这项工作部分是由 jsp KAKENHI 授予号 JP17K11914 支持的。

这项研究得到了作者的机构审查委员会的批准, 所有患者都完成了书面同意表格。
1. 材料的制备
<ol><li>使用个人计算机, 计算机断层扫描 (CT) 数据的面部骨骼和腓骨, 转换软件, 如 InVesalius20和三维 (3 维) CAD 软件 (如搅拌机21)。 注: 为精确设计推荐1毫米 CT 数据的最大厚度。对于实际的手术模拟, 使用病人的 CT 资料。为了研究, 使用免费的人类3维数据22。</li>
	<li>使用3维打印机23, 螺丝, 金属板, 和一个小锯, 不仅检查设计, 而且真实的对象和结果。 注: 本研究是实验性的。金属板、螺丝和小锯子可用于模型手术。而不是金属板, 塑料固定板也可以打印的3维打印机, 连同手术指南。</li>
	<li>使用 InVesalius20将面部骨骼和腓骨的成像数据转换为3维数据 (. stl 格式)。 注: CT 数据基本上以二维 (2 维) 图片的形式记录下来。因此, 在使用3维数据之前, 必须将数据转换为3维数据。免费软件足以达到这个目的。本报告不解释如何将数据传输到3维文件中;其他地方可提供教学视频和指南。</li>
	<li>将每个. stl 文件导入搅拌器21。 注意: CAD 软件通常接受. stl 样式的3维格式。首先, 应在特定的 CAD 软件中通过导入来打开上颌和腓骨. stl 文件。</li>
</ol>2. 设计
<ol><li>骨缺损的修复与骨修复
	<ol>
<li>决定要切除的区域。 注意: 在这个实验性的模拟手术中, 上颌的任何部分都可以被设置为切除区。因为重建后的总上颌骨是困难的, 只有一小部分的上颌将是一个选择初学者。在临床环境中, otorhinolaryngologists 将根据癌变区域决定该区域。</li>
		<li>制作一架大型飞机, 并将其放在该区域的边框上以在对象模式下进行删除 (图 1a和1b)。通过放置第二个平面 (图 1b-1d) 然后继续这样做, 直到飞机环绕整个区域进行拆卸。在对象模式中统一这些平面。</li>
		<li>选择所有这些平面的顶点, 并通过在编辑模式中制作边和面 (图 1e) 将它们连接起来, 以环绕区域进行移除。 注意: 切除的飞机应该被复制和维护, 因为这些原始的飞机在固化切除术时使用和丢弃。在本研究中, 建议每个场合都复制每一个平面和固体, 以使其能够重用它们。</li>
		<li>使用编辑模式中的布尔修饰符从面部骨骼中减去切除固体。这导致一个剃光面部骨 (图 1f), 这是上颌缺损模型。</li>
	</ol></li>
	<li>放置腓骨骨
	<ol>
<li>将腓骨放入上颌缺损区 (图 2a)。放置小立方体在两点 (远端8厘米从腓头和5厘米近侧踝) 在腓骨作为标记 (紫色小立方体显示在图 2)。 注: 在临床情况下, 腓骨从腓头远端8厘米至离侧踝近5厘米之间可使用。通过这个标记, 我们可以很容易地理解可以使用的区域。</li>
		<li>将小多维数据集链接到作为对象模式中的父设置的腓骨。</li>
		<li>将小立方体作为标记, 在上颌病变的几个点, 重建是必要的。用这个标记, 必要的再生产点的能见度增加。</li>
		<li>如果腓骨是从中线放置的, 则在物体模式下, 将腓骨与肺泡骨的前缘吻合。</li>
		<li>使用上上颌截骨前平面作为第一个腓骨截骨平面 (图 2b)。</li>
		<li>放置一个新的截骨平面在适当的对象模式 (图 2c)。将这架新飞机连接到腓骨作为父母的设置。 注意: 通过将父母设置为腓骨, 即使腓骨被移到不同的地方, 这种新的截骨平面与腓骨之间的相对方向仍然保持不变。由这两个切割面包围的腓骨的面积成为第一个腓骨块。</li>
		<li>将腓骨和两个截骨平面复制为对象模式中的父设置。移动这个复制的腓骨, 它有第一块区域, 两端有两个切割平面, 到第二个需要重建的区域 (图 2e) 来规划第二个腓骨块。</li>
		<li>通过在对象模式中添加新平面, 放置第二个切削平面。 注: 第一和第二切割平面将成为第二个腓骨块的两端。如果需要第三个块, 则添加类似的过程。应保持相邻腓骨块之间适当长度的间隙。 注意: 第一和第二块之间的差距被认为是一个舒适的截骨的关键。如果这一差距很大, 截骨将是容易的, 因为广泛的工作空间, 但血管长度是有点浪费。相比之下, 如果差距很小, 截骨变得麻烦, 但第二个或第三个街区可以通过消除浪费的未使用的骨头。</li>
