The use of navigation (BrainLAB Vector vision(2)) and intraoperative 3D imaging system (Siemens Arcadis Orbic 3D) in the treatment of gunshot wounds of the maxillofacial region

Analysis of the implementation of a circuit for intra-operative superposition and comparison of the surgical outcomes using ICBCT in maxillofacial surgery

PURPOSE

This paper describes a novel circuit for intraoperative analysis with ICBCT in maxillofacial surgery. The aim is to establish guidelines, define indications, and conduct an analysis of the implementation of the circuit for intraoperative comparison of surgical outcomes in relation to 3D virtual planning in maxillofacial surgery.

METHODS

The study included 150 maxillofacial surgical procedures. Intraoperative actions involved fluoroscopy localization, intraoperative CBCT acquisition, segmentation, and superimposition, among other steps. Surgical times due to intraoperative superposition were measured, including time required for ICBCT positioning and acquisition, image segmentation, and comparison of 3D surfaces from the surgical planning.

RESULTS

Successful intraoperative comparison was achieved in all 150 cases, enabling surgeons to detect and address modifications before concluding the surgery. Out of the total, 26 patients (17.33%) required intraoperative revisions, with 11 cases (7.33%) needing major surgical revisions. On average, the additional surgical time with this circuit implementation was 10.66 ± 3.03 min (n = 22).

CONCLUSION

The results of our research demonstrate the potential for performing intraoperative surgical revision, allowing for immediate evaluation, enhancing surgical outcomes, and reducing the need for re-interventions.

Use of intraoperative 3D imaging in the maxillofacial operating room: A French national survey

PURPOSE

To gain a comprehensive understanding of the utilization of intraoperative 3D imaging among maxillofacial surgeons practicing in France through a web-based questionnaire.

METHODS

An 18-point multiple-choice questionnaire was developed and distributed to participants. The questionnaire was divided into two sections, with the first section gathering general information about the respondents and the second section providing an overview of the utilization of 3D imaging techniques, such as cone-beam computed tomography (CBCT), computed tomography (CT) scan, and magnetic resonance imaging (MRI), including the conditions, frequencies, and indications for use, with a particular focus on the number of acquisitions per procedure and the other departments with whom the equipment is shared.

RESULTS

A total of 75 participants completed the survey, with 30% of university hospital departments and 0% of private clinics currently utilizing intraoperative 3D imaging systems. The main indications for 50% of the users were for temporomandibular joint surgery and orbital fractures.

CONCLUSION

The results of this survey indicate that the utilization of intraoperative 3D imaging in French maxillofacial surgery is limited to university centers, with poor utilization and a lack of standardization in indications for use.

Computer-assisted navigation in oral and maxillofacial surgery: A systematic review

Background

The term "navigation" describes a device that can pinpoint critical anatomical features, the most direct path to the target, and the optimal surgical orientation. This study aimed to conduct a comprehensive literature search on computer-assisted navigation for use in oral and maxillofacial surgery.

Methods

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, relevant studies were retrieved from five electronic databases: Medline, Web of Science, PubMed, Google Scholar, and Saudi Digital Library (SDL). The central question was, "Does the computer-assisted navigation system improve the outcome of surgical procedures in the oral and maxillofacial region?" The Cochrane Risk of Bias 2 was used to determine the various types of bias.

Results

Post-traumatic midfacial reconstruction is one of the many fields that have benefited from the use of computer-assisted navigation because of its reliability. It can also be used to extricate difficult foreign entities from the operative zone. Locating critical anatomical components, communicating the surgical plan to the patient, and verifying surgical success can improve the function and appearance of patients with dentofacial abnormalities. In addition, it decreases the surgical error margin and duration.

Conclusion

Computer-assisted navigation is promising in surgical practice. The accuracy of surgery can be significantly enhanced by first planning the process in a virtual environment and then performing it under close supervision in real time. In addition, the time required for preoperative planning and surgery can be reduced by creating and improving software programs.

