3D-planning bij. orthognatische heelkunde complexe heelkundige mka-problemen. dienst MKA UZLeuven

3D-planning bij orthognatische heelkunde complexe heelkundige mka-problemen c.politis - r. jacobs - t. dormaar - j. schoenaers – r. coropciuc

y. sun – e. shaheen

dienst MKA UZLeuven

Lokale moderatoren : • • • • • •

Leuven, prof. dr. Reinhilde Jacobs, MKA - Orale Beeldvorming Antwerpen, dhr. Wouter Polspoel, Dentsply Implants nv Bonheiden, dr. Olivier Tanésy, MKA-chirurgie Hasselt, dr. Jan Jacobs, Maxillo-Faciale Chirurgie Oostende, dr. Mario Schurgers, Hoofdarts Ronse, dr. Patrick Torfs, Stomatologie

outline • 3D-planning in orthognatische heelkunde welk traject wordt doorlopen door de patiënt? o in welke fase past de 3D-technologie? • navigatie-chirurgie • templates in transplantatie van hoektanden o

situering orthognatische heelkunde MOC Hoofd-Hals-Oncologie 130 nieuwe patiënten per jaar

MONDKANKER

41 nieuwe schisispatiënten per jaar

AANGEBOREN AFWIJKINGEN

175 nieuwe ORTHOGNATISCH patiënten per jaar

Zorgtraject Schisis ALGEMEEN

1988

1989

2015

voorbeelden van technieken

zorgtraject orthognatische heelkunde tijd

niet ziekenhuis gebonden o.a. thuis

ziekenhuisgebonden

opname, operatie, ontslag

niet ziekenhuis gebonden

JA

misschien

NEEN

bespreken proefmodellen

vastleggen van: • datum ingreep • datum orthognatische 1,2,3 • informed consent • consult anesthesie •indien inlichten orthodontist minderjarig en alléén: nieuwe afspraak mét ouders/verantwoordelijke

terug naar: • orthodontist • algemeen tandarts • parodontoloog • dietiste • psycholoog •verwijsbrief huisarts !

orthognatische 1 • • • • • • • • • • • • •

Clinical examination

Orthognathic questionnaire TMJ-questionnaire Clinical images Impressions + wax bite (thin and thick) + intra oral scanning Bite registration (T-Scan) Bite-force measurement PANORAMIC RX, Lateral ceph, AP Facial soft tissue scan (3D photo Planmeca) CBCT full skull with thin wax bite (Newtom) Informed consent 3D planning Informed consent prospective clinical study Tracing en Bolton analysis

Preoperatieve vragenlijst

Klinische foto’s

EMD 930715V168

Automated stitching of three facial captures into one 3D image with VECTRA software.

3D-facial surface mask

Klinische foto’s

Afdrukname

Intra oral scanner

T-Scan

T-Scan

Bite force

RX OPG

RX tele

3D face scan

3D face scan

CBCT Newtom

CBCT Newtom • ERRORS o o

joint : resting position occlusion: • CO-CR ? • sunday bite

o o o

occlusal plane: NHP airway: inhaling, exhaling lip balance: mental strain?

CBCT Newtom • ERRORS o o o o o

metal artifacts motion positioning pressure on chin posture soft tissue contrast

wasbeet: correct

wasbeet: fout

3D-team worksetting after “orthognathic 1” •

Intra oral and extra oral images are checked


High resolution casts preparation o

Small holes are drilled in the plaster casts away from the teeth

o

Then scanned with our optical scanner


High resolution casts preparation o

The output of the optical scanner is not a clean STL file

o

3-matic software is used to fix these casts


2D ceph. Analysis of RX Tele in Onyx

3D-team worksetting after “orthognathic 1” • 3D preparation o

Import CT/CBCT to Proplan 2.1 (Materialise, Belgium)

o

Segmentation of the following objects via thresholding • Mandible • Skull + maxilla • Soft tissue

image segmentation

• goal: find regions of interest, representing objects or meaningful parts (maxilla, mandible, chin, soft tissue, teeth) o methods: • some homogeneity within themselves • some contrast on their border: edge detection sharp change in image intensities o methods: • region growing –shrinking • clustering methods • boundary detection • thresholding (histogram) = manually examining… • •

edge linking Hough transform


Registration of 3D photo to soft tissue

image registration • spatially aligning two or more images o o o

fusion of information in the image determination of scene changes identity in one image KNOWN, identity and location in another image can be determined (navigation)

reference image source image

target image = resampled to register the reference image using a transformation function using the coordinates of a number of corresponding points


Nerve tracing

wat we héél erg missen in orthognatische heelkunde dCBCT toont NIET de zenuw, in het béste geval enkel het beenderig kanaal dat de zenuw bevat MSCT idem

MRI kan effectief zenuw visualiseren, maar wordt hiervoor bijna niet gebruikt!

