To what extent can mastication functionality be restored following mandibular reconstruction surgery? A computer modeling approach.

STATEMENT OF PROBLEM: Advanced cases of head and neck cancer involving the mandible often require surgical removal of diseased sections and subsequent replacement with donor bone. During the procedure, the surgeon must make decisions regarding which bones or tissues to resect. This requires balancing tradeoffs related to issues such as surgical access and post-operative function; however, the latter is often difficult to predict, especially given that long-term functionality also depends on the impact of post-operative rehabilitation programs. PURPOSE: To assist in surgical decision-making, we present an approach for estimating the effects of reconstruction on key aspects of post-operative mandible function. MATERIAL AND METHODS: We develop dynamic biomechanical models of the reconstructed mandible considering different defect types and validate them using literature data. We use these models to estimate the degree of functionality that might be achieved following post-operative rehabilitation. RESULTS: We find significant potential for restoring mandibular functionality, even in cases involving large defects. This entails an average trajectory error below 2 mm, bite force comparable to a healthy individual, improved condyle mobility, and a muscle activation change capped at a maximum of 20%. CONCLUSION: These results suggest significant potential for adaptability in the masticatory system and improved post-operative rehabilitation, leading to greater restoration of jaw function.

Estimating tongue deformation during laryngoscopy using a hybrid FEM-multibody model and intraoperative tracking - a cadaver study.

Throat tumour margin control remains difficult due to the tight, enclosed space of the oral and throat regions and the tissue deformation resulting from placement of retractors and scopes during surgery. Intraoperative imaging can help with better localization but is hindered by non-image-compatible surgical instruments, cost, and unavailability. We propose a novel method of using instrument tracking and FEM-multibody modelling to simulate soft tissue deformation in the intraoperative setting, without requiring intraoperative imaging, to improve surgical guidance accuracy. We report our first empirical study, based on four trials of a cadaveric head specimen with full neck anatomy, yields a mean TLE of 10.8 ± 5.5 mm, demonstrating methodological feasibility.

Muscle Path Wrapping on Arbitrary Surfaces.

OBJECTIVE: Musculoskeletal models play an important role in surgical planning and clinical assessment of gait and movement. Faster and more accurate simulation of muscle paths in such models can result in better predictions of forces and facilitate real-time clinical applications, such as rehabilitation with real-time feedback. We propose a novel and efficient method for computing wrapping paths across arbitrary surfaces, such as those defined by bone geometry. METHODS: A muscle path is modeled as a massless, frictionless elastic strand that uses artificial forces, applied independently of the dynamic simulation, to wrap tightly around intervening obstacles. Contact with arbitrary surfaces is computed quickly using a distance grid, which is interpolated quadratically to provide smoother results. RESULTS: Evaluation of the method demonstrates good accuracy, with mean relative errors of 0.002 or better when compared against simple cases with exact solutions. The method is also fast, with strand update times of around 0.5 msec for a variety of bone shaped obstacles. CONCLUSION: Our method has been implemented in the open source simulation system ArtiSynth (www.artisynth.org) and helps solve the problem of muscle wrapping around bones and other structures. SIGNIFICANCE: Muscle wrapping on arbitrary surfaces opens up new possibilities for patient-specific musculoskeletal models where muscle paths can directly conform to shapes extracted from medical image data.

Multi-modal Framework for Image-guided Trans-oral Surgery with Intraoperative Imaging and Deformation Modeling.

Treatment of throat cancers have improved due to minimally-invasive trans-oral approaches. Surgeons rely on preoperative imaging to guide their resection; however, large tissue deformations occur during trans-oral procedures due to placement of necessary retractors and laryngoscopes which hinders the surgeon's ability to accurately assess tumor extent and location of critical structures. We propose an image-guided framework utilizing intraoperative imaging and deformation modeling to improve surgeon accuracy and confidence. A CT-compatible laryngoscopy system previously developed was evaluated in this framework. Intraoperative images were acquired during laryngoscopy; force-sensing capabilities were enabled in the laryngoscope; and tracking of the scope and anatomic features was trialed. Tissue deformation and displacement were quantified and determined to be extensive, with values <; 4.6 cm in the tongue, <; 1.8 cm in bony structures, and <; 108.9 cm3 in airway volume change. Surgical navigation using intraoperative imaging and tracking was evaluated. Preliminary assessment of deformation modeling showed potential to supplement intraoperative imaging. Future work will involve streamlined integration of the components of this framework.

