Search Results (19)

Background: Reconstruction of the maxilla and midface remains one of the most demanding challenges in craniofacial surgery, requiring precise planning and a clear understanding of defect geometry to achieve functional and esthetic restoration. Advances in computer-assisted surgery (CAS) and virtual surgical planning (VSP), based on 3D segmentation of radiologic imaging, have significantly improved the management of maxillary deformities, allowing for further knowledge of patient-specific information, including anatomy, pathology, surgical planning, and reconstructive issues. The integration of computer-aided design and manufacturing (CAD/CAM) and 3D printing has further transformed reconstruction through customized titanium meshes, implants, and surgical guides. Methods:This systematic review, conducted following PRISMA 2020 guidelines, synthesizes evidence from clinical studies on CAD/CAM-assisted reconstruction of maxillary and midfacial defects of congenital, acquired, or post-resection origin. It highlights the advantages and drawbacks of maxillary reconstruction with patient-specific implants (PSISs). Primary outcomes are represented by accuracy in VSP reproduction, while secondary outcomes included esthetic results, functions, and assessment of complications. Results: Of the 44 identified articles, 10 met inclusion criteria with a time frame from April 2013 to July 2022. The outcomes of 24 treated patients are reported. CAD/CAM-guided techniques seemed to improve osteotomy accuracy, flap contouring, and implant adaptation. Conclusions: Although current data support the efficacy and safety of CAD/CAM-based approaches, limitations persist, including high costs, technological dependency, and variable long-term outcome data. This article critically evaluates the role of PSISs in maxillofacial reconstruction and outlines future directions for its standardization and broader adoption in clinical practice. Full article

Background: Spinal deformity correction surgery, particularly in scoliosis, often necessitates long fusion constructs and complex osteotomies that create significant structural bone defects. These defects threaten the integrity of spinal fusion, potentially compromising surgical outcomes. Bone grafting remains the cornerstone of addressing these defects, traditionally relying on autologous bone. However, limitations such as donor site morbidity and insufficient graft volume have made urgent the development and adoption of biologic substitutes and synthetic alternatives. Additionally, innovations in three-dimensional (3D) printing offer emerging solutions for graft customization and improved osseointegration. Objective: This scoping review maps the evidence of the effectiveness of the use of biologic and synthetic bone grafts in scoliosis surgery. It focusses on the role of novel technologies, particularly osteobiologics in combination with 3D-printed scaffolds, in enhancing graft performance and surgical outcomes. Methods: A comprehensive literature search was conducted using PubMed, Scopus, and the Cochrane Library to identify studies published within the last 15 years. Inclusion criteria focused on clinical and preclinical research involving biologic grafts (e.g., allografts, demineralized bone matrix-DBM, bone morphogenetic proteins-BMPs), synthetic substitutes (e.g., ceramics, polymers), and 3D-printed grafts in the context of scoliosis surgery. Data were extracted on graft type, clinical application, outcome measures, and complications. The review followed PRISMA-ScR guidelines and employed the Arksey and O’Malley methodological framework. Results: The included studies revealed diverse grafting strategies across pediatric and adult populations, with varying degrees of fusion success, incorporation rates, and complication profiles. It also included some anime studies. Emerging 3D technologies demonstrated promising preliminary results but require further validation. Conclusions: Osteobiologic and synthetic bone grafts, including those enhanced with 3D technologies, represent a growing area of interest in scoliosis surgery. Despite promising outcomes, more high-quality comparative clinical studies are needed to guide clinical decision-making and standardize practice. Full article