The Application of Cone Beam Computed Tomography (CBCT) on the Diagnosis and Management of Maxillofacial Trauma

The assessment and management of facial trauma in an acute setting is one of the core services provided by oral and maxillofacial units in the United Kingdom. Imaging is a pre-requisite for appropriate diagnosis and treatment planning, with a combination of plain radiographs and medical-grade CT being the mainstay. However, the emergence of cone beam CT in recent years has led to its wider applications, including facial trauma assessment. It can offer multi-planar reformats and three-dimensional reconstruction at a much lower radiation dose and financial cost than conventional CT. The purpose of this review is to appraise its potential indications in all anatomical areas of maxillofacial trauma and provide our experience at a level 1 trauma centre.

The Use of Dynamic Navigation Systems as a Component of Digital Dentistry

The development of dynamic navigation system (DNS) has facilitated the development of modern digital medicine. In the field of dentistry, the cutting-edge technology is garnering widespread recognition. Based on the principles of 3-dimensional visualization, virtual design, and precise motion tracking, DNS is mainly composed of a computer, a tracking system, specialized tracer instruments, and navigation software. DNS employs a workflow that begins with preoperative data acquisition and imaging data reconstruction, followed by surgical instrument calibration and spatial registration, culminating in real-time guided operations. Currently, the system has been applied in a broad spectrum of dental procedures, encompassing dental implants, oral and maxillofacial surgery (such as tooth extraction, the treatment of maxillofacial fractures, tumors, and foreign bodies, orthognathic surgery, and temporomandibular joint ankylosis surgery), intraosseous anesthesia, and endodontic treatment (including root canal therapy and endodontic surgery). These applications benefit from its enhancements in direct visualization, treatment precision, efficiency, safety, and procedural adaptability. However, the adoption of DNS is not without substantial upfront costs, required comprehensive training, additional preparatory time, and increased radiation exposure. Despite challenges, the ongoing advancements in DNS are poised to broaden its utility and substantially strengthen digital dentistry.

Image-guided surgery in otolaryngology: A review of current applications and future directions in head and neck surgery

Image-guided surgery (IGS) has become a widely adopted technology in otolaryngology. Since its introduction nearly three decades ago, IGS technology has developed rapidly and improved real-time intraoperative visualization for a diverse array of clinical indications. As usability, accessibility, and clinical experiences with IGS increase, its potential applications as an adjunct in many surgical procedures continue to expand. Here, we describe the basic components of IGS and review both the current state and future directions of IGS in otolaryngology, with attention to current challenges to its application in surgery of the nonrigid upper aerodigestive tract.

New Solutions to Improve the Accuracy of the Navigation-Guided Foreign Body Removal in Craniomaxillofacial Deep Space

OBJECTIVE

Surgical navigation-guided removal of foreign bodies in the craniomaxillofacial region has been proven to be an effective method. However, there have been some unsuccessful patients due to reduced navigation accuracy or complicated and undetectable anatomy. This article summarizes the experience and proposes some solutions to achieve better results.

STUDY DESIGN

Two solutions were proposed to optimize the surgical navigation procedure: using a 3-dimensionally printed customized mandible retainer to indirectly maintain the consistency of the foreign body's visual images of preoperative planning and intraoperative navigation and importing real-time endoscopic imaging during surgery to provide vision under complex anatomy. Two patients were selected for each method.

RESULTS

The foreign bodies were successfully and minimally invasively removed in all patients assisted by optimized surgical navigation. During follow-up at 3 to 6 months postoperatively, no complications were found.

CONCLUSION

Improving navigation accuracy and providing real vision might be effective at compensating for insufficient navigation due to navigation positioning errors or the interference of imperceptible and complicated anatomy.

How useful is intraoperative cone beam computed tomography in maxillofacial surgery? An overview of the current literature

Intraoperative imaging is increasingly used by surgeons and has become an integral part of many surgical procedures. This study was performed to provide an overview of the current literature on the intraoperative use of cone beam computed tomography (CBCT) imaging in maxillofacial surgery. A bibliographic search of PubMed was conducted in March 2020, without time limitation, using "intraoperative imaging" AND "maxillofacial surgery" AND "cone beam computed tomography" as key words. Ninety-one articles were found; after complete reading, 16 articles met the eligibility criteria and were analysed. The results showed that the majority of the indications were related to maxillofacial trauma, particularly zygomaticomaxillary complex fractures. Final verification with intraoperative CBCT before wound closure was the most common use of this device. However, innovative uses of intraoperative CBCT are expanding, such as CBCT coupling with mirror computational planning, and even the combined use of initial intraoperative CBCT acquisition with navigation. Immediate, fast, and easy evaluation of bone repositioning to avoid the need for further surgical revision is the main advantage of this technique. Imaging quality is comparable to that of multi-slice computed tomography, but with lower radiation exposure. Nevertheless, CBCT is still not widely available in maxillofacial centres, probably because of its cost, and perhaps because not everyone is aware of its advantages and versatility, which are reported in this review.

