reality: technological developments, limitations could overcome predictability results improved. article covers intraoperative phase surgery; “why” provided, developments control, current state art, quality how, now, wow. Historically, several 2-dimensional (2D) radiographs had approach deformity correction. Today none these any impact anymore, and—by way—there never nor what was loaded orbit. Surgery orbit based 2D walk mist darkness. headway 3D imaging, case helical cone-beam computed tomography (CBCT) (only selected MRI), meets requirement treat defect aid data set. However, eighties decade were look at, meant trying understand patient’s depended views by radiologist. nineties onwards, computer allowed interactively use volume sets independent analyzing platforms. Clinicians became able set result. Mirroring unaffected side onto deformed first attempt virtually correct bony framework create blueprint unilateral defects (Fig. 1). technique developed taken routine Freiburg group Rainer Schmelzeisen, Alexander Schramm, Nils-Claudius Gellrich, cooperation former Leibinger Company, make STN Zeiss/Leibinger system applicable those days.2Gellrich N.-C. Schramm Hammer B. et al.Computer-assisted posttraumatic deformity.Plast Reconstr Surg. 2002; 110: 1417-1429Crossref PubMed Scopus (231) Google All performed machine itself; early 2000s industry serve demands surgeon, feasible software stand-alone machines, system. Brainlab resulted advancement logistics availability advanced tools planning.3Metzger M.C. Bittermann G. Dannenberg L. al.Design atlas human skull automatic segmentation preoperative navigation.Int J Comput Assist Radiol 2013; 8: 691-702Crossref (21) viewed offspring frame-based stereotaxy, introduced Horsley Clarke 1908.4Horsley V. R.H. structure functions cerebellum examined new method.Brain. 1908; 31: 45-124Crossref (404) Scholar, 5Schurr P.H. Merrington W.R. Horsley–Clarke stereotaxic apparatus.Br 1978; 65: 33-36Crossref (19) 6Jensen R.L. Stone J.L. Hayne R.A. Introduction Horsley-Clarke stereotactic frame.Neurosurgery. 1996; 38: 563-567PubMed 7Schramm Schmelzeisen R. Navigational facial skeleton. Springer Science & Business Media, 2007Google Their apparatus, produced at cost £300, included geometric measurements Cartesian coordinate frame.5Schurr Scholar,6Jensen An position brain within frame generated cats monkeys, compensated head sizes.5Schurr not until 1947 modified version proposed Spiegel Wycis, surgery.8Spiegel E.A. Wycis H.T. Marks M. al.Stereotaxic apparatus operations brain.Science. 1947; 106: 349-350Crossref (553) link made frameless stereotaxy 1987: pointer tip articulating mechanical arm related image acquired before operation.7Schramm Scholar,9Watanabe E. Watanabe T. Manaka S. al.Three-dimensional digitizer (neuronavigator): equipment tomography-guided surgery.Surg Neurol. 1987; 27: 543-547Abstract Full Text PDF (322) Optical tracking instrument increased freedom movement easier system.7Schramm almost laid groundwork, kick-started describing 18 patients group.2Gellrich one systems days provided Fig. 2. Developments another effect next utilization navigation: OR itself. Already 1980s applications neurosurgery described, but fixed scanner limited hampered widespread use.10Shalit M.N. Israeli Y. Matz al.Intra-operative computerized axial tomography.Surg 1979; 11: 382-384PubMed 11Lunsford L.D. Parrish Albright therapeutic tomographic scanner.Neurosurgery. 1984; 15: 559-561Crossref (93) 12Schichor C. Terpolilli N. Thorsteinsdottir J. al.Intraoperative cranial neurosurgery.Neurosurg Clin Am. 2017; 28: 595-602Abstract (13) 13Nimsky Carl Historical, current, modalities.Neurosurg 453-464Abstract (11) Advances quality, equipment, mobility CT CBCT scanners over years paved oral maxillofacial surprising among applications.14Stanley R.B. Use repair orbitozygomatic fractures.Arch Facial Plast 1999; 1: 19-24Crossref (78) In meantime, gap closed between navigation, implant desired other. Individualization implants historically achieved preshaping whatever biomaterial thereby experience skills surgeon. Deeply respected colleagues Beat Hammer, Joe Gruss, Paul Manson, others own prebend, mold nonindividual reference model, outstanding results. But time they already some kind reference, whether schematic drawings aforementioned draped sterile foil molding material. With printing technologies more individualized biomodels given (deformed) anatomy corrected shape nonpreformed toward implant, either preoperatively intraoperatively 3).15Doerfler H.