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REVIEW ARTICLE
Year : 2021  |  Volume : 24  |  Issue : 10  |  Page : 1415-1422

The role of simulator and digital technologies in head and neck reconstruction


Department of Prosthetic Dental Science, College of Dentistry, King Saud University, Riyadh, Saudi Arabia

Date of Submission14-Sep-2020
Date of Acceptance01-Mar-2021
Date of Web Publication16-Oct-2021

Correspondence Address:
Dr. A F Alfouzan
Department of Prosthodontics, College of Dentistry, King Saud University, P O Box - 89300, Riyadh - 11682
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_566_20

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   Abstract 


This review summarizes the development of digital technology in the field of head and neck surgeries. Advances in digital technology assist surgeons during preoperative planning, where they can simulate their surgeries with improvement in the resulting accuracy of the surgery. In addition to digital technologies having many applications in the surgical field, they can be used in medical devices, surgical and educational models, and tissue engineering.

Keywords: Cancer, digital technologies, head and neck


How to cite this article:
Alfouzan A F. The role of simulator and digital technologies in head and neck reconstruction. Niger J Clin Pract 2021;24:1415-22

How to cite this URL:
Alfouzan A F. The role of simulator and digital technologies in head and neck reconstruction. Niger J Clin Pract [serial online] 2021 [cited 2022 Dec 8];24:1415-22. Available from: https://www.njcponline.com/text.asp?2021/24/10/1415/328237




   Introduction Top


Simulated and advanced digital technologies have been used for the treatment of head and neck cancer patients. Surgical cancer resection is one of the primary modalities in the treatment of head and neck cancer. Currently, advanced digital technologies assist with surgical planning, simulation of cancer resection, and defect reconstruction. Surgical planning and simulation have aided in reduction of required planning time while simultaneously reducing errors, increasing surgeons' surgical skills, and improving patients' aesthetic appearances. The introduction of three-dimensional (3D) printing, microvascular surgery, robotic-assisted surgery, and surgical navigation have aided the improvement of the surgical field.[1],[2]

History of Three-Dimensional Printing

The printing revolution started in the 15th century when Johannes Gutenberg invented the printing press. Since then, in 1981, Hideo Kodama from Nagoya Municipal Industrial Research Institute, Japan, published the first 3D printed plastic models.[3],[4] Subsequently, in 1986, Charles Hull invented 3D printing and developed stereolithography (SLA), which was the first process that creates virtual 3D objects using computed design software.[5] Computationally, slices of 2D thin layers are sent to the 3D printer, after which a UV laser starts hardening the 2D slices individually until the 3D object is completed.[6]

Mankovich et al. in 1990 described a rapid prototyping technique for medical use, transferring the engineering method to the surgical field.[7] Then, in 1991, Stratasys Limited produced the world's first fused deposition molding machine (FDM).[8] Then, in the mid-1990s, several materials, such as plastics, ceramics, and metals, became available on the market.[6] Sailar et al., in 1998, evaluated twenty stereolithographic models for craniofacial surgery patients, assessing the importance of the models in the preoperative diagnosis and planning of the surgery.[9] In 1999, D'Urso et al. produced 3D biomodels for 45 patients with cranial, maxillofacial, and skull base cervical spinal pathologies. The biomodels were used for patient education, diagnosis, and operative planning. They reported an improvement in the measurement accuracy and suggested modest improvements in surgical time with improving patient education.[10]

In the 21st century, the first human organ was 3D printed (a human bladder) by the Wake Forest Institute for Regenerative Medicine. They then coated the bladder with cells taken from patients and implanted it with the newly formed cells.[11] Several human organs were also 3D printed using human cells, including a functional miniature kidney, a prosthetic leg with complex components, and bioprinted blood vessels.[8] The field of otolaryngology surgery has high potential applications for 3D printing technology such as constructing surgical models, educational models, and tissue engineering.