	</ol></li>
	<li>腓骨切割导轨的设计
	<ol>
<li>仅可视化腓骨和切割平面, 以便在对象模式下设计腓骨切割指南 (图 3a)。</li>
		<li>在编辑模式下, 通过沿边缘滑动顶点 (图 3b-3d), 使每个切割平面较小, 仅占用腓骨切割部分的一半面积。 注: 切口导轨的拟合侧为腓骨的侧面。由于饲用血管位于内侧, 指南不是设计在内侧的方面。</li>
		<li>将两端的两个平面联合起来, 以在对象模式中构建一个实体 (图 4a-4e)。选择所有这些平面的顶点, 并通过在编辑模式中制作边和面来形成矩形实心来连接它们。</li>
		<li>使用布尔修饰符 (图 5a-5c) 从这个矩形实体中减去腓骨。 注: 这种减法的表面完全适合腓侧侧面。同样的程序在每一个必要的腓骨块重复。</li>
		<li>在对象模式中统一每个减法实体。</li>
		<li>在减去的固体附近放置一个立方体 (图 5d)。挤出工作面制造柱子 (图 5e-5g)。把这些柱子与减去的固体结合起来。这是腓骨切割指南 (图 5h-5j)。</li>
	</ol></li>
	<li>上颌截骨切口指南 注意: 为了切开上颌, 没有必要为每一个切割面设计指南, 因为只有有限的区域是用腓骨重建的。通常, 两个切割指南, 包括内侧肺泡和侧颧骨地区, 设计。<ol>
<li>准备上颌和颧骨的飞机, 这是原始剩余的表面后, 上颌骨切除。宽度为1厘米的边距足够 (图 6a)。</li>
		<li>挤出步骤2.4.1 中准备的面使平面变厚, 并使用凝固修饰符将其凝固在编辑模式下 (图 6b)。</li>
		<li>删除在步骤2.1 中决定在两端的切除平面上加厚的固体;这就是如何设计上颌切割导轨。 注意: 如果管接头表面是锯齿状的, 则较小的拟合区域就足够了。如果拟合曲面易于平整, 则需要大面积的区域以避免导轨的任何滑动。</li>
	</ol></li>
	<li>腓骨段固定指南 注: 将转移到上颌骨的腓骨段被认为是准确的大小和长度, 但转移的位置可以自由地偏离, 如果不使用固定指南。腓骨和每一个切割平面 (如步骤2.2 所做的) 在这个段中再次使用。<ol>
<li>在布尔修饰符中构造每个腓骨块, 方法是在 "编辑" 模式下, 取出腓骨与实心之间的相交区域 (图 7a和7b)。</li>
		<li>提取每个腓骨块表面的一半。</li>
		<li>在对象模式中联合所有这些曲面 (图 7c)。</li>
		<li>使用刀切 (图 8a) 在编辑模式下删除小面孔, 以确保金属板的贴合空间。</li>
		<li>在编辑模式下使用凝固修饰符 (图 8b-8e) 使曲面变厚。 注: 要稳定固定导轨, 避免翘曲, 必须要有最低的2–3毫米厚度。如果机翼是两端设计的, 它将帮助指导上颌骨不使用任何金属板。</li>
	</ol></li>
</ol>3. 3 维印刷模型手术和真实指南
注: 本报告的主要目的是说明设计手术指南的方法;如果不需要3维打印, 则不需要下面描述的过程。
<ol><li>导出. stl 格式的指南设计, 可以打印3维。</li>
	<li>打印所有指南和骨骼。 注: 在印刷中, 筏被认为是扰乱平滑表面印刷和导致锯齿状表面和较差的骨骼, 所以需要平滑的平面必须向上指出。</li>
	<li>
执行模型手术如下:
	<ol>
<li>与实际手术类似, 先将上颌切口引导至面部骨模型 (图 9a)。然后, 用锯子将脸部骨与切割平面一起切开。</li>
		<li>将腓骨切割指南附在腓骨骨模型上, 将其切成块 (图 9b)。将腓骨块连接至固定指南 (图 9c和9d)。</li>
		<li>使用螺钉和钢板固定本固定指南复杂的上颌缺损 (图 9e)。在固定指南未用螺钉和钢板固定的地方, 将腓骨段修复至上颌骨后, 取下固定指南。这完成了重建 (图 9f)。</li>
	</ol>
</li>
	<li>扫描3维重建的图像, 并用3维扫描仪24将其记录到. stl 格式中。</li>
	<li>比较后模型手术. stl 文件和 CAD 重建设计 (图 10) 使用比较软件25。 注: 通过对虚拟重构设计与制导重建模型的比较, 计算出实际精度。由于 CAD/凸轮精度是在下颌重建10的 2.5 mm 偏差内获得的, 因此该方法需要类似的精度。如果无法获得所需的精度, 请重做虚拟设计。</li>
</ol>

