Anaplastology dr jehad al sukhun

ISSN: 2161-1173
Anaplastology
The International Open Access
Anaplastology
Special Issue Title: Maxillofacial surgery
Handling Editors
Laith Mahmoud Abdulhadi
University of Malaya, Malaysia
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ISSN: 2161-1173 Anaplastology, an open access journalMaxillofacial surgeryAnaplastology
Open AccessCase Report
Anaplastology Al-Sukhun and Penttila, Anaplastology 2013, S:6
http://dx.doi.org/10.4172/2161-1173.S6-004
Keywords: Stereolithography; Maxillofacial trauma; Tumour
reconstruction
Introduction
Functional reconstruction of the maxillofacial skeleton implies
replication of the normal volume and contour of both soft and hard
tissue to produce normal form and function of the face, mouth and
jaws. Maxillofacial defects may result following ablative surgery
for malignancy, trauma and corrective surgery for congenital facial
deformities. Hence, when planning the reconstruction, the extent of
the resection, type of the missing tissues, and the precise function and
contour are all important considerations. Successful rehabilitation,
following ablative surgery for malignancy is likely to depend on the
preoperative fitness score as outlined by the American Joint Cancer
Committee (AJCC), [1] and the associated surgical trauma of the
resection and reconstruction. Stereolithography, a preoperative
technique, accurately measures and contours a reconstruction plate for
the placement at the time of the skeletal resection [2-8]. It significantly
decreases operating time and increases the surgeon’s option to manage
complex reconstructions (Table 1). However, these technologies are
expensive. Therefore, their use must be critically evaluated with regard
to accuracy, informative value, cost and benefits in terms of improved
diagnosis and better surgery. Stereolithography as a technique has been
mainly used to fabricate a template for custom cranioplasty to cover
defects in the skull [2-10]. Its application to the field of maxillofacial
skeleton to fabricate and/or pre-adapt reconstructive plates has been
limited to a few cases reported in the literature [11,12]. The purpose
of this paper was to share our clinical experience on the use of pre-
adapted/fabricated plates, using stereolithography, for accurate repair
of maxillofacial defects. In this paper we present five cases where
pre-adapted/fabricated plates were either used to reconstruct defects
following tumour resection or for secondary reconstructions of
maxillofacial trauma.
Case One
A 44-year-old man was referred to the division of the oral and
maxillofacial surgery at the Helsinki University Hospital for the
management of numbness of the lower lip and persistent dull pain
in the lower left quadrant of the mandible, following a series of root
canal fillings carried out on 35, 36 and 37. The medical history was
unremarkable. Intra-oral examination did not reveal any evidence
of swelling and the mucosa was non-tender, healthy and smooth.
Extra orally, there was no swelling and the skin showed a normal
texture with no fixation to the underlying tissues (Figure 1). CT-
scan and MRI imaging showed a homogeneous lesion occupying the
left maxilla / left maxillary sinus and extending to affect the left part
of the mandible inferiorly and the zygoma, orbit and anterior base of
the skull superiorly. The histological features were consistent with a
cribriform variant of adenoid cystic carcinoma. The size of the tumour
and its anatomical complexity made it difficult to reconstruct the defect
while maintaining optimal aesthetic and functional results. Therefore,
pre-surgical planning was an important part of the operation. A
model of the skull including the mandible was constructed using
stereolithography (Figure 1). The model was then used to pre-adapt
the reconstructive surgical plates to accurately bridge and restore
the defects. There were minor anatomical differences between the
model and the resected area. Therefore, the plates were slightly bent
*Corresponding author: Jehad Al-Sukhun, Department of Oral and Maxillofacial
Surgery, Euro Oral LTD, Fredrikinkatu 41A 9, 00120 HUS, Helsinki, Finland, Tel:
+358503071886; Fax: +3589483720; E-mail: jalsukhun@hotmail.com
Received July 22, 2013; Accepted August 25, 2013; Published August 27, 2013
Citation: Al-Sukhun J, Penttila H (2013) Stereolithography and the Use of
Pre-Adapted / Fabricated Plates for Accurate Repair of Maxillofacial Defects.