Three-Dimensional Printing Techniques [Figure 1]
Figure 1: Three-dimensional printing techniques

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The first step in the printing process is image acquisition through computed tomography or cone-beam-computed tomographic scan for the three-dimensionally printed object. This process is followed by transferring the medical imaging and exporting it into molding software. The molding software processes the images into positive space models that represent the actual hard tissue anatomy or negative space models that represent the intervening spaces next to the positive spaces.[12] Several molding software packages are available on the market, including Mimics, Rhino, Amira, ITK-snap, 3D slicer, InVesalius, and SurgiCase. Mimics molding software (Materialise NV, Leuven, Belgium) is the most common software used for the object molding.[8]

Subsequently, the product of molding software is converted to printing software; some changes may be required, depending on the material used for printing and the resolution differences between the software and printing abilities. The commonly used printing software are 3D system, SolidWorks, and Alaris.[10] Several 3D techniques have been used for medical object printing including SLA, FDM, inject printing, and selective laser sintering (SLS).[13]

Stereolithography

SLA was the first printing technology, introduced in 1991 in Vienna. It relies on ultraviolet laser to cure the resin. The laser contacts the surface layer of a pooled resin, thereby hardening the surface layer of the polymer along a path specific to the design. Once the entire layer is cured, the build platform descends incrementally into the pool of resin until it is completely covered by a new layer of liquid resin, and the process repeats. The molds produced by this material are slightly brittle, robust, and light; however, they are hydrophobic and, if exposed to high humidity, may physically warp over time.[14],[15],[16]

Fused Deposition Modeling

The FDM technique is currently considered the most popular for personal desktop 3D printers. It relies on feeding a thermoplastic polymer filament through a heated printer head. After the plastic melts to the liquid phase, it is forced out of the print head's nozzle on the building platform layer by layer, much like a computerized glue gun, until the 3D object is completed. The printer head can move in two-dimensions during the deposition of each layer, and when it is completed, it moves upward to start the next layer.[6],[17] Some printers have multiheaded jets, making the printing procedure quicker and less expensive.[14] Various thermoplastics materials can be used with this technique, including acrylonitrile butadiene styrene, polylactic acid, polyvinyl alcohol, and nylon and ethylene and polycarbonate plastics.[18],[19],[20]

Inkjet Printing

Inkjet printing consists of liquid binding resin that solidifies powder base material. First, the building platform is covered with powder material; subsequently, the printer head traces the object pattern, and the first layer is produced after deposition of the liquid binding resin. Once the first layer is completed, the platform descends, and the second layer is produced by deposition of a thin layer of powder and the process above is repeated until the printed object is completed.[21],[22]

Selective Laser Sintering

SLS uses powered polymer, which is fused or sintered by carbon dioxide laser into the desired pattern and layer-by-layer until the object is completed. SLS can print several materials, like biocompatible polymers and metals. The 3D printed object is dipped in powder during the printing, eliminating the need for a support structure during printing.[6]

Digital Surgical Simulation and Planning

The process of digital surgical planning depends on converting the preoperative computed tomography scan to digital imaging and communications in medicine (DICOM) format. The DICOM data can be used in numerous ways, such as creating 3D stereolithics-simulated digital planning and for navigation intraoperatively.[23] The 3D preoperative virtual surgical planning and simulation for cancer resection and reconstruction has been transferred to the operating room, using surgical cutting guides, templates, and prebent surgical plates that replace the traditional freehand method, resulting in improved accuracy of the surgery with decreased operative and ischemic time, improved bone-to-bone contact, and improved facial symmetry. In addition, using 3D printed patients' specific models for defect sites and defect's reconstruction enables hands-on evaluation during the surgery.[2],[23],[24],[25],[26],[27]

3D printing models are extensively used during surgical planning and simulation for maxillary and mandibular reconstruction after cancer resection. The application of 3D printing during surgery was used in four main categories by using the positive space or the negative space of patient-specific data: contour models, guides, splints, and implants.[10]

Contouring modeling uses positive-space models that usually depend on 3D printing of precise, specific bony anatomy, and as a replica for contouring hardware such as titanium plates, making it easier than an intraoperative procedure, where it is harder to see due to bleeding and the surrounding soft tissue structures.[10] Contouring 3D printing models have been used during orbital reconstruction; titanium mesh can match the orbital contour using positive models mirrored from the uninjured orbit and then placing it intraoperatively.[28],[29] Fu et al. used individualized titanium mesh to support the orbital floor and restore the maxillary contour during reconstruction of maxillary and orbital floor defects with free fibular flaps.[28] In addition, recontoured titanium mesh can be used during reconstruction of nasal defects. Horn et al. used a preoperative 3D printed model to recontour the titanium mesh that was used for nasal reconstruction after cancer resection.[30]

