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14 Decision-Making inOrthognathic Surgery by Virtual Planning andExecution
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Fig. 14.15 The resected condylar fragment must be dened
Fig. 14.16 The ramus must be set in the appropriate
position with placement of the newly shaped condyle in the center of the fossa and a rotation of the ramus accord­ing to the left side
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U. Meyer and K. Valentin
Fig. 14.17 The soft tissue simulation helps to get an idea of the postoperative facial appearance
Splint Fabrication
extended soft tissue incisions and enlarged areas of bone denudation.
Three-dimensional (3D) guided orthognathic surgical planning utilizing custom splints or patient- specic cutting/drilling guides and pre­fabricated osteosynthesis plates may well become one of the basic standards enabling the surgeon to better predict the skeletal maxilla/ mandible relationship following surgery in most
Three-dimensional (3D) guided orthognathic surgical planning utilizing custom splints can nowadays be performed in an in-house setting, a major advantage of this kind of planning and execution system. Even complex diseases, like hemifacial hypertrophy, can be treated based on a splint-based surgery.
cases [27–33]. Complex facial reconstructions with prefabricated drilling guides and osteosyn­thesis plates are a domain for the more complex craniofacial malformations. One disadvantage is the fact that they are much more expensive; another one is that they often need more
1. The digital data of the splint (in an STL mode)
is then transferred to the printer (Fig.14.18).
2. The printer fabricates the nal splint, used for
the intraoperative transfer of the planning dur­ing surgery (Fig.14.19).
14 Decision-Making inOrthognathic Surgery by Virtual Planning andExecution
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Fig. 14.18 The bite splints (rst splint to dene the max­illary position, second splint to dene denite occlusal situation) are created and sent in an STL format to the 3D printer
Fig. 14.20 Postoperative CBCT view of the patient
sition between the virtual plan and the postop­erative outcomes. Baan and colleagues used this technique to assess the degree of correspon­dence between the planned and performed posi­tions [34]. De Riu and co-workers also suggested that the simple superimposition of the simula­tion and the cephalometric results is an unsatis­factory method, as it fails to consider the magnitude of the surgical manipulation leading to an error of a given magnitude [35]. For instance, a slight positional error can be com­pletely acceptable for large manipulations but
Fig. 14.19 In-house splint fabrication by a 3D printer
would be unacceptable when the manipulation takes place at a small scale and thus needs to be extremely precise [36].
Control ofOperative Outcome
The control of the presented case demon­strates the outcome of a virtual planning proce-
One of the most frequently used methods to evaluate the accuracy of virtual planning is the use of the mean error differences in superimpo-
dure and splint-based surgery (Fig. 14.20). Special attention should also be placed to the position of the TMJ (Fig.14.21).
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U. Meyer and K. Valentin
Fig. 14.21 Condylar positioning demonstrates a regular position of both (a) unaffected and b) newly created) condyles
a
b
References
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3. Assael LA. The biggest movement: orthognathic surgery undergoes another paradigm shift. J Oral Maxillofac Surg. 2008;66:419–20.
4. Bell RB. Computer planning and intraoperative navigation in cranio-maxillofacial surgery. Oral Maxillofac Surg Clin North Am. 2010;22:135–56.
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6. Baker SB, Goldstein JA, Seruya M. Outcomes in computer-assisted surgical simulation for orthogna­thic surgery. J Craniofac Surg. 2012;23:509–13.
7. Mori Y, Shimizu H, Minami K, Kwon TG, Mano T. Development of a simulation system in man­dibular orthognathic surgery based on integrated three- dimensional data. Oral Maxillofac Surg. 2011;15:131–8.
8. Zinser MJ, Mischkowski RA, Dreiseidler T, Thamm OC, Rothamel D, Zoller JE. Computer-assisted orthognathic surgery: waferless maxillary position­ing, versatility, and accuracy of an image-guided visualisation display. Br J Oral Maxillofac Surg. 2013;51:827–33.
9. Farrell BB, Franco PB, Tucker MR.Virtual surgical planning in orthognathic surgery. Oral Maxillofac Surg Clin North Am. 2014;26:459–73.
10. Lin HH, Lo LJ.Three-dimensional computer-assisted surgical simulation and intraoperative navigation in
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orthognathic surgery: a literature review. J Formos Med Assoc. 2015;114:300–7.