Anaplastology S6: 004. doi: 10.4172/2161-1173.S6-004
Copyright: © 2013 Al-Sukhun J, et al. This is an open-access article distributed
under the terms of the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the
original author and source are credited.
Stereolithography and the Use of Pre-Adapted / Fabricated Plates for
Accurate Repair of Maxillofacial Defects
Jehad Al-Sukhun1
* and Heikki Penttila2
1
Department of Oral and Maxillofacial Surgery, Euro Oral LTD, Fredrikinkatu 41A 9, 00120 HUS, Helsinki, Finland
2
Department of Physics, University of Jyvaskyla, Finland
Abstract
The purpose of this paper was to share our clinical experience on the use of pre-adapted / fabricated plates
fabricated plates were either used to reconstruct defects following tumour resection or for secondary reconstructions
of maxillofacial trauma. Our opinion concerning Stereolithography Models (SMs) is that they probably do not offer
the surgeon relevant diagnostics information, but they are very useful in the surgical planning of any maxillofacial
operation. SMs allow direct simulation of osteotomies, grafts and the measurement of bone movements. Pre-
fabricated/adapted plates combined with SMs reduce intra-operative time and morbidity, increase accuracy of
the surgical reconstruction and minimize complications and surgeons’ stress. However, these technologies are
expensive. Therefore, considering their cost, we see indications in secondary corrections of the maxillofacial trauma
and tumour reconstruction.
1. Useful in the surgical planning of virtually any maxillofacial operation
2. Direct simulation of osteotomies, grafts and the measurement of bone move-
ments
3. Reduce intra-operative time and morbidity
4. Increase accuracy of the surgical reconstruction and minimize complications
5. Reduce Surgeons' stress
6. Improved preoperative selection of implants and transplants
7. High informative value of SMs for teaching and patient information
8. Documentation of unusual cases.
Table 1: Advantages of Stereolithography models (SMs) in surgery.

Citation: Al-Sukhun J, Penttila H (2013) Stereolithography and the Use of Pre-Adapted / Fabricated Plates for Accurate Repair of Maxillofacial
Defects. Anaplastology S6: 004. doi: 10.4172/2161-1173.S6-004
Page 2 of 6
and adapted to fit accurately to the remaining bone. The tumour
was surgically resected along with a bilateral supra omohyoid neck
dissection. The defect, after the hemifacectmoy, was reconstructed by
combining two classical free flaps: 1) A Deep Circumflex Iliac Artery
free (DCIA) flap and 2) A Free Fibular (FF) flap. The DCIA and FF
grafts were fixed using the pre-adapted surgical plates (Figure 1). No
references were found in the literature about the use of this technique
for treating defects similar to those described in this paper. The patient
was followed up at monthly intervals during the first six months and
then progressively less frequently. A postoperative CT-scan and MRI
were performed preoperatively, immediately after the surgery and one
month postoperatively. Analysis of the aesthetic and functional results
of this type of reconstruction was difficult since there were no objective
parameters allowing us to evaluate them by standard criteria. Therefore,
analysis was based on an interview with the patient, his family and
other staff members of our department. Difficulties in performing any
of the functions e.g. eating and speaking, were unremarkable. In terms
of facial aesthetics, the results were very satisfactory. The colour and
texture of the skin used enabled an adequate degree of facial harmony
to be maintained. The final appearance of the scars was good. This was
due to the technique that took advantage of facial cutaneous folds,
and attempts to restore the relaxed skin tension lines. The second step
would have been to fit ocular and dental prostheses. However, given
the immediate need for complementary radiotherapy, it was decided to
defer this treatment until later.
