Use Of Virtual Surgical Planning Research Articles

Epidemiological analysis and emergency nursing care of oral and craniomaxillofacial trauma: a narrative review.

We conducted a literature review on the epidemiology and emergency nursing care of oral and craniomaxillofacial trauma in order to facilitate rescue and care planning. Traumatic accidents alter oral and craniomaxillofacial anatomy and physiology, resulting in craniomaxillofacial scars and deformities, temporomandibular disorders, and oromandibular dysfunction. Such trauma affects speech, chewing, and eating; results in long hospitalization and burdensome healthcare expenses; and in severe cases may lead to potentially life-threatening complications such as respiratory obstruction and brain injury. EMBASE, MEDLINE, and PubMed were investigated for relevant systematic reviews. By conducting a literature review of reports on oral and craniomaxillofacial trauma to summarize the epidemiological characteristics and emergency care of oral and craniomaxillofacial trauma. Numerous studies, both domestic and foreign, have investigated the epidemiological characteristics of oral and craniomaxillofacial trauma and have reported different incidences of this trauma, with significant inter- and intraregional variation. The studies show that most patients with maxillofacial trauma are young adults, and males consistently outnumber females. Maxillofacial trauma can be physical or chemical, though most are physical injuries, the road traffic accident (RTA) is the leading cause of oral and maxillofacial trauma. Oral and maxillofacial trauma can be simple soft tissue trauma, simple bone trauma, or soft tissue plus bone trauma, the brain injury is the most common concomitant injury of patients with maxillofacial trauma. Different studies have reached different conclusions about the temporal distribution of maxillofacial trauma. Several important emergency care models in the management of oral and craniomaxillofacial trauma have resulted in improved outcomes. These include accurate assessment, effective airway maintenance, careful management. The more common use of virtual surgical planning, surgical navigation, computer-aided surgery and 3D printing will no doubt continue to improve accuracy and efficiency in the management of these patients. By conducting a literature review of domestic and foreign reports on oral and craniomaxillofacial trauma to summarize the epidemiological characteristics and emergency care of oral and craniomaxillofacial trauma, we aimed to provide a reference for the rescue and care planning for patients with oral and craniomaxillofacial trauma.

Surgical Margins After Computer-Assisted Mandibular Reconstruction: A Retrospective Study.

Purpose: The use of virtual surgical planning in head and neck surgery is growing strongly. In the literature, its validity, accuracy and clinical utility for mandibular reconstruction are widely documented. Virtual planning of surgical bone resection and reconstruction takes place several days before surgery and its very sensitive nature can negatively affect an intervention aimed at maximum precision in term of oncological safety.Methods: The study focuses on a retrospective evaluation of the surgical margins in 26 consecutive cases with oral cavity malignancy and who underwent computer-assisted mandibular resection/reconstruction guided by the different types of bone, periosteal and peri-mandibular tissue involvement. The goal was to analyze the strategic and technical aspects useful to minimize the risk of positive or close margins and to vary the reconstructive strategy in the case of intraoperative findings of a non-radical planned resection.Results: No intraoperative or perioperative complications occurred. In 20 patients, virtual surgical planning permitted mandibular reconstruction to be performed using composite fibular free flaps, characterized by high accuracy and negative bone margins. In the remaining 6 patients, also virtually planned but otherwise reconstructed due to poor general condition (advanced age, severe comorbidity), negative bone margins were obtained. Intraoperative enlargement of the resection was carried out in one case and positive soft tissue margins were observed in another case.Conclusion: The results were satisfactory in terms of oncological radicality and precision. The functional benefits and reduction in operating times, previously demonstrated in other articles also by the authors, seem to justify the side effects related to the risk of modifying the planned surgery. During virtual planning, the surgeons must bear in mind that an unexpected progression of the tumor or a limited planned resection will entail modifying the extent of the resection intraoperatively and nullifying the virtual planning on which the reconstruction was based. Further investigations are necessary to clarify all aspects of virtual surgical planning in this setting.

Pushing the Limits in Extremity Reconstruction Using Virtual Surgical Planning: A Case Series Study.