Objectives: Pelvic tumor resections demand high surgical precision to ensure clear margins while preserving function. Although patient-specific instruments (PSIs) improve osteotomy accuracy, positioning errors remain a limitation. This study evaluates the feasibility, accuracy, and usability of a novel dual-function augmented reality (AR) system for intraoperative guidance in PSI positioning and osteotomy execution using a head-mounted display (HMD). The system provides dual-function support by assisting both PSI placement and osteotomy execution. Methods: Ten fresh-frozen cadaveric hemipelves underwent AR-assisted internal hemipelvectomy, using customized 3D-printed PSIs and a new in-house AR software integrated into an HMD. Angular and translational deviations between planned and executed osteotomies were measured using postoperative CT analysis. Absolute angular errors were computed from plane normals; translational deviation was assessed as maximum error at the osteotomy corner point in both sagittal (pitch) and coronal (roll) planes. A Wilcoxon signed-rank test and Bland–Altman plots were used to assess intra-workflow cumulative error. Results: The mean absolute angular deviation was 5.11 ± 1.43°, with 86.66% of osteotomies within acceptable thresholds. Maximum pitch and roll deviations were 4.53 ± 1.32 mm and 2.79 ± 0.72 mm, respectively, with 93.33% and 100% of osteotomies meeting translational accuracy criteria. Wilcoxon analysis showed significantly lower angular error when comparing final executed planes to intermediate AR-displayed planes (p < 0.05), supporting improved PSI positioning accuracy with AR guidance. Surgeons rated the system highly (mean satisfaction ≥ 4.0) for usability and clinical utility. Conclusions: This cadaveric study confirms the feasibility and precision of an HMD-based AR system for PSI-guided pelvic osteotomies. The system demonstrated strong accuracy and high surgeon acceptance, highlighting its potential for clinical adoption in complex oncologic procedures. Full article

Objectives: This pre-clinical feasibility study evaluates the accuracy of a novel augmented reality-based (AR-based) guidance technology using head-mounted displays (HMDs) for the placement of patient-specific instruments (PSIs)—also referred to as surgical guides—and osteotomy performance in pelvic tumour resections. The goal is to improve PSI placement accuracy and osteotomy execution while assessing user perception and workflow efficiency. Methods: The study was conducted on ten 3D-printed pelvic phantoms derived from CT scans of cadaveric specimens. Custom PSIs were designed and printed to guide osteotomies at the supraacetabular, symphysial, and ischial regions. An AR application was developed for the HoloLens 2 HMD to display PSI location and cutting planes. The workflow included manual supraacetabular PSI placement, AR-guided placement of the other PSIs and osteotomy execution. Postoperative CT scans were analysed to measure angular and distance errors in PSI placement and osteotomies. Task times and user feedback were also recorded. Results: The mean angular deviation for PSI placement was 2.20°, with a mean distance error of 1.19 mm (95% CI: 0.86 to 1.52 mm). Osteotomies showed an overall mean angular deviation of 3.73° compared to planned cuts, all within the predefined threshold of less than 5°. AR-assisted guidance added less than two minutes per procedure. User feedback highlighted the intuitive interface and high usability, especially for visualising cutting planes. Conclusions: Integrating AR through HMDs is a feasible and accurate method for enhancing PSI placement and osteotomy performance in pelvic tumour resections. The system provides reliable guidance even in cases of PSI failure and adds minimal time to the surgical workflow while significantly improving accuracy. Further validation in cadaveric models is needed to ensure its clinical applicability. Full article

