The need for overcorrection: evaluation of computer-assisted, virtually planned, fronto-orbital advancement using postoperative 3D photography

Abstract

OBJECTIVE The main indication for craniofacial remodeling of craniosynostosis is to correct the deformity, but potential increased intracranial pressure resulting in neurocognitive damage and neuropsychological disadvantages cannot be neglected. The relapse rate after fronto-orbital advancement (FOA) seems to be high; however, to date, objective measurement techniques do not exist. The aim of this study was to quantify the outcome of FOA using computer-assisted design (CAD) and computer-assisted manufacturing (CAM) to create individualized 3D-printed templates for correction of craniosynostosis, using postoperative 3D photographic head and face surface scans during follow-up. METHODS The authors included all patients who underwent FOA between 2014 and 2020 with individualized, CAD/CAM-based, 3D-printed templates and received postoperative 3D photographic face and head scans at follow-up. Since 2016, the authors have routinely planned an additional “overcorrection” of 3 mm to the CAD-based FOA correction of the affected side(s). The virtually planned supraorbital angle for FOA correction was compared with the postoperative supraorbital angle measured on postoperative 3D photographic head and face surface scans. The primary outcome was the delta between the planned CAD/CAM FOA correction and that achieved based on 3D photographs. Secondary outcomes included outcomes with and those without “overcorrection,” time of surgery, blood loss, and morbidity. RESULTS Short-term follow-up (mean 9 months after surgery; 14 patients) showed a delta of 12° between the planned and achieved supraorbital angle. Long-term follow-up (mean 23 months; 8 patients) showed stagnant supraorbital angles without a significant increase in relapse. Postsurgical supraorbital angles after an additionally planned overcorrection (of 3 mm) of the affected side showed a mean delta of 11° versus 14° without overcorrection. The perioperative and postoperative complication rates of the whole cohort (n = 36) were very low, and the mean (SD) intraoperative blood loss was 128 (60) ml with a mean (SD) transfused red blood cell volume of 133 (67) ml. CONCLUSIONS Postoperative measurement of the applied FOA on 3D photographs is a feasible and objective method for assessment of surgical results. The delta between the FOA correction planned with CAD/CAM and the achieved correction can be analyzed on postoperative 3D photographs. In the future, calculation of the amount of “overcorrection” needed to avoid relapse of the affected side(s) after FOA may be possible with the aid of these techniques.

The Use and Outcomes of 3D Printing in Pediatric Craniofacial Surgery: A Systematic Review

“…22 The individual case studies each described a patient with a frontoethmoidal meningoencephalocele, 23 a complex craniofacial cleft with hypertelorism, 24 an orbital fracture, 25 and a cranial intraosseous lipoma. 26 3DP was used in preoperative planning with the creation of mock surgical models in 2 studies, 23,24 used to create custom intraoperative cutting guides or molds in 6 studies, [20][21][22][24][25][26] and used to create custom cranioplasty implants in 2 studies. 24,26 The specific technology and materials used in the 3DP process were described in most of the included studies (Supplemental Table 2, Supplemental Digital Content 2, http://links.lww.com/ SCS/F801).…”

“…22 One study mentioned that the estimated cost savings due to reduced operating time was 10,800€ based on historical comparison. 24 Two studies mentioned that the use of 3DP reduced intraoperative blood loss, 20,23 with 1 study quoting an estimated 6% reduction in average blood loss compared with previously documented cases. 23 One case study felt that the use of 3D printed materials also led to a 14.2% reduction in overall hospital length of stay compared with cases in previous literature.…”

“…39 This was the most common application of 3DP found in this review, with cutting guides or molds utilized in 6 articles. [20][21][22]24,26 Splints (type III) require accurate virtual surgery to cut the anatomy and move the pieces to the final position for appropriate contour. 28 One of the most common applications of these splints is in orthognathic surgery to correct dentoskeletal discrepancies.…”

Improved Facial and Skull-base Symmetry Following Osteotomy and Distraction of Unilateral Coronal Synostosis

“…Median improvement in orbital dystopia was 87.5%, and three patients were overcompensated, with one (case 10) showing an even greater deviation than that measured preoperatively. Several studies indicate that overcorrection is desired to achieve better results at long-term follow-up 35–37 ; therefore, it will be interesting to evaluate how these residual deviations develop at the 3-year follow-up.…”

“…Several studies indicate that overcorrection is desired to achieve better results at long-term follow-up [35][36][37] ; therefore, it will be interesting to evaluate how these residual deviations develop at the 3-year follow-up. Evaluation of the data suggested that FOD resulted in a slight undercorrection in the ODA, in which case a more pronounced distraction would be desirable.…”