Comparative finite element analysis of skull mechanical properties following parietal bone graft harvesting in adults

Introduction: Parietal bone grafts are commonly used in cranio-maxillo-facial surgery. Both the outer and the internal layer of the calvarium can be harvested. The bone defect created by this harvesting may induce significant weakening of the skull that has not been extensively evaluated. Our aim was to evaluate the consequences of parietal bone graft harvesting on mechanical properties of the skull using a finite element analysis. Methods: Finite elements models of the skull of 3 adult patients were created from CT scans. Parietal external and internal layer harvest models were created. Frontal, lateral, and parietal loading were modeled and von Mises stress distributions were compared. Results: The maximal von Mises stress was higher for models of bone harvesting, both on the whole skull and at the harvested site. Maximal von Mises stress was even higher for models with internal layer defect. Conclusions: Harvesting parietal bone modifies the skull's mechanical strength and can increase the risk of skull fracture, mainly on the harvested site. Outer layer parietal graft harvesting is indicated. Graft harvesting located in the upper part of the parietal bone, close to the sagittal suture and with smooth internal edges and corners should limit the risk of fracture

Maxillary sinus textiloma: a case report

<p>Abstract</p> <p>Introduction</p> <p>Textilomas have been reported in many locations. We report the first case of textiloma located in the maxillary sinus that mimicked a sinus cyst recurrence on computed tomography images.</p> <p>Case presentation</p> <p>A 60-year-old Caucasian man was referred for persistent infection of the right maxillary sinus. A maxillary sinus benign cyst had been removed three months before. Computed tomography showed a sinus opacity evoking a cyst recurrence. A new operation was planned to remove the cyst by a Caldwell-Luc approach. After excision of very thick fibrous tissue, a compress was discovered in the maxillary sinus. The patient did not present with any sinus infection after the operation.</p> <p>Conclusion</p> <p>The surgeon should always take into account the possibility of textilomas in a patient with a history of sinus surgery.</p

Accuracy evaluation of CAD/CAM generated splints in orthognathic surgery: a cadaveric study

Introduction To evaluate the accuracy of CAD/CAM generated splints in orthognathic surgery by comparing planned versus actual post-operative 3D images. Methods Specific planning software (SimPlant® OMS Standalone 14.0) was used to perform a 3D virtual Le Fort I osteotomy in 10 fresh human cadaver heads. Stereolithographic splints were then generated and used during the surgical procedure to reposition the maxilla according to the planned position. Pre-operative planned and postoperative 3D CT scan images were fused and imported to dedicated software (MATLAB®) 7.11.) for calculating the translational and rotational (pitch, roll and yaw) differences between the two 3D images. Geometrical accuracy was estimated using the Root Mean Square Deviations (RMSD) and lower and upper limits of accuracy were computed using the Bland & Altman method, with 95 % confidence intervals around the limits. The accuracy cutoff was set at +/− 2 mm for translational and ≤ 4° for rotational measurements. Results Overall accuracy between the two 3D images was within the accuracy cutoff for all values except for the antero-posterior positioning of the maxilla (2.17 mm). The translational and rotational differences due to the splint were all within the accuracy cutoff. However, the width of the limits of agreement (range between lower and upper limits) showed that rotational differences could be particularly large. Conclusion This study demonstrated that maxillary repositioning can be accurately approximated and thus predicted by specific computational planning and CAD/CAM generated splints in orthognathic surgery. Further study should focus on the risk factors for inaccurate prediction

Three-Dimensional Cephalometric Landmarking and Frankfort Horizontal Plane Construction: Reproducibility of Conventional and Novel Landmarks