Technology is advancing in benefit to solving complex problems. Preoperative planning is essential in any reconstructive process given the importance of achieving good results. New technologies facilitate the process to anticipate intraoperative findings. Virtual surgical planning has contributed in the evolution of craniomaxillofacial surgery. However, limited reports have been published regarding its usefulness in extremity reconstruction. The aim of this study was to push the limits and evaluate the use of virtual surgical planning with three-dimensional images for reconstruction of complex extremity defects using a free, open-source software. Patient candidates for upper or lower extremity microsurgical reconstruction with multiple defects or defects requiring reconstruction of various tissue components were included. Computed tomography angiography images were analyzed for virtual surgical planning using Horos software (Horos, Annapolis, Md.). Two upper and eight lower extremities were reconstructed with free flaps using virtual surgical planning; six cases had multiple defects, and four cases underwent different tissue components reconstruction. The postoperative period was uneventful, and there was no flap failure. A didactic video of the process and examples of some cases are presented. Virtual surgical planning is a powerful planning method, and the authors propose its use in complex extremity defects reconstruction. Therapeutic, IV.

Clinical Accuracy of Bimaxillary Surgery Completed with Custom Prefabricated Splints vs. Patient-specific Surgical Guides and Plates

Abstract Purpose Virtual surgical planning (VSP) has improved outcomes in bimaxillary orthognathic surgery when compared to traditional cephalometric analysis and model surgery. However, several studies have shown discrepancies between the planned and post-operative position of the maxilla with the use of VSP and splints. Patient-specific Implants (PSIs) have the maxillary movement and final position built into them as dictated by the virtual surgical plan, completely independent of the mandibular position and have shown promising results, but are limited in number and by sample size and no study to date has directly compared the accuracy of splints versus PSIs. The purpose of our study was to determine the accuracy of splints versus PSIs in executing a virtual surgical plan. Materials and Methods A retrospective analysis of patients who underwent bimaxillary orthognathic surgery with splints or PSIs planned with VSP at our institution from 2017 to present was completed. The difference in maxillary positions from the VSP to the post-operative CBCT were evaluated in both cohorts. The primary predictor variable was the planned 3D position of the maxillary mid-incisors, and right and left first molars in the antero-posterior, transverse, and vertical dimensions. The primary outcome variable was the post-operative 3D position of these points. The root mean square deviation (RMSD) was used to calculate the absolute value of the mean differences. A paired t test was used to determine if there were statistically significant differences between the predicted and observed positions with p < 0.05 Results A total of 65 patients (46 female, 19 male) aged 14 to 58 years (mean age, 23.3 years). 10 patients (8 female, 2 male) aged 14 to 54 years (mean age, 24.8 years) underwent bimaxillary surgery with a Le Fort 1 osteotomy and a mandibular sagittal split osteotomy or intraoral vertical ramus osteotomy and were rigidly fixated after the use of a splint to facilitate the final maxillary position, whereas 55 patients (38 female, 17 male) aged 14 to 58 years (mean age, 22.7 years) were rigidly fixated with the use of a PSI. The difference between the planned and actual movements varied in all dimensions in the splint cohort but was greatest in the anteroposterior dimension for all points in the PSI cohort. The only statistically significant differences in pre-operative and post-operative position of the splint group were the mid-incisor transverse and vertical dimensions, whereas all differences in the PSI cohort were found to be statistically significant with the exception of the maxillary right 1st molar in the transverse dimension and the maxillary left 1st molar in the vertical dimension. There was an overall tendency for undertreatment in all directions as shown in the deviation from 0 toward under (-) or over (+) correction, regardless of type of surgery performed. Also, there was no indication that posterior or anterior movements were more or less accurate in either group. The PSI group was more accurate at all 3 maxillary points in all 3 dimensions, ranging from 1% to 62.8% more accurate than the splint group. Conclusion The use of a PSI allows for greater control of the post-operative position of the maxilla when planned via VSP and is more accurate than the use of a splint.

Intraosseous Venous Malformation of the Zygomatic Bone: Comparison between Virtual Surgical Planning and Standard Surgery with Review of the Literature.