Application of Computer-Aided Navigation Technology in the Extraction of Foreign Body From the Face

In the oral and maxillofacial foreign body (FB) extraction surgery, computer-aided navigation technical surgery is minimally invasive and safe, and can improve the accuracy, especially for areas with relatively complex and dangerous anatomical structures. A total of 11 patients, including 8 males and 3 females, who underwent the extraction surgery of FB from oral and maxillofacial regions using computer-aided navigation technical surgery were reviewed. According to the positional relationship between the maxillofacial region and the bone tissue, the FBs were divided into 3 categories: FB in the bone; FB aside the bone; and soft-tissue FB. During the operation, the BrainLab Navigation system was used to observe and guide the operation in real-time to evaluate the effectiveness and accuracy of computer-aided navigation technical surgery in the extraction of FBs from the maxillofacial regions. The FBs were successfully located and removed in 11 patients. No adjacent nerves, blood vessels, and other important anatomical structures were injured during the operation. The postoperative function and shape were not significantly affected.

Effect of Navigation System on Removal of Foreign Bodies in Head and Neck Surgery

Foreign bodies retained in oral and maxillofacial regions include different types and properties. Road traffic accident is one of the major causes of the maxillofacial trauma. Foreign bodies can cause direct or indirect damage to the body, even life-threatening. It is a demanding procedure to detect the accurate position and implement surgical removal of the embedded fragments in the soft tissue in clinic.Usually, foreign bodies are close to important structures such as the head and neck region with limited intraoperative visibility and anatomical intricacies. Therefore, the key to remove foreign bodies in head and neck surgery is precise localization and reasonable surgical approaches. The authors reported that the foreign bodies adjacent to large vessels in a case were successfully removed assisted by AccuNavi-A surgical navigation system.

Surgery Navigation in Treating Congenital Midfacial Dysplasia of Patients With Facial Cleft

AIM

To explore a new accurate way for the treatment of congenital midfacial dysplasia in facial cleft patients.

MATERIALS AND METHODS

Between November 2015 and November 2016, 8 patients with nasal deformity and midfacial dysplasia (Tessier Nos. 3-11 cleft) were collected (median age, years; range = 15-20 years). Expanded frontal flap for nasal reconstruction and image-guided navigation-assisted surgery for modified nasal-maxillary-hard palatine osteotomy to advance the peri-pyriform bone structure were performed in all the patients. After 6 to 12 months of follow-up, the authors analyzed the differences between preoperative planning and postoperative results through computed tomography data.

RESULTS

Patients were satisfied with surgery, and computed tomography data showed that there was little difference between preoperative planning and postoperative results with the navigation-assisted surgery.

CONCLUSION

Using expanded frontal flap with navigation-assisted surgery for peri-pyriform advancement, the authors could treat congenital nasal deformity and midfacial dysplasia effectively, accurately, and safely in craniofacial cleft patients.

Surgical Navigation: A Systematic Review of Indications, Treatments, and Outcomes in Oral and Maxillofacial Surgery

PURPOSE

This systematic review investigates the most common indications, treatments, and outcomes of surgical navigation (SN) published from 2010 to 2015. The evolution of SN and its application in oral and maxillofacial surgery have rapidly developed over recent years, and therapeutic indications are discussed.

MATERIALS AND METHODS

A systematic search in relevant electronic databases, journals, and bibliographies of the included articles was carried out. Clinical studies with 5 or more patients published between 2010 and 2015 were included. Traumatology, orthognathic surgery, cancer and reconstruction surgery, skull-base surgery, and foreign body removal were the areas of interests.

RESULTS

The search generated 13 articles dealing with traumatology; 5, 6, 2, and 0 studies were found that dealt with the topics of orthognathic surgery, cancer and reconstruction surgery, skull-base surgery, and foreign body removal, respectively. The average technical system accuracy and intraoperative precision reported were less than 1 mm and 1 to 2 mm, respectively. In general, SN is reported to be a useful tool for surgical planning, execution, evaluation, and research. The largest numbers of studies and patients were identified in the field of traumatology. Treatment of complex orbital fractures was considerably improved by the use of SN compared with traditionally treated control groups.