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<li>Rendon-Medina, M. A., Andrade-Delgado, L., Telich-Tarriba, J. E., Fuente-Del-Campo, A., Altamirano-Arcos, C. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Dimensional+error+in+rapid+prototyping+with+open+source+software+and+low-cost+3D-printer%5BTitle%5D)+AND+%22Plastic+and+Reconstructive+Surgery+-+Global+Open%22%5BJournal%5D)">Dimensional error in rapid prototyping with open source software and low-cost 3D-printer.</a> Plastic and Reconstructive Surgery - Global Open. 6 (1), 1646(2018).</li>
<li>Nizam, A., Gopal, R. N., Naing, L., et al. <a target="_blank" href="https://www.researchgate.net/publication/45492328_Dimensional_accuracy_of_the_skull_models_produced_by_rapid_prototyping_technology_using_stereolithography_apparatus">Dimensional accuracy of the skull models produced by rapid prototyping technology using stereolithography apparatus.</a> Archives of Orofacial Sciences. 1, 60-66 (2006).</li>
</ol>

作者没有什么要申报的。

CAD/CAM 重建被认为有助于达到准确的截骨长度, 宽度和角度的切割骨骼, 而使用切割指南4,5,6,7,8 ,9,10,11,12,13,14,15,16,17 ,18,19。骨转移的安排也被认为是正确的使用固定指南11。由于订单、工艺、裁剪平面和排列计划在实际手术前已经决定, 节省时间是另一个优势2,12,13,14。
此外, 除了这些理论优势外, cad/cam 技术的一个优点是, 由于手术指导, 任何外科医生都可以以同样的方式切割同一地方, 从而使技术标准化。如果指南是非常准确的, 这是可能的, 每个外科医生可以获得准确的重建结果, 而不是使用一个自由的方法, 结果是相当依赖于专业知识。由于这种 CAD/CAM 技术最近出现, 类似的报告很少。西方国家提供商业指南;然而, 设计方法对公众并不开放。由于这种设计方法是新的, 我们期望它能在将来得到广泛的发展和推广。
这种内部 CAD/CAM 方法并不总能显示出优越性。一个临床问题是, 当 CT 检查数据不是由细切片或在手术前获得时, 该技术就变得无用了, 外科医生要么不快速决定切除区域, 要么突然改变切除区域。手术内。
设计上的问题是, 如果设计者没有足够的经验去观察和学习手术过程, 就无法获得合适的外科指导设计。毕竟, 在这种情况下, 设计者不知道真正的外科医生会做什么确切的空间, 以便在每一个手术的情况下没有对象。
作为一个成本问题, 一台3维打印机对于初学者设计者来说是必要的, 它可以创建尝试错误的设计来具体化实际的指南。在成为一个经验丰富的设计师后, 设计的物化不再是不可或缺的。幸运的是, 计算机和3维打印机变得越来越便宜, 这意味着我们可以独立设计和制造外科指南, 而不必依赖昂贵的公司的服务。缺点是, 我们还不能3维打印用于固定的金属板。塑料是我们可用于3维印刷的主要材料。因此, 我们必须在手术前先弯曲金属板。由于可处理金属的价格低廉的3维打印机有望在将来使用, 因此也可以设计固定板, 所有程序都不依赖于自由手技术。
熔融沉积建模是最常用的3维印刷技术之一。3维物体是通过喷嘴挤压热塑性聚合物而建立的。当热塑性材料得到冷时, 内部应力可能产生变形 (翘曲)26。丙烯腈丁二烯苯乙烯 (ABS) 和聚乳酸 (PLA) 是用于热塑性纤维的主要塑料。佩特罗波利斯等。7提到, 由于 abs 下颌骨模型特别容易翘曲, 与 PLA 相比, abs 塑料对外科模型的理想程度较小。ABS 和 PLA 塑料都是气体消毒和足够刚性作为模板27。与 ABS 相比, PLA 的熔化温度较低, 具有更低的灵活性。因此, 我们使用 PLA 和低温等离子灭菌方法在45摄氏度以下的临床情况。因为我们使用的 PLA 的玻璃温度是60°c, 我们没有使用高压灭菌 (大约121°c) 或乙烯气体氧化物绝育 (大约60°c)。
翘曲变形仍然是可能的。然而, 以前的报告证实了在颌面部手术领域中的有限差分印刷模型的准确性28。一些文章使用扫描 CT 数据对干人下颌骨和有限差分打印复制副本进行了比较研究。这些研究表明, 消费者级的有限差分打印模型有一个可接受的准确性, 类似于工业选择性激光烧结 (SLS) 打印机27,29,30的结果。尼扎姆等。1的人认为, CT 扫描的质量也是尺寸误差的主要决定因素之一, 同时也是快速原型机。
即使精确的指南设计实际上, 打印指南有时不适合手术前的手术骨模型。我们认为这有两个原因。
1. 指南设计要附着的区域表面骨状的形状太平, 不能钩住 (尤其是上颌骨)。如果这些表面是平滑的, 而不是不均匀的, 导向表面容易变得光滑, 并有可能对错误的骨区。为了避免这种情况, 应设计更广泛和更广泛的附加区域, 以捕捉确切的骨区。同时, 如果附上区域变得更大, 被破坏的区域变得更大, 导致一个更宽的疤痕。
2. 另一方面, 如果这个表面的形状太不均匀和复杂, 整形外科指南也很难适应。由于一个粗糙的表面与许多小过程的 CAD/凸轮导轨诱导摩擦阻力时, 附着在骨骼, 过度缠绕和复杂的导向表面也容易错误的地方。为了避免这种情况, 在实际手术前进行试错印和模型手术是必要的。因此, 不建议将3维打印外包出去。
最后, 即使指南能够适应模型手术, 当它不适合临床情况下, 它应该被认为是一种参考指南。这与商业指南不适合的情况类似。在真正的手术中, 最终的决定应该基于对外科医生的咬合和面部美感的承认, 而不是由指南。
虽然使用内部 CAD/CAM 方法比商业方法更便宜, 但实际成本, 包括外科医生的自愿工作和设计和印刷的时间, 总是被低估或忽视。然而, 即使商业指南变得更便宜, 这种内部方法仍然有一个独特的优势, 这是外科医生可以直接和容易地执行的尝试和错误重建在虚拟仿真和实现之间的位置关系面部骨和腓骨段。
指南的设计限于硬组织, 如骨骼在本报告。然而, 手术指南可以设计为软组织切割和固定, 如脂肪或肌肉组织。指南被认为是适用于手术, 目的是执行3维结构重建使用软组织。固定指南将很快被设计为乳房重建后, 癌症消融手术后, 最适合重塑的转移脂肪组织从腹部到乳房。
总之, 采用内部方法, 可以在医院设计和打印 cad/cam 手术指南。除了使用 CAD/CAM 进行精确的重建外, 这些技术还可以被那些生活在有商业指南的地区以外的外科医生使用。这种技术是上颌重建的一种选择。

