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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_980_Библиотеки_им_академика_М_И_Перельмана
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Digitally Assisted Orthognathic Surgical Planning: Denition, History, andInnovation
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Fig. 20 Two years postoperative facial views (a) and occlusion (b) showing satisfactory correc-
tion of the asymmetry and good stability
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Fig. 21 Photorealistic 3D soft tissue prediction of 3D VSP using 3D stereophotogrammetry; preoperative facial appearance (left), postoperative result (middle), the 3D prediction (right)
Fig. 22 The display of the
3D prediction planning to
allow the image to rotate
the image and fully
understand the objective of
the orthoganthic surgical
procedure (Permission
obtain from the published
of ourprevious
publication 21)
N. M. AlOtaibi and A. F. Ayoub
Digitally Assisted Orthognathic Surgical Planning: Denition, History, andInnovation
https://t.me/medicina_free
a
b
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Fig. 23 Virtual 3D model of case 2. (a) Presurgical 3D model of thehard and soft tissue demon-
strating prognathic mandible with mild mandibular asymmetry and deviation of chin point toward
the right side. (b) The asymmetry was limitedto the lower third of the face
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Fig. 24 The VSP of case 2. The planned bilateral sagittal split osteotomy for mandibularsetback
showing theimproved facial symmetry (middle column) as well as the facial height, mandibular
prominence (white arrow)and overall esthetics
N. M. AlOtaibi and A. F. Ayoub
Fig. 25 Virtual occlusion. Prepared virtual occlusion of case 2 (frontal, lingual, and sides views).
The dentition 3D data was scannedusing an intraoral scanner. Occlusogram (middle row)demonstrates occlusal contact points virtually using color-coded map
Digitally Assisted Orthognathic Surgical Planning: Denition, History, andInnovation
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5 Surgical Splint
A surgical splint refers to a medical device used intraoperatively to guide the osteotomy segments to the preplanedpositioning based on dental occlusion (nonanatomical splint) or bone structure (anatomical splint). The splint is fabricated by
traditional lab method or 3D printing using computer-aided design/computer-aided
manufacture (CAD/CAM).
5.1 Dental “Nonanatomical” Splint
5.1.1 Dental “Conventional” Occlusal Splint
Conventional splints areconstructed on dental occlusion. Two methods are routinely used to guide the nal digital occlusion; the direct operator-based
approach orthe scanned nalocclusal method. In the rst approach, the nal
occlusion is adjusteddigitally; most of the software packages provide this facility based on the mathematical spring approach to achieve the best possible interdigitation of the occlusal surfaces. The lack of haptic feedback “tactile sensation”
is one of the limitations of virtual occlusion in digital planning [25]. However,
the emergence of virtual collision detection combined with occlusogram facilitates the visualization of occlusal contact points on the digital model [26, 27]
(Fig.25).
Alternatively, the maxillo-mandibular dental study models are scanned in
thedesired nalocclusionusing a CBCT or intraoral scanner. The scanned images
will guide the movements of the osteotomyocclusal segments. In complex segmental osteotomies, the authors prefer to carry the surgery on physical casts and set the
nal occlusion manually; then, the nal occlusion is scanned usingIOS or CBCT.
Once VSP is completed, the design of surgical splints iscarried out using the
same software package. The designed splints isthen exported as (.STL) les and
sent for rapid prototyping machine (3D printers) to produce the physical splints.
The splint design can include palatal coverage, buccal extension, and holes for wiring if required (Fig.26).
The main limitation of the nonanatomical “dental”split is its reliance on the
dentalocclusion, which is considered a non-xed target during surgerydue to the
condylar movement in addition to the inherent inaccuracies in predictingthe mandibular autorotation. The intermediate occlusal splint can lead to inaccurate positioning of the maxilla, subsequently affecting the nal outcome and facial
esthetics. A number of pitfalls arise from traditional model surgery and intermediate splint, including inaccuracies in centric relation, intraoperative condylar sagging, and inaccuratemandibular autorotation. These errors can be eliminated by
using an anatomical splint and cutting guides that do not rely on dental occlusion
[28, 29].
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Fig. 26 3D design of surgical splints with and without buccal extension
Fig. 27 The application of
the cutting guide and the
printed plates for xation
of design of anatomical
splint
N. M. AlOtaibi and A. F. Ayoub
5.2 Anatomical Splints andPrinted Plates
The anatomical splint refers to a medical device that guides the position of the maxillary osteotomysegment independent of the mandibular dentition during orthognathic surgery. Printed plates are also used for xation of the osteotomy
segmentaccording to the pre-planned anatomical position independentof the dental
occlusion (Fig.27).
Digitally Assisted Orthognathic Surgical Planning: Denition, History, andInnovation
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Currently, anatomical splints are produced as customized cutting guides and
plates. Customized cutting guides and plates can provide an accurate surgical
approach and eliminate injury to vital structures, which is useful for inexperienced surgeons and trainees. The plates reposition the maxillary osteotomy segments in relation to the lateral nasal process and zygomatic buttress. Therefore,
it eliminates the errors of the non-anatomic splints. However, the cost is signicantly more than the conventional plates and screws. The major drawback of
anatomical splint is the inability for intraoperative adjustments. The current evidence is not enough to recommend the routineuse of customized cutting guides
and plates in orthognathic surgery [30].