Automatic prediction of tongue muscle activations using a finite element model.

Computational modeling has improved our understanding of how muscle forces are coordinated to generate movement in musculoskeletal systems. Muscular-hydrostat systems, such as the human tongue, involve very different biomechanics than musculoskeletal systems, and modeling efforts to date have been limited by the high computational complexity of representing continuum-mechanics. In this study, we developed a computationally efficient tracking-based algorithm for prediction of muscle activations during dynamic 3D finite element simulations. The formulation uses a local quadratic-programming problem at each simulation time-step to find a set of muscle activations that generated target deformations and movements in finite element muscular-hydrostat models. We applied the technique to a 3D finite element tongue model for protrusive and bending movements. Predicted muscle activations were consistent with experimental recordings of tongue strain and electromyography. Upward tongue bending was achieved by recruitment of the superior longitudinal sheath muscle, which is consistent with muscular-hydrostat theory. Lateral tongue bending, however, required recruitment of contralateral transverse and vertical muscles in addition to the ipsilateral margins of the superior longitudinal muscle, which is a new proposition for tongue muscle coordination. Our simulation framework provides a new computational tool for systematic analysis of muscle forces in continuum-mechanics models that is complementary to experimental data and shows promise for eliciting a deeper understanding of human tongue function.

A comparison of simulated jaw dynamics in models of segmental mandibular resection versus resection with alloplastic reconstruction.

STATEMENT OF PROBLEM: Composite mandibular resection resulting in mandibular discontinuity can alter jaw motion, occlusal forces, and mastication, whether or not the jaw is reconstructed. The biomechanical events associated with these changes are difficult to assess clinically and, therefore, are not well documented or researched. PURPOSE: The purpose of this study was to model movements of a mandible with a discontinuity defect, and to compare them to movements of a mandible with its continuity restored by alloplastic reconstruction. MATERIAL AND METHODS: Computational models were created with a novel simulation platform. The variables designed into the models included gravity, external forces, and jaw muscle activity. Each jaw was observed at rest, when opened by external force or by muscle drive, and during the generation of unilateral occlusal force on the nonoperated side. Scarring was simulated with springlike forces. Outputs included individual muscle forces and torques, as well as mandibular incisor and condylar motions. RESULTS: Both models displayed plausible resting postures, and jaw opening with deviation toward the defect side when scarring was simulated. Opening caused by downward force on the incisors differed from that due to muscle activation. Jaw rotations during unilateral molar contact on the unaffected side were muscle specific and influenced by mandibular discontinuity. CONCLUSIONS: Plausible jaw movements after hemimandibulectomy and/or alloplastic reconstruction could be predicted by dynamic modeling. The effect of soft tissue forces on jaw posture and movements varied with the condylar support available. In both models, different opening trajectories were produced by external force on the jaw and by jaw muscle activation. Mandibular rotation during unilateral molar contact depended on which muscles were activated, and the availability of bilateral condylar support.

Predicting muscle patterns for hemimandibulectomy models.

Deficits in movement and bite force are common in patients following segmental resection of the mandible consequent to oral cancer or injury. We have previously developed a dynamic model to analyse the biomechanics of an ungrafted segmental jaw resection with unilateral muscle and joint loss and post-surgical scarring. Here, we describe an inverse-modelling algorithm for automatically predicting muscle activations in the model for prescribed jaw movement and bite-force production. We present the results of simulations that postulate combined muscle activation patterns that could theoretically be used by patients to overcome post-surgical deficits. Such predictions could be the basis for future muscle retraining in clinical cases.

Towards predicting biomechanical consequences of jaw reconstruction.

We are developing dynamic computer models of surgical jaw reconstructions in order to determine the effect of altered musculoskeletal structure on the biomechanics of mastication. We aim to predict post-reconstruction deficits in jaw motion and force production. To support these research goals we have extended our biomechanics simulation toolkit, ArtiSynth [1], with new methods relevant to surgical planning. The principle features of ArtiSynth include simulation of constrained rigid-bodies, volume-preserving finite-element methods for deformable bodies, contact between bodies, and muscle models. We are adding model editing capabilities and muscle activation optimization to facilitate progress on post-surgical simulation. Our software and research directions are focused on upper-airway and cranio-facial anatomy, however the toolset and methodology are applicable to other musculoskeletal systems.