Patient-Specific Polyetheretherketone Facial Implants in a Computer-Aided Planning Workflow Godoberto Guevara-Rojas, MSc, Michael Figl, MSc, DSc, Kurt.

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Patient-Specific Polyetheretherketone Facial Implants in a Computer-Aided Planning Workflow Godoberto Guevara-Rojas, MSc, Michael Figl, MSc, DSc, Kurt Schicho, MD, DSc, PhD, Rudolf Seemann, MSc, MD, DMD, MBA, PhD, Hannes Traxler, MD, Apostolos Vacariu, MD, Claus-Christian Carbon, MA, PhD, Rolf Ewers, MD, DMD, PhD, Franz Watzinger, MD, DMD, PhD Journal of Oral and Maxillofacial Surgery Volume 72, Issue 9, Pages 1801-1812 (September 2014) DOI: 10.1016/j.joms.2014.02.013 Copyright © 2014 American Association of Oral and Maxillofacial Surgeons Terms and Conditions

Figure 1 A-C, Preoperative 3-dimensional photograms of the 27-year-old female patient. The midface hypoplasia is clearly visible. Journal of Oral and Maxillofacial Surgery 2014 72, 1801-1812DOI: (10.1016/j.joms.2014.02.013) Copyright © 2014 American Association of Oral and Maxillofacial Surgeons Terms and Conditions

Figure 2 A-D, Concept of our planning approach. Virtual Le Fort III osteotomy for achievement of the desired outcome according to soft tissue prediction and subtraction of the original (ie, actual preoperative) situation provides an initial definition of the polyetheretherketone patient-specific implant design. Journal of Oral and Maxillofacial Surgery 2014 72, 1801-1812DOI: (10.1016/j.joms.2014.02.013) Copyright © 2014 American Association of Oral and Maxillofacial Surgeons Terms and Conditions

Figure 2 A-D, Concept of our planning approach. Virtual Le Fort III osteotomy for achievement of the desired outcome according to soft tissue prediction and subtraction of the original (ie, actual preoperative) situation provides an initial definition of the polyetheretherketone patient-specific implant design. Journal of Oral and Maxillofacial Surgery 2014 72, 1801-1812DOI: (10.1016/j.joms.2014.02.013) Copyright © 2014 American Association of Oral and Maxillofacial Surgeons Terms and Conditions

Figure 3 Iterations of osteotomy movements and simulation of soft tissue changes. A,B, Axial images with 0-mm bone segment reposition. C,D, Axial images showing bone segment reposition (3 mm anterior) and respective soft tissue changes. E,F, Axial images showing bone segment reposition (5 mm anterior) and respective soft tissue changes. Journal of Oral and Maxillofacial Surgery 2014 72, 1801-1812DOI: (10.1016/j.joms.2014.02.013) Copyright © 2014 American Association of Oral and Maxillofacial Surgeons Terms and Conditions

Figure 3 Iterations of osteotomy movements and simulation of soft tissue changes. A,B, Axial images with 0-mm bone segment reposition. C,D, Axial images showing bone segment reposition (3 mm anterior) and respective soft tissue changes. E,F, Axial images showing bone segment reposition (5 mm anterior) and respective soft tissue changes. Journal of Oral and Maxillofacial Surgery 2014 72, 1801-1812DOI: (10.1016/j.joms.2014.02.013) Copyright © 2014 American Association of Oral and Maxillofacial Surgeons Terms and Conditions

Figure 4 “Expressiveness” is an important measure of the quality of a simulation, especially in esthetic surgery. A, Reconstruction from computed tomography data provided precise information on the shape and geometry of the facial surface for the surgeon, but were obviously not sufficiently illustrative to inform the patient, primarily because the hair, eyebrows, and eyelashes were not visualized. B, Merging of a (conventional) digital photograph with the 3-dimensional reconstruction from the computed tomography data clearly enhanced the “natural and realistic” look, but lacked reliability and precision owing to distortions of the surface geometry from the matching method. Journal of Oral and Maxillofacial Surgery 2014 72, 1801-1812DOI: (10.1016/j.joms.2014.02.013) Copyright © 2014 American Association of Oral and Maxillofacial Surgeons Terms and Conditions

Figure 5 Intraoperative view. Left, Electromagnetic patient reference frame fixed on the calvaria using microscrews, and Right, patient-specific implant in situ. Reliable and precise intraoperative positioning of the implant can be achieved with navigation. Journal of Oral and Maxillofacial Surgery 2014 72, 1801-1812DOI: (10.1016/j.joms.2014.02.013) Copyright © 2014 American Association of Oral and Maxillofacial Surgeons Terms and Conditions

Figure 6 Screenshot of the soft tissue simulation model with color coding for the Hausdorff distance, evaluated using the software MESH. Left, Color coded (“cold to warm”) point to surface distances are shown. Far left, Perceptible within the histogram, almost all the distances remained less than 0.7 mm. Right, a rendering of the simulation planning CT is shown. Journal of Oral and Maxillofacial Surgery 2014 72, 1801-1812DOI: (10.1016/j.joms.2014.02.013) Copyright © 2014 American Association of Oral and Maxillofacial Surgeons Terms and Conditions

Figure 7 Histogram showing the point to surface distances of the points from the first to the second surface. Journal of Oral and Maxillofacial Surgery 2014 72, 1801-1812DOI: (10.1016/j.joms.2014.02.013) Copyright © 2014 American Association of Oral and Maxillofacial Surgeons Terms and Conditions

Figure 8 Preoperative and postoperative photogrammetry images of the patient, showing the esthetic benefit. The postoperative photographs were taken 2 months after surgery. A,C,E, Preoperative photogrammetry images of the patient. B,D,F, Postoperative photogrammetry images of the patient. Journal of Oral and Maxillofacial Surgery 2014 72, 1801-1812DOI: (10.1016/j.joms.2014.02.013) Copyright © 2014 American Association of Oral and Maxillofacial Surgeons Terms and Conditions

Figure 8 Preoperative and postoperative photogrammetry images of the patient, showing the esthetic benefit. The postoperative photographs were taken 2 months after surgery. A,C,E, Preoperative photogrammetry images of the patient. B,D,F, Postoperative photogrammetry images of the patient. Journal of Oral and Maxillofacial Surgery 2014 72, 1801-1812DOI: (10.1016/j.joms.2014.02.013) Copyright © 2014 American Association of Oral and Maxillofacial Surgeons Terms and Conditions

Figure 9 A, Axial and B, coronal images showing that the geometries of the bone segment and implant differed mainly at the edges (green contour indicates the bone segment; red contour, the implant). Journal of Oral and Maxillofacial Surgery 2014 72, 1801-1812DOI: (10.1016/j.joms.2014.02.013) Copyright © 2014 American Association of Oral and Maxillofacial Surgeons Terms and Conditions