Preoperatively, 3D models can also be utilized to prepare the commercial titanium plate preoperatively. Azuma et al., in 2014, compared mandibular symmetry after unilateral mandibular cancer resection and reconstruction for 28 patients; 12 patients received prebent reconstruction plates that were molded on medical rapid prototyping models designed using CAD-CAM technique utilizing a combined powder bed and inkjet head 3D printer, and 16 patients received the conventional reconstruction method. The patients who received prebent reconstruction plates had significantly better mandibular contours than the patients who received conventional reconstruction of the mandible, resulting in better esthetic outcomes with potentially better quality of life.[31]

Surgical guides are the most popular application of 3D printing in the medical field, using the negative spaces around the bony anatomy to print specific templates that fit only one specific area of the particular bone to guide cutting or drilling procedures during surgery. Using the 3D printed surgical guides, the surgeon can precisely perform the planned and simulated surgery with reduced operative time and improved accuracy.[10],[32],[33]

Surgical splints are negative space models, unlike contouring models and guides, that use exact patient replicas and use virtual replicas (not existing) for splinting the final position of the patient after surgery. A 3D-printed surgical splint depends on virtual planning of the final position using designing software to stimulate the surgical result.[10] Adolphs et al. used 3D-printed splints for orthognathic surgery by designing the splint virtually with RapidSplint software.[34]

The contour model is a common 3D printing method used in craniofacial surgery, whereas guides and splints are more commonly used in maxillofacial surgery. Some surgeries require the use of more than one 3D-printed model, as in jaw reconstruction, in which contour model is used for titanium plate prebending and another one to guide the osteotomies.[10]

3D implant objects have been reported in creating virtual skull defects and used ultrahigh-molecular weight polyethylene implants to repair the defect, printing nanoscale hydroxyapatite/polyamide condylar head replacements as implants for condylar head reconstructions, printing models used to cast polymethylmethacrylate implants for skull defects and printing chrome arch bars for intramaxillary fixations. The custom-created porous polyethylene implants can replace titanium mesh implants.[10],[35]

Three-Dimensional Printed Surgical Plates

The use of 3D printed, patient-specific surgical plates in head and neck reconstruction can eliminate the need for prebending of surgical plates, which helps improve surgical accuracy, facilitating the reconstructive procedure and reducing operating room time.[36],[37],[38] It also eliminates the adverse effects of plate-bending such as plate fracture, corrosion, screw loosening, and bone resorption.[39] The 3D prebent reconstruction plate can be used with bone grafts or in free tissue reconstruction. Damage to tooth roots, dental implants, and nerves can be avoided by guiding the position of fixations holes.[40]

Several technologies, including computer-aided design and computer-aided manufacturing (CAD/CAM), SLS, electron beam melting (EBM), and selective laser melting (SLM), have been used to construct surgical plates.[41],[42],[43],[44],[45]

In the last decade, the CAD/CAM system has emerged; the system is based on the subtractive method of milling conventional titanium surgical plates using drills and burs. CAD/CAM technology is not currently appropriate for manufacturing highly accurate and sufficiently customized structures. SLS and EBM technologies can also be 3D-mill pure and alloyed titanium; however, these technologies produce bulky-looking plates with limited architecture versatility.[41],[42],[43],[44],[45]

SLM is a high-tech 3D metal printing procedure that can result in higher mechanical prosperities and accuracy than EBM or SLS. It uses high-power laser beams to fuse fine titanium powder into a whole. Working with digital planning to produce SLM surgical plates can produce any design shape with great individuality.[39] In 2018, Yang et al. used SLM technology to design and manufacture patient-specific surgical plates and compared them to commercial titanium plates.[39]

Tissue Engineering

3D printing materials expand to involve tissue engineering; the technology can precisely print accurately shaped scaffolds that can fit patient anatomical structure. Scaffolds are needed during bone reconstruction for stem cell seeding, ingrowth, and new tissue formation. It must fit into the defect, having mechanical properties capable of bearing the load and yield biocompatible degradation by products.[46],[47] Various methods in the literature have been described for fabrication of the scaffolds, including solid free-form fabrication (SFF) and SLS using polycaprolactone bioresorbable polymer.[48] Through SFF and SLS techniques, the fabrication of a biphasic scaffold to produce the bony anatomy of cortical medullar bone or the anatomy of complex articular surface, such as the temporomandibular joint, can be accomplished. The SFF technique of scaffolding fabrication allows the use of 3D computed tomography data to design anatomically shaped scaffolds with varying internal architectures that provide more precise control over pore size, porosity, stiffness, and permeability.[49] Zopf et al., in 2015, three-dimensionally printed polycaprolactone bioresorbable scaffolds for auricular and nasal reconstructions using the SLS technique. The scaffold demonstrated new cartilage growth after seeding with chondrogenic growth factor; then, they in vivo implanted scaffolds subcutaneously in a porcine model.[50]

