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Midface Fracture
Simulation and Repair:
A Computer-Based
Algorithm
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Introduction

 Midface or maxillofacial fractures are frequently encountered in

the trauma setting and pose a challenge to facial plastic and
reconstructive surgeons.

 Patient evaluation due to the potential involvement of the

neurovascular and structural components of the face as well as
proximity to the airway.
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Introduction

 Treatment of a middle face fracture with a support segment

taken back to a stable element through a rigid fixation plate

 The choice of location, size, and shape of a rigid or semi-rigid

fixation plate during fracture repair is important because of the
complex nature of the middle facial bone.
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Introduction

 Modalities CT multiplanar and three-dimensional reconstruction

(3D) allow visualization of the bones and midface sinus spaces.

 Virtual surgery planning (VSP) and computer assisted design

(CAD) allow precise 3D reconstruction of the face. This modality
makes it possible to assess and model future operations before
surgery.
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Introduction

 In this article, researchers introduced a computer-based

algorithm that uses two affordable and commercially available
software packages to reconstruct the fracture of the middle face
plate.
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Methods

Retrospective review:

 Patient with midface frature fixation from January 1 2010 to

December 31 2015

 Study obtained from Huma Research Protections Office and

Institutional Review Board, University of Maryland

 Demographic and clinical data including age, sex, type of

midface fracture.
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Methods

Inclusion and Exclusion Criteria:

• Patient underwent midface frakture fixation and had both

preoperative and postoperative CT imaging

• Patient who did not have preoperative or postoperative imaging

were excluded

• CT image was poor quality or did not adequately was excluded

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Methods

Image Acguisition:

• AquariusNet (TeraRecon Inc., Foster City, CA) is a program that

transforms 2D CT imaging data into 3D form, allowing for
visualization and manipulation of imaging at any angle.

• Images were saved to JPEG format for further processing.

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Methods

The Computer-Based Algorithm

 The preoperative and postoperative images exported from

AquariusNET were then imported into Photoshop CS6
(AdobeSystems Inc., San Jose, CA)

 The fixation plates were sized to real-life scale with the “Free
Transform” tool.

 The ruler markers on the 3D CT image and fixation plate images

were printed and compared with an actual ruler for confirmation
of proportion.
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Methods

Cross-Sectional Survey

 A Likert-type scale rating system of 0 to 10 was utilized (0 =

completely different; 5 = somewhat similar; 10 = identical)

 The real postoperative 3DCT image and its corresponding virtual

image were displayed side by side.

 17 pairs of images were displayed on the survey, with 34 total

images assessed on a scale from 0 to 10.
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Methods

Statistical Analysis

• Mean and standard deviation values for the questions in each

set of images were calculated.

• Unpaired t-tests was used to compare resident and attending

response

• Respondents were divided into two groups (The Surgeon Group

and The Radiology Group).

• All statistical analyses were performed using MedCalc for

Windows, version 15.0 (MedCalc Software,Ostend, Belgium)
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Results

 In total, 35 physicians completed the survey, including 18

attendings and 17 residents.

 Respondents included were as follows: 14 from radiology, 10

from otolaryngology, and 11 from OMFS.

 A total of 34 images (17 pairs of virtual and actual preoperative)

were assessed from 10 cases.

 Fracture types included zygomaticomaxillary complex (n=8),

LeFort type I (n=1), and naso-orbito-ethmoid fracture (n=1)
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Results
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Results
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Results
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Discussion

 Data from this study indicate that this computer algorithm is

capable of producing virtual images that are comparable to real
postoperative 3D CT images of repaired middle facial fractures.

 The fracture rating reduction score is slightly lower than the plate
appearance score. This is probably due to the fact that it is
sometimes difficult to retrospectively match the fracture
reduction pattern achieved.
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Discussion

 In fact the plate produced by the algorithm has proven identical

to the original plate from the time when the user was asked to
coat the Stryker plate.

 This study found that all experts determined that there was a
strong resemblance between virtual images and postoperative
images.
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Discussion

 Radiologists assess images significantly higher than surgeons,

which may be caused by different perspectives through which
doctors evaluate images.

 VSP has been reported to be widely used in surgical procedures

such as reconstruction of mandibular fibular free flaps,
orthognathic surgery, orbital repair, and orthopedic procedures.
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Discussion

 VSP has been shown to reduce total operating time in

craniofacial operations, which leads to greater operational
efficiency in craniofacial operations.

 In the researchers' experience, it takes around 30 to 90 minutes

to complete a middle face fracture repair. This varies depending
on the pattern of fractures of different injuries.
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Discussion

 Use of Algorithms to better understand the anatomy and process

of reconstructing the middle face, to prepare operations by
reducing fractures in their respective fields and determine the
size, shape, and bending of fixation plates.

 Another limitation of this study is its retrospective nature. As a

preliminary study, the purpose of this study is to describe and
assess the ability of the algorithm.
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Conclusions

 The algorithm described has the ability to model middle face

fracture improvements and hardware placement accurately.

 VSP plays a role in preoperative planning, an algorithm using a

commercially available program allows the surgeon to
personally prepare the procedure.