Intraosseous venous malformations affecting the zygomatic bone are infrequent. Primary reconstruction is usually accomplished with calvarial grafts, although the use of virtual surgical planning, cutting guides and patient-specific implants (PSI) have had a major development in recent years. A retrospective study was designed and implemented in patients diagnosed with intraosseous venous malformation during 2006–2021, and a review of the scientific literature was also performed to clarify diagnostic terms. Eight patients were treated, differentiating two groups according to the technique: four patients were treated through standard surgery with resection and primary reconstruction of the defect with calvarial graft, and four patients underwent resection and primary reconstruction through virtual surgical planning (VSP), cutting guides, STL models developed with CAD-CAM technology and PSI (titanium or Polyether-ether-ketone). In the group treated with standard surgery, 75% of the patients developed sequelae or morbidity associated with this technique. The operation time ranged from 175 min to 210 min (average 188.7 min), the length of hospital ranged from 4 days to 6 days (average 4.75 days) and the postoperative CT scan showed a defect surface coverage of 79.75%. The aesthetic results were “excellent” in 25% of the patients, “good” in 50% and “poor” in 25%. In the VSP group, 25% presented sequelae associated with surgical treatment. The operation time ranged from 99 min to 143 min (average 121 min), the length of hospital stay ranged from 1 to 2 days (average of 1.75 days) and 75% of the patients reported “excellent” results. Postoperative CT scan showed 100% coverage of the defect surface in the VSP group. The multi-stage implementation of virtual surgical planning with cutting guides, STL models and patient-specific implants increases the reconstructive accuracy in the treatment of patients diagnosed with intraosseous venous malformation of the zygomatic bone, reducing sequelae, operation time and average hospital stay, providing a better cover of the defect, and improving the precision of the reconstruction and the aesthetic results compared to standard technique.

Use of anterior ramus bone graft for mandibular reconstruction in elderly patients

In this study, we investigated the feasibility of using a geometrically designed anterior ramus graft to reconstruct lateral mandibular defects. This was achieved by assessing the anatomical dimensions of the mandibular ramus on computed-tomographies. The design sequence and application of the graft was also demonstrated using one of our cases. The following dimensions were measured; a and b - horizontal length from mid-ramus to the posterior and anterior ramus border respectively, c - longest length of the graft, Mp - width at the centre of the ramus, h - vertical length of the angle at its cross-section, w - horizontal length of the angle at its cross-section, x - cross-sectional area along the mandible angle. A total of 80 mandibular rami were examined. The mean length of a, b, c were 17.3 ± 1.8 mm, 15.9 ± 1.2 mm, 54.6 ± 3.8 mm, respectively. The mean width of Mp was 9.8 ± 1.1 mm. The mean cross section area of Eo-Md (x) was 326.7 ± 67.8 mm2. The average length of h and w were 26.5 ± 3.2 and 15.6 ± 2.1 mm, respectively. The use of virtual surgical planning (VSP) to geometrically design the graft was also described. Together with VSP, the anterior ramus bone graft will allow for reconstruction of the mandible with greater surgical efficiency, reduced complexity and without the need for extra-oral bone harvest. This may be an useful alternative in situations where simpler reconstructive procedures are preferred.

Same-Admission Microvascular Maxillofacial Ballistic Trauma Reconstruction Using Virtual Surgical Planning: A Case Series and Systematic Review.

Retrospective case series; systematic review. It is unknown whether the use of virtual surgical planning (VSP) to facilitate same-admission microsurgical reconstruction of the mandible following acute maxillofacial ballistic trauma (MBT) is sufficient to achieve definitive reconstruction and functional occlusion. A single-center retrospective analysis was conducted for patients who underwent microsurgical reconstruction of the mandible using VSP after acute MBT. The PubMed/MEDLINE, Embase, ScienceDirect, and Scopus databases were systematically reviewed using blinded screening. Studies were evaluated via thematic analysis. Five patients were treated by same-admission and microsurgical reconstruction of the mandible using VSP. We observed an average of 16.4 ± 9.1 days between initial presentation and reconstruction, an average length of stay of 51.6 ± 17.9 days, 6.2 ± 2.8 operations, and 1.6 ± 0.9 free flaps per patient. Four types and 8 total flaps were employed, most commonly the anterior lateral thigh flap (37.5%). Care yielded complete flap survival. Each patient experienced at least 1 minor complication. All patients achieved centric occlusion, oral nutrition, and an approximation of their baseline facial aesthetic. Follow up was 191.0 ± 183.9 weeks. Systematic review produced 8 articles that adhered to inclusion criteria. Consensus themes in the literature were found for clinical goal and function of VSP when practicing MBT reconstruction, yet disagreement was found surrounding optimal treatment timeline. Same-admission microsurgical reconstruction after MBT is safe and effective to re-establish mandibular form and function. VSP did not delay reconstruction, given the need for preparation prior to definitive reconstruction.