Case Two
A 60-year-old man with a 5-cm mass in the upper right hard palate
was initially seen at the department of oral and maxillofacial surgery
at Helsinki University Central Hospital. A CT-scan confirmed a large
mass in the right antrum with loss of orbital floor and invasion of the
tumour to the middle base of the skull. Histology results confirmed
a mixed form of an adenoid cystic carcinoma. Through a Weber–
Ferguson approach a right hemi-maxillectomy in continuation
with craniotomy was carried out. A vertical ramus osteotomy in
combination with a parasymphysial mandibular osteotomy was also
performed to enhance access to the base of the skull with minimal
A
B C
D
Figure 1:
Postoperative, three dimensional formatted image displaying the defect after the resection of the tumour and the pre-adapted reconstructive surgical plates in
place. The plates produced the exact contour of the maxilla and the mandible and maintained skeletal symmetry.

Page 3 of 6
morbidity. A left supra-omohyoid neck dissection with preservation
of the neck vessels was included in this ablation. A DCIA flap with
internal oblique was harvested from the ipsi-lateral side. The bone was
vertically oriented and plated into position to replace the maxillary
buttress, the anterior maxillary wall and antrum. The orbital rime
was reconstructed using a free calvarial bone. The muscle was passed
medially into the palatal defect and sutured to the lower eyelid skin
superior to the graft. A reconstructive plate was pre-adapted prior to
surgery using a stereolithrographic model of the skull (Figure 2) and
used to hold the DCIA graft in place to maintain the three-dimensional
contour of the mid-facial skeleton. A titanium mesh was also pre-
contoured and adapted to match the anatomy of the orbital floor and
used to reconstruct the inferior orbital wall (Figure 2). A further plate
was pre-adapted, prior to the surgery, to restore the mandible into its
original contour following the neck dissection and the anastamosis.
The facial artery was anastmosed end-to-end into the DCIA and the
vein end-to-end into the facial vein. Facial swelling decreased in two
weeks, postoperatively, and the patient made excellent progress after
the surgery and was able to return home within five weeks.
Case Three
A 18-year old female was initially seen with an osteosarcoma lesion
occupying most of the left maxilla (Figure 3). Using a Weber-Ferguson
approach a subtotal maxillectomy was carried out without a formal
neck dissection. A DCIA flap with internal oblique was harvested from
the right hip. To determine the amount of bone needed to restore the
defect, a cure acrylic model of the defect was pre-fabricated using a
stereolithrographic model of the skull (Figure 3). Using the model, the
bone was contoured to reproduce the pyriforms and the exact contour
of the maxilla. Pre-adapted plates were used to hold the bone in place,
in order, to produce the exact contour of the maxilla. No attempts were
made to reconstruct the nasal floor, which was allowed to epithelialize.
The facial artery was anastmosed end-to-end into the DCIA and
the vein end-to-end into the facial vein. There were no immediate
postoperative problems and the patient made excellent progress and
was able to go home within five weeks.
Case Four
A 36-year-old female patient who suffered a unilateral, secondary,
leftorbitalblow-outfracture,witha3cm2
defectinthelateralaspectofthe
orbital floor, was selected for this study. Standard clinical examination
consisted of clinical controls preoperatively and at 1, 2, 4, 8, 16 and 36
weeks postoperatively. CT-scan imaging was performed preoperatively
and 30 weeks postoperatively using a CT scanner (Siemens Somatom,
Erlangen, Germany. A resin model of the skull including the right and
left orbits was constructed using stereolithography. The model was then
used to develop a custom-fabricated titanium plate of the left orbital
floor using the standard prosthetic, alginate impression and fabrication
techniques (Figure 1). The orbital cavity was explored through a lower
eyelid approach. The plate was then placed subperiosteally and held in
place using three ready made titanium screws (Figure 4). There were no
complications postoperatively e.g. no signs of diplopia, enophthalmos,
infection. The patient was pleased with the aesthetic outcome. This
custom pre-fabricated surgical plate proved to be a simple and reliable
method to repair large secondary defects of the orbital floor.
A
B
C D
Figure 2: (A) Frontal view of the stereolithrography model with the pre-adapted plates in place. A titanium mesh was also pre-contoured and adapted to match the
the pre-adapted reconstructive plates in place (C) Preoperative MRI showing a homogenous mass occupying the left maxilla and sinus and extends to affect the
reconstructive surgical plates together with the titanium mesh bridged the defect, produced the exact contour of the maxilla and maintained skeletal symmetry.