cad/cam 技术的使用最近在牙科和义齿工作中有所增加。继 cad/cam 的进化后, 腓骨瓣转移使用 cad/cam 现在用于下颌骨重建领域的肿瘤广泛切除恶性肿瘤1,2,3。一些西方国家的公司已经开始为下颌骨地区提供和销售 CAD/凸轮切割指南。下颌骨的 CAD/凸轮重建被认为在精确度4、5、6、7、8、9、10等方面有优势. ,11。然而, 一个缺点是这项技术在世界范围有限的地区是可利用的, 并且它是非常昂贵的12。因此, 上颌病变的 cad/cam 重建尚未流行。上颌重建的病例数低于下颌骨, 商业指南不常见。
由于在日本没有销售商用上颌 cad/凸轮导轨, 我们使用内部方法开发了 cad/cam 外科指南。cad/cam 指南的临床效果已报告13、14、15、16、17、18、19, 但没有报告如何设计它们。本报告的目的是用一种低成本的内部方法显示 cad/cam 设计方法。

<table><tbody><tr><td>Information Technology Center, Renato Archer, Campinas, Brazil</td><td>InVesalius</td><td>Free software https://www.cti.gov.br/en/invesalius</td><td></td></tr><tr><td>The Blender Foundation, Amsterdam, Netherlands</td><td>Blender</td><td>Free software https://www.blender.org/</td><td></td></tr><tr><td>TurboSquid, Inc. 935 Gravier St., Suite 1600, New Orleans, LA.</td><td>Free 3D skeletal data file</td><td>Free3D https://free3d.com/3d-models/human</td><td></td></tr><tr><td>MakerBot Industries, LLC One MetroTech Center, 21st Fl, Brooklyn, NY.</td><td>MakerBot Replicator+</td><td>https://www.makerbot.com/replicator/</td><td></td></tr><tr><td>YouTube (Google, Inc.), 901 Cherry Ave. San Bruno, CA</td><td>video sharing website.</td><td>https://www.youtube.com/results?search_query=invesalius+dicom+to+stl</td><td></td></tr><tr><td>Artec 3D, 2, rue Jean Engling, Luxembourg</td><td>Artec Eva Lite</td><td>https://www.artec3d.com/portable-3d-scanners/artec-eva-lite</td><td></td></tr><tr><td>CloudCompare</td><td>CloudCompare</td><td>http://www.danielgm.net/cc/</td><td></td></tr></tbody></table>

designing cad/cam surgical guides for maxillary reconstruction using an in-house approach

计算机辅助设计/计算机辅助制造 (cad/cam) 现正作为颌面外科的制备技术进行评估。由于这项技术成本高昂, 而且在世界上只有有限的地区可用, 我们开发了一种新的 CAD/CAM 外科指南, 采用内部方法。采用 CAD 软件, 确定上颌切除面积、截割面、腓骨切割面和角度。一旦确定了切除区域, 就用布尔修饰符提取必要的面孔。这些肤浅的面孔被团结了适合骨头的表面和加厚稳定固体。不仅在腓骨和上颌骨的切割指导, 而且转移骨段的位置安排是通过加厚表面的面孔定义的。CAD 设计被记录为. stl 文件和三维 (3 维) 打印为实际的外科指南。为了检查指南的准确性, 采用3维打印的面部和腓骨模型进行手术。这些方法可用于协助未提供商业指南的外科医生。

