Interdisciplinary Surgical Management of Multiple Facial Fractures With Image-Guided Navigation

doi:10.1016/j.joms.2015.03.029

Journal of Oral and Maxillofacial Surgery

Volume 73, Issue 9, September 2015, Pages 1767-1777

https://doi.org/10.1016/j.joms.2015.03.029 Get rights and content

Purpose

To evaluate the effectiveness of interdisciplinary surgical management of multiple facial fractures with image-guided surgical navigation.

Patients and Methods

From 2011 through 2014, 36 patients with multiple facial fractures were enrolled in the study. With individual virtual 3-dimensional (3D) modeling, interdisciplinary planning and surgical simulation were carried out on an Accu-Navi software platform. Through an interactive collaboration among specialists, all patients underwent 1-stage open reduction under guidance of the navigation system. The outcome was assessed by superimposing the postoperative 3D computed tomographic (CT) model on the preoperative plan and clinical examination.

Results

Through the registration procedure, an accurate match between the actual intraoperative position and the CT images was achieved within a systematic error of 1 mm. The fractured bone segments were released and repositioned according to the preoperative plan and simulation with the aid of instrument- and probe-based navigation. All patients underwent uneventful healing without serious complications. Postoperative assessment of surgical intervention showed a quantitative discrepancy less than 2 mm (1.49 ± 0.27), showing a satisfactory concordance.

Conclusion

In the interdisciplinary surgical management of multiple facial fractures, image-guided surgical navigation, including preoperative planning, surgical simulation, postoperative assessment, and computer-assisted navigation, proved an optimal strategy and valuable option for this potentially complicated procedure.

Section snippets

Patients and Study Design

Thirty-six patients (30 men and 6 women) presenting with multiple facial fractures were admitted to the Department of Oral and Craniomaxillofacial Science, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China, from July 2011 through December 2014. Their ages ranged from 17 to 64 years (average age, 44.1 yr), and the patients had a history of trauma 7 days to 17 years before surgical interventions. Patients' clinical characteristics are presented in Table 1.

Results

All patients were treated with image-guided surgical navigation, including interdisciplinary preoperative planning and surgical simulation. The accuracy of the navigation system, including the accuracy of 3D modeling, registration accuracy, and tracking accuracy, was within 1 mm, as verified by repetitive pinpointing of the anatomic landmarks during the intraoperative navigation procedure. Intraoperative instrument- and probe-based navigation was used initially to maneuver the fractured bone

Discussion

Multiple facial fractures are generally defined as fractures that simultaneously involve the upper, middle, and lower face.² This kind of trauma is often associated with emergency conditions, such as craniocerebral and cervical spinal injuries.¹² Moreover, their high-energy injury patterns typically involve multiple hard and soft tissues with disruption of tendons, ducts, and motor nerves that can lead to severe post-traumatic deformities and functional impairments.² Although treatment of