CONCLUSIONS

SN seems to be a very promising addition to the surgical toolkit. Planning details of the surgical procedure in a 3-dimensional virtual environment and execution with real-time guidance can significantly improve precision. Among factors to be considered are the financial investments necessary and the learning curve.

Implementation of a miniaturised navigation system in head and neck surgery for the detection and removal of foreign bodies

The removal of embedded blast-generated fragments from soft tissue is very difficult, especially in the head and neck regions. First, because many retained foreign materials are non-metallic and can, therefore, not be detected by fluoroscopy, and second, because a broad exploration of the soft tissue is not possible in the facial area for functional and cosmetic reasons. Intraoperative navigation computer-assisted surgery (CAS) may facilitate the retrieval of foreign bodies and reduce exploration trauma. In a blind trial, five test specimens of different materials (glass, metal, wood, plastic, and stone) were inserted on the left and right sides of the head and neck of ten body donors through an intraoral incision. A second physician then detected and removed the foreign bodies from one side of the body without and from the other side of the body with navigation. We measured the duration of surgery, the extent of tissue trauma caused during surgery, the time it took to remove the foreign bodies, and the subjective evaluation of the usefulness of navigation. With the aid of the navigation system, the various foreign bodies were detected after an average of 26.7 (±35.1) s (p < 0.0001) and removed after an average of 79.1 (±66.2) s (p = 0.0239), with an average incision length of 10.0 (±3.5) mm. Without the navigation system, the foreign bodies were located after an average of 86.5 (±77.7) s and removed after an average of 74.1 (±45.9) s, with an average incision length of 13.0 mm (±3.6) mm (=0.0007). Intraoperative navigation systems are a valuable tool for removing foreign bodies from the soft tissue of the face and neck. Both the duration of surgery and the incision length can be reduced using navigation systems. Depending on the material of the foreign bodies and the signal intensity in the CT/MRI scanner, however, the detection reliability varies. All in all, navigation is considered to be a useful tool.

Using methylene blue as a marker to find and remove tiny metallic foreign bodies embedded in the soft tissues of children: A randomised controlled trial

BACKGROUND

Embedment of metallic foreign bodies in the soft tissues is commonly encountered in the emergency room. Most foreign bodies are easily removed, but removal is difficult if the foreign body is very small or deeply embedded.

OBJECTIVE

To determine the usefulness of methylene blue staining in the surgical removal of tiny metallic foreign bodies embedded in the soft tissue.

METHODS

This prospective study involved 41 children treated between May 2007 and May 2012. The patients were randomly divided into a methylene blue group and a control group. In the control group, foreign bodies were located using a C-arm and removed via direct incision. In the methylene blue group, foreign bodies were located using a C-arm, marked with an injection of methylene blue and then removed surgically. The clinical outcomes, complications, operation time, surgical success rate, incision length, frequency of C-arm use, and length and depth of the foreign body were compared between the two groups.

RESULTS

The surgical success rate was significantly higher in the methylene blue group. The average operation time was significantly shorter in the methylene blue group. The C-arm was used significantly less frequently in the methylene blue group than in the control group. The incision length was significantly shorter in the methylene blue group than in the control group.

CONCLUSIONS

Methylene blue staining facilitated the location and removal of tiny metallic foreign bodies from the soft tissue, and significantly reduced operation time, incision length and radiation exposure compared to the conventional method.

Application of a real-time three-dimensional navigation system to various oral and maxillofacial surgical procedures

The aim of this study was to confirm the effectiveness of a real-time three-dimensional navigation system for use during various oral and maxillofacial surgeries. Five surgeries were performed with this real-time three-dimensional navigation system. For mandibular surgery, patients wore acrylic surgical splints when they underwent computed tomography examinations and the operation to maintain the mandibular position. The incidence of complications during and after surgery was assessed. No connection with the nasal cavity or maxillary sinus was observed at the maxilla during the operation. The inferior alveolar nerve was not injured directly, and any paresthesia around the lower lip and mental region had disappeared within several days after the surgery. In both maxillary and mandibular cases, there was no abnormal hemorrhage during or after the operation. Real-time three-dimensional computer-navigated surgery allows minimally invasive, safe procedures to be performed with precision. It results in minimal complications and early recovery.

