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determined to be effective in determining Le Fort fractures, while the
three radiologists who analyzed the MSCT were the factors for attaining
high and low percentages of accuracies for determining such fractures.
A new strategy for generating and using cutting guides is introduced in
[68] for craniofacial surgery with the use of three-dimensional (3D)printed cutting guides used for matching computer models with surgical
procedures. CAD is used for preplanning of the performed surgeries.
After anatomical data input into a CAD model, virtual surgical planning
is used for the surgical procedures. Preoperative simulations are formed
by using surgical sequence steps. CT scans are then used for accuracy
evaluation of the procedure postoperatively. It is observed that the
duration of the surgery is significantly decreased due to the use of all-inone surgical guide system used by the authors. The experimental design
of the surgery helped with the enhancement of each step of surgery.
Cone-beam CT (CBCT) is a technique that can generate a 3D
reconstruction of the local area of body with a lower dose of radiation at
a reduced cost. Craniomaxillofacial reconstruction surgery data is used in
[69] to identify the feasibility of using CBCT data to design and generate
customized implants for patients. Even though CBCT data is more
difficult to process than conventional CT data for the implant provider,
presurgical planning is determined to be faster and more efficient by the
authors noting that no consultation with a radiologist was necessary.
Augmented Reality (AR) is used for zygomaticomaxillary complex
fracture treatment [52]. Preoperative 3D CT fracture images of patients with
zygomaticomaxillary complex fractures are collected with the associated
plants designed. Two surgical teams, one with the traditional optical and the
other team using AR navigation system, are formed. Good auxiliary effects
are attained by the AR navigation team for the reduction of
zygomaticomaxillary complex fractures. Additionally, optimal surgical time
and better accuracy are attained by the team that utilized AR.Soft tissue
analysis relates to facial asymmetry analysis due to the CT scan results that
displayed a good correlation of soft tissue with skeletal facial shape and
facial asymmetry [60, 61], thus methods based on soft tissue analyses are
valid for asymmetry analyses. 3D soft tissue imaging is a nonionizing tool
for analyzing facial symmetry [54, 57, 58]. Reliability and repeatability of
such 3D imaging are observed even when landmark-based analysis is
conducted [54, 55]. In addition, relatively high reproducibility is possible
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based on the landmark-based analysis [59]. An example of such an AR
system is 3dDMhead™ System [56].
CT and MRI techniques are used in [53] along with 3D
photogrammetric models for determining metopic and sagittal
craniosynostosis patients’ cosmetic satisfaction; data are collected from
adult metopic and sagittal craniosynostosis patients operated on in early
childhood for comparison to the controls based on craniofacial and aesthetic
characteristics. The authors concluded that the results of 3D imaging should
be taken with caution when evaluating facial symmetry.
Using 3D printing techniques of implants for craniofacial procedures,
color jet printing and stereolithography were the most common techniques
that were observed [51]. From maximizing positive surgical outcomes
perspective, upon comparison of 3D printed versus traditional implants, 3D
printing implementation used in craniofacial surgeries indicated a
significantly better prognosis, and reductions in operative time, length of
stay, and immediate complications.
4 Mandibular Reconstruction and Imaging
Modalities
CT scans, MRI, and CBCT are the commonly used techniques for
mandibular surgeries as it was the case for craniofacial procedures
explained previously [72]. 3D printing technologies have been used in the
medical field with one common use including stereolithography (SLA) with
liquid resin and selective laser melting (SLM) with powder materials [73].
Titanium is a metal commonly used in 3D printing of jaw reconstruction
plates [76]. Advanced manufacturing with CAM/CAD applications is also
seen. The following are some of the uses of these technologies:
CAD/CAM manufacturing condylar reconstruction following resectiondisarticulation of the mandible experienced by a series of oncological
patients are studied in [66] with analysis on clinical outcomes and
degrees of complications. None of the patients experienced plate
exposure, plate loosening, and joint pain. Only one patient experiences
condylar displacement. Reconstruction by using CAD/CAM plates
including condyles is determined to be an encouraging technique with
further analysis needed on larger populations.