Background/Objectives: Limb malalignment disrupts physiological joint forces and predisposes individuals to the development of osteoarthritis. Surgical interventions such as distal femur or high tibial osteotomy aim to restore mechanical balance on weight-bearing joints, thereby reducing long-term morbidity. Accurate alignment is crucial since it cannot be adjusted after stabilization with plates and screws. Recent advances in personalized medicine offer the opportunity to tailor surgical corrections to each patient’s unique anatomy and biomechanical profile. This study evaluates the benefits of 3D planning and patient-specific cutting guides over traditional 2D planning with standard implants for alignment correction procedures. Methods: We assessed limb alignment parameters pre- and postoperatively in patients with varus and valgus lower limb malalignment undergoing acute realignment surgery. The cohort included 23 opening-wedge high tibial osteotomies and 28 opening-wedge distal femur osteotomies. We compared the accuracy of postoperative alignment parameters between patients undergoing traditional 2D preoperative X-ray planning and those using 3D reconstructions of CT data. Outcome measures included mechanical axis deviation and tibiofemoral angles. Results: 3D reconstructions of computerized tomography data and patient-specific cutting guides significantly reduced the variation in postoperative limb alignment parameters relative to preoperative goals. In contrast, traditional 2D planning with standard non-custom implants resulted in higher deviations from the targeted alignment. Conclusions: Utilizing 3D CT reconstructions and patient-specific cutting guides enhances the accuracy of postoperative limb realignment compared to traditional 2D X-ray planning with standard non-custom implants. Patient-specific instrumentation and personalized approaches represent a key step toward precision orthopedic surgery, tailoring correction strategies to individual patient anatomy and potentially improving long-term joint health. This improvement may reduce the morbidity associated with lower limb malalignment and delay the onset of osteoarthritis. Level of Evidence: Therapeutic Level III. Full article

Objective: Frontal sinus surgery is still challenging for surgeons; the frontal osteotomy with the preparation of a frontal bone flap to access the sinus is usually hand-crafted by experienced surgeons. The objective of our study is to present a fully digital protocol for the manufacturing of “in-house” surgical cutting guides, customized to the patient’s anatomy, to perform precise frontal sinus osteotomy, showing the costs, times, and intraoperative complications reduction. Materials and Methods: A prospective study was conducted on 12 patients with complex pathologies involving the frontal sinus who underwent frontal sinus osteotomy in the Maxillofacial Surgery Unit of the Federico II University of Naples, from January 2021 to April 2025, considering the last surgery in November 2023. The same digital protocol to manufacture the surgical cutting guide was used for all the 12 patients. The first step was to upload the preoperative CT images in DICOM format to the software Mimics Medical to perform a rapid segmentation of the skull region of interest to create a 3D object and to identify the frontal sinus margins and the osteotomy lines. The second step was to realize the surgical cutting guide, incorporating the design of titanium plates to fix onto the skull in order to make a precise osteotomy. The final digital step was to export the cutting guide 3D object in the software “Formlab-Form 3B” to print the model with a specific resin. The model was then used during the surgery to perform the precise frontal osteotomy by piezo surgery. The clinical outcomes, in terms of complications and recurrences, were then recorded. Results: In all the patients, no intraoperative complications occurred; the median follow-up was 31.7 months and at one year of follow-up only one patient experienced a recurrence. The mean operative time was about 4 h, with a frontal osteotomy time of about 23 min. Digital protocol time was about 4 h while printing times were between 2 and 4 h. Conclusions: This “in-house” protocol seems to demonstrate that the use of intraoperative templates for the realization of the frontal sinus osteotomy reduces preoperative and intraoperative costs and times, reducing the risk of intraoperative complications, and also allows less experienced surgeons to perform the procedure safely. Obviously, this study is to be considered a “pilot study”, and other studies with large cohorts of patients will have to confirm these promising results. Full article