11. Rubio-Palau J, Prieto-Gundin A, Cazalla AA, Serrano MB, Fructuoso GG, Ferrandis FP, Baro AR. Three­dimensional planning in craniomaxillofacial surgery. Ann Maxillofac Surg. 2016;6:281–6.
12. Fawzy HH, Choi JW. Evaluation of virtual surgical plan applicability in 3D simulation-guided two-jaw surgery. J Craniomaxillofac Surg. 2019;47:860–6.
13. Freina L, Ott M.A literature review on immersive vir­tual reality in education: state of the art and perspec­tives; Computer Science. 2015, Corpus ID: 17385833.
14. Epker BN, Wylie GA. Control of the condylar­proximal mandibular segments after sagittal split osteotomies to advance the mandible. Oral Surg Oral Med Oral Pathol. 1986;62:613–7.
15. Bettega G, Dessenne V, Raphael B, Cinquin P. Computer-assisted mandibular condyle position­ing in orthognathic surgery. J Oral Maxillofac Surg. 1996;54:553–8.
16. Lee W, Park JU. Three-dimensional evaluation of positional change of the condyle after mandibular setback by means of bilateral sagittal split ramus oste­otomy. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2002;94:305–9.
17. Nishimura A, Sakurada S, Iwase M, Nagumo M.Positional changes in the mandibular condyle and amount of mouth opening after sagittal split ramus osteotomy with rigid or nonrigid osteosynthesis. J Oral Maxillofac Surg. 1997;55:672–6; discussion 677–678.
18. Ellis E 3rd. A method to passively align the sagittal ramus osteotomy segments. J Oral Maxillofac Surg. 2007;65:2125–30.
19. Xi T, de Koning M, Berge S, Hoppenreijs T, Maal T.The role of mandibular proximal segment rotations on skeletal relapse and condylar remodelling follow­ing bilateral sagittal split advancement osteotomies. J Craniomaxillofacial Surg. 2015;43:1716–22.
20. Aboul-Hosn Centenero S, Hernandez-Alfaro F. 3D planning in orthognathic surgery: CAD/CAM surgical splints and prediction of the soft and hard tissues results—our experience in 16 cases. J Craniomaxillofac Surg. 2012;40:162–8.
21. Bartella AK, Kamal M, Scholl I, Steegmann J, Ketelsen D, Holzle F, et al. Virtual reality in preop­erative imaging in maxillofacial surgery: implementa­tion of “the next level”. Br J Oral Maxillofac Surg. 2019;57(7):644–8.
22. Kim Y, Kim H, Kim YO. Virtual reality and aug­mented reality in plastic surgery: a review. Arch Plast Surg. 2017;44(3):179–87.
23. Naudi K, Benramdan R, Brocklebank L, Khambay B, Ayoub A. The virtual human face—superimpos­ing the simultaneously captured 3D photorealis­tic skin surface of the face on the untextured skin image of the CBCT scan. Int J Oral Maxillofac Surg. 2013;42(3):393–400.
24. Maliha SG, Diaz-Siso JR, Plana NM, Torrie A, Flores RL. Haptic, physical and web-based simulators: are they underused in maxillary surgery training. J Oral Maxillofac Surg. 2018;76(11):2424.e1–2424.e11.
25. Zinser MJ, Sailer HF, Ritter L, Braumann B, Maegele M, Zoller JE. A paradigm shift in orthognathic sur­gery? A comparison of navigation, computer-aided designed/computer-aided manufactured splints, and “classic” intermaxillary splints to surgical transfer of virtual orthognathic planning. J Oral Maxillofac Surg. 2013;71(2151):e1–e21.
26. Alkhaye A, Piffkó J, Lippold C, Segatto E.Accuracy of virtual planning in orthognathic surgery: a system­atic review. Head Face Med. 2020;16(1):34.
27. Metzger MC, Hohlweg-Majert B, Schwarz U, Teschner M, Hammer B, Schmelzeisen R. Manufacturing splints for orthognathic surgery using a three- dimensional printer. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008;105:e1–7.
28. Bai S, Bo B, Bi Y, Wang B, Zhao J, Liu Y, etal. CAD/ CAM surface templates as an alternative to the inter­mediate wafer in orthognathic surgery. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2010;110:e1–7.
