A method for accuracy of placement analysis on radiolucent polyether-ether-keton facial implants: A case series.

Facial asymmetry is defined as a bilateral difference between facial components. Correction, often desired by the patient, can be performed with the aim of bone born patient-specific solid implants designed using 3D CAD software. This treatment is embedded in the daily practice of today's healthcare. However, an analysis of the implant's accuracy of placement has not been reported. This case series describes the accuracy analysis of bone born aesthetic facial implants manufactured out of polyether-ether-ketone (PEEK). The accuracy analysis was based on postoperative (cone beam) computed tomography ((CB)CT) data and preoperative 3D planning. The analysis showed a median entry point error of 0.7 mm (min: 0.1, max: 3.3, interquartile range: 0.78). The median maximal orientation error was 5.5° (min: 0.1, max: 36.8, interquartile range: 7.13). Both parameters showed an excellent intraobserver and interobserver agreement with an ICC above 0.84. The described cases show that the analysis method is an objective approach for determining the accuracy of PSI placement and indicates that these implants can be placed accurately on the osseous face.

Reliability and validity of handheld structured light scanners and a static stereophotogrammetry system in facial three-dimensional surface imaging.

Several new systems for three-dimensional (3D) surface imaging of the face have become available to assess changes following orthognathic or facial surgery. Before they can be implemented in practice, their reliability and validity must be established. Our aim, therefore, was to study the intra- and inter-system reliability and validity of 3dMD (stereophotogrammetry), Artec Eva and Artec Space Spider (both structured light scanners). Intra- and inter-system reliability, expressed in root mean square distance, was determined by scanning a mannequin's head and the faces of healthy volunteers multiple times. Validity was determined by comparing the linear measurements of the scans with the known distances of a 3D printed model. Post-processing errors were also calculated. Intra-system reliability after scanning the mannequin's head was best with the Artec Space Spider (0.04 mm Spider; 0.07 mm 3dMD; 0.08 mm Eva). The least difference in inter-system reliability after scanning the mannequin's head was between the Artec Space Spider and Artec Eva. The best intra-system reliability after scanning human subjects was with the Artec Space Spider (0.15 mm Spider; 0.20 mm Eva; 0.23 mm 3dMD). The least difference in inter-system reliability after scanning human subjects was between the Artec Eva and Artec Space Spider. The most accurate linear measurement validity occurred with the Artec Space Spider. The post-processing error was 0.01 mm for all the systems. The Artec Space Spider is the most reliable and valid scanning system.

[Adjunctive aesthetic procedures in orthognathic surgery]. / Esthetische aangezichtschirurgie gecombineerd met orthognathische chirurgie.

In addition to function, occlusion and airway volume, aesthetics play an important role in the planning and execution of orthognathic surgery. To improve the aesthetic outcome of orthognathic surgery, there are several procedures that can be combined with orthognathic surgery secondarily, or in the same operation. These include: lipofilling, dermal fillers, facial implants, liposuction, ear corrections, eyelid corrections, or a lip lift. Patients often appreciate it when the options for additional procedures are discussed. However, both undertreatment and overtreatment can lead to unfavorable outcomes. Proper care and thoroughness are of course required, as to not change the characteristic facial aspects of a patient too much.

Postoperative skeletal stability at the one-year follow-up after splintless Le Fort I osteotomy using patient-specific osteosynthesis versus conventional osteosynthesis: a randomized controlled trial.

The purpose of this study was to assess the 1-year skeletal stability of the osteotomized maxilla after Le Fort I surgery, comparing conventional osteosynthesis with patient-specific osteosynthesis. Patients were assigned to a conventional or patient-specific osteosynthesis group using prospective randomization. The primary outcome was the three-dimensional change in postoperative skeletal position of the maxilla between the 2-week and 1-year follow-up cone beam computed tomography scans. Fifty-eight patients completed the protocol for the 2-week postoperative analysis, and 27 patients completed the 1-year follow-up study protocol. Of the 27 patients completing the entire protocol, 13 were in the conventional group and 14 in the patient-specific osteosynthesis group. The three-dimensional translation analysis showed that the use of the patient-specific osteosynthesis resulted in a skeletally stable result, comparable to that of conventional miniplate fixation. For both the patient-specific osteosynthesis and conventional miniplate fixation groups, median translations of less than 1 mm and median rotations of less than 1° were observed, indicating that both methods of fixation resulted in a stable result for the 27 patients examined. For the Le Fort I osteotomy, the choice between patient-specific osteosynthesis and conventional osteosynthesis did not affect the postoperative skeletal stability after 1 year of follow-up.

