Geometry-based algorithm for the prediction of nonpathologic mandibular movement.

PURPOSE: The goal of this study was to create a model for human mandibular movement prediction based on the geometry of the mandible. MATERIALS AND METHODS: Ten nonpathologic individuals underwent motion tracking and sagittal radiographs. From the data, a mathematical algorithm for mandibular movement prediction was developed based on mandibular geometry. The algorithm was then used to predict the mandibular movement of a cadaver subject. The algorithm was also validated in a living subject by comparing to recorded mandibular movement. RESULTS: Both mandibular movement predictions were free of bone collisions and showed mandibular movement that mimicked the in vivo situation. Comparisons between the predicted and recorded mandibular movements for the living human subject verified that the prediction model was accurate. CONCLUSIONS: The mandibular movement can be predicted based on the mandibular opening radius. The model is validated in living human subjects and shows effectiveness in predictions for cadaver models. Mandibular movement prediction may be a useful tool for physicians as well as investigators who focus on temporomandibular joint research.

Clinical feasibility of computer-aided surgical simulation (CASS) in the treatment of complex cranio-maxillofacial deformities.

PURPOSE: The purpose of this study was to establish clinical feasibility of our 3-dimensional computer-aided surgical simulation (CASS) for complex craniomaxillofacial surgery. MATERIALS AND METHODS: Five consecutive patients with complex craniomaxillofacial deformities, including hemifacial microsomia, defects after tumor ablation, and deformity after TMJ reconstruction, were used. The patients' surgical interventions were planned by using the authors' CASS planning method. Computed tomography (CT) was initially obtained. The first step of the planning process was to create a composite skull model, which reproduces both the bony structures and the dentition with a high degree of accuracy. The second step was to quantify the deformity. The third step was to simulate the entire surgery in the computer. The maxillary osteotomy was usually completed first, followed by mandibular and chin surgeries. The shape and size of the bone graft, if needed, was also simulated. If the simulated outcomes were not satisfactory, the surgical plan could be modified and simulation could be started over. The final step was to create surgical splints. Using the authors' computer-aided designing/manufacturing techniques, the surgical splints and templates were designed in the computer and fabricated by a stereolithographic apparatus. To minimize the potential risks to the patients, the surgeries were also planned following the current planning methods, and acrylic surgical splints were created as a backup plan. RESULTS: All 5 patients were successfully planned using our CASS planning method. The computer-generated surgical splints were successfully used on all patients at the time of the surgery. The backup acrylic surgical splints and plans were never used. Six-week postoperative CT scans showed the surgical plans were precisely reproduced in the operating room and the deformities were corrected as planned. CONCLUSION: The results of this study have shown the clinical feasibility of our CASS planning method. Using our CASS method, we were able to treat patients with significant asymmetries in a single operation that in the past was usually completed in 2 stages. We were also able to simulate different surgical procedures to create the appropriate plan. The computerized surgical plan was then transferred to the patient in the operating room using computer-generated surgical splints.

Accuracy of the computer-aided surgical simulation (CASS) system in the treatment of patients with complex craniomaxillofacial deformity: A pilot study.

PURPOSE: Current surgical planning methods are usually not adequate for the treatment of patients with complex craniomaxillofacial (CMF) deformities. To this end, we have developed a 3-dimensional (3D) computer-aided surgical simulation (CASS) planning method for the treatment of patients with complex CMF deformities. The purpose of this pilot study was to evaluate the accuracy of this technique in the treatment of patients with complex CMF deformities. PATIENTS AND METHODS: Five patients with complex CMF deformities were enrolled. Surgeries were planned with the CASS planning method. Surgical plans were transferred to patients at the time of surgery via computer-generated splints. After surgery, outcome evaluation was completed by first superimposing the postoperative computed tomography (CT) model onto the planned model, and then measuring the differences between planned and actual outcomes. The criteria used to determine the accuracy of the technique were as follows: a linear difference between planned and actual outcomes of less than 2 mm, and an angular difference of less than 4 degrees . RESULTS: All patients underwent surgery as planned. With the use of CASS planning, medians of the differences between planned and actual postoperative outcomes were limited to 0.9 mm and 1.7 degrees . CONCLUSION: The results of this pilot study are promising. They will be used as the basis of calculations needed to determine the sample size for a larger and more comprehensive study that will be undertaken to assess the accuracy of CASS planning methods.

Cost-effectiveness analysis for computer-aided surgical simulation in complex cranio-maxillofacial surgery.