Pedicle screw navigation: a systematic review and meta-analysis of perforation risk for computer-navigated versus freehand insertion

Object

In this paper the authors' goal was to compare the accuracy of computer-navigated pedicle screw insertion with nonnavigated techniques in the published literature.

Methods

The authors performed a systematic literature review using the National Center for Biotechnology Information Database (PubMed/MEDLINE) using the Medical Subject Headings (MeSH) terms “Neuronavigation,” “Therapy, computer assisted,” and “Stereotaxic techniques,” and the text word “pedicle.” Included in the meta-analysis were randomized control trials or patient cohort series, all of which compared computer-navigated spine surgery (CNSS) and nonassisted pedicle screw insertions. The primary end point was pedicle perforation, while the secondary end points were operative time, blood loss, and complications.

Results

Twenty studies were included for analysis; of which there were 18 cohort studies and 2 randomized controlled trials published between 2000 and 2011. Foreign-language papers were translated. The total number of screws included was 8539 (4814 navigated and 3725 nonnavigated). The most common indications for surgery were degenerative disease, spinal deformity, myelopathy, tumor, and trauma. Navigational methods were primarily based on CT imaging. All regions of the spine were represented. The relative risk for pedicle screw perforation was determined to be 0.39 (p < 0.001), favoring navigation. The overall pedicle screw perforation risk for navigation was 6%, while the overall pedicle screw perforation risk was 15% for conventional insertion. No related neurological complications were reported with navigated insertion (4814 screws total); there were 3 neurological complications in the nonnavigated group (3725 screws total). Furthermore, the meta-analysis did not reveal a significant difference in total operative time and estimated blood loss when comparing the 2 modalities.

Conclusions

There is a significantly lower risk of pedicle perforation for navigated screw insertion compared with nonnavigated insertion for all spinal regions.

Application of intraoperative computed tomography with or without navigation system in surgical correction of spinal deformity: a preliminary result of 59 consecutive human cases

STUDY DESIGN

A retrospective analysis of patients undergoing spinal deformity correction surgery by the assistance of intraoperative computed tomography (iCT) with or without navigation system.

OBJECTIVE

To share our preliminary experience and analysis of the iCT navigation system applied to spinal deformity surgery.

SUMMARY OF BACKGROUND DATA

The iCT navigation system has been shown to improve accuracy and safety in posterior instrumentation. It not only decreased the operation time but also prevented excessive radiation exposure to the medical staff. To date, there are only few reports about the application of the iCT navigation system in spinal deformity surgery.

METHODS

From April 2009 to September 2010, 59 patients who had a diagnosis of scoliosis, kyphosis, or scoliokyphosis and underwent iCT-assisted surgical correction were included. Without randomization, 28 patients were operated with the iCT-navigation system, and the other 31 patients were operated with standard procedure under iCT assistance. The detailed procedures, preoperative and intraoperative images were illustrated. The accuracy of screw placement, time for screw insertion, postoperative correction rate, and iCT scanning data were analyzed.

RESULTS

There were significant differences between 2 groups in (1) the preoperative Cobb angle (76.2° and 62.6° in the navigation and non-navigation groups), (2) the accuracy and the revision rate of thoracic pedicle screws and total pedicle screws, and (3) the average screw insertion time. The breach rate and the revision rate of thoracic pedicle screws and total pedicle screws were significantly lower and the average screw insertion time was significantly lesser in the navigation group than in the non-navigation group. There were no statistically significant difference in (1) the breach rate and the revision rate of lumbar pedicle screws, (2) the mean iCT scanning time and time-out, (3) the mean number of fusion segments, (4) the mean number of iCT scans, and (5) the postoperative correction rate. Complications were encountered in 2 patients in the non-navigation group but none in the navigation group. There was no reoperation due to implant malposition in both groups.

CONCLUSION

The iCT navigation system provides desirable accuracy of posterior spinal instrumentation for patients during surgical correction of spinal deformity without radiation exposure to the medical staff, especially in thoracic spine instrumentation. Meanwhile, the iCT in itself is an effective means of assessing complex instrumentation of the spinal deformity.