In some dentofacial deformity patients, especially patients undergoing surgical orthodontic treatments, Computed Tomography (CT) scans are useful to assess complex asymmetry or to plan orthognathic surgery. This assessment would be made easier for orthodontists and surgeons with a three-dimensional (3D) cephalometric analysis, which would require the localization of landmarks and the construction of reference planes. The objectives of this study were to assess manual landmarking repeatability and reproducibility (R&R) of a set of 3D landmarks and to evaluate R&R of vertical cephalometric measurements using two Frankfort Horizontal (FH) planes as references for horizontal 3D imaging reorientation. Thirty-three landmarks, divided into “conventional”, “foraminal” and “dental”, were manually located twice by three experienced operators on 20 randomly-selected CT scans of orthognathic surgery patients. R&R confidence intervals (CI) of each landmark in the -x, -y and -z directions were computed according to the ISO 5725 standard. These landmarks were then used to construct 2 FH planes: a conventional FH plane (orbitale left, porion right and left) and a newly proposed FH plane (midinternal acoustic foramen, orbitale right and left). R&R of vertical cephalometric measurements were computed using these 2 FH planes as horizontal references for CT reorientation. Landmarks showing a 95% CI of repeatability and/or reproducibility > 2 mm were found exclusively in the “conventional” landmarks group. Vertical measurements showed excellent R&R (95% CI < 1 mm) with either FH plane as horizontal reference. However, the 2 FH planes were not found to be parallel (absolute angular difference of 2.41°, SD 1.27°). Overall, “dental” and “foraminal” landmarks were more reliable than the “conventional” landmarks. Despite the poor reliability of the landmarks orbitale and porion, the construction of the conventional FH plane provided a reliable horizontal reference for 3D craniofacial CT scan reorientation

Experiences with a new biplanar low-dose X-ray device for imaging the facial skeleton: A feasibility study

Methods We evaluated 48 biplanar radiographs from 12 patients (posteroanterior/lateral), originally taken for a scoliosis examination with a biplanar low-dose X-ray device. For this study, the images were further evaluated for the perceptibility of 38 facial skeleton landmarks. To determine the reliability and reproducibility of perceptibility, two independent observers determined the landmarks twice, during a time interval of at least two weeks. Results Both interoperator and intraoperator reliability were excellent for all landmarks [intraclass correlation coefficient (ICC) > 0.92]. Conclusions The biplanar low-dose X-ray device demonstrated good feasibility for precisely assessing the anatomical landmarks of the facial skeleton. Given its excellent precision, the biplanar low-dose X-ray device data sets should be forwarded from the treating orthopedic surgeon or neurosurgeon to the orthodontist or dentist for further assessment in their field.For this study, no author has received any funding. During the time this retrospective study took place, the institute/laboratory in which Prof. P. Rouch works and Dr. A. Laville worked received funding from the EOS-Imaging company for other EOS studies. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript

Biplanar Low-Dose Radiograph Is Suitable for Cephalometric Analysis in Patients Requiring 3D Evaluation of the Whole Skeleton

Background: The biplanar 2D/3D X-ray technology (BPXR) is a 2D/3D imaging system allowing simultaneous stereo-corresponding posteroanterior (PA) and lateral 2D views of the whole body. The aim of our study was to assess the feasibility of cephalometric analysis based on the BPXR lateral skull view to accurately characterize facial morphology. Method: A total of 17 landmarks and 11 angles were placed and/or calculated on lateral BPXR and lateral cephalograms of 13 patients by three investigators. Five methods of angle identification were performed: the direct construction of straight lines on lateral cephalograms (LC-A) and on BPXR (BPXR-A), as well as the calculation of angles based on landmark identification on lateral cephalograms (LA-L) and on BPXR with the PA image (BPXR-LPA) or without (BPXR-L). Intra- and interoperator reliability of landmark identification and angle measurement of each method were calculated. To determine the most reliable method among the BPXR-based methods, their concordance with the reference method, LC-A, was evaluated. Results: Both imaging techniques had excellent intra- and interoperator reliability for landmark identification. On lateral BPXR, BPXR-A presented the best concordance with the reference method and a good intra- and interoperator reliability. Conclusion: BPXR provides a lateral view of the skull suitable for cephalometric analysis with good reliability