Background: Mandibular reconstruction has evolved significantly since its inception in the early 1900s. Currently, the fibula free flap (FFF) is considered the gold standard for mandibular and maxillary reconstructions, particularly for extensive defects, and the introduction of Extended Reality (XR) and virtual surgical planning (VSP) is revolutionizing maxillofacial surgery. Methods: This study focuses on evaluating the accuracy of using in-house cutting guides for mandibular reconstruction with FFF supported by virtual surgical planning (VSP). Planned and intraoperative osteotomies obtained from postoperative CT scans were compared in 17 patients who met the inclusion criteria. The proposed analysis included measurements of deviation angles, thickness at the centre of gravity, and the maximum thickness of the deviation volume. Additionally, a mandibular resection coding including 12 configurations was defined to classify and analyze the precision of mandibular osteotomies and investigate systematic errors. Preoperative, planned, and postoperative models have been inserted in an interactive VR environment, VieweR, to enhance surgical planning and outcome analysis. Results: The results proved the efficiency of adopting customized cutting guides and highlighted the critical role of advanced technologies such as CAD/CAM and VR in modern maxillofacial surgery. A novel coding system including 12 possible configurations was developed to classify and analyze the precision of mandibular osteotomies. This system considers (1) the position of the cutting blade relative to the cutting plane of the mandibular guide; (2) the position of the intersection axis between the planned and intraoperative osteotomy relative to the mandible; (3) the direction of rotation of the intraoperative osteotomy plane around the intersection axis from the upper view of the model. Conclusions: This study demonstrates the accuracy and reliability of in-house cutting guides for mandibular reconstruction using fibula free flaps (FFF) supported by virtual surgical planning (VSP). The comparison between planned and intraoperative osteotomies confirmed the precision of this approach, with minimal deviations observed. These findings highlight the critical role of CAD/CAM and XR technologies in modern maxillofacial surgery, offering improved surgical precision and optimizing patient outcomes. Full article

Background: Patients with a triad of severe temporomandibular joint (TMJ) pathologies, obstructive sleep apnea (OSA), and dentofacial deformities often experience significant functional and aesthetic impairments. A combination of total TMJ reconstruction and maxillomandibular advancement (MMA) has emerged as a promising treatment option, which can address the complexity of these conditions simultaneously. Methods: This paper presents a practical protocol for TMJ reconstruction using patient-specific alloplastic total joint prosthesis in conjunction with additional splintless osteotomies. This approach integrates the recent advancements in virtual surgical planning (VSP), custom TMJ prostheses, and three-dimensional (3D) custom osteotomy guide and implant manufacturing, allowing for precise anatomical correction and enhanced treatment outcomes. Three patients were treated with the present protocol. Postoperative assessments mainly included maximum inter-incisal opening, apnea–hypopnea index (AHI), and patient satisfaction with facial aesthetics. Results: All surgeries were performed without complications. The follow-up period ranged from 7 to 12 months. For the two patients with TMJ ankylosis, the postoperative maximum inter-incisal opening (MIO) increased from 3–5 to 35 mm and from 12 to 32 mm, respectively. Additionally, all three cases demonstrated that the protocol could significantly decrease AHI (with improvements of 57.5, 49, and 66.4 events/h, respectively) and achieve satisfactory aesthetics. Conclusions: These findings suggest that this protocol is a viable option for addressing complex cases involving severe TMJ pathologies, OSA, and dentofacial deformities. Future studies with larger cohorts and long-term follow-up are needed to further validate these findings. Full article

The extraction of deeply impacted lower third molars is a common yet challenging surgical procedure associated with complications such as mandibular fractures, pain, and swelling. This study evaluated the effectiveness of customized 3D-printed titanium plates in reducing the risk of intraoperative iatrogenic mandibular fractures. This innovative approach aims to improve surgical outcomes, enhance patient safety, and boost confidence for both surgeons and patients. Eighteen patients with Pell and Gregory class II/IIIC impacted lower third molars underwent preoperative CBCT scans, which facilitated the design and fabrication of customized plates and drilling guides. The surgical procedure involved incision, flap elevation, precise plate placement, osteotomy, odontotomy, extraction, and the postoperative assessment of pain, swelling, trismus, and anxiety using validated scales and facial scanning. The results show that customized titanium plates successfully prevented mandibular fractures in all cases. Although initial postoperative discomfort, including swelling, trismus, and pain, was observed, significant improvements occurred within one week. This technique provided structural reinforcement during surgery and healing without adverse events or fractures. Customized 3D-printed titanium plates represent a safe and effective solution for minimizing mandibular fractures, offering promising improvements in surgical outcomes. Full article