Dentoalveolar outcomes in maxillary reconstruction: A retrospective review of 85 maxillectomy reconstructions.

Although microvascular free flaps are often used to reconstruct maxillary defects, dentoalveolar rehabilitation is arguably less common despite its importance to midface function and aesthetics. The aim of this study is to review the contemporary management of maxillary defects in a single quaternary referral institution to identify factors that assist or impede dentoalveolar rehabilitation. A retrospective review of maxillary reconstructions performed between February 2017 and December 2020 was performed. Patient characteristics, defect classification, operative techniques, complications and dentoalveolar outcomes were recorded. A total of 85 maxillary reconstructions were performed in 73 patients. Of the 64 patients where dental rehabilitation was required, 31 received a functional denture (48%) with 24 (38%) being implant-retained. Significant predictors of successful rehabilitation included the use of virtual surgical planning (VSP; 86% vs. 25%, p < 0.001), preoperative prosthodontic assessment (82% vs. 21%, p < 0.001), prefabrication (100% vs. 40%, p=0.002) and use of the zygomatic implant perforator flap technique (100% vs. 39%, p=0.001). Preoperative prosthodontic consultation was associated with 21-fold increase in the odds of rehabilitation (odds ratio 20.9, 95% confidence interval 6.54-66.66, p < 0.005). Preoperative prosthodontic evaluation, VSP and reconstructive techniques developed to facilitate implant placement are associated with increased dental rehabilitation rates. Despite using an institutional algorithm, functional dentures are frequently prevented by factors including soft tissue constraints, disease recurrence and patient motivation.

Narrative review of facial gender surgery: approaches and techniques for the frontal sinus and upper third of the face.

Facial gender confirmation surgery (FGCS) is a series of procedures which seek to harmonize a patient's face with his/her self-image and gender identity. Originally described in San Francisco in the 1980s, FGCS has evolved to encompass all elements of the craniofacial skeleton and facial soft tissue. This field in plastic and reconstructive surgery has quickly gained more attention in the past decade due to the pioneering work of groups around the world along with increased social acceptance and medical care of the transgender community. This narrative review focuses on the upper third of the face. Key differences in the forehead and the hairline of cis men and women are discussed which inform pharmacologic and surgical interventions. Hairline modifying therapies including pharmacotherapy and hair transplantation are explained. Virtual surgical planning (VSP), a tool broadly used in surgical fields, has a special role in FGCS and we offer advice in using VSP when addressing the frontal sinus. Use of VSP allows the surgeon to provide reproducible and accurate results. We then discuss the history of the frontal sinus setback and offer our algorithmic approach to recontouring the forehead with detailed description of the operative steps and decision making. Finally, postoperative care and complications considered.

Association of Virtual Surgical Planning With External Incisions in Complex Maxillectomy Reconstruction

