Assessment goals of perfect anatomical reduction, complete stable fixation

Assessment
of Virtual Surgical Planning Applications in the Management of Mandibular
Fractures

 

A protocol submitted in partial
fulfillment of the requirements for

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Doctoral Degree in Oral and
Maxillofacial Surgery,

Faculty of Dentistry, Ain-Shams
University

Submitted by

Akram Zakaria Ahmed Abdelaal

B.D.S. – Mansoura University 2001

MSC – Al-Azhar University (Cairo Branch) 2007

 

Supervisors

Salah Abd Elfatah Ahmed

Professor and chairman of Oral and Maxillofacial surgery department

Faculty of Dentistry – Ain Shams University

Karim
Mohamed AbdelMohsen

Lecturer of Oral and Maxillofacial surgery

Faculty of Dentistry – Ain Shams University

 

Faculty of Dentistry,

 Ain Shams University  

2018

 

 

Introduction
and review of literature:

 

   Maxillofacial trauma is a chief reason of universal
mortality and morbidity.(1, 2) It is a common incidence in Egypt and is associated
with high incidence of facial fractures. Mandibular fractures exist as one of
the most frequent facial fractures.(3-5)

    The mandible is the second most frequent
facial fracture, with the nasal bone fracture being the first.(6, 7) The purpose of mandibular fracture reduction is to
restore occlusion, permitting patients to restore masticatory functions. Before
repair, patients must be carefully examined.(8, 9)

  Some of the most severe injuries are by road
traffic accidents (RTA)   but others
result from interpersonal violence, industrial accidents, sports, missiles home
accidents and or gun shots.(10) RTA have been reported as a principal cause of mandible
fractures in many third world countries while interpersonal altercations are
mostly accountable in the developed countries.(11-15)

     Fractures of the mandible cause both
functional and social disabilities in addition to cosmetic morbidities. The aim
of treatment is the restoration of anatomical form and function, with
particular care to restore the occlusion.    
The perfect technique of treatment of mandibular fracture should have
the goals of perfect anatomical reduction, complete stable fixation and
painless mobilization of the injured region around its articulation (16-20)

   Traditionally, the jaws were immobilized using a variety of
techniques. At present open reduction and internal fixation (ORIF) is the mainstay
of treatment and is achieved with different plating systems. It has eliminated
the need for maxilla-mandibular fixation (MMF) and facilitates stable anatomic
reduction while reducing the risk of post-operative displacement of fractured
fragments, and permitting immediate return to the function.(21, 22)

       With the
occurrence of stereolithographic models by computer aided design (CAD) /
computer aided modeling (CAM) or 3D printing technology, the surgeons become
able to plan the fractured bone reduction and to bend and adapt the mini-plates
preoperative away from operating room.(23, 24) However, the introduction of virtual surgical
planning in the last few years developed a new era of highly precise and
accurate surgeries.(25-28)

     Virtual surgical planning using
preoperative computed tomographic (CT) data which is rendered 3D model to be
processed for digitalized simulation of bone reduction and transferred to the
operating room in the form of templates and guides to be applied as the
planned, and so it ensures high reproducibility of the virtually planned
surgery clinically, reducing the side errors, besides its time saving advantage
for both the operator and the patient.(26-30)

    An organized review examined methodically
158 articles published between 2005 and 2015, focused on 3D printing
applications in surgery and they established the reality that the main
advantages of this technology are the potential of preoperative planning
(48.7%), the precision of the process used (33.5%), and the reduction of the operating
time (32.9%).(31)

    Despite the presence of lots of studies
assessing the accuracy of virtual planning in the fields of orthognathic and reconstructive
surgeries, which is not the case considering maxillofacial trauma. , many authors hypothesized that virtual surgical planning
would offer increased surgical accuracy shown by nearly identical postoperative
3D CT analysis.(32-34)

Aim of the
study:

   

         The aim of this study is to evaluate
the accuracy of the 3-dimensional virtual surgical planning for the management
of mandibular fractures reduction.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Patients
and methods:

 

    This is a comparative prospective study
conducted on 20 patients at Oral and Maxillofacial Surgery Department, Ain-Shams
University Hospital, Faculty of Dentistry, with diagnosis of mandibular
fractures.

Patients should fulfill the following
criteria:

·       
Patients of both
sexes.

·       
Above 16 years.

·       
No previous
history systemic disease affecting bone healing.

·       
Recent
fractures, within two weeks from the incidence of trauma.

Exclusion criteria:

·       
Children under 16 years.

·       
Mandibular fractures with gap
defects requiring bone grafting.

·       
Infected fracture site.

·       
Pathologic mandibular fractures.

 

   For all
patients multi-slice CT scans of the mandible will be obtained preoperatively.
The obtained Digital Imaging in the sort of DICOM files (Digital Imaging and
Communications in Medicine) will be imported into Mimics Medical 19.0 software (*)
and 3-dimensionally rendered into models of the mandible, then will be
transferred to 3-matic Medical 11.0 (x64)(**) to be virtually
analyzed, and surgically planned using the various tools provided by this
software.

 

(*)(Materialise,
Leuven, Belgium)  (**)  Belgian company 

  
Patients will be divided into 2 groups, group I comprise 10 patients
have

mandibular fractures in which the
traditional technique will be used where intermaxillary fixation to restore
occlusion will be held first then open reduction and internal fixation using titanium
miniplates. While for group II which also comprise 10 patients have mandibular
fractures in which stereolithographic (STL) model with the fracture
anatomically reduced will be 3D printed to be used for preoperative plate
adaptation and surgical guide fabrication when necessary. Soft diet will be
recommended for 1-4 weeks postoperatively for both groups.

Data collection:

  
For both groups, immediate postoperative CT scan will be obtained, DICOM
files will be imported and rendered 3-diamensionally model as previously
mentioned. Utilizing the Mimics Medical 19.0 and 3-matic Medical 11.0 (x64)
software, both the preoperative virtual surgical planning and the actual
postoperative 3D model will be superimposed on each other.

Statistics:

   The statistical analysis of data done by
using Microsoft office Excel 2007 program and (SPSS) program statistical
package for social science version 16.

 

 

 

 

 

 

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2018

 

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