3D-team worksetting after “orthognathic 1” • Creation of composite models o

Scanned casts registered, matched to upper and lower jaw via point based registration

registration proces necessitates image features that can be used to establish correspondence between two images • points • lines • regions • templates

3D-team worksetting after “orthognathic 1” • Creation of composite models o

Scanned casts registered to upper and lower jaw via point based registration

3D-team worksetting after “orthognathic 1” • Horizontal reference o

Reposition the objects into the NHP

o

The software offers: manually, Frankfurt plane or occlusion plane

o

Difficulty • How do we ascertain that the NHP is used as the horizontal reference plane?

3D-team worksetting after “orthognathic 1” • Cephalometry o

3D: We have our own UZLeuven analysis based on the 2D used analysis and some added 3D measures to account for canting.


orthognatische 2

orthognatische 2 • • • • •

3D virtual simulation VTO: chin surgery? change occlusal plane? Facebowregistration in case of bimax Check wax bite Set-up o model surgery: intermediate wafer o models in occlusion: final wafer

3D-team worksetting after “orthognathic 2” • • •

The clinical plan is set by the surgeon Cast models are put in occlusion by the surgeon (occlusion cast) Occlusion casts are scanned with a high resolution CBCT (Planmeca)


In case of bimax the thick waxbite is scanned with the intra oral scanner and registered in the proplan software


Perform planned osteotomies (e.g. Le Fort 1, BSSO…)


Registration of occlusion to upper jaw

The registration steps are all point based registration with at least 3 points. But for better results, we recommend 4-5 points per registration


Registration of cut mandible to occlusion

The registration steps are all point based registration with at least 3 points. But for better results, we recommend 4-5 points per registration


Apply planned movements

In case of bimax: the Le Fort 1 object, the BSSO object and the occlusion cast are all repositioned according to the clinically predefined plan from the surgeon. At this steps the 3D cephalometry is used to accurately reposition the objects. Followed by repositioning of rami



In case of monomax BSSO: only the rami are needed to be repositioned and the condylar points are used as references



In case of monomax Le Fort 1: the occlusion cast, the Le Fort 1 object and the mandible are rotated around the condylar axis (to simulate auto-rotation) until the planned anterior intrusion of extrusion is reached


Soft tissue simulation

Simulation is done by selecting the bone fragments and the preoperative soft tissue (in this case the 3D photo). The software calculates the new soft tissue and under the 3D cephalometry step the facial contour is recalculated manually


Soft tissue simulation

maw weke delen (esthetiek) VOLGT de door de chirurg bepaalde bewegingen van het BOT en de TANDEN

in esthetische chirurgie VOLGEN BOT en TANDEN de door patiënt/chirurg gewenste weke delen uitkomst

glijschuif

3D-team worksetting after “orthognathic 2” • •

Monomax  final wafer

Bimax  intermediate and final wafer

3D-team worksetting after “orthognathic 2” • • •

Design in 3-matic (Materialise) 3D Print in biocompatible material Object connex 350 (Stratasys, USA) The wafers are tested on the first pair of plaster casts and manually further trimmed and sharp edges are smoothed

Intermediate wafer

Final wafer

3D technologie voordelen

• Verschillende opties kunnen vooraf gesimuleerd worden

• Productie ‘in huis’ van waefers en cutting guides

• Complexe procedures kunnen beter voorbereid worden: yaw, pitch, roll

• Behoud van alle data voor latere superpositie en vergelijking

nadelen

• • • •

Ingenieurs nodig

Investering hardware Investering software Time-consuming

oude technieken

Manual planning: mono-maxillaire osteotomie

Modellen opeen

Manual final wafer manufacturing

Manual planning: bi-maxillaire osteotomie

Manual manufacturing of intermediate wafer

traditional facebow registration and transfer from facebow to the articulator is performed. this is our starting point. a magnetic articulator is used to replace the classic articulator.

Digital model surgery: begin days….

This magnetic articulator was scanned by a smart optical scanner to digitize the occusal surface of maxilla and mandible; a virtual wax bite was generated.


orthognatische 3

orthognatische 3 • • • •

Fitting final and intermediate wafers Attest for (NSAID, paracetamol, isobetadine mondspoeling) Check surgical hooks pre-op anesthesie in orde?

3D-team worksetting after “orthognathic 3”

• All wafers are tested and clinically checked • In the report in the KWS you can find the final decision • PPT is ready for further discussion


stafvergadering preoperatief

Klinische beelden

OPG

TELE en AP

Zenuwtracing

Gezondheidstoestand Condyli R

L

T-Scan Pre op: 01-07-2015 First contact

Maximum Intercuspat ion

Luchtweg Pre op

2D planning Pre-op Cephalometrie 2D (Onyx)