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High complication rate and possible revision surgeries mandible contour
surgery encouraged researchers to investigate the use of VSP and 3-D
surgical plate printing [77]. 3D CT data are used as the input to VSP.
Expected symmetrical results along with patient satisfaction with
aesthetic results are observed. The use of VSP and 3D printed surgical
plates are determined to be safe and accurate with the satisfaction of the
surgeons on the performance of the surgical templates.
Preoperative surgical planning of mandibular reconstruction by using
CAD/CAM procedures and patient-specific reconstruction plate design
by using this technology is investigated in [78]. The planning is
accomplished through the placement of the virtual plate within the
CAD/CAM design to measure the accuracy of the plate fitting in the
virtual environment. This method in application appeared as an effective
and satisfying method for accurate mandibular reconstruction by the
authors.
Positional and functional evaluation of the temporomandibular joint (TJ)
by using VSP with CAD/CAM approach is completed as a part of the
craniofacial reconstruction [79]. Two groups are formed for traditional
and VSP mandibular reconstructions. Pre- and postoperative CT data are
used for CAD-CAM planning and quantitative comparison of the formed
two groups for evaluation of the TJ, respectively. The results overall
indicated VSP’s precision in reconstruction compared to the traditional
method leading to normative anatomic relations.
MRI and CT data are collected for tumor delineation and 3D bone virtual
construction of the oral squamous cell carcinoma patients respectively in
[80]. These two data sets are merged to form 3D bone and tumor
demonstrations of these patients. The post-operative evaluations are
compared with historical data for accuracy comparison purposes. The
authors conclude the MRI- and CT-based tumor visualization along with
the 3D resection planning to be a safe and accurate method for oncologic
resection of the mandible.
Segmental mirroring is a method that can be used to digitally redesign
deformed segment of a bone by digitally replacing the deformed segment
with the unaffected contralateral mandible for adapting a reconstruction
plate. Authors of [81] evaluated accuracy degree of segmental mirroring
through 3D conformance analysis. Except for mandibular condyle
involved process and the coronoid process, segmental mirroring
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technique is determined to be highly accurate playing a crucial role in
attaining optimal results.
Reliable and accurate match between the iliac crest flap and mandible is
investigated in [82] by using 3D-CT, 3D model prototyping, and CT
angiography for treatment planning to determine functional
reconstruction of mandibular segment defects. It is concluded that the
used digital techniques helped with accuracy and preplanning due to the
observed height, width, length, and bone healing accuracies of the iliac
crest flap along with the ideal bone union between the iliac crest flap and
the mandible after 6months of the procedures.
Reproducibility and predictability are the main positive aspects of
computer-assisted surgeries as outlined above. There are some
shortcomings of these techniques in applications:
Due to the use of the technology prior to the surgery, its inflexibility
causes difficulty to improvise during surgery.
In malignant jaws, predetermination of the surgical margins can lead to
complexities during the surgery due to compromised local-regional
control of disease and patient survival [83].
A fast-growing tumor during the planning phase would pose a challenge
during the actual surgery due to ever-changing tissue dynamics; inability
to determine the soft tissue surrounding the tumor during surgery is
possible due to the changes since the preplanning phase.
Unexpected intraoperative changes may cause alteration of the
preplanned surgical work [84, 85].
Accuracy and success of the technology also depend on the patient
selection and preoperative patient assessment by the surgeon. Computerassisted surgeries are mainly seen in reconstruction of bone.
Augmented reality is one of the recent methods utilized in jaw
reconstruction surgeries. One advantage of AR is to be able to all-in-one
package to assist the surgeon by providing visual assistance through the
overlap of patients’ 3D images and the intraoperative procedure; this can be
particularly helpful for educating inexperienced surgeons [86]. Integration
of robotics with AR technology is also one of the recent advancements of
mandible plastic surgery [87]. AR technology is used for wafer-free maxilla
repositioning [89], template-free surgeries in mandible angle osteotomy
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[88], tumors positioned at jaws, etc. [90]. Reliability of the AR technology
utilized is an important part of the choice of AR for reconstructive surgery.