使用这里提出的程序, 首先确定切除区。使用 CAD 软件, 切除区域完全受面约束。这个区域从面部骨头被一个布尔操作减去。腓骨图像被放置在缺陷上, 腓骨切割面放置在适当的重建点。所有腓骨切开的面孔在父母设置连接了腓骨。这些面孔被做了更小和团结了做固体。腓骨被从这些固体中减去, 然后成为腓骨切割指南。面部骨的其余表面也加厚;这些成为上颌切割指南。腓骨段的表面两侧被联合并提取成固定指南。最后, 在搅拌器中设计了腓骨切割导、上颌切口导、腓骨固定指南。这些指南的设计以. stl 格式导出。他们成为了真正的塑料对象的3维印刷 (图 9a和9b)。
进行模型手术 (图 9c-9f)。上颌切开引导和腓骨切割指南完全安装在面部骨和腓骨骨模型。用锯切模型, 用钛板和螺钉固定结果。经固定后, 3 维重建图像由3维扫描仪24确定。后模型手术. stl 文件和 CAD 重构设计是通过比较软件25的指导和程序的准确性进行比较的。模型手术的数据如图 10所示;重建可以近似地执行在2毫米偏差之内。
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/58015/58015fig1.jpg"> 图 1: 决定上颌切除术的面积.(a) 原始的面部骨骼. stl 文件被导入到搅拌机中。(b) 第一切面插入颧骨病变。(c) 下一架切割机放置。(d) 还设置了牙槽区的切割平面。(e) 切割面必须统一, 并完全环绕切除区。(f) 使用布尔修饰符, 从面部骨骼中减去上颌骨区域。<a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/58015/58015fig1large.jpg" target="_blank">请单击此处查看此图的较大版本.</a>
<img alt="Figure 2" class="xfigimg" src="/files/ftp_upload/58015/58015fig2.jpg"> 图 2: 规划腓骨段的位置.(a) 将腓骨. stl 文件导入搅拌机。腓骨远端部分先放在肺泡区。(b) 切割平面被复制并链接到腓骨作为父母的设置。(c) 根据规划外科医生的喜好, 下一架切割机放置在腓骨上。被夹在这两架飞机之间的腓骨区域成为第一个必要的腓骨段。(d) 确定下一个腓骨段的位置, 将被复制的腓骨放置。下一架切割机也根据外科医生的判断放置。(e) 最后, 如本例所示, 设计了三个腓骨块。<a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/58015/58015fig2large.jpg" target="_blank">请单击此处查看此图的较大版本.</a>
<img alt="Figure 3" class="xfigimg" src="/files/ftp_upload/58015/58015fig3.jpg"> 图 3: 沿边缘滑动顶点.(a) 三对切割机与腓骨相连, 作为父母的设置。(bd)为了获得适当的参考设计, 平面的顶点沿编辑模式的边缘移动。<a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/58015/58015fig3large.jpg" target="_blank">请单击此处查看此图的较大版本.</a>
<img alt="Figure 4" class="xfigimg" src="/files/ftp_upload/58015/58015fig4.jpg"> 图 4: 设计制作盒, 作腓骨切割指南.(a) 这架切割机的尺寸将减小, 以成为合适的切割导轨尺寸。(b) 切割机的最终尺寸被突出显示。(c) 切割平面是通过沿边缘滑动顶点来确定的, 类似于图 3。(d) 通过在对象模式中添加新平面, 两个切割平面都是统一的。(e) 最后, 在编辑模式中添加平面以环绕整个曲面。<a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/58015/58015fig4large.jpg" target="_blank">请单击此处查看此图的较大版本.</a>
<img alt="Figure 5" class="xfigimg" src="/files/ftp_upload/58015/58015fig5.jpg"> 图 5: 制作腓骨切割指南.(a) 使用图 4所示的步骤, 设计了三个方框。(b) 每个盒子都是用布尔修饰符的减法来共享的。(c) 每个盒子的相对表面与腓骨表面完全相同。(d) 制作柱子, 在减去的固体附近放置一个立方体。(e) 这个立方体的表面是挤压的。(f) 重复此挤压, 主要支柱。(g) 增加其他支柱, 对减去固体的附着物进行。(h) 柱子和减去的固体是统一的。(i和j) 这个切割指南完全适合于腓骨的表面。每个边缘成为切割平面, 引导切割锯。<a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/58015/58015fig5large.jpg" target="_blank">请单击此处查看此图的较大版本.</a>
<img alt="Figure 6" class="xfigimg" src="/files/ftp_upload/58015/58015fig6.jpg"> 图 6: 设计上颌切割导轨.(a) 上颌骨和颧骨的其余表面仅在切割区附近准备好。(b) 这些飞机加厚, 以构造固体适合颧骨和上颌骨, 使用凝固修饰剂在编辑模式。这个固体的边缘成为锯切的平面。<a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/58015/58015fig6large.jpg" target="_blank">请单击此处查看此图的较大版本.</a>
<img alt="Figure 7" class="xfigimg" src="/files/ftp_upload/58015/58015fig7.jpg"> 图 7: 取出转移平面.(a) 每个腓骨段用布尔修饰符的交集隔开。(b) 在这种情况下, 牙槽重建优先于颧骨突出。(c) 收集和联合所有表面的面孔, 以便为固定指南的建造作准备。<a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/58015/58015fig7large.jpg" target="_blank">请单击此处查看此图的较大版本.</a>
<img alt="Figure 8" class="xfigimg" src="/files/ftp_upload/58015/58015fig8.jpg"> 图 8: 设计腓骨段固定指南.(a) 使用刀具工具, 线条被设计成表面。(b) 通过删除顶点和面来制作一个小窗口。此窗用于钛板固定。(c) 在制作了几扇窗户后, 表层表面会用凝固修饰剂加厚。(d和e) 只有固定指南是可视化的。在两端, 增加的翅膀, 以修复这个指南, 其余的面部骨骼。<a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/58015/58015fig8large.jpg" target="_blank">请单击此处查看此图的较大版本.</a>
<img alt="Figure 9" class="xfigimg" src="/files/ftp_upload/58015/58015fig9.jpg"> 图 9: 模型手术.(a) 使用3维打印机, 可以实现面部骨、腓骨骨和手术指南。(b) 检查切割指南完全适合腓骨。(c和d) 使用切割指南切割的腓骨段设置为固定指南。固定指南可以完全适合切口段。(e和f) 使用钛板和螺钉, 腓骨段转移到上颌骨。除去固定指南后, 增加了更多的钢板和螺钉, 以加强固定。<a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/58015/58015fig9large.jpg" target="_blank">请单击此处查看此图的较大版本.</a>
<img alt="Figure 10" class="xfigimg" src="/files/ftp_upload/58015/58015fig10.jpg"> 图 10: 将模型与计划进行比较.术后模型扫描3维, 并与虚拟计划进行比较。刻度 (毫米) 显示与虚拟计划的偏离距离。转移的骨头主要有低偏差 (绿色), 而金属固定板有更高的偏差 (红色)。然而, 偏差主要在2毫米以下。此图像与图 9所示的示例不同。<a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/58015/58015fig10large.jpg" target="_blank">请单击此处查看此图的较大版本.</a>