Maxillectomy can commonly be performed through a transoral approach, but maxillectomy defect reconstruction can be difficult to precisely design, contour, and inset through this approach. To evaluate whether the use of virtual surgical planning (VSP) and 3-dimensional (3-D) modeling is associated with a decrease in the requirement of lateral rhinotomy (LR) for patients undergoing total and partial maxillectomy reconstruction. This retrospective cohort study was conducted among patients undergoing subtotal or total maxillectomy with microvascular free flap reconstruction with or without VSP and 3-D modeling at a single tertiary care academic medical center between January 1, 2008, and October 3, 2019. Maxillectomy and free flap reconstruction with or without VSP. Necessity of LR or other external incision for contouring, placement, and fixation of reconstruction as well as surgical complications. Fifteen patients (12 men [80%]; mean age, 64 years) underwent maxillectomy with free flap reconstruction without VSP. Eight patients (53%) in this group underwent total maxillectomy, and 4 patients in this group (27%) underwent partial maxillectomy. Twenty-three patients (18 men [78%]; mean age, 58 years) underwent maxillectomy with free flap reconstruction and VSP and 3-D modeling. Twelve of these patients (52%) underwent total maxillectomy, and 11 (48%) underwent partial maxillectomy. Lateral rhinotomy was necessary for 1 patient (4%) in the VSP group vs 12 patients (80%; 95% CI, 54%-98%) in the pre-VSP group. There were no LR complications in the VSP group vs 6 in the pre-VSP group. Among both groups, 14 patients underwent fibula free flap, 22 patients underwent subscapular system free flap, and 2 patients underwent cutaneous or osteocutaneous radial forearm free flap. There were no flap failures in the LR group and 1 flap failure in the group without LR. This cohort study suggests that the use of VSP and 3-D modeling for maxillectomy reconstruction is associated the a decrease in the need for external incisions without compromising reconstructive flap utility.

A Comprehensive Analysis of Complications of Free Flaps for Oromandibular Reconstruction.

To determine the frequency and management of short- and long-term complications related to oromandibular free flap reconstruction and identify potentially predictive factors of hardware complications. Retrospective chart review. A retrospective database from chart review was formed consisting of 266 oromandibular free flap reconstructions performed at a single institution over a 15-year period. Data were collected on demographics, surgical treatment, complications, and management of complications. Subgroup univariate and multivariate analyses were performed to compare patients with hardware complications and those without. Eighty-one of 266 patients (30.5%) that underwent oromandibular reconstruction had an early complication (<4 weeks after surgery), and the most common complications were cervical wound dehiscence (11.3%) and fistulas (9.40%). Eighty of 266 patients (30.1%) had a long-term complication (>4 weeks after surgery) and the most common complication was plate exposure (26.7%). Univariate and multivariate analyses showed no association between whether there was hardware extrusion and fibula versus scapula, smoking history, virtual surgical planning (VSP), and dental implantation (P > .05). Only early complications (OR, 3.59, 95% CI, 1.83-7.05, P < .01) and patients undergoing oromandibular reconstruction for osteoradionecrosis (OR, 2.26, 95% CI, 1.10-4.64, P=.03) were strongly and independently associated with subsequent hardware extrusion on univariate analysis. Both short- and long-term complications are common after oromandibular reconstruction. The most important predictive factor for a late complication is an early complication and prior radiation. There was no difference of plate complications among the various free flap types. Dental implantation and use of VSP were not associated with hardware complications. 4 Laryngoscope, 131:1997-2005, 2021.

Current trends in midface reconstruction and use of virtual surgical planning

Virtual surgical planning (VSP) applicability has recently expanded to include midface reconstruction with free tissue transfer. For the midface, an area that is crucial both functionally and aesthetically, even minor reconstructions (in the millimeter range) can make profound differences in form and function. The use of VSP allows the surgeon to improve accuracy and precision in areas where millimeters drastically impact outcomes. This review focuses on complex midface reconstruction requiring free tissue transfer and assesses the role of VSP in this patient population.

Virtual Surgical Planning and 3D-Printed Guided Biopsy of Bilateral Lesions in the Mandible: A Case Report

Purpose: To report the use of virtual surgical planning and a 3D printed drill guide for the biopsy of mandibular lesions. Case report: A 38-year-old woman presented with two bilateral lesions in the mandibular body, in close proximity to the inferior alveolar nerve and the molar roots. An incisional biopsy was planned with coDiagnostiX software using the cone beam computed tomography DICOM files and a cast model that had been digitalized using a bench scanner (7series, Dental Wings, Quebec, Canada). A tooth-supported drill guide was produced by 3D printing with digital light processing technology (Moonray S, Sprintray, CA, USA). The surgical procedure was performed under local anesthesia. No complications were observed intraoperatively or during postoperative recovery. Conclusion: The use of an intraoperative surgical 3D-printed drill guide enables a smaller surgical procedure and more precise bone biopsies.