Another technique used apart from imaging techniques is bioprinting for
jaw reconstruction. Bone tissue engineering is used for reconstruction of
mandible defects with a mixture of bone marrow aspirate concentrate, bone
morphogenic protein, and particulate allogeneic bone grafts, contained in a
Titanium mesh or resorbable membrane in [6].
In the next section, the use of imaging techniques for optimization of
maxillary surgeries will be covered.
5 Maxillary Surgery and Imaging Modalities
Maxillary surgeons also utilize CT scans, MRI, and CBCT techniques as a
part of maxillary surgeries. Additionally, advanced use of materials with
additive manufacturing for 3D imaging of implants and printing modalities
have also been utilized for attaining optimal maxillofacial implant design.
In [8], applying biomechanical approaches for optimizing maxillofacial
surgical implant design, the authors used the reference geometry of a
possible patient attained by using the geometric data of a CT-scan (an
example of a commercially available mandible model is by the company
SYNBONE® (Zizers, Switzerland).) In the first step of the modelling, the
reference geometry is simplified in a CAD system (an example of such a
system is SIEMENS 3D CAD system NX™ (Plano, USA)). The outcomes
are then transferred into a system that utilizes the finite element method (an
example of such a system is FEM system ALTAIR HyperWorks® (Troy,
USA).) CT scans can be used during preprocessing to be able to merge the
corresponding patient-specific data and the anatomical reference geometric
model. This merging allows to determine essential parameters that relate to
mastication in the FEM system after making a connection between the CT
scan and CAD model data.
Another recent advancement in image analysis of maxillofacial surgery
is the use of deep learning [9]. The most common method of artificial
neural network (ANN) in this area of application for maxillofacial surgery
is the multilayer perceptron, which consists of an input layer, several hidden
layers, and an output layer. The ANN development for computer-assisted
surgeries includes the basic traditional three steps of the well-known ANN
approach:
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1. Image reconstruction: CT image reconstruction using attenuated X-rays
by either using iterative reconstruction or filtered back projection.
2.
Image segmentation: The segmentation of the image voxel by voxel
based on its physical properties given that it can be a bony structure,
soft tissue, or air.
3.
Surgical planning: Typical application involves a combination of
computer-simulated bone reconstruction and subsequent designing of
appropriate patient-specific implants.
Some of the well-known ANN applications include convolutional
neural network and .net-based methods.
ANN is used for automated maxillofacial surgical planning purposes
with the goal of the reconstruction of skull plates due to the simplicity of
the local anatomical geometry. Automatic designs of skull implants are
designed by using single-layered multilayer perceptron [5, 7]. The authors
reconstructed cranial bone from CT images of patients with skull defects.
ANN can also be used for optimization of parametrized implant designs.
A CNN is designed in [10] for skull reconstruction of missing or fractured
sections of the skull. One of the challenges in such an application is the
shortcoming of computing power to handle high-resolution images for
training and validation purposes. Automation through such approaches was
expected to optimize surgical times and outcomes.
Generative adversarial network (GAN) is a method in which two ANNs
compete. Given a training set consisting of images attained for
maxillofacial surgery, GAN learns to generate new data with the same
statistical characteristics as the training set. In this case, a GAN can
generate new images that can look authentic to human observers, having
many realistic characteristics. CT images of patients with ameloblastoma or
gingival cancer are used as the basis for a GAN developed in [91] for
reconstructing the morphology of the mandible based on CT images.