One of advancements of digital technology in the field is bionics, in which surgeons integrate electronics into static 3D-printed implants, creating biologically active constructs. Mannoor et al. generated a 3D-printed bionic ear. They 3D-printed a human ear in a cell-seeded hydrogen matrix along with a conducting polymer consisting of infused sliver nanoparticles that permitted in-vitro culture of chondrocytes within an inductive coil antenna in the ear, enhancing the auditory sensing for radio frequency reception.[51]

Dental Implants

Digital technologies have been used to plane the position and aid in the placement of dental implants for cancer patients rather than free-hand placement or guidance by laboratory stent based on oral impressions or made from cold cure or processed acrylic. The first surgical implant guide was not integrated with patient's digital data and surgical plane.[52] Klein et al. started the digital surgical planning method to position a dental implant when they integrated the computer tomography scan data with the prosthetic plane and produced dental implant drill guides based on the implants placed in the CT.[53],[54] The importance of implant digital planning systems is the precise understanding of the underlying critical anatomical structures, including the mandibular canal, mental foramen, incisive canal, and maxillary sinuses.[52],[55]

Cone-beam-computed tomography can be used for digital planning of implant position, fabrication of static implant guides, and fully guided dynamic navigation.[23] The static implant guides use CAD/CAM technologies to drill the guide based on virtual surgical planning, while the dynamic implant placement depends on tracking the drill optically. Therefore, through connecting the tracking device to the patient and detection using the camera, surgeons triangulate the anatomical position of the patient into the digital software. The dynamic navigation can be helpful for cases with limited mouth opening, where it is not possible to use a bulky guide or in cases of poor visualization of the surgical field. In addition, the dynamic navigation method can provide optimal safety during surgery by providing the surgeon with the exact position of the adjacent teeth and the surrounding vital structures. During implant procedures, the surgeon can locate implants based on real-time navigation using presurgical digital planning with the navigation with no need for surgical drill guides.[56]

Planning the position of dental implants in fibular bone that is used for jaw reconstructions after cancer resection during the surgical planning and simulation for the reconstruction has been implemented, resulting in improved graft position that improves the accuracy of reconstruction surgical plate contouring, avoiding dental malocclusion.[57],[58]

Surgical Simulation Models

Several attempts have been made to train surgical residents to improve their skills, and one of these is 3D-printed anatomical model with silicone rubber simulating the soft tissue. Recently, complex anatomy has been printed for stimulation and training, including temporal bone anatomy and nasal cavity at the skull base, developing a technique to drill via an endoscopic endonasal approach to reach the pituitary gland, endoscopic drilling to the sphenoid sinus, and endoscopic sinus surgery.[59],[60] To simulate costochondral cartilage, Berens et al. in 2016 mixed silicon with starch, placed in 3D-printed mold to practice creating auricular frameworks.[61] Microtia surgeons in training can use the resulting models because they resemble human cartilage in terms of texture and firmness. This training tool uses several colors and in general is considered a simple and cost-efficient way to simulate individual real patient cases.[61]

Sterilization

The Food and Drug Administration's (FDA) Center for Device and Radiological Health reviewed medically used additively manufactured devices. The safety and effectiveness of the medically 3D-printed devices should be reviewed before they are used for patients. Sterilization of 3D-printed objects that will be used in the operation room is mandatory. Many 3D-printed materials deform at high temperature; therefore, the selection of an autoclavable material is very important.[6],[62]

Robotic Surgery

Transoral robotic surgery was first reported for oropharyngeal tumor in 2005 by Mclead.[63] Then, in 2009, United States FDA approved the use of da Vinci robotic surgery for the oropharynx.[64] Transoral robotic surgery is consider minimally invasive surgery that gives the surgeons the ability to resect cancerous tissue within the oropharynx, hypopharynx, and upper portions of the larynx that would have been treated with primary chemotherapy or substantially more aggressive conventional approaches such as lip-split mandibulotomy.[64] Robotic surgery has many advantages, including improved visualization, increased dexterity, restored proper hand–eye coordination, and restored proper ergonomic position.[65],[66]