Background/Objectives: Hallux valgus is a common foot deformity that requires surgical correction to restore proper alignment. Precision in the osteotomies performed during these surgeries is critical to avoid complications and improve outcomes. However, variability in surgeon experience can negatively affect precision. In this context, advances in 3D printing have enabled the development of customized surgical guides, which may enhance precision and reduce variability among surgeons with different levels of expertise. This study aims to evaluate the effectiveness of a 3D-printed surgical guide in minimally invasive hallux valgus correction, focusing on the accuracy of osteotomies performed by novice surgeons, experienced surgeons, and theoretically trained consultants. Methods: An ex vivo study was performed with 30 cadaveric feet, divided into three groups according to the level of experience of the surgeons: 3D guide group, Master’s students, professionals. All surgeons performed Akin and Reverdin-Isham osteotomies, but the experimental group (the 3D guide group) utilized a customized 3D-printed surgical guide for enhanced precision during these procedures. Radiographic measurements of osteotomy angles and alignment were taken after the interventions, and compared with the planned values. Statistical analyses were conducted to evaluate the variability in the precision of the cuts. Results: The use of the 3D-printed surgical guide significantly reduced angular variability in the experienced group, achieving higher levels of accuracy than experienced surgeons. Effect sizes, which ranged from small to large, indicated a greater impact on angle measurements (η² = 0.46, p < 0.001); no significant differences were found between the groups in other evaluated parameters. Conclusions: The incorporation of 3D-printed surgical guides in hallux valgus surgery significantly improves osteotomy accuracy, particularly in less experienced surgeons. This suggests that these guides can help standardize procedures, reduce the learning curve, and lower intraoperative complications. Full article

The purpose of this paper was to describe and to evaluate the accuracy of a protocol that involves CAD/CAM-generated cutting guides and customized titanium plates for waferless orthognathic surgery. Twenty-one patients consecutively treated between January 2021 and January 2023 were included. The preoperative virtual surgical plan (VSP) was compared with the final position determined from the postoperative CT scan and STL files. An alignment algorithm was employed to adjust the skull position in areas unaffected by the surgery. Absolute and signed deviations were calculated across all three dimensions for each maxilla, mandible and chin landmark. The accuracy analysis revealed an overall deviation of 0.93 mm (95% confidence interval [95%CI]: 0.86 to 0.99), which was < 2 mm for all assessed landmarks (p < 0.05; one-sample t-test). The mandibular landmarks showed greater deviation than the maxillary ones (p < 0.001; independent-samples t-test). Considering the deviations along the three axes, statistically significant differences were identified (p < 0.001; one-way analysis of variance). The reported protocol provides evidence on the benefit of guided orthognathic surgery when performed using a defined VSP protocol, improving accuracy in the maxilla, mandible and chin position, considered both globally and as isolated variables. Full article

(1) Background: The adoption of Virtual Surgical Planning (VSP) and 3D technologies is rapidly growing within the field of orthopedic surgery, opening the door to highly innovative and individually tailored surgical techniques. We present an innovative correction approach successfully used in a child affected by “windswept deformity” of the knees. (2) Methods: We report a case involving a child diagnosed with “windswept deformity” of the knees. This condition was successfully addressed through a one-stage bilateral osteotomy of the distal femur. Notably, the wedge removed from the valgus side was flipped and employed on the varus side to achieve the correction of both knees simultaneously. The surgical technique was entirely conceptualized, simulated, and planned in a virtual environment. Customized cutting guides and bony models were produced at an in-hospital 3D printing point of care and used during the operation. (3) Results: The surgery was carried out according to the VSP, resulting in favorable outcomes. We achieved good corrections of the angular deformity with an absolute difference from the planned correction of 2° on the right side and 1° on the left side. Moreover, this precision not only improved surgical outcomes but also reduced the procedure’s duration and overall cost, highlighting the efficiency of our approach. (4) Conclusions: The integration of VSP and 3D printing into the surgical treatment of rare limb anomalies not only deepens our understanding of these deformities but also opens the door to the development of innovative, personalized, and adaptable approaches for addressing these unique conditions. Full article