Some of the more traditional techniques such as CT, CAD, and CAM
approaches used for imaging include the following:
Cinematic rendering (CR) is a recent 3D visualization methodology
utilizing photorealistic images from volumetric CT data [93]. Looking at
the frontal and lateral views, the depth of perception provided by CR
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through realistic shadowing effects allowed improved display of
maxillofacial structures in [92]. In the corresponding work, the relative
position of the arch is observed to be more accurate based on the
increased shadowing deep to the zygomatic arch. Additionally, the CR
image is observed to display the superior orbital fissure and the bony
framework outlining the perimeter of the orbit more accurately.
Spiral CT scanning of patients with bone tumor and 3D reconstruction is
completed on a computer in [94]. The authors compared 3D-cut image
with the findings of actual operation showing that 3D-cut technique
could help for preoperative planning and estimation of possible
difficulties that may be encountered intraoperatively. Especially, it is of
practical value for those with bone tumors.
The evaluation of the time it takes to perform intraoperative CT scans
during maxillofacial surgery is conducted in [95] for determining any
trend toward minimizing total scan times as experience is gained with the
technique. The authors also identified the reasons for cases that required
intraoperative revision based on the results of intraoperative CT
scanning. While no reduction is realized during the study, the surgeon
that had the most experience with the CT software had the shortest total
scan times. During complex maxillofacial reconstruction cases,
intraoperative CT imaging is recommended.
CAD/CAM-printed titanium mesh is used in [96] to provide structural
support for free flap reconstruction to configure its functional, structural,
and aesthetic effectiveness during reconstruction of maxillary bone
defects. The use of preoperative CT data comes into play during virtual
planning to superimpose onto the postoperative CT scan; the difference
between the virtually planned position and the postoperative position of
the titanium mesh is calculated accordingly in the study.
CT data is used for the designs of templates of maxillary resection, fibula
cutting, and positioning as well as evaluation of postsurgical accuracy
evaluation in [97]. Rapid prototyping is used for fabrication of the
templates. The results indicated possible increase in accurate
performance of maxillary reconstruction if preoperative simulation and
templating are designed prior to surgery.
It is possible to reduce acquisition time under several conditions of
maxillofacial trauma patients. Second- and third-generation dual-source
CT is used for the comparison of maxillofacial trauma patients’ image
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quality and exposure parameters in [98]. It is concluded by the authors
that third-generation dual-source CT yields faster acquisition times and
substantial dose reduction using automated exposure control.
Virtual reality (VR) is also used as a part of maxillofacial surgery
simulation. Using 3D CT data of patients, a VR maxillofacial surgery
simulator was developed in [122]; A virtual training system was
constructed with haptic tactile feedback and virtual manipulation
capabilities for maxillofacial procedures by the authors. The next section is
devoted to orbital and zygomatic fracture-associated simulation and the
relevant optimization efforts in the research literature.
6 Orbital Process and Zygomatic Bone Fractures
and Imaging Modalities
CT and MRI have been used extensively similarly for orbital reconstruction
surgeries. Examples include:
Pre- and postsurgery facial CT scans of orbital blowout fractures of
patients [111].
CT scan data use after positioning the patient’s landmarks to orient the
patient in space during surgical navigation [112].
Postoperative orbital cone beam CT data are used for assessment of
orbital wall reconstruction upon using radiopaque grafts in [113].
High-resolution CT scan of patient’s craniofacial skeleton using
multidetector CT scanner for orbital floor fracture reconstruction is
accomplished in [114].
Preoperative multi-slice intraoperative 3D cone beam CT data is
collected for zygomatic fracture fixation in [115].
Segmentations of CT scan are used in [116] for normal 3D zygomatic
bone imaging.
Orbital wall reconstruction of craniofacial trauma patients and control
subjects using postoperative CT scan data using different slicing
thicknesses [117].
CT data sets consisted of slice images are used as a part of orbital
fracture fixation in [118]. The 3D facial bone model that included the
orbital wall is reconstructed from the segmented images in the study.
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In addition to the classic methods of simulation and imaging modalities
used such as CT and MRI, the anatomic structure of orbital cavity may pose
challenges in complex cases, such as limited visual ability of the region.