Zygomatic bone shape in intentional cranial deformations: a model for the study of the interactions between skull growth and facial morphology

Intentional cranial deformations (ICD) were obtained by exerting external mechanical constraints on the skull vault during the first years of life to permanently modify head shape. The repercussions of ICD on the face are not well described in the midfacial region. Here we assessed the shape of the zygomatic bone in different types of ICDs. We considered 14 non-deformed skulls, 19 skulls with antero-posterior deformation, nine skulls with circumferential deformation and seven skulls with Toulouse deformation. The shape of the zygomatic bone was assessed using a statistical shape model after mesh registration. Euclidian distances between mean models and Mahalanobis distances after canonical variate analysis were computed. Classification accuracy was computed using a cross-validation approach. Different ICDs cause specific zygomatic shape modifications corresponding to different degrees of retrusion but the shape of the zygomatic bone alone is not a sufficient parameter for classifying populations into ICD groups defined by deformation types. We illustrate the fact that external mechanical constraints on the skull vault influence midfacial growth. ICDs are a model for the study of the influence of epigenetic factors on craniofacial growth and can help to understand the facial effects of congenital skull malformations such as single or multi-suture synostoses, or of external orthopedic devices such as helmets used to correct deformational plagiocephaly.R.H.K. and S.K. were supported by the Union des Blessés de la Face et de la Tête, Fondation des ‘Gueules Cassées’. S.K. was supported by the Fédération Française d’Orthodontie (FFO)

Modélisation biomécanique et étude de la fonctionnalisation d’un implant personnalisé de reconstruction mandibulaire en titane poreux

Several articles report on the regeneration of bone defects using synthetic porous structures mimicking bone micro-architecture. Porous implants exhibiting mechanical properties close to that of bone tissue with enhanced osseointegration ability can be manufactured by means of selective laser melting of titanium. However, bone growth into the pores of such implant could be limited due to oversized elastic properties. We implemented an experimental study with ewes to assess the influence of the overall stiffness of these implants on bone ingrowth in critical-size mandibular defects. Fully load-bearing porous and control implants of varying overall stiffness were developed and implanted in two groups of six ewes. Bone ingrowth was assessed by mechanical characterization of bone-implant interfaces and by the measurement of the newly formed bone volume using micro-CT imaging. Higher bone ingrowth was identified in porous implants compared to control implants. Low-stiffness porous implants exhibited significantly higher bone ingrowth as compared to porous implants with stiffness closer to that of the missing bone. A finite elements model was developed to improve bone fixation of the implant and load transfer through the bone-implant interfaces.Plusieurs études rapportent l’intérêt de structures poreuses synthétiques reproduisant la micro-architecture osseuse pour obtenir une régénération des pertes de substance osseuses. La fusion laser sélective de titane permet de fabriquer des implants poreux aux propriétés mécaniques très proches de celles de l’os et au potentiel d’ostéointégration élevé. Néanmoins, la recolonisation osseuse des pores de ces implants peut être limitée par leurs propriétés élastiques que nous considérons surdimensionnées. Nous avons mis au point une étude expérimentale chez la brebis afin d’évaluer l’influence des propriétés élastiques de ces implants, utilisés dans des pertes de substance mandibulaires, sur leur recolonisation osseuse. Des implants poreux et contrôles permettant une reprise intégrale de la sollicitation mécanique ont été développés. Deux groupes de six brebis ont été équipés d’implants poreux et d’implants contrôles controlatéraux de raideur variable. La régénération osseuse au sein des implants a été évaluée par caractérisation mécanique des interfaces os–implant et par la mesure du volume osseux néoformé à partir d’acquisitions micro-CT. Les implants poreux ont permis une meilleure régénération osseuse que les implants contrôles. Les implants poreux à la raideur la plus basse ont montré une régénération osseuse significativement plus élevée que les autres implants poreux. Un modèle en éléments finis a été développé afin d’optimiser la fixation des implants et la transmission des contraintes aux interfaces os-implant