PURPOSE: The purpose of this study is to assess the costs and benefits of computer-aided surgical simulation (CASS) and to compare it with the current surgical planning methods for complex cranio-maxillofacial (CMF) surgery. MATERIALS AND METHODS: The comparison of methods applies to all CMF surgeries where the patient's condition is severe enough to undergo a computed tomography scan and a stereolithographic model is necessary for the surgical planning process. The costs for each method can be divided into time and other costs. The time was estimated based on the authors' experience as well as on a survey of a small group of 6 experienced CMF surgeons in the United States. The other costs were estimated based on the authors' experience. RESULTS: CASS has lower costs in terms of surgeon time, patient time, and material costs. Specifically, total surgeon hours spent in planning are 5.25 hours compared with 9.75 for current standard methods. Material and scanning costs are Dollars 1,900 for CASS compared with about Dollars 3,510 for standard methods. Patient time for planning is reduced from 4.75 hours to 2.25 hours with CASS. The reduction in both time and other costs remains when the fixed fee costs of CASS are added to the variable costs. Amortized across the 600 patients per year (1,800 for the assumed 3-year life of the training and software), this adds only a few dollars and a fraction of an hour per surgery. Even in the case of a small clinic when the cost is amortized for 6 patients per year (18 patients for the assumed 3-year life of the training and software), the per surgery costs (9.65 hours and Dollars 2,456) will still favor CASS. CONCLUSION: Any great new design should consist of at least 2 of the 3 following features: faster, cheaper, and better outcome. This analysis demonstrates that CASS is faster and less costly than the current standard planning methods for complex CMF surgery. Previous studies have also shown that CASS results in better surgical outcomes. Thus, in all regards, CASS appears to be at least as good as the current methods of surgical planning.

The accuracy of cephalometric tracing superimposition.

PURPOSE: The purpose of this study was to compare the accuracy of 4 methods for cephalometric tracing superimposition. They are the FH@Porion method, S-N@Sella method, least-squared averaged 5 landmarks (LS-5) method, and manual geometric method. MATERIALS AND METHODS: Eight lateral cephalometric radiographs were used. Cephalometric tracing was performed by 2 examiners. One had extensive experience in landmark digitization while the other had minimal experience. The radiographs were scanned and the reference landmarks ANS, Point A, Point B, and Pogonion were digitized, creating 8 master tracings. Then 6 digital copies of each master tracing were made, 3 for each examiner. Subsequently, the examiners were asked to digitize and trace predetermined cranial base landmarks and structures. Tracings occurred at 1-month intervals. As a result, 3 separate tracings of each set were obtained from each examiner. The tracings of each set were superimposed using 4 different methods in the CASSOS software (SoftEnable Technology Ltd, Hong Kong SAR, China). For each method of superimposition, the coordinates of ANS, Point A, Point B, and Pogonion were recorded. Their means and variances were calculated. The variance represents the variability of the superimposition method. A general linear model for repeated measures was computed to test whether there were statistically significant differences among the 4 superimposition methods, 2 examiners, 4 reference landmarks, and 2 directions. Because the distribution of the variances was skewed, they were transformed to log variances. Finally, the errors of the superimposition in millimeters for each given examiner, superimposition method, reference landmark, and direction (X, Y) were calculated. RESULTS: There was a statistically significant difference in measurement variability among the 4 superimposition methods (P < .001). For both examiners, the variability of the different superimposition methods from the highest to the lowest was: Frankfort Plane registered at Porion method, Sella-Nasion registered at Sella method, least-square averaged 5 landmarks method, and the manual geometric method. In addition, there was a statistically significant difference in the magnitude of superimposition errors between the 2 examiners (P < .001). The experienced examiner was consistently more precise than the inexperienced examiner across all methods. Moreover, there was a statistically significant difference among 4 reference landmarks (P < .001). For both examiners, the recorded variability of each given reference landmark from the lowest to the highest was: ANS, Point A, Point B, and Pogonion. Furthermore, the variability differences between horizontal and vertical directions did not reach a conventional level of significance (P = .123). Finally, the recorded errors in millimeters for each superimposition method were summarized. A smaller error in millimeters represented a higher accuracy in superimposition. The error of using manual geometric or LS-5 methods for both examiners was less than 0.50 mm, while the error of using the other 2 methods was up to 0.99 mm for the experienced examiner and 2.88 mm for the inexperienced examiner. CONCLUSION: The error of both manual and LS-5 methods was within 0.5 mm. The LS-5 method had its advantage because it could be automated by the computer.