Patient-reported aesthetic outcomes of upper blepharoplasty: a randomized controlled trial comparing two surgical techniques.

It is not yet established whether additional orbicularis oculi muscle excision leads to better patient-reported aesthetic outcomes (PRO) compared to a skin-only resection blepharoplasty. A double-blind randomized controlled trial of upper blepharoplasty, with or without muscle excision, was performed on 54 White European patients who assessed the procedure via PRO. FACE-Q questionnaires covering eyes in general, upper eyelids, forehead and eyebrows, overall face, age appearance appraisal, age appraisal, social functioning, satisfaction with the outcome, and adverse effects were completed preoperatively and at 6 and 12 months after upper blepharoplasty. The Patient and Observer Scar Assessment Scale was used to assess scarring. The FACE-Q scores for skin-only and skin/muscle upper blepharoplasty were similar regarding the upper eyelids, forehead and eyebrows, overall face, patient perceived aging and age, social functioning, and satisfaction with the results, and also increased for both procedures with time. The FACE-Q score regarding the eyes in general was higher in the skin-only group at the 12-month follow-up. Scarring and adverse effects did not differ between the groups. Additional muscle resection does not seem to influence patient satisfaction. Thus, when performing an upper blepharoplasty, there is no need for additional muscle resection as a routine procedure to improve patient satisfaction.

The use of xenografts to prevent inferior border defects following bilateral sagittal split osteotomies: three-dimensional skeletal analysis using cone beam computed tomography.

The aim of this retrospective study was to investigate grafting in the osteotomy gap during bilateral sagittal split osteotomy (BSSO), using a xenograft and fibrin glue. Hard tissue defects in the inferior mandibular border were assessed using cone beam computed tomography scans taken 1 week and 1year postoperatively. The study group of 20 patients underwent bone grafting during BSSO (mean age 26.1years; mean horizontal displacement 8.5mm) and the control group of 20 patients did not (mean age 30.2 years; mean horizontal displacement 7.6mm). The mean height of the mandibular defects was significantly lower in the study group, but there was no significant difference in volume measurements between the groups. Grafting had a negligible effect on large displacements (9.0-15.0mm), which might have been due to an inadequate amount and/or positioning of the graft, or to poor dimensional stability. This may be resolved by improved graft positioning or by using a different kind of (xeno)graft.

Splintless surgery using patient-specific osteosynthesis in Le Fort I osteotomies: a randomized controlled multi-centre trial.

The accuracy of orthognathic surgery has improved with three-dimensional virtual planning. The translation of the planning to the surgical result is reported to vary by >2mm. The aim of this randomized controlled multi-centre trial was to determine whether the use of splintless patient-specific osteosynthesis can improve the accuracy of maxillary translation. Patients requiring a Le Fort I osteotomy were included in the trial. The intervention group was treated using patient-specific osteosynthesis and the control group with conventional osteosynthesis and splint-based positioning. Fifty-eight patients completed the study protocol, 27 in the patient-specific osteosynthesis group and 31 in the control group. The per protocol median anteroposterior deviation was found to be 1.05mm (interquartile range (IQR) 0.45-2.72mm) in the patient-specific osteosynthesis group and 1.74mm (IQR 1.02-3.02mm) in the control group. The cranial-caudal deviation was 0.87mm (IQR 0.49-1.44mm) and 0.98mm (IQR 0.28-2.10mm), respectively, whereas the left-right translation deviation was 0.46mm (IQR 0.19-0.96mm) in the patient-specific osteosynthesis group and 1.07mm (IQR 0.62-1.55mm) in the control group. The splintless patient-specific osteosynthesis method improves the accuracy of maxillary translations in orthognathic surgery and is clinically relevant for planned anteroposterior translations of more than 3.70mm.

Aesthetic outcomes of upper eyelid blepharoplasty: a systematic review.