Watch this Scientific Journal Video about Designing CAD/CAM Surgical Guides for Maxillary Reconstruction Using an In-house Approach at JoVE.com

Designing CAD/CAM Surgical Guides for Maxillary Reconstruction Using an In-house Approach

介绍了计算机辅助设计/计算机辅助制造 (cad/cam) 外科指南的设计方法。切割平面分离, 联合, 加厚, 以方便地可视化必要的骨转移。这些设计可以三维打印和检查的准确性。

用内部方法设计上颌重建的 cad/cam 手术指南

Computer-aided design/computer-assisted manufacturing (CAD/CAM) is now being evaluated as a preparative technique for maxillofacial surgery. Because this ...

designing-cadcam-surgical-guides-for-maxillary-reconstruction-using

Nanyang Technological University

Research

JoVE Journal

Medicine

9.0K 次观看.  Kyoto Prefectural University of Medicine. 介绍了计算机辅助设计/计算机辅助制造 (cad/cam) 外科指南的设计方法。切割平面分离, 联合, 加厚, 以方便地可视化必要的骨转移。这些设计可以三维打印和检查的准确性。

视频: Designing CAD/CAM Surgical Guides for Maxillary Reconstruction Using an In-house Approach

使用有限元模型分析 SARPE 的膨胀模式

Finite Element Analysis Model for Assessing Expansion Patterns from Surgically Assisted Rapid Palatal Expansion

Surgically assisted rapid palatal expansion (SARPE) was introduced to release bony resistance to facilitate skeletal expansion in skeletally mature patients. However, asymmetric expansion between the left and right sides has been reported in 7.52% of all SARPE patients, of which 12.90% had to undergo a second surgery for correction. The etiologies leading to asymmetric expansion remain unclear. Finite element analysis has been used to evaluate the stress associated with SARPE in the maxillofacial structures. However, as a collision of the bone at the LeFort I osteotomy sites occurs only after a certain amount of expansion, most of the existing models do not truly represent the force distribution, given that the expansion amount of these existing models rarely exceeds 1 mm. Therefore, there is a need to create a novel finite element model of SARPE that could perform a clinically required amount of expander activation for further analysis of the expansion patterns of the hemimaxillae in all three dimensions. A three-dimensional (3D) skull model from cone beam computed tomography (CBCT) was imported into Mimics and converted into mathematical entities to segment the maxillary complex, maxillary first premolars, and maxillary first molars. These structures were transferred into Geomagic for surface smoothing and cancellous bone and periodontal ligament creation. The right half of the maxillary complex was then retained and mirrored to create a perfectly symmetrical model in SolidWorks. A Haas expander was constructed and banded to the maxillary first premolars and first molars. Finite element analysis of various combinations of buccal osteotomies at different angles with 1 mm clearance was performed in Ansys. A convergence test was conducted until the desired amount of expansion on both sides (at least 6 mm in total) was achieved. This study lays the foundation for evaluating how buccal osteotomy angulation influences the expansion patterns of SARPE.

作者聚焦：开发一种用于改进正颌手术技术的新型有限元分析模型 

A set of novel finite element models of surgically assisted rapid palatal expansion (SARPE) that could perform a clinically required amount of expander activation with various angles of buccal osteotomy was created for further analysis of the expansion patterns of the hemimaxillae in all three dimensions.

用于评估手术辅助快速腭扩张模式的有限元分析模型

Surgically assisted rapid palatal expansion (SARPE) was introduced to release bony resistance to facilitate skeletal expansion in skeletally mature ...

科研

生物工程

A Postoperative Evaluation Guideline for Computer-Assisted Reconstruction of the Mandible

Valid comparisons of postoperative accuracy results in computer-assisted reconstruction of the mandible are difficult due to heterogeneity in imaging modalities, mandibular defect classification, and evaluation methodologies between studies. This guideline uses a step-by-step approach guiding the process of imaging, classification of mandibular defects and volume assessment of three-dimensional (3D) models, after which a legitimized quantitative accuracy evaluation method can be performed between the postoperative clinical situation and the preoperative virtual plan. The condyles and the vertical and horizontal corners of the mandible are used as bony landmarks to define virtual lines in the computer-assisted surgery (CAS) software. Between these lines the axial, coronal, and both sagittal mandibular angles are calculated on both pre- and postoperative 3D models of the (neo)mandible and subsequently the deviations are calculated. By superimposing the postoperative 3D model to the preoperative virtually planned 3D model, which is fixed to the XYZ axis, the deviation between pre- and postoperative virtually planned dental implant positions can be calculated. This protocol continues and specifies an earlier publication of this evaluation guideline.