-M. Huempfner-Hierl H. Kruber D. al.Template-based wall using statistical analysis.J Oral Maxillofac 75: 1475-e1Abstract (10) Scholar,16Kim Y.C. Jeong W.S. Park al.The accuracy specific prebented 3D-printed prototype model reconstruction.J Craniomaxillofac 45: 928-936Crossref (25) still valid method, helps master nearly Latest allows provide patient-specific biomodels, are autoclavable. A shaping parallel. Research average Marc Metzger’s (Freiburg) preface preformed encountered.17Metzger Schön Tetzlaf al.Topographical CT-data analysis floor.Int 2007; 36: 45-53Abstract (31) 18Bell Computer cranio-maxillofacial surgery.Oral Surg North 2010; 22: 135-156Abstract (144) 19Metzger Craniomaxillofacial Implants Based Modeling. Digital Technologies Surgery. Springer, 2018: 167-173Google theory, prevents necessity bending altogether, thus saving being less dependent surgeon.19Metzger Scholar,20Strong E.B. Fuller S.C. Wiley D.F. al.Preformed vs titanium mesh reconstruction.Otolaryngol Head Neck 149: 60-66Crossref (40) Another advantage lies possibility import planning. can determined characteristics defect; evaluate sizes manufacturers (see also article,“Advanced Diagnostics Three-dimensional Virtual Surgical Planning Reconstruction”, issue).20Strong 21Bittermann Metzger Schlager al.Orbital reconstruction: prefabricated implants, transfer, revision surgery.Facial 2014; 30: 554-560Crossref 22Hierl Doerfler al.Computer-aided versus conventional traumatology meshes: workflow.J 2019; 77: 1663-1672Abstract (3) emerging sets, taking shaped changed requirements represent: above replacement “functionalization” “preventive design” came up. Functionalization implies added example, information purposes. Furthermore, extensions flings so properly leavers reliable site. Preventive design typical mistakes might occur diminished: refers change shape, sharp edges, interference optic nerve eye muscles especially cone area. why Hannover Group Majeed Rana distinct topography thickness, slightly thickened circular rounded cord-style border, inverted snow-shovel area posterior ledge, multiple linear openings perpendicular transition zone medial parasagittal oblique vector floor.23Rana Chui C.H.K. Wagner al.Increasing selective laser-melted navigation.J 2015; 73: 1113-1118Abstract (58) implementations seen 4, 5. Diagnosis precedes findings imaging.24Manson P.N. Markowitz Mirvis al.Toward CT-based treatment.Plast 1990; 85: 202-212Crossref (162) 25Tanrikulu Erol Comparison radiography midfacial fractures.Dentomaxillofac Radiol. 2001; 141-146Crossref (41) 26Wilde F. Hilbert Kamer combination segmentation, description method.Int 2009; 134Google 27Wilde Lorenz K. Ebner A.-K. C-arm zygomatico-orbital reduction.J 71: 894-910Abstract (54) 28Wikner Riecke Gröbe al.Imaging trauma.Facial 528-536Crossref (6) As article,”Advanced issue regarded gold standard preceding preferred. provides excellent resolution bone but, unlike CBCT, soft-tissue evaluated, contrast agent.28Wikner concepts workflows, simulation serves obtained. objective perform ideal matches surgery.1Schramm Scholar,7Schramm Scholar,29Hohlweg-Majert al.Navigational models.World 2005; 29: 1530-1538Crossref (72) Scholar,30Schramm Wilde Die computergestützte Gesichtsschädelrekonstruktion.HNO. 59: 800Crossref (9) Although greater detail factors include many types simulations without loss information, images displayed plane models (STL data) imported.1Schramm Scholar,31Markiewicz M.R. Bell Modern reconstruction.Curr Opin Otolaryngol 19: 295-301Crossref 32Wilde midface reconstruction.Facial 545-553Crossref (27) 33Parthasarathy modeling, custom its perspectives surgery.Ann 9Crossref allow anatomically positioned size, fit assessed 5).26Wilde Scholar,32Wilde indicated reconstruction, step ladder process STL computer-aided (CAD) 6A) directly produce manufacturing (CAM) laser melting 6B). During surgeons difficult transferring possible. combine devices, task.Fig. 6Computer-aided (A) corresponding (B).(Courtesy Ruud Schreurs, MSc, Frank Wilde, MD, DDS, DDS.)View Large Image Figure ViewerDownload Hi-res Download (PPT) Customized CAD-/CAM-fabricated increasingly reconstructions. Titanium favorable material Selective powder high-precision geometry manufactured. Because now obtain 5 working from delivery, become exclusively functionalization preventive parameters incorporated much implant’s design, perfect lid manufactured pot” sit position.” exact guides, incorporation “old” screw hole positions (in cases), markers rulers achieving goal.23Rana Scholar,34Schreurs Becking A.G. first! novel protocol 45https://doi.org/10.1016/j.jcms.2017.03.026Crossref postoperative definitely higher. Apart orbit—which pioneered higher relevance—any other body profits advances Nowadays, modern infrared-based integral part reconstruction.1Schramm Before start operation room "fused" screen. known registration points clearly identifiable reproducible both patient's permanently tracked because movements cannot prevented necessary array attached head, register limiting 7).1Schramm Once registered DICOM set, visualized screen system, enables verify realignment fragments inserted exposure ionizing radiation. process, template align and/or place 8).1Schramm direction rulers, markers, interpretation surgeon.23Rana Scholar,35Dubois Essig Schreurs al.Predictability reconstruction. cadaver study, III: implant-oriented 43: 2050-2056Crossref functionalized usable validated documented CBCT. relatively precise about osteosynthesis repositioning fragments, completely replace radiological examination, visualize entire recommendable validation immediately modifications incorrect fragment