Although upper blepharoplasty is a common cosmetic surgical intervention, a better scientific understanding of the aesthetic results and the preferred surgical technique to achieve the best aesthetic results is still needed. A systematic search using four search engines (PubMed, Embase, CINAHL, and Cochrane) was performed to identify any study on the aesthetic outcome of a solitary upper blepharoplasty; these were subjected to quality assessment for possible inclusion. Eligible studies were randomized controlled trials, controlled trials, cohort studies, and case series (n ≥ 10). A total of 4043 studies were assessed, of which 26 were included. Aesthetic outcomes included patient-reported outcome measures, scarring, eyebrow height, tarsal platform show, and panel or expert evaluation. Meta-analysis was not possible. Patients were generally satisfied with the aesthetic result and scar formation after an upper blepharoplasty. The amount of tarsal platform show increases, which positively affects the aesthetics. The eyebrow seems to move down slightly. The surgical technique used (skin only or skin/muscle removal) did not influence patient satisfaction or the physician-assessed aesthetic outcomes. Patients are generally satisfied after an upper blepharoplasty. The optimal design of the skin excision is still a matter of debate, especially when addressing lateral hooding. Further objective research is advised.

Functional outcomes of upper eyelid blepharoplasty: A systematic review.

OBJECTIVE: Various functional outcomes after upper blepharoplasty are reported in the literature. We systematically reviewed the literature to assess the objective and subjective functional effects of upper blepharoplasty. METHODS: After a systematic search of four search engines (Pubmed, Embase, Cinahl and Cochraine), any study on objective and subjective (patient reported) functional outcome after upper blepharoplasty was subjected to a quality assessment for possible inclusion in the review. The intervention was defined as a solitary surgical upper blepharoplasty containing the removal of skin, with or without the removal of a strip of orbicularis oculi muscle and/or upper orbital fat. Eligible studies were randomized controlled trials, controlled trials, cohort studies and case series (n ≥ 10). RESULTS: A total of 3525 studies were assessed, of which 28 studies were included in this systematic review. Favorable outcomes after an upper blepharoplasty were reported and included enlarged visual field, enhanced quality of life related to fewer headaches and improved vision. Furthermore, sensitivity of the eyelids decreased, with differences in recovery. Outcomes for eyebrow height, astigmatism, contrast sensitivity and eyelid kinematics were not consistent between the studies. No meta-analysis could be performed due to the limited scope of included studies and the great variety in outcomes and blepharoplasty techniques. CONCLUSIONS: Upper blepharoplasty is accompanied by a great variety of beneficial functional outcomes including an increased visual field and improvement in headache- and vision-related quality of life. Further research is needed, especially where results are conflicting (effects on eye dryness and eyebrow height) and/or the data are limited (contrast sensitivity, astigmatism).

Multi-modality 3D mandibular resection planning in head and neck cancer using CT and MRI data fusion: A clinical series.

OBJECTIVES: 3D virtual surgical planning (VSP) and guided surgery has been proven to be an effective tool for resection and reconstruction of the mandible. Currently, most widely used 3D VSP approaches to mandibular resection do not include detailed tumour information in the VSP. This manuscript presents a strategy where the aim was to incorporate tumour visualisation into the 3D virtual plan. Three-dimensional VSP of the mandibular resections was based on the fusion of CT and MRI data which was subsequently applied in clinical practice. METHODS: All patients diagnosed with oral squamous cell carcinoma between 2014 and 2017 at the University Medical Centre Groningen were included. The tumour was delineated on the MRI data, after which this dataset was fused with the CT bone data in order to construct a 3D bone and tumour model for virtual resection planning. Guided resections were performed and post-operative evaluation quantified the accuracy of the resection. The histopathological findings and patient and tumour characteristics were compared to those of a historical cohort (2009-2014) of conventional mandibular continuity resections. RESULTS: Twenty-four patients were included in the cohort. The average deviation from planned resection was found to be 2.2 mm. Histopathologic analysis confirmed all resection planes (bone) were tumour free, compared to 96.4% in the historic cohort. CONCLUSION: MRI-CT base tumour visualisation and 3D resection planning is a safe and accurate method for oncologic resection of the mandible. It is an improvement on the current methods reported for 3D resection planning based solely on CT data.

The design, production and clinical application of 3D patient-specific implants with drilling guides for acetabular surgery.

An innovative procedure for the development of 3D patient-specific implants with drilling guides for acetabular fracture surgery is presented. By using CT data and 3D surgical planning software, a virtual model of the fractured pelvis was created. During this process the fracture was virtually reduced. Based on the reduced fracture model, patient-specific titanium plates including polyamide drilling guides were designed, 3D printed and milled for intra-operative use. One of the advantages of this procedure is that the personalised plates could be tailored to both the shape of the pelvis and the type of fracture. The optimal screw directions and sizes were predetermined in the 3D model. The virtual plan was translated towards the surgical procedure by using the surgical guides and patient-specific osteosynthesis. Besides the description of the newly developed multi-disciplinary workflow, a clinical case example is presented to demonstrate that this technique is feasible and promising for the operative treatment of complex acetabular fractures.