Methods: a comparative analysis of radiography, microcomputed tomography, and histology for bone tissue engineering.

This study focused on the assessment of radiography, microcomputed tomography, and histology for the evaluation of bone formation in a 15.0-mm defect in the rabbit radius after the implantation of a tissue-engineered construct. Radiography was found to be useful as a noninvasive method for obtaining images of calcified tissue throughout the time course of the experiment. With this method, however, image quality was low, making it difficult to obtain precise information about the location and quantity of the bone formed. Microcomputed tomography was used to create three-dimensional reconstructions of the bone (25-microm resolution). These reconstructions allowed for greater spatial resolution than the radiography, but did not allow for imaging of the implanted scaffold material or the surrounding, nonmineralized tissue. To visualize all materials within the defect area at the cellular level, histology was used. Histological analysis, however, is a destructive technique that did not allow for any further analysis of the samples. Each technique examined here has its own advantages and limitations, but each yields unique information regarding bone regeneration. It is only through the use of all three techniques that complete characterization of the bone growth and tissue/construct responses after implantation in vivo.

Radiographic analysis for jaw motion normalization.

PURPOSE: This study incorporated 3 objectives: 1 ) to evaluate the physical location of the center of rotation as determined by a custom mathematical algorithm, 2 ) to identify and compare the geometric center of the condylar head in radiographs with the calculated center of rotation, and 3 ) to determine whether a correlation exists between jaw motion characteristics and the mandibular geometry of the subject. MATERIALS AND METHODS: Lateral cephalometric radiographs of 9 subjects who underwent motion path analysis were obtained. The determined center of rotation of each mandible was calculated through a custom algorithm and recorded on the radiograph. Circular templates were used to determine the geometric center of the condyle for comparisons. Finally, measurements of 4 geometric jaw parameters were made and compared with motion characteristics to investigate whether mandibular geometry can be correlated to motion parameters. RESULTS: All calculated centers of rotation were found to lie in the condylar head of the mandible. The average difference between the calculated center of rotation and geometric center of the condylar head was 2.87 mm (SD, 1.69 mm). In addition, correlations were found linking the length of the mandibular rotational arm to the rotational and translational motions. However, there was no correlation found with the other geometric mandibular parameters. CONCLUSIONS: Analysis of mandibular motion allows for an accurate determination of the center of rotation. Previously identified characteristic motion exists in terms of primary rotation, followed by translation of the mandible with rotation. The magnitude of each phase differs between subjects. This study points to a natural mechanism of mandibular opening as the amount of rotation increased for longer rotational arms and amount of translation increased for shorter ones, serving to lessen the disparity in the opening amounts among individuals.

Flow perfusion enhances the calcified matrix deposition of marrow stromal cells in biodegradable nonwoven fiber mesh scaffolds.

In this study, we report on the ability of resorbable poly(L-lactic acid) (PLLA) nonwoven scaffolds to support the attachment, growth, and differentiation of marrow stromal cells (MSCs) under fluid flow. Rat MSCs were isolated from young male Wistar rats and expanded using established methods. The cells were then seeded on PLLA nonwoven fiber meshes. The PLLA nonwoven fiber meshes had 99% porosity, 17 microm fiber diameter, 10 mm scaffold diameter, and 1.7-mm thickness. The nonwoven PLLA meshes were seeded with a cell suspension of 5 x 10(5) cells in 300 microl, and cultured in a flow perfusion bioreactor and under static conditions. Cell/polymer nonwoven scaffolds cultured under flow perfusion had significantly higher amounts of calcified matrix deposited on them after 16 days of culture. Microcomputed tomography revealed that the in vitro generated extracellular matrix in the scaffolds cultured under static conditions was denser at the periphery of the scaffold while in the scaffolds cultured in the perfusion bioreactor the extracellular matrix demonstrated a more homogeneous distribution. These results show that flow perfusion accelerates the proliferation and differentiation of MSCs, seeded on nonwoven PLLA scaffolds, toward the osteoblastic phenotype, and improves the distribution of the in vitro generated calcified extracellular matrix.

In vitro degradation of porous poly(propylene fumarate)/poly(DL-lactic-co-glycolic acid) composite scaffolds.