Accuracy of custom temporomandibular joint replacement surgery using a virtual surgical planning protocol.

Accurate placement of TMJ implant components may be facilitated by virtual surgical planning (VSP) technologies. The aim of this study was to assess the accuracy of a typical VSP protocol and describe the pattern of surgical error associated with total alloplastic TMJ replacement. A retrospective analysis was undertaken on 40 adult patients who were implanted with a fully customised, 3D printed TMJ prosthesis due to end-stage TMJ disease. Planned TMJ implant position based on preoperative CBCT images was compared with final position on postoperative OPGs using a previously validated linear rescaling method. Translational discrepancy was described in the anterior-posterior direction and superior-inferior direction. Rotational discrepancy was described as anterior or posterior. Lin's concordance between preoperative and postoperative position was 0.97, with no significant differences (p > 0.05). The Bland-Altman analysis showed a 95% limit of agreement between planned and final position of - 5.9 to 5.4 mm. Overall, final implant position was more anterior (0.4 mm), superior (0.4 mm) and posteriorly rotated (2.4°) compared with planned position. The use of VSP in TMJ replacement surgery results in accurate implant placement with good agreement between planned and final implant position. Discrepancies in planned and final implant position tended to result in the mandibular component of the implant being translated anterior superiorly and rotated posteriorly, with potential implications for the biomechanical performance of the implant and overall device longevity. These results should be used to assist TMJ surgeons pre- and intraoperatively to facilitating accurate implant positioning and optimal surgical rehabilitation.

Virtual Planning for Exchange Cranioplasty in Cranial Vault Remodeling

The use of virtual surgical planning and computer-aided design/computer-aided manufacturing has gained popularity in the surgical correction of craniosynostosis. This study expands the use of virtual surgical planning and computer-aided design/computer-aided manufacturing in cranial vault reconstruction by using these methods to reconstruct the anterior vault using a single endocortically-plated unit constructed from the posterior calvarium. This technique was designed to reduce the risk of undesirable contour deformities that can occur when multiple bone grafts are used to reconstruct the anterior vault and fronto-orbital rim. Six patients were included in this study, all of which had nonsyndromic craniosynostosis. Excellent aesthetic outcomes were obtained in all patients, without complication. Additionally, the placement of a single reconstructive unit constructed from the posterior calvarium was efficient, aesthetically pleasing, and minimized postoperative contour deformities secondary to bone gaps, resorption, and often palpable resorbable plates.

Virtual surgical planning in mandibular reconstruction using scapular free flaps: a technical note

Indications for the scapular flap in head and neck reconstruction has been described previously.1 Use of virtual surgical planning (VSP) is increasing,2 leading to reduced operating time, greater accuracy, and improved aesthetic/functional outcomes.3 However, there are as yet no reports describing the use of VSP in scapular free flaps (based on the circumflex scapular vessels). Additionally, use of a ‘bone-only’ scapular flap has not, to our knowledge, been described previously. We describe the use of VSP in two cases in which scapular free flaps were used to reconstruct mandibular defects.

Scoping Zygomaticomaxillary Complex Fractures With the Eyes of Virtual Reality: Operative Protocol and Proposal of a Modernized Classification.

Fractures of the zygomaticomaxillary complex (ZMC) represent an extremely heterogeneous group of injuries to the midfacial skeleton. Traditionally, the diagnosis of such fractures was based on 2-dimensional radiograms and, more recently, on volumetric computed tomography (CT) scans, while the treatment was exclusively based on the surgeon's experience. Many classification attempts have been made in the past, but no paper has taken into account the importance of virtual surgical planning (VSP) in proving a modernized classification. The authors propose a classification based on the use of VSP which can guide the surgeon to identify the optimal reduction method and reproduce it in the operating room through the use of navigation. Patients with ZMC fractures were collected to create a study model. The VSP was used to generate 3-dimensional models of fractures. Fractured segments were duplicated and digitally put in the optimal reduction position. Repositioned fragments were overlapped to their original preoperative counterparts and exported to the surgical navigator to be navigated. Planned virtual reduction was overlaid to postoperative CT scan to assess the accuracy of reduction, explored using color maps and the calculation of root mean square error. For all patients, the application of VSP was successfully accomplished. High accuracy was confirmed between the planned virtual reduction and the postoperative CT scan. A 5-item classification based on VSP is proposed. All patients were included in the presented subclasses. The adoption of virtual planning in ZMC fractures allows for an improved study of the displacement of the fracture and might indicate to the surgeons the required maneuvers to achieve optimal reduction. The presented proposal of classification might be an aid to simplify the choice of the most appropriate reduction method and might provide a deeper insight into the morphologic characteristics of fractures.