[Perioral treatment options in cosmetic facial surgery]. / Periorale behandelingsmogelijkheden in de cosmetische aangezichtschirurgie.

The perioral region is unique and important in the face, both from a functional and an aesthetic point of view. There is a strong relationship between the perioral soft tissues, such as the lips and the corners of the mouth, and the underlying dentition and the jaws. Perioral ageing phenomena, such as depressed corners of the mouth, volume loss and wrinkles, can be improved, however, to a limited extent with intraoral treatment. These ageing phenomena can usually be treated more effectively with several extraoral treatment modalities that also enhance perioral aesthetics. The perioral cosmetic treatment options can be divided into various lifting procedures and volumising techniques. Considering that the dentist has to deal regularly with patients with perioral aesthetic wishes and also functional problems, it is important that one has knowledge of the different perioral treatment options, for both cosmetic and functional options.

Splintless surgery: does patient-specific CAD-CAM osteosynthesis improve accuracy of Le Fort I osteotomy?

To analyse the accuracy of maxillary positioning after Le Fort I osteotomy, we retrospectively assessed the outcome in three patients (mean (range) age 40 (21 - 60) years) who had been treated with patient-specific CAD-CAM osteosynthesis plates as part of a bimaxillary osteotomy. Virtual surgical planning in each case was based on cone-beam computed tomography (CT) (Simplant® O&O, Dentsply Implants NV, Kessel-Lo, Belgium), and patient-specific CAD-CAM drilling guides and osteosynthesis plates were produced for maxillary positioning and fixation. We evaluated the accuracy of the placement by virtual comparison of the preoperative and postoperative images. In the upper dentition, postoperative analysis showed a mean (SD) deviation of 1.3 (1.4) mm from the preoperative plan. The method enables accurate placement of the maxilla, independent of the condyle or mandible, without the need for extraoral reference points.

[The 3D-printed dental splint: a valuable tool in the surgical treatment of malocclusion after polytrauma]. / De driedimensionaal geprinte dentale spalk bij chirurgische behandeling van malocclusie na polytrauma.

A 22-year old male was referred to the Department of Oral and Maxillofacial Surgery of a university clinic 2 months after he had sustained multiple traumatic injuries abroad because of an anterior malocclusion. The malocclusion was the sequel of an unrecognised, untreated, already consolidated paramedian mandibular fracture on the right and a fracture of the contralateral mandibular angle on the left. Preoperatively, a cobalt-chrome 3D-printed dental splint was prepared. Surgical correction of the malocclusion was carried out by segmental osteotomies of the mandible at the original fracture sites. This involved a vertical paramedian osteotomy on the right side and a unilateral sagittal split osteotomy on the left mandibular angle side. The mandibular segment was mobilised in the correct occlusion with the aid of the 3D-printed dental splint. The splint was fixed to the teeth with dental composite. The custom made 3D-printed dental splint is considered a promising procedural innovation in oral and maxillofacial surgery.

[Cosmetic treatment during orthognathic surgery]. / Cosmetische ingrepen tijdens orthognathische chirurgie.

The goal of a combined orthodontic-surgical treatment is to correct the dysgnathia and malocclusion and thereby achieve an improvement of function. As a supplement to osteotomy, enhancement of facial aesthetics is increasingly being used to gain more harmony in the face and/or to achieve facial rejuvenation. In this regard, one might think of contour- or projection improvement by performing an intra-oral zygoma osteotomy or the placement of an alloplastic implant. By means of lipofilling, changes to the contours of the soft tissue can be realised. A sub mental fat surplus can be corrected by liposuction or lipectomy, resulting in a normalisation of the chin-neck angle. Otoplasty and limited rhinolplasty can also be combined with an osteotomy, while a blepharoplasty and a lip lift for older patients can be applied for facial rejuvenation. These aesthetic corrections can often be performed in the same surgical session as the osteotomy and contribute to significant patient satisfaction.

[Blepharoplasty in aesthetic facial surgery]. / Ooglidcorrecties in de cosmetische aangezichtschirurgie.