Robotic surgery is undertaken with miniaturized surgical instruments with magnified visualization fields. The surgeons can control the procedure while they are sitting in a remote console and can manipulate an endoscope and two additional instruments that are placed in the patient's mouth. The surgeon can manipulate every movement of the robotic instruments. A 3D camera is mounted at the end of the scope, giving the surgeon 3D HD vision of the field of the surgery; therefore, a real surgery is performed in a virtual environment.[65],[67]

Microvascular Surgery

Alexis Carrel, in 1902, performed the triangulation method of end-to-end anastomosis, a procedure that remains common today. For his achievement, he was awarded the Nobel Prize in 1912.[68] The introduction of heparin in 1916 by Jay Mclean to control blood clotting was essential for the development of microvascular surgery. In the early 1920s, the operation microscope was introduced by Nylen and Holmgren, leading to the development of modern microsurgery.[68] Malis in 1966 developed bipolar electrocautery that can be used under magnification. Subsequently, a variety of tissues began to be transferred for reconstruction using microvascular surgery.[68]

Virtual Reality and Augmented Reality

The term “virtual reality” refers to a computer capable of producing interactive 3D visualization with head-mounted displays and controllers equipped with one or more position trackers.[69] It is simulation of a real world depending on computer graphics, a 3D world that communicates with real people interacting, resulting in content, items, services, and real economic value through e-commerce, according to many scientists.[70] The first application of virtual reality in the medical field was in the early 1990s, when it was used to preoperatively plan surgery and to visualize complex anatomical structure during surgery.[71]

Haptic Technology

The sense of touch by applying motion, force, and vibration can be transmitted to the user using haptic technology.[69] Haptic technology can be added to virtual reality, producing virtual tactile feeling. It can be used with virtual reality for surgical planning. Using a haptic device, the surgeon can feel if two fragments of bone come together or if a dental occlusion is correct.[69] Olsson et al. combined stereovisualization with six degrees-of-freedom and a half-transparent mirror with stereo glasses that gave surgeons a stereoscopic view of data during preoperative surgical planning for craniomaxillofacial reconstruction. The device had a head tracker that allowed the surgeon to see objects at different angles and to look around in real time, simply viewing the patient's specific anatomy in a 3D view when they move their head. The system was produced by a real surgical procedure and allows simulation of mandibulectomy and fibular reconstruction.[72] Furthermore, the surgeons can test and plane the configuration of vessels and skin paddles using this system.[72]

Virtual reality with haptic technology has been used for surgeon training and to improve surgical skills. It permits training surgeons in bone drilling, swing, and plate fixation with haptic force feedback. Several benchtop studies are ongoing to incorporate haptic technology with robot-assisted surgical systems.[73],[74],[75]

Surgical Navigation

Augmented reality-based navigation systems can be used for virtual surgical plane for guidance. An interactive image-guided visualization (IGV) display was utilized to transfer virtual surgical planning to intraoperative surgery. Zinser et al. used surgical navigation with an interactive IGV display that allowed the superimposition of real time with virtual visual intraoperative data during bimaxillary osteotomy in 16 patients, resulting in clinically acceptable precision of the maxilla position in the anteroposterior and mediolateral angles.[76]

A 3D surgical navigation system has also been used to assess resected surgical margins based on PET/CT image fusion during surgery, and it appeared to be helpful in improving the local control of advanced cancer.[77]

The surgeon can track his instruments during the surgery on a 3D dataset view of the patient. Optical tracking can be accomplished by two methods, active and passive. The active method uses infrared cameras to detect light-emitting diodes to achieve instrument tracking. The passive method relies on reflectors rather than light sources for instrument tracking, eliminating the need for batteries and electrical cords.[78] Therefore, intraoperative navigation allows real-time feedback of the position of the surgical instruments and correlates it with the patient's CT scan. When the patient has complex bony anatomy that results in difficulty in placement of the printed cutting guide, intraoperative navigation can be used to ensure correct positioning of the guide.[23],[79]


   Conclusion Top


This review discussed developments of digital technologies in the field of head and neck cancer surgery. Improvements and advances in surgical planning, cancer resection, and defect reconstruction were developed. In addition, transition from structural to functional 3D objects has been developed, as in tissue engineering.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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