This study investigated the in vitro degradation of porous poly(propylene fumarate) (PPF-based) composites incorporating microparticles of blends of poly(DL-lactic-co-glycolic acid) (PLGA) and poly(ethylene glycol) (PEG) during a 26-week period in pH 7.4 phosphate-buffered saline at 37 degrees C. Using a fractional factorial design, four formulations of composite scaffolds were fabricated with varying PEG content of the microparticles, microparticle mass fraction of the composite material, and initial leachable porogen content of the scaffold formulations. PPF scaffolds without microparticles were fabricated with varying leachable porogen content for use as controls. The effects of including PLGA/PEG microparticles in PPF scaffolds and the influence of alterations in the composite formulation on scaffold mass, geometry, water absorption, mechanical properties and porosity were examined for cylindrical specimens with lengths of 13 mm and diameters of 6.5 mm. The composite scaffold composition affected the extent of loss of polymer mass, scaffold length, and diameter, with the greatest loss of polymer mass equal to 15+/-5% over 26 weeks. No formulation, however, exhibited any variation in compressive modulus or peak compressive strength over time. Additionally, sample porosity, as determined by both mercury porosimetry and micro-computed tomography did not change during the period of this study. These results demonstrate that microparticle carriers can be incorporated into PPF scaffolds for localized delivery of bioactive molecules without altering scaffold mechanical or structural properties up to 26 weeks in vitro.

Biomechanical evaluation of the pins of a mandibular external distractor.

PURPOSE: Our goal was to establish whether the pins of an external distractor were capable of overcoming tissue resistance to distraction. MATERIALS AND METHODS: The study was carried out in 2 parts. The first part of the study determined the bending rigidity of the distractors pins. To accomplish this, the distractor was installed on the mandible of a stereolithographic model using 4 regular 2.0-mm steel pins. An osteotomy was not performed. The distractor was activated using a torque gauge, and the bending rigidity of the pins was recorded. The second part of the study determined the tissue resistance to mandibular distraction using fresh cadavers. Six cadavers were divided into 2 groups to determine tissue resistance to angular and linear distraction, respectively. The devices used to measure tissue resistance were a modified external multiplanar distractor and a torque gauge. RESULTS: In the anteroposterior direction, the tissue resistance to linear distraction clearly exceeded the bending rigidity of the pins for the first 7.5 mm of activation. After this, the opposite was true. In the vertical direction, the tissue resistance clearly exceeded the bending rigidity of the pins for the first 8.0 mm of activation. After this, the opposite was true. For the first 15.0 degrees of angular distraction in the sagittal plane, the tissue resistance was almost identical to the bending rigidity of the pins. After this, the tissue resistance significantly exceeded the bending rigidity of the pins. For the first 7.0 degrees of angular distraction in the transverse plane, the tissue resistance was marginally greater than the bending rigidity of the pins. After this, the bending rigidity of the pins increased significantly. CONCLUSION: The 2.0-mm steel pins used in most external multiplanar distractors are not capable of overcoming the tissue resistance to linear or angular distraction.

Evaluation of the in vitro degradation of macroporous hydrogels using gravimetry, confined compression testing, and microcomputed tomography.

This study investigated the in vitro degradation characteristics of macroporous hydrogels based on poly(propylene fumarate-co-ethylene glycol) (P(PF-co-EG)). Four formulations were fabricated to test the effect of porosity and cross-linking density on the degradation of the resulting macroporous hydrogels. Macroporosity was introduced by the addition of sodium bicarbonate and ascorbic acid, the precursors of the carbon dioxide porogen, in the initiation system for the hydrogel cross-linking. Macroporous hydrogels with porosities of 0.80 +/- 0.03 and 0.89 +/- 0.03 were synthesized by the addition of sodium bicarbonate of concentrations 40 and 80 mg/mL and ascorbic acid of concentrations 0.05 and 0.1 mol/L, respectively. Poly(ethylene glycol) diacrylate (PEG-DA) was utilized as a cross-linker. The molecular weight between cross-links had a significant effect on weight loss after 12 weeks, where samples with M(C) of 1,880 +/- 320 synthesized with a P(PF-co-EG):PEG-DA ratio of 3:1 had a significantly greater mass loss due to degradation than those with M(C) of 1,000 +/- 100 synthesized with a P(PF-co-EG):PEG-DA ratio of 1:1. In contrast, porosity played a minimal role in determining the weight loss. Mechanical testing of the hydrogels under confined compression showed a decrease in compressive modulus over the degradation time for all formulations. In addition, an increase in hydrogel equilibrium water content and pore wall thickness was observed with degradation time, whereas the hydrogel porosity and surface area density remained invariant. The results from microcomputed tomography corroborated with the rest of the measurements and indicated a bulk degradation mechanism of the macroporous hydrogels.