29. Zinser MJ, Mischkowski RA, Sailer HF, Zoller JE. Computer-assisted orthognathic surgery: fea­sibility study using multiple CAD/CAM surgical splints. Oral Surg Oral Med Oral Pathol Oral Radiol. 2012;113:673–87.
30. Vale F, Scherzberg J, Cavaleiro J, Sanz D, Caramelo F, Malo L, Marcelino JP. 3D virtual planning in orthog­nathic surgery and CAD/CAM surgical splints gen­eration in one patient with craniofacial microsomia: a case report. Dental Press J Orthod. 2016;21:89–100.
31. Shaheen E, Sun Y, Jacobs R, Politis C. Three­dimensional printed nal occlusal splint for orthog­nathic surgery: design and validation. Int J Oral Maxillofac Surg. 2017;46:67–71.
32. Lin HH, Lonic D, Lo LJ. 3D printing in orthognathic surgery—a literature review. J Formos Med Assoc. 2018;117:547–58.
33. Uribe F, Janakiraman N, Shafer D, Nanda R.Three­dimensional cone-beam computed tomography-based virtual treatment planning and fabrication of a surgical splint for asymmetric patients: surgery rst approach. Am J Orthod Dentofac Orthop. 2013;144:748–58.
34. Baan F, Liebregts J, Xi T, Schreurs R, de Koning M, Berge S, etal. A new 3D tool for assessing the accuracy of bimaxillary surgery: the OrthoGnathicAnalyser. PLoS One. 2016;11:e0149625.
35. De Riu G, Virdis PI, Meloni SM, Lumbau A, Vaira LA.Accuracy of computer-assisted orthognathic sur­gery. J Craniomaxillofac Surg. 2017;46:293–8.
36. Zhang N, Liu S, Hu Z, Hu J, Zhu S, Li Y.Accuracy of virtual surgical planning in two-jaw orthogna­thic surgery: comparison of planned and actual results. Oral Surg Oral Med Oral Pathol Oral Radiol. 2016;122:143–51.
Part VI
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Diseases: Deformational Cephaly
Prevention andTreatment
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ofDeformational Cephaly
HelenaSophieKriege, ChristophRunte, UlrichMeyer, andDieterDirksen
15
Introduction
The increase in size of an infant’s skull results from the growth of the brain, which pushes the individual skull plates apart. Without external inuences, one would expect the head to expand evenly in all directions, resulting in a symmetri­cally shaped skull. If this is not possible due to an internal or external inuence, a growth de­cit occurs in one or more areas of the skull. The shape of the skull deformation is usually deter­mined by the direction in which this growth decit occurs. In the case of deformities caused by craniosynostosis, Virchow’s law states that the growth of the plane perpendicular to a fused suture is restricted and is enhanced in a plane parallel to it to provide space for the growing brain [1].
The different types of skull deformity as well as their etiology and phenotype are shown in Table15.1 and Fig.15.1.
H. S. Kriege · C. Runte · D. Dirksen (*) Department of Prosthodontics, University of Muenster, Muenster, Germany e-mail: crunte@uni-muenster.de;
dirksdi@uni-muenster.de
U. Meyer Department of Prosthodontics, University of Muenster, Muenster, Germany
Center for Jaw-, Face- and Skull Surgery, Münster, Germany e-mail: praxis@mkg-muenster.de
As shown in Table15.1, non-synostotic defor­mities are mainly limited to plagio- and brachy­cephalism. In most cases, the reason is a preferred supine position of the infants [2]. The increased stay in this preferred position leads to an occipital attening of the infant’s skull, which either devel­ops laterally (plagiocephaly) as shown in Fig.15.2 or symmetrically at the back of the head (brachycephaly).
Due to gravity, the mass of the head is pressed against the substrate and consequently the os occipitale is attened while the skull expands lat­erally in a compensatory manner. The barrier cre­ated by lateral expansion of the head clearly makes it more difcult for the infant to actively move out of this preferred position, even with increasing mobility. Pediatricians became aware of this condition much more frequently after the American Association of Pediatrics published a statement in 1992 recommending supine sleeping positioning to prevent sudden infant death syn­drome [3].