2D planning Post op: BSSO

LLL: 52,5 mm I1l-MP: 50,3 mm Advies: kinplastie adv. 7mm nodig

19˚

3D planning Pre op

3D planning Post op: BSSO

3D planning Wekedelen: pre en post op

3D planning Wekedelen: pre en post op

Facial contour pre op 24⁰

Facial contour post op 18⁰


gegevens datawarehouse

opname, operatie, ontslag

opname

E450

OKA1 OKA2

PAZA

E450

ontslag


follow-up surgery week 1 - 6

follow-up scheme postop week 1 - 6 week 1

week 2

week 3

week 4

week 5

week 6

formasa postop

+

+

+

+

+

+

removal IMF

+

-

-

-

-

-

removal elastics

-

-

-

-

-

+

removal waefer

-

-

-

-

-

+

controle occlusie

+

+

+

+

+

+

rx opg

+

-

-

-

-

+

rx tele/face

+

-

-

-

-

+

klinische nikon

+

CBCT

+

-

-

-

-

+

bite registration

-

-

-

-

-

+

bite force

-

-

-

-

-

+

+

klinisch week week week week week week maand 1 2 3 4 5 6 3

maand 6

occlusie

+

+

+

+

+

+

+

+

tmj

+

-

-

-

-

+

+

+

mondopening

-

-

-

-

-

+

+

+

geluid

-

-

-

-

-

+

+

+

pijn in tmj

+

+

+

+

+

+

+

+

pijn buiten tmj

+

-

-

-

-

+

+

+

sensibiliteit lippen

+

-

-

-

-

+

+

+

mondhygiëne

+

+

+

+

+

+

+

+

last osteosynthese

+

-

-

-

-

+

+

+

relapse

-

-

-

-

-

+

+

+

patiënt tevreden?

+

-

-

-

-

+

+

+

T-scan post op

First contact

Maximum Intercuspation

2D superimposition postop

3D superimposition

post-operative CBCT is registered to the pre-operatively CT using voxel based registration with mutual information

Pre-op CT

Post-op 6 weeks CBCT

Registration

Amira (Fei, USA)

3D superimposition

Amira (Fei, USA)

3D superimposition same corresponding landmarks on the maxilla of the virtual planning Virtual planning Le Fort1

Actual output postop 6w

Proplan (Materialise, Belgium)

3D superimposition differences between the virtual planning and the surgical outcome

Angular (°) •Roll

Linear (mm) •Canting

•Pitch

•In/ex-trusion ant. and post.

•Yaw

•Rotation ant. and post.

3D superimposition

Proplan (Materialise, Belgium)

3D superimposition - example

3D superimposition - example

Pitch

1,29˚

Roll

0,35˚

Yaw

0,43˚

ant In/extrusion post

1,75 mm

Cant

0,29 mm

Rotation

2,25 mm

ant

0,65 mm

post

1,25 mm

3D face scan Progress: pre op, post op simulation, 6m

3D Superimposition Pre en post op 6w luchtweg

35% increase

3D Superimposition Pre en post op 6w luchtweg


follow-up orthodontics

OMFS‐IMPATH KULeuven 3D lab UZLeuven - KULeuven juni 2015

MONDKANKER

• • • • • •

fase 1: 3D-printing: segmentatie tumor fase 2: resectie: cutting guides fase 3: reconstructie: planning/ predictie + cutting guides fase 4: 3D planning + surgical templates + brainlab navigatie fase 5: 3D planning inclusief prothetisch herstel fase 6: 3D printing van weefsels

fase 1 : planning •

Anatomical replica with segmentation of the tumor

Operatie 14-5-2014 • •

Halsklierevidement Maxillectomie links via Ferguson-Weber toegang

Operatie 14-5-2014 • •

Halsklierevidement Maxillectomie links via Ferguson-Weber toegang

fase 2 : resectie •

Tumor right lower jaw and floor of mouth with invasion of jaw bone





 Cutting guides



fase 3 : reconstructie •

Casus osteosarcoma bij adolescent  Cutting guide on fibular

fase 3 : reconstructie •

Casus osteosarcoma bij adolescent Application of cutting guide on fibular

fase 4 : 3D printing en navigatie •

Brainlab navigation

Pointer

Navigation star (skull reference base)

+ SOFTWARE


5 years old girl with mouth opening: 8mm


Evaluation on 3D printed model

wegens operatief risico verwezen naar UZL vanuit Antwerpen


Brainlab navigation system


Brainlab navigation system

 Image-guided surgery using pointer to check the surgical outcome


Mouth opening of 30 mm by the end of the surgery

fase 5 : resectie + reconstructie + prothetisch herstel op implantaten






MONDKANKER

AANGEBOREN AFWIJKINGEN

ORTHOGNATISCH

ALGEMEEN

•

3D planning TAT Pre-processing

Recipient region

Segmentation donor tooth

3D planning simulation

Donor in recipient region

Measurements

Report + advise of possible treatment solutions

Voorstel: Owv groter donor element dan recipient site en angulatie van elementen 33 en 36  1st stap orthodontisch tilting van element 33 om de nodig 0,5 mm extra ruimte te creëren. Toekomst: Endodontisch behandeling element 38

•

3D planning TAT: ingesloten element 23

•

3D planning TAT: virtual position element 23

•

3D planning guided implantology Pre-processing Laser scanner

Laser scanning

3D planning simulation 3D Surgical planning

Design surgical template and 3D printing

Segmentation of jaw

3D-planning bij. orthognatische heelkunde complexe heelkundige mka-problemen. dienst MKA UZLeuven

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