Page 4 of 6
Case Five
A 33-year-old male patient who suffered unilateral, secondary,
multiple left zygomatico-orbital fractures with a 2 cm2
defect in the
lateral aspect of the orbital wall. The zygomatic-orbital complex was
displaced inferiorly and posteriorly. A unicoronal flap was reflected to
gain access to the lateral orbital wall and the zygomatic arch. Calvarial
bone was harvested and used to restore the lateral orbital defect. The
zygomatico-orbital complex was osteotomised as shown in Figure 5
and bone was repositioned in place using pre-adapted surgical plates for
accurate reconstruction of the skeletal contour and restoring the facial
A
B
Figure 3:
proposed location of the pre-adapted reconstructive plates. Acrylic model of the defect was pre-fabricated and used to shape the DCIA graft to restore the contour
A
DC
B
Figure 4:
the orbital defect and held in place using three ready made titanium screws. (C) A preoperative computed tomography scan (CT-scan) showing secondary left
orbital blow-out fracture and enlarged orbital volume. (D) A postoperative three dimensional formatted image showing the position and shape of the plate on the
symmetry (Figure 5). There were no complications postoperatively e.g.
no signs of infection, facial assymetry etc. The patient was pleased with
the aesthetic outcome. The ability to complete the non-surgical aspect
of the patient’s treatment in the laboratory allowed for precision not
often achievable in an operative procedure.
Summary and Discussion
Stereolithography is a process that uses data generated from
Computer-Assisted Design (CAD) to generate three-dimensional
models. The data drives a laser over a bath of photosensitive resin

Page 5 of 6
which produces a series of stacked slices, which produce an accurate
three-dimensional resin model [5]. This technique can be used by the
maxillofacial surgeon to produce three-dimensional representations
of the facial bony structures using data from CT or MRI scans [2-
10]. In particular, it allows the maxillofacial surgeon to appreciate
spatial displacements in all three dimensions and to make accurate
measurement of the deformity. However, prospective clinical studies
are needed to demonstrate the value of stereolithographic modelling
in reconstructive surgery [13]. The literature on stereolithography and
its application in reconstructive surgery is limited to case reports and
discussions about the feasibility of the technique [2-13]. There are no
prospective studies demonstrating that the use of SMs improves the
outcomes of reconstructive surgical procedures. Because of the lack of
prospective clinical studies in the literature proving the value of SMs
in reconstructive surgery, stereolithographic modelling is considered
experimental and long term studies are welcomed to affirm the known
usefulness of this relatively new technology in the field of reconstructive
surgery.
The correction of post-traumatic facial asymmetry and defects
following major ablation surgery to remove malignancies have always
been difficult [2,11]. Great accuracy is required to achieve successful
surgical results, due to the fact that facial deformity and asymmetry is
often the result of relatively small magnitudes of bony displacement or
deformity.
We were able to practise the surgery on the model, thus allowing
full appreciation of the osteotomy bone cuts required to achieve the
A
B
C
Figure 5:
reconstructive plates. The model also demonstrates the cuts used to mobilize the zygomatico-orbital complex. The plate shown was only used for the purpose
complex. (C) Postoperative, three dimensional formatted image showing the pre-adapted reconstructive surgical plates in place. Their location exactly replicates
the landmarks as out lined on the model preoperatively.
desired results. The ability to complete the non-surgical aspect of the
patient’s treatment in the laboratory, to pre-adapt or pre-fabricate
surgical plates, ensured that the surgical accuracy achieved brought
about a satisfactory outcome to the patient both functionally and
aesthetically. SMs also provided an estimation of the volume of both
bony and soft tissue structures for possible implantation and of bony
cavities for reconstructive purposes (Case 3). Valuable theatre time was
saved by allowing the pre-adapted / fabricated bone plates to be used
for fixation on the post-operative SMs that demonstrate the planned
realignment of the facial bones. Stereolethrography and pre-adapted /
fabricated plates made these goals a reality.