In contrast to positional and synostotic skull deformations, the skull can also be deformed by intentional manipulations. Targeted manipulation of the head shape is already a prehistoric phe­nomenon that occurred almost on every conti­nent. In diverse cultures, inuence has been exerted on the shape of the infant’s skull for aes­thetic reasons, ethical identication, clarication of sociocultural status, or alleged health benets,
© Springer Nature Switzerland AG 2023 U. Meyer (ed.), Fundamentals of Craniofacial Malformations,
https://doi.org/10.1007/978-3-031-28069-6_15
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osterior Plagiocephaly
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Table 15.1 Skull deformations with associated etiology and phenotype
Skull deformation Etiology Phenotype Plagiocephaly Deformational or synostosis of coronal (anterior
plagiocephaly) or lambdoid (posterior plagiocephaly) suture Brachycephaly Deformational or bicoronal craniosynostosis Short head Scaphocephaly (dolichocephaly) Trigonocephaly Craniosynostosis of the metopic suture “Triangle” head Oxycephaly Premature bilateral closure of the coronal suture, results from
Fig. 15.1 Skull shapes in lateral (left) and cranial view
Premature fusion of the sagittal suture Long, narrow head
untreated synostotic brachycephaly
H. S. Kriege et al.
Asymmetrical distortion of the head
“Steeple head,” “tower head”
Normal Skull Shape
P
Brachycephaly
Trigonocephaly
Scaphocephaly
15 Prevention andTreatment ofDeformational Cephaly
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Fig. 15.2 Plagiocephaly in cranial view. The skull has signicantly more volume on the patient’s left side. The back of the head is attened on the right side
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for example [4]. The rst demonstrably inten­tional changes can be dated to 45,000 BC among Neanderthals [5]. Probably best known, however, are the characteristic long skulls of ancient indig­enous cultures in South and Central America, which were achieved by bandaging or plating the skull [6]. The African tribe of Mangbetu bandaged their infant’s skulls until the mid-twentieth cen­tury (Fig.15.3) [7, 8].
By the age of 8–12 weeks, approximately 38% of infants exhibit a positional plagiocephaly and 15% a brachycephaly [9]. As adolescence progresses (age 12–17), the incidence of plagio­cephaly and brachycephaly decreases to 1.1%, and 1% in teenagers born after 1992 [10].
Fig. 15.3 Photograph of Mangbetu woman with baby. The baby has its skull bandaged. The backward elongated skull is clearly visible (1929–1937; Central Africa, Republic of Congo; photograph taken by Casimir Zagourski; Collection Nationaal Museum van Wereldculturen. Coll.no. 60033952; https://hdl.handle.
net/20.500.11840/308179)
Etiology
Risk factors for the development of a deforma­tional plagiocephaly can be categorized as bio­logical, obstetric, infant care practical, and sociodemographic factors (Table15.2).
At birth, the weight of the brain is about 400g [12]. It doubles after around 6months, while the head circumference increases by about 25% (Fig. 15.3). The weight then triples only at the age of approximately two and a half years. These gures illustrate the potential for intervention in the rst months of life. The percentile curve of head circumference for boys aged 0–24months is shown in Fig.15.4.
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Table 15.2 Risk factors and causes for developing plagiocephaly [11]
Biological risk factors:
• Male gender
• Torticollis, limited head rotation, head rotational asymmetry preferred head position/orientation
• Higher birth weight
• Developmental delay
• Head circumference, macrocephaly
• Lower level of activity
• APGAR score Obstetric factors:
• Birth order (parity)
• Mode of delivery: forceps, vacuum, or assisted delivery
• Prematurity
• Intrauterine position/cranial immobility lower gestational age
• Multiple birth
• Multiple gestation pregnancies Infant care practice:
• Supine sleep position
• Little time spent prone (“tummy time”)
• Feeding pattern (bottle feeding)/non-varying position during feeding
• Use of car seats, swings, carriers, bouncy seats, rockers
• Smoking Sociodemographic factors:
• Lower parental age
• Lower educational level
H. S. Kriege et al.
Fig. 15.4 World Health Organization publication on boys’ head circumference from birth to 2 years of age (WHO child growth standards (percentiles); https://cdn.
who.int/media/docs/default- source/child- growth/child-
growth- standards/indicators/head- circumference- for- age/ boys- chart%2D%2Dhead- circumference- for- age- birth­to- 2- years- (percentile).pdf?sfvrsn=3829cc5_0) [13]
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