Reconstruction of a Hemirhinectomy Defect Using a Three-Dimensional Printed Custom Soft Tissue Cutting Guide.

The 3-stage paramedian forehead flap is the gold standard for subtotal and complete nasal defects, but significant surgeon artistry and experience are required to achieve good, consistent results. The authors describe the use of virtual surgical planning and three-dimensional printing to create a patient-specific soft tissue cutting guide for the design of a forehead flap in the reconstruction of a hemirhinectomy defect. Application of this technology to these challenging reconstructive scenarios promises to improve accessibility and consistency of results.

Trends in Utilization of Virtual Surgical Planning in Pediatric Craniofacial Surgery.

While the use of virtual surgical planning (VSP) has been well described in the adult craniofacial literature, there has been little written about pediatric uses or trends. The purpose of this study is to evaluate the evolving utilization of VSP for pediatric craniofacial procedures. The authors' prospective institutional review board-approved craniofacial registry was queried for index craniofacial procedures from January 2011 through December 2018. Data was collected regarding utilization of traditional surgical planning versus VSP, as well as the extent of VSP's influence on the operative procedure. These data were analyzed for trends over time and compared using appropriate statistics. During the study period, a total of 1131 index craniofacial cases were performed, of which 160 cases (14.1%) utilized VSP. Utilization of VSP collectively increased over time, from 2.0% in 2011 to 18.6% in 2018 (P < 0.001). Utilization rates of VSP varied across procedures from 0% of craniosynostosis cases and fronto-orbital advancement cases to 67% of osteocutaneous free tissue transfers (P < 0.001). The most profound contributor to increase in VSP utilization was orthognathic surgery, utilized in 0% of orthognathic procedures in 2011 to 68.3% of orthognathic procedures in 2018 (P < 0.001). Utilization of virtual surgical planning for pediatric craniofacial procedures is increasing, especially for complex orthognathic procedures and osteocutaneous free tissue transfers. Utilization patterns of individual components of the VSP system demonstrate unique footprints across the spectrum of craniofacial procedures, which reinforces the specific and variable benefits of this workflow for treating pediatric craniofacial disorders.

Protocol for fully digital and customized management of concomitant temporomandibular joint replacement and orthognathic surgery

End-stage temporomandibular joint (TMJ) disease is caused by a multitude of pathological processes that impair TMJ anatomy and function. In many cases, end-stage TMJ disease and dentofacial skeletal deformities coexist. The optimal treatment for such conditions is total alloplastic joint replacement and orthognathic surgery. Such procedures have historically been conducted in two separate stages. Furthermore, while technological improvements resulting from the widespread adoption of virtual reality initially led to significant improvements in the field of orthognathic planning, the adoption of virtual design techniques to optimize TMJ reconstruction was a later achievement. Therefore, planning for TMJ replacement and orthognathic surgery did not develop in parallel, leading to various combinations of planning for orthognathic surgery and TMJ replacement with the aim of performing both procedures simultaneously in one stage. Nowadays, improvements in virtual planning and three-dimensional printing have allowed these procedures to be conducted in the same surgical step based on fully digital planning and entirely customized surgery. This paper introduces a fully digital protocol for the treatment of end-stage TMJ disease and associated acquired dentofacial deformities, in which all surgical steps are customized and the whole surgery is performed in succession using automated procedures, thanks to the combined use of virtual surgical planning, surgical guides, custom-designed TMJ prostheses, and patient-fitted osteosynthesis devices.