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6 Innovations inDigital Planning andFuture Perspectives
Digital assisted surgery is rapidly emerging and developinginnovation. It is important to acknowledge that maxillofacial practice has undergone signicant changes in
response to technological advances, the innovations of 3D imaging, virtual surgical
planning, and 3D printing.
Virtual reality (VR), augmented reality (AR), and mixed reality (MR) are some
of the new terms in simulation technology. Virtual reality is an articial computergenerated environment that replicates a real-life setting and renders either an immersive, semi-immersive, or non-immersive 3D digital environment [31]. AR is a
technology thatallows the superimposition of the digital-generated virtual model/
image onto the real world [32]. Thus, AR is in stark contrast to VR, which completely replaces and excludes the real world and the surrounding environment [33].
In contrast, MR is a multisensory articial computer-generated experience that
engages the users through the simulation of sensory perception like vision and hearingin real time to feel part of the real-world experience. The two main features of
MR are immersion and interaction. Immersion indicates the presence of the surgeonin the virtual setting, and interaction refers to the user’s reection toward the
virtual stimuli. Generally, the user wears a head-mounted wearable deviceto engage
the visual senses, headphones to engage the auditory sense, and gloves to simulatehis tactile sense [34].
6.1 Virtual Reality
Virtual reality has been applied in various medical and surgical elds which
includerobotics, psychology, training, and patient education. In orthognathic surgery, VR is mainly used for virtual planning, surgical training, patient education,
and participation in decision-makingprocess [35, 36] (Fig.28).
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Fig. 28 The application of
virtual reality in
orthognathic surgery
trainingfor the interactive
visualization of the 3D
virtual skulland the
manipulation of surgical
instruments
6.2 Augmented Reality
N. M. AlOtaibi and A. F. Ayoub
Augmented reality can be implemented in orthognathic surgery through a at monitor, allowing the superimposition of VSP directly on the surgical site [37]. Also, it
can be used to provide visualization of the patient’s anatomical structures obtained
by CBCT data directly at the surgical site, which allows intraoperative anatomical
evaluation and provides safe surgery.
6.3 Dynamic Navigation
Dynamic navigation guides the surgeon during the surgical procedure via real-time
mapping on a monitor. The dynamic navigation is based on the principle of the
Global Positioning System (GPS), which is based primarily on requiresthree components: a localizer like a satellite in space which works as a reference to send signals that are received and interpreted by a surgical probe; the second component is
the surgical probe, which corresponds to the tracking waves emitted by the localizer
to determine the location in relation to the xed points of the localizer. The nal
component is the road map represented by the patient’s CT/CBCT [38]. Three fundamental steps are consideredin dynamic navigation, the registration, calibration,
and the tracking [39, 40]. The navigation utilizes two different technologies for
tracking the surgical movements of the cutting instruments, either optical or electromagnetic systems. The movements are tracked in relation to the the preoperative
Digitally Assisted Orthognathic Surgical Planning: Denition, History, andInnovation
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CBCT scans and the prediction planning of the of the position of the osteotomy
segments. Currently, tremendous efforts focus on improving and developing navigation in maxillofacial surgery to help overcome obstacles of the current system. A
combination of AR and navigation systems can be used to improve intraoperative
surgical precision [41, 42]. The application of AR-guided navigation in orthognathic surgery aims to facilitate accurate positioning of bonesegments according to
thevirtual planning and identify any mismatch between theexecuted and theplanned
position [43, 44]. The ability to gain real-time feedback allows verication and validation of repositioning of the segmented jaw; thus, it holds great potential to enhance
the accuracy of execution of VSP and optimize the surgical outcomes. Current
reports showed several limitationsof usingdynamic navigation in orthognathic surgery, which includesthe increased operating time, the bulkiness of appliance, and
limited visibility of the surgical site due to obstruction of surgical access by the
stereo-cameras of the navigation system [42, 43].
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6.4 Robotic Orthognathic
Since the introduction of the rst robotic surgical system for CT-guided brain biopsy
in 1988, robotic-guided surgery has been expanding into various surgical elds,
such as neurosurgery, orthopedics, and craniofacial surgery [45]. Robotic surgery
refers to the application of advanced technology to perform surgical procedures on
patients using robotic arms. Robotic surgery provides several benets such as elimination of human errors, shorter operation time, reduction of surgical complications,
and faster recovery [46, 47]. During robotic orthognathic surgery, a combination of
robotics and navigation devices is used to perform the procedure. For orthognathicsurgery, specic modications are required in ten design ofthe robotic arm,
including bone cutting instrument with an integrated cooling system, 3D cameras,
and a collision-sensing system for the recognition of bony interferences [48].
Robotic orthognathic surgery will help in the precise translation of the treatment
plan in the operative room to achieve target esthetic and functional outcomes.
Moreover, it facilitates the elimination of surgical splints and overcomes inaccuracies of maxillary repositioning. Despite the potential advantages of robotic orthognathic surgery, the safety and convenience need further development before its
application clinically [48]. To date, all of the published studies on robotic orthognathic surgery are in the preclinical phase [48–50]. It remains early days for
roboticarms to be usedin the maxillofacial eld, and only time will tell whether the
technology can be used to perform orthognathic surgery effectively and safely.
In conclusion, further development and optimization of digital assisted orthognathic technology are needed before wide application of these technologies in routine care.
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N. M. AlOtaibi and A. F. Ayoub
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