The quality and accuracy of anatomical reproduction of the SMs,
the presence of artefacts, as well as the informative value for diagnosis
and surgical planning have been assessed on the basis of the subjective
surgeons’ experience. On the basis of our clinical practice, SMs resulted
in accurate anatomic reproductions at least in the limits required for
surgical applications. SMs may present over or under-contours in the
reproduction of maxillofacial bones [10]. In general, the dimensional
errors were within acceptable values. However, the defect that was
commonly observed in these models was a poor reproduction of
the dental elements, which was of no relevance to the reconstructive
procedure.
Consideringtheinformativevalueofthesemodels,stereolithography
has offered a clear diagnostic improvement, especially in complex
post-traumatic, secondary corrections, like those involving the orbital
region (Cases 4 and 5). However, the authors feel that it is important

Page 6 of 6
that surgeons are aware of the limited advantage of using SMs in the
study of acute trauma cases. The increased cost and time required for
these exams is not justified. Similarly, no substantial diagnostic benefit
is obtained when applying the technique to benign jaw pathologies or
tumours. Our opinion of SMs is that they probably do not offer the
clinician relevant diagnostic information but they are very useful in
the surgical planning of virtually any maxillofacial operation. SMs
allow direct simulation of osteotomies, grafts and the measurement
of bone movements. Pre-fabricated / adapted plates combined with
SMs reduce the intra-operative time and morbidity, increase the
accuracy of surgical reconstruction and minimize complications and
surgeons’ stress. Therefore, considering their cost, we see indications in
secondary corrections of craniofacial trauma, tumour reconstruction,
malformations and also in some preprosthetic-implant procedures.
Finally, our clinical practice suggests a high informative value of SMs
for teaching, patient information and documentation of unusual cases.
Acknowledgement
We would like to thank Mr Jarmo Nummenpää, medical illustrator, and Dr Anni
Suomalainen, consultant radiologist, at the Helsinki University Central Hospital, for
their technical expertise in providing the images and the photographs.
References
1.
Cancer. (3rdedn), Philadelphia, USA.
2. Joffe JM, McDermott PJ, Linney AD, Mosse CA, Harris M (1992) Computer-
generated titanium cranioplasty: report of a new technique for repairing skull
3.
Computer-assisted three-dimensional planning in craniofacial surgery. Plast
Reconstr Surg 92: 576-585.
4.
Stereolithographicmodelling for reconstructive head surgery. Acta
5. Anderl H, ZurNedden D, Mühlbauer W, Twerdy K,Zanon E, et al. (1994) CT-
47: 60-64.
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models for planning of craniomaxillofacial surgery. Phidas 2: 4-6.
7. Winder J, Cooke RS, Gray J, Fannin T, Fegan T (1999) Medical rapid
prototyping and 3D CT in the manufacture of custom made cranial titanium
plates. J Med Eng Technol 23: 26-28.
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craniofacial surgery: comparison of milling and stereolithography for 3D model
manufacturing. Pediatr Radiol 22: 458-460.
10. Perez-Arjona E, Dujovny M, Park H, Kulyanov D, Galaniuk A, et al. (2003)
Stereolithography: neurosurgical and medical implications. Neurol Res 25:
227-236.
11. Peckitt NS (1998) Stereolithography and the manufacture of customized
Maxillofac Surg 36: 481.
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accurate, preoperative adaptation of a reconstruction plate. J Oral Maxillofac
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craniofacial anomalies archive at St. Louis Children’s Hospital: 20 years of
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Citation: Al-Sukhun J, Penttila H (2013) Stereolithography and the Use of
Pre-Adapted / Fabricated Plates for Accurate Repair of Maxillofacial Defects.
Anaplastology S6: 004. doi: 10.4172/2161-1173.S6-004
This article was originally published in a special issue, Maxillofacial surgery
handled by Editor(s). Dr. Laith Mahmoud Abdulhadi, University of Malaya,
Malaysia.
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