Here, we propose a practical, feasible and reproducible evaluation guideline for computer-assisted reconstruction of the mandible in order to create uniformity between studies regarding postoperative accuracy evaluation. This protocol continues and specifies an earlier publication of this evaluation guideline.

可读机辅助重建术后评估指南

Valid comparisons of postoperative accuracy results in computer-assisted reconstruction of the mandible are difficult due to heterogeneity in imaging ...

医学

3D Planning and Printing of Patient Specific Implants for Reconstruction of Bony Defects

We are in the midst of the 3D era in most aspects of life, and especially in medicine. The surgical discipline is one of the major players in the medical field using the constantly developing 3D planning and printing capabilities. Computer-assisted design (CAD) and computer assisted manufacturing (CAM) are used to describe the 3D planning and manufacturing of the product. The planning and manufacturing of 3D surgical guides and reconstruction implants is performed almost exclusively by engineers. As technology advances and software interfaces become more user-friendly, it raises a question regarding the possibility of transferring the planning and manufacturing to the clinician. The reasons for such a shift are clear: the surgeon has the idea of what he wants to design, and he also knows what is feasible and could be used in the operating room. It allows him to be prepared for any scenario/unexpected results during the operation and allows the surgeon to be creative and express his new ideas using the CAD software. The purpose of this method is to provide clinicians with the ability to create their own surgical guides and reconstruction implants. In this manuscript, a detailed protocol will provide a simple method for segmentation using segmentation software and implant planning using a 3D design software. Following the segmentation and stl file production using segmentation software, the clinician could create a simple patient specific reconstruction plate or a more complex plate with a cradle for bone graft positioning. Surgical guides can be created for accurate resection, hole preparation for proper reconstruction plate positioning or for bone graft harvesting and re-contouring. A case of lower jaw reconstruction following plate fracture and nonunion healing of a trauma sustained injury is detailed.

This protocol describes the use of 3D planning and printing for reconstruction of bony defects. We use segmentation tools to create 3D models followed by 3D design software to create patient specific implants for reconstruction purposes concomitant to ablative surgery or as a second stage.

患者特异性植入物重建的三维规划与打印

We are in the midst of the 3D era in most aspects of life, and especially in medicine. The surgical discipline is one of the major players in the medical ...

Treatment of Facial Deformities using 3D Planning and Printing of Patient-Specific Implants

Technological advancements in surgical planning and patient-specific implants are constantly evolving. One can either adopt the technology to achieve better results, even in the less experienced hand, or continue without it. As technology develops and becomes more user-friendly, we believe it is time to allow the surgeon the option to plan his/her operations and create his/her own patient-specific surgical guides and fixation plates allowing him full control over the process. We present here a protocol for 3D planning of the operation followed by 3D planning and printing of surgical guides and patient-specific fixation implants. During this process we use two commercial computer-assisted design (CAD) software. We also use a fused deposition&#160;modeling printer for the surgical guides and a selective laser sintering printer for the titanium patient-specific fixation implants. The process includes computed tomography (CT) imaging acquisition, 3D segmentation of the skull and facial bones from the CT, 3D planning of the operations, 3D planning of patient-specific fixation implant according to the final position of the bones, 3D planning of surgical guides for performing an accurate osteotomy and preparing the bone for the fixation plates, and 3D printing of the surgical guides and the patient-specific fixation plates. The advantages of the method include full control over the surgery, planned osteotomies and fixation plates, significant reduction in price, reduction in operation duration, superior performance and highly accurate results. Limitations include the need to master the CAD programs.

As technology develops and becomes more user-friendly, planning of operations and patient-specific surgical guides and fixation plates should be performed by the surgeon. We present a protocol for 3D planning of orthognathic skeletal movements and 3D planning and printing of patient-specific fixation plates and surgical guides.

使用患者特定植入物的 3D 规划和打印治疗面部畸形

Technological advancements in surgical planning and patient-specific implants are constantly evolving. One can either adopt the technology to achieve ...

Real-Time Dynamic Navigation System for the Precise Quad-Zygomatic Implant Placement in a Patient with a Severely Atrophic Maxilla

Zygomatic implants (ZIs) are an ideal way to address cases of a severely atrophic edentulous maxilla and maxilla defects because they replace extensive bone augmentation and shorten the treatment cycle. However, there are risks associated with the placement of ZIs, such as penetration of the orbital cavity or infra-temporal fossa. Furthermore, the placement of multiple ZIs makes this surgery risky and more difficult to perform. Potential intraoperative complications are extremely dangerous and may cause irreparable losses. Here, we describe a practical, feasible, and reproducible protocol for a real-time surgical navigation system for precisely placing quad-zygomatic implants in the severely atrophic maxilla of patients with residual bone that does not meet the requirements of conventional implants. Hundreds of patients have received ZIs at our department based on this protocol. The clinical outcomes have been satisfactory, the intraoperative and postoperative complications have been low, and the accuracy indicated by infusion of the designed image and postoperative three-dimensional image has been high. This method should be utilized during the entire surgical procedure to ensure ZI placement safety.