Blepharoplasty is the most commonly performed procedure in aesthetic facial surgery. The upper eyelid is part of the same aesthetic subunit as the eyebrow and the lower eyelid is part of the same aesthetic subunit as the cheek. In upper eyelid blepharoplasty the excess skin and possibly also a portion of the sphincter is removed. A low-hanging eyebrow is preferably corrected by lifting the brow instead of over excising the redundant eyelid skin. Blepharoplasty of the lower eyelid is generally carried out by a very limited excision of the skin and the orbicularis oculi muscle in order to prevent lower lid retraction (ectropion). Rejuvenation in the lower lid region is also achieved by fat resection or redistribution, by means of which the double convex contour deformity is reduced. Blepharoplasty is generally performed under local anaesthesia and complications are rare. Patient satisfaction is generally high.

[Microfat transfer in cosmetic facial procedures]. / Vettransplantatie in de cosmetische aangezichtschirurgie.

Loss of volume in the soft tissues of the face is considered to be an important cause of facial ageing. This volume loss can be compensated by microfattransfer. This technique offers a natural and long-lasting effect. Fat is harvested with liposuction and after centrifugation it is injected into the target areas in the face using small blunt cannulas. The goal is to place the fat in the desired place in such a way that the fat will survive and become integrated in the acceptor tissue. Microfattransfer can be combined with other cosmetic facial procedures such as blepharoplasties and facelifts. Although fatgrafting is a safe technique, complications may occur. These are mostly related to technique and amount of fat injected. Microfattransfer is a useful adjunctive procedure in maxillofacial surgery. Because only 40-50% of the result of microfattransfer is permanent touching up is often necessary. Microfattransfer should be considered as a staged treatment modality.

[Wrinkle fillers in cosmetic facial procedures]. / Rimpelvullers in de cosmetische aangezichtschirurgie.

During the last decade cosmeticfacial procedures have become part of the professional work of both dentists and maxillofacial surgeons. A shift has taken place from invasive surgical treatment towards minimally invasive treatments. Besides the use ofbotulinum toxin type A, non-permanent wrinkle fillers can be an alternative to invasive surgical treatment. Since botulism was first described in the 18th century, the neurotoxin has continued to develop, as a result of which Botox, now available in synthetically produced form, can safely be employed in healthcare. The frequency with which patients visit dentists and maxillofacial surgeons offers the professional group the possibility to inform patients about cosmetic facial treatments and to carry them out according to diagnosis.

[Facial ageing and cosmetic facial surgery]. / Verouderingsverschijnselen in het aangezicht en cosmetische aangezichtschirurgie.

The aim of cosmetic facial surgery is to enhance facial beauty by reducing the effects of ageing or by beautifying certain aspects of the face. The face can be subdivided anatomically into the skin, the fat compartments, the ligaments (the links between the skin and the underlying facial skeleton), the superficial musculoaponeurotic system and the masticatory and mimic musculature. As a result of the influence of gravity and ageing, changes which progress according to a fixed pattern take place at all levels of the soft tissue of the face. The supporting facial skeleton also reduces in volume in a characteristic manner. A thorough knowledge of the facial anatomy and the ageing process is essential for safe, effective and predicable facial rejuvenating surgery. The dentist generally has a long-lasting relationship with his patients and therefore may play an important role in advising patients with respect to the (im)possibilities of cosmetic facial surgery.

[Lifting procedures in cosmetic facial surgery]. / Liftingprocedures in de cosmetische aangezichtschirurgie.

A prominent characteristic of the aging face is the descent of skin and subcutaneous tissues. In order to reduce this and create a more youthful appearance, several lifting procedures can be employed. In the forehead and eyebrow region the transblepharoplastic brow lift, the direct brow lift, the temporal brow lift, the coronal brow lift and the endoscopic brow lift can be distinguished. For the mid-face, the facelift is known to be an effective treatment for aging characteristics. Classic facelifts can be divided into the one layer-, two layer- and the deep plane facelift. Nowadays the minimal access cranial suspension lift is popular. The lifting capacity of this lift may be less, but the risk of complications is lower and the result is often more natural. A neck lift improves the chin-neck angle and a submental liposuction/lipectomy can contribute to this. Complications in lifting procedures are rare. Hematoma is the most frequent complication. Skin necrosis of the wound edges and laceration of the end branches of the facial nerve can also occur. There is a tendency towards minimally invasive procedures with smaller risk of complications and shorter recovery periods.