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Application of real-time surgical navigation for zygomatic fracture reduction and fixation
2022, Journal of Plastic, Reconstructive and Aesthetic Surgery
Citation Excerpt :
Kim et al. use the navigation system in patients with multiple facial fractures and assessed the outcome by superimposing the 3D CT model. They found the quantitative discrepancy was less than 2 mm (1.49 ± 0.27), which was similar to our result21. Yang et al. reported that with navigation, the mean total displacement of zygomatic sutures could be significantly decreased to 0.53 mm, particularly the zygomaticosphenoid suture, which showed almost no gap postoperatively22.
Inappropriate treatment of zygomatic fractures can reduce esthetic and functional outcomes. The aim of this study was to answer the research question: "Among patients with a unilateral zygomatic fracture, is the use of computer-assisted real-time navigation system during fracture reduction precise and accurate to create postoperative facial symmetry?”
Using a retrospective cohort study design, we enrolled a cohort of unilateral zygomatic fractures undergoing open reduction and internal fixation (ORIF) with the aid of the computer-based navigation system at Chang Gung Memorial Hospital, Taiwan, during January 2015 and March 2018. The predictor variable was the comparison before and after surgery. The main outcome variables included (1) two-dimensional (2D) reduction of the displacement at five anatomical landmarks: zygomaticofrontal, inferior orbital rim, zygomaticosphenoidal, zygomaticomaxillary, and zygomaticotemporal lines/buttresses and (2) three-dimensional (3D) differences on distances between zygomatic surface to the porion plane and the midpoint of zygomatic arch (ZA) to the mid-porion (MP) plane. The Wilcoxon signed-rank test was computed to compare between pre- and postoperative data, and a p-value less than 0.05 was considered statistically significant.
The cohort comprised 24 subjects (50% females, 75% left-sided) with a mean age of 30.5 +/- 13.8 years. On 2D analysis, the significant fracture reduction was found: 4.78 vs. 1.22 mm, 1.78 vs. 0.40 mm, 3.50 vs. 0.07 mm, 3.06 vs. 0.55 mm, and 2.55 vs. 0.50 mm at zygomaticomaxillary, zygomaticofrontal, inferior orbital rim, zygomaticosphenoidal, and zygomaticotemporal landmarks. The 3D evaluations revealed the significant reduction of the differences between the left and right zygomatic surface to the porion plane (4.09 ± 2.12 vs. 0.46 ± 0.35 mm) and between the left and right ZA midpoints to the MP plane (4.89 ± 2.59 vs. 0.71 ± 0.44 mm) (p<0.001 for both 2D and 3D analyses).
The results of this study suggest that the real-time surgical navigation system can effectively guide the ORIF of zygomatic fractures. Future research studies should focus on the learning curve and cost-effectiveness analysis of this technique.
Surgical Navigation for Oral and Maxillofacial Surgery
2019, Oral and Maxillofacial Surgery Clinics of North America
Citation Excerpt :
This will instantaneously demonstrate proper reduction without the need to obtain a postoperative CT scan and without additional radiation exposure to the patient. Such utility, as shown by Kim and colleagues,4 showed a less than 2 mm discrepancy in 36 patients with multiple facial fractures treated with virtual surgical planning and surgical navigation. When integrated with VSP, intraoperative navigation is therefore superior to intraoperative CT scanning for the evaluation of proper fracture reduction or implant positioning.
Use of Virtual Surgical Planning and Virtual Dataset With Intraoperative Navigation to Guide Revision of Complex Facial Fractures: A Case Report
2019, Journal of Oral and Maxillofacial Surgery
The use of intraoperative navigation has become prevalent in multiple surgical fields, including neurosurgery, orthopedic surgery, spine surgery, and head and neck surgery. In the past decade, its use also has become popular in oral and maxillofacial surgery. Previous studies have suggested the use of intraoperative navigation improves surgical precision and accuracy and decreases intraoperative risks and postsurgical morbidity. This report presents a case in which intraoperative navigation was used for revision and secondary reconstruction of multiple facial fractures. Preoperative virtual surgical planning allowed customization of osteotomies of multiple bony segments and virtual reduction of these segments to their anatomically correct position. Then, the newly reconstructed 3-dimensional virtual computed tomographic dataset was used as a template in the navigation system to guide the osteotomies and precisely reposition bony fragments during surgery. This report describes the workflow necessary to use this technology.
Development of a novel anatomical thin titanium mesh plate with reduction guidance and fixation function for Asian zygomatic-orbitomaxillary complex fracture
2018, Journal of Cranio-Maxillofacial Surgery
Citation Excerpt :
Computer-assisted techniques have already helped many surgeons perform accurate preoperative simulations that provide ideal 3-dimensional (3D) surgical simulation plans. However, favorable results have been difficult to achieve because of inaccurate translation of these computer-based images into real-world surgical outcomes (Schramm et al., 2009; Kim et al., 2015). While Thomas et al. applied a computer-generated stereolithographic (STL) guiding template to assist screw pre-drilling for fracture reduction, the effectiveness of this solution needs to improve because the essential guiding template cannot be applied over the whole course of surgery (Li et al., 2011; Schouman et al., 2015).
For this study we developed an anatomical thin titanium mesh (ATTM) plate for Asian zygomaticomaxillary complex (ZMC) fracture repair with reduction guidance and fixation function. The ATTM plate profile was designed as an L-shape to fix at the anterior maxilla and lateral buttress of the ZMC. Computer-aided stamping analysis was performed on four screw-hole patterns in the ATTM plate — a control without screw-holes, square screw-holes, double screw-holes, and large-diameter, double screw-holes — using upper/lower dies of averaged ZMC reconstruction models. A regular ATTM plate of 0.6 mm thickness was manufactured and pre-bent using a patient-matched stamping process to verify its feasibility on three ZMC fracture models with one, two, and three fracture segments. The stamping analysis found that the double screw-holes design resulted in the most favorable performance among all the designs because of maximum von Mises stress (408 MPa) under the ultimate tensile strength. Positioning practice showed that the stamped, pre-bent ATTM plate can be used as a reduction guide to provide precise ZMC segment fixation in a completely passive fashion while limiting redundant rotation/micromovement between the separate bones in all directions.
This study concluded that the ATTM plate with double screw-hole pattern design, using a patient-matched, pre-bent technique, can fit the ATTM plate/ZMC interface well, decrease mobility of unstable fracture segments, and provide good original facial contour recovery, while improving reduction efficiency.
Introduction of Digital-Assisted Multidisciplinary Treatment in the Functional and Morphological Reconstruction of Naso-Orbital-Ethmoid Fractures
2022, Journal of Craniofacial Surgery
Three-Dimensional Printed Customized Surgical Guides for the Precise Correction of Complex Midfacial Post-Traumatic Deformities
2022, Journal of Craniofacial Surgery

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: Drs JW Kim and JY Wu contributed equally to this study.

: This research was supported by the International Research and Development Program of the National Research Foundation of Korea funded by the Republic of Korea and the Chinese Science and Technology Exchange Center, Ministry of Science and Technology in China; the Intramural Research Funds of Ewha Womans University School of Medicine, Seoul, Korea (1-2014-0643-001-1); the National Natural Science Foundation of China (81371193); and the Project from the Shanghai Key Laboratory of Medical Imaging Computing and Computer Assisted Intervention (13DZ2272200-4).

: Conflict of Interest Disclosures: None of the authors reported any disclosures.

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Craniomaxillofacial traumaInterdisciplinary Surgical Management of Multiple Facial Fractures With Image-Guided Navigation

Purpose

Patients and Methods

Results

Conclusion

Section snippets

Patients and Study Design

Results

Discussion

J Craniomaxillofac Surg

Oral Maxillofac Surg Clin North Am

Br J Oral Maxillofac Surg

Int J Oral Maxillofac Surg

Injury

J Oral Maxillofac Surg

Int J Oral Maxillofac Surg

J Craniomaxillofac Surg

J Craniomaxillofac Surg

J Oral Maxillofac Surg

Br J Oral Maxillofac Surg

Craniomaxillofacial trauma
Interdisciplinary Surgical Management of Multiple Facial Fractures With Image-Guided Navigation