Here, we present a protocol to achieve precise quad-zygomatic implant placement in patients with severely atrophic maxilla using a real-time dynamic navigation system.

实时动态导航系统，用于在严重萎缩性上颌骨患者中精确放置四颧植入物

Zygomatic implants (ZIs) are an ideal way to address cases of a severely atrophic edentulous maxilla and maxilla defects because they replace extensive ...

Digital Hybrid Model Preparation for Virtual Planning of Reconstructive Dentoalveolar Surgical Procedures

Virtual, hybrid three-dimensional (3D) model acquisition is presented in this article, utilizing the sequence of radiographic image segmentation, spatial registration, and free-form surface modeling. Firstly cone-beam computed tomography datasets were reconstructed with a semi-automatic segmentation method. Alveolar bone and teeth are separated into different segments, allowing 3D morphology, and localization of periodontal intrabony defects to be assessed. The severity, extent, and morphology of acute and chronic alveolar ridge defects are validated concerning adjacent teeth. On virtual complex tissue models, positions of dental implants can be planned in 3D. Utilizing spatial registration of IOS and CBCT data and subsequent free-form surface modeling, realistic 3D hybrid models can be acquired, visualizing alveolar bone, teeth, and soft tissues. With the superimposition of IOS and CBCT soft tissue, thickness above the edentulous ridge can be assessed about the underlying bone dimensions; therefore, flap design and surgical flap management can be determined, and occasional complications may be avoided.

A workflow for creating three-dimensional (3D) virtual hybrid models has been designed based on cone-beam computed tomography dataset and intraoral optical scans utilizing radiographic image segmentation methods and free-form surface modeling. Digital models are used for the virtual planning of reconstructive dentoalveolar surgical procedures.

用于重建牙槽外科手术虚拟规划的数字混合模型制备

Virtual, hybrid three-dimensional (3D) model acquisition is presented in this article, utilizing the sequence of radiographic image segmentation, spatial ...

Guided Endodontics: Three-Dimensional Planning and Template-Aided Preparation of Endodontic Access Cavities

Pulp canal obliterations (PCO) are often a consequence of dental trauma, such as luxation injuries. Even though dentin apposition is a sign of vital pulp, pulpitis or apical periodontitis may develop in the long term. Root canal treatment of teeth with severe PCO and pulpal or periapical pathosis is challenging for general practitioners and even for well-equipped endodontic specialists. To ensure detection of the calcified root canal and avoid excessive loss of tooth structure or root perforation, static navigation using templates ("Guided Endodontics") was introduced a few years ago. The general workflow includes three-dimensional imaging using cone-beam computed tomography (CBCT), a digital surface scan, and superimposition of both in a planning software. This is followed by virtual planning of the access cavity and the design of a template that will guide the drill to the desired target point. To do this, a true-to-scale virtual image of the drill must be placed in a way that the tip of the drill reaches the orifice of the calcified root canal. Once the template has been fabricated using computer-aided design and computer-aided manufacturing (CAD/CAM) or a 3D printer, guided preparation of the access cavity can be performed clinically. For research purposes, a postoperative CBCT image can be used to quantify the accuracy of the access cavity performed. This work aims to present the technique of static guided endodontics from imaging to clinical implementation.

Guided endodontics describes a template-aided approach for access cavity preparation. The procedure requires cone-beam computed tomography and a surface scan to produce a template. An incorporated sleeve guides the drill to the target point. This allows the preparation of minimally invasive endodontic access cavities in calcified teeth.

引导牙髓病学:牙髓通路腔的三维规划和模板辅助制备

Pulp canal obliterations (PCO) are often a consequence of dental trauma, such as luxation injuries. Even though dentin apposition is a sign of vital pulp, ...

小鼠上颌骨正畸模型骨重塑分析指南

The Establishment of a Murine Maxillary Orthodontic Model

Due to the lack of reproducible protocols for establishing a murine maxillary orthodontic model, we present a reliable and reproducible protocol to provide researchers with a feasible tool to analyze mechanical loading-associated bone remodeling. This study presents a detailed flowchart in addition to different types of schematic diagrams, operation photos, and videos. We performed this protocol on 11 adult wide-type C57/B6J mice and harvested samples on postoperative days 3, 8, and 14. The micro-CT and histopathological data have proven the success of tooth movements coupled with bone remodeling using this protocol. Furthermore, according to the micro-CT results on days 3, 8, and 14, we have divided bone modeling into three stages: preparation stage, bone resorption stage, and bone formation stage. These stages are expected to help researchers concerned with different stages to set sample collection time reasonably. This protocol can equip researchers with a tool to carry out regenerative analysis of bone remodeling.

作者聚焦:深入了解高效的小鼠上颌正畸模型方案

Here we demonstrate step-by-step a manageable, orthodontic tooth movement protocol operated on a murine maxillary model. With the explicit explanation of each step and visual demonstration, researchers can master this model and apply it to their experimental needs with a few modifications.

小鼠上颌骨正畸模型的建立

Due to the lack of reproducible protocols for establishing a murine maxillary orthodontic model, we present a reliable and reproducible protocol to ...

用内部方法设计上颌重建的 cad/cam 手术指南

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