Complex orbital fracture reconstruction and complex midfacial fracture
reduction using real-time surgical navigation have been effective [101].
Similar to the prior sections, researchers used recent technologies such
as computer-aided surgical simulation, surgical navigation, and a patientspecific implant for designing and implementing surgeries. On a revision
surgery, the technical accuracy of surgical navigation determined to be less
than 1 mm and the volume restoration is identified to be significantly
superior to that achieved with traditional methods in [99] upon the use of
computer-aided surgical simulation, surgical navigation, and a patientspecific implant.
In a case study, the authors of [100] investigated the impact of using
predeveloped 3D titanium mesh implants that were made using polylactic
acid material on patients with significant loss on one or more loss on
zygomatic bone, maxilla, nasal bone, infraorbital rim, and mandible. The
final design of the implant is formed by using 3D modeling of computed
tomography (CT) scan images. This technique of 3D printing technique
with the use of polylactic acid for preparing titanium mesh is identified to
yield better outcomes in restoring the bone structure and maintaining
function.
A 3D C-arm computed tomography is used intraoperatively with the
surgical navigation in [100]. Volumetric measurement differences of
anterior, middle, and posterior angles over the medial transitional buttress
are collected for orbital reconstruction. Implant position is identified by
using the surgical navigation system while intraoperative 3D C-arm CT was
utilized for the adequacy of zygoma reduction and orbital reconstruction
after plating. The authors reported a decrease in implant adjustment time
and improve on accuracy of zygomatico-orbital fracture reconstruction
using navigation system and intraoperative 3D C-arm. While such a method
is reported to have positive outcomes, several other researchers reported the
contrary for the use of 3D C-arm system by itself intraoperatively.
Reduction or inadequate repair of zygomatico-orbital complex fractures are
observed in [105] requiring adjustment upon the use of 3D C-arm system
intraoperatively. Intraoperative CT use was determined to require
adjustment during the surgery during secondary and delayed primary orbital
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reconstruction in [103]. Additional disadvantages determined included
radiation exposure due to postoperative imaging, surgical morbidity, and
revision surgery [106, 107]. The use of intraoperative navigation system
(NS) was observed to be beneficial during surgeries. It is determined to help
with accurate matching of preoperative virtual planning of bone fracture
with the actual fracture [108]. Optimal results are attained for aesthetic and
functional orbital fracture reconstruction with the use of orbital implant
upon the use of NS during surgery through confirmation of orbital implant
location and reducing displaced zygotic fracture [104, 109, 119].
Intraoperative NS is particularly helpful in symmetric postoperative design
of patients that have zygomaticomaxillary complex fractures.
AR is introduced to be a new potentially beneficial area of application
for cosmetic reconstruction surgery planning in [110]; The authors
investigated the benefits of AR-assisted reconstruction of bony defects that
include the facial skeleton and the skull base. CT scan data served as the
real patient data with the 3D reconstructed scan data transferred into the AR
device (Magic Leap 1, Magic Leap, Plantation, Florida) used for the study.
The model then included a defect involving the frontal skull and orbital rim.
The AR device is then combined with Brainlab® Mixed Reality Viewer
(Brainlab AG, Munich, Germany) by manually positioning the holographic
projection of the original skull model (ground truth) over the real model
with the inserted defect by the authors. The authors reported promising
volumetric and aesthetic results for the use of AR during assisting
craniofacial defect procedures as a single-step reconstruction method.
Cosmetic results are determined to be good quality for AR-assisted
procedures while also noting that patient-specific CAD/CAM implants
represent the gold standard in esthetic aspects.
In addition to the above-mentioned better attainment of surgical
procedure outcomes, advantages in aesthetic, functional, and preciseness by
using navigation guidance, intraoperative visualization usage, and careful
approach during extensive orbital fracture to not cause vital structural injury
are determined to be essential [102–104].
7 Conclusions and Future Work
In this work results are attained similar to [147–180]. It is paramount to
note the importance of living well and healthy to prevent surgeries, unless it
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