New digital technologies are improving the accuracy of orthognathic surgery. One of the new approaches transfers the surgical plan into real surgery without using an occlusal splint. This pilot study aims to validate the splintless approach to orthognathic surgery on a series of cases. Five patients were enrolled. Surgeries were planned using a digital surgical simulation method thanks to three-dimensional images. The splintless surgical approach was planned for maxillary reposition. This consisted of cutting guides and three-dimensionally (3D) printed custom titanium plates. These two were created using the computer-aided design and computer-aided manufacturing (CAD-CAM) technique and were used intraoperatively to guide the osteotomy and repositioning of the bony segments without the use of the surgical splint. The difference between the planned surgery and the real final position was analyzed thanks to superimposition techniques and landmark analysis. Statistical tests were performed to detect significant differences. No difference was found in any of the landmarks. Midline landmarks differed from the planned position by 0.34 mm. Higher variability was found in the posterior landmark. These findings suggest that a splintless approach is useful in transferring the surgical plan without using an occlusal splint. Full article

Background: The accuracy of the coronal alignment corrections using conventional high tibial osteotomy (HTO) falls short, and multiplanar deformities of the tibia require consideration of both the coronal and sagittal planes. Patient-specific instrumentations have been introduced to improve the control of the correction. Clear evidence about customized devices for HTO and their correction accuracy lacks. Methods: The databases PUBMED and EMBASE were systematically screened for human and cadaveric studies about the use of customized devices for high tibial osteotomy and their outcomes concerning correction accuracy. Furthermore, a 3D-printed customized system for valgus HTO with three pilot cases at one-year follow-up was presented. Results: 28 studies were included. The most commonly used custom-made devices for HTO were found to be cutting guides. Reported differences between the achieved and targeted correction of hip-knee-ankle angle and the posterior tibial slope were 3° or under. The three pilot cases that underwent personalized HTO with a new 3D-printed device presented satisfactory alignment and clinical outcomes at one-year follow-up. Conclusion: The available patient-specific devices described in the literature, including the one used in the preliminary cases of the current study, showed promising results in increasing the accuracy of correction in HTO procedure. Full article

Purpose: This retrospective study aims to compare the accuracy of two different CAD/CAM systems in orthognathic surgery. The novelty of this work lies in the method of evaluating the accuracy, i.e., using an Iterative Closest Point (ICP) algorithm, which matches a pair of 2D or 3D point clouds with unknown dependencies of the transition from scan s_(k) to scan s_(k+1). Methods: The study population was composed of ten patients who presented to the Maxillofacial Surgery Department of the University “Sapienza” of Rome for the evaluation and management of skeletal malocclusions. The patients were divided into two groups, depending on the technique used: group 1: splintless group (custom-made cutting guide and plates); group 2: splint group (using a 3D-printed splint). STL files were imported into Geomagic^® Control X™ software, which allows for comparison and analysis using an ICP algorithm. The RMSE parameter (3D error) was used to calculate the accuracy. In addition, data were compared in two different patient subgroups. The first subgroup only underwent a monobloc Le Fort I osteotomy (p-value = 0.02), and the second subgroup underwent a Le Fort I osteotomy associated with a segmental osteotomy of the maxilla (p-value = 0.23). Results: Group 1 showed a 3D error of 1.22 mm ± SD 0.456, while group 2 showed a 3D error of 1.63 mm ± SD 0.303. These results have allowed us to compare the accuracy of the two CAD/CAM systems (p-value = 0.09). Conclusions: The ICP algorithm provided a reproducible method of comparison. The splintless method would seem more accurate (p-value = 0.02) in transferring the surgical programming into the operating room when only a Le Fort I osteotomy is to be performed. Full article