Clinical application of digital design combined with personalized three-dimensional printing technology in the treatment of deep oromaxillofacial-cervical tumors

Zhichen Guo; Chenxi Li; Bin Ling; Zhongcheng Gong

doi:10.4103/digm.digm_27_21

ORIGINAL ARTICLE

Year : 2021 | Volume : 7 | Issue : 1 | Page : 3

Clinical application of digital design combined with personalized three-dimensional printing technology in the treatment of deep oromaxillofacial-cervical tumors

Zhichen Guo¹, Chenxi Li², Bin Ling², Zhongcheng Gong²
¹ Department of Oral and Maxillofacial Oncology Surgery, Xinjiang Medical University Affiliated First Hospital, Urumqi 830054; School of Stomatology, Xinjiang Medical University. Urumqi 830011; Stomatological Research Institute of Xinjiang Uygur Autonomous Region. Urumqi 830054, Xinjiang; Clinical Research Center of Shaanxi Province for Dental and Maxillofacial Diseases, College of Stomatology, Xi'an Jiaotong University, Xi'an 710049, Shaanxi, China
² Department of Oral and Maxillofacial Oncology Surgery, Xinjiang Medical University Affiliated First Hospital, Urumqi 830054; School of Stomatology, Xinjiang Medical University. Urumqi 830011; Stomatological Research Institute of Xinjiang Uygur Autonomous Region. Urumqi 830054, Xinjiang, China

Date of Submission	02-Jun-2021
Date of Decision	24-Jun-2021
Date of Acceptance	29-Jun-2021
Date of Web Publication	07-Dec-2021

Correspondence Address:
Chenxi Li
Department of Oral and Maxillofacial Oncology Surgery, Xinjiang Medical University Affiliated First Hospital; School of Stomatology, Xinjiang Medical University; Stomatological Research Institute of Xinjiang Uygur Autonomous Region. No. 137 Liyushan South Road, Urumqi 830054
China
Zhongcheng Gong
Department of Oral and Maxillofacial Oncology Surgery, Xinjiang Medical University Affiliated First Hospital; School of Stomatology, Xinjiang Medical University; Stomatological Research Institute of Xinjiang Uygur Autonomous Region. No. 137 Liyushan South Road, Urumqi 830054
China

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/digm.digm_27_21

Abstract

Background and Purpose: The emergence of digitalized technology has greatly promoted the progress of craniomaxillofacial and head and neck surgery. This present study aimed to explore and describe the advantages of digital design combined with personalized three-dimensional (3D) printing technology in the treatment of deep oromaxillofacial-cervical tumors. Patients and Methods: Nine patients with deep tumor of oral and maxillofacial and neck region admitted to Xinjiang Medical University Affiliated First Hospital from June 2017 to March 2021 were all treated by the digitalized surgery. Preoperatively, radiological examination including computed tomography (CT) angiography, plain and enhanced CT scan, and magnetic resonance imaging were performed in all patients. The software packaged of MIMICS, 3-matic and MAYA was cooperatively used to offer 3D modeling and create 3D texturing for morphological and functional reconstruction. The application effect was assessed by analyzing the relevant data and every patient followed up regularly after the operation. Results: The reconstructed images were acquired through computer-aided three-dimension reconstruction, as well as the navigated devices were established through 3D printing. There were totally nine patients including 4 males and 5 females with a mean age of 48.5 years old, whose tumor size ranged from 1.5 cm × 2.2 cm to 3.5 cm × 4.2 cm. The analysis of data also showed that five cases were characterized by oromaxillofacial osseous defect, 2 primary lesions were adjacent to bone and 2 were noncontacted with bone; the location of 7 cases were closely next to blood vessels of oral-maxillofacial-cervical region, while 2 were contactless. Conclusions: Although the tumors occurred in the deeply maxillofacial area are difficult to resect due to several complex anatomical and functional subunits in this area, digital design combined with 3D technology is a promising tool to provide precise diagnosis with an accurately targeted treatment for maxillofacial deep tumor. The preoperative design and the combined navigation technology can further improve the accuracy and safety for curing deep maxillofacial and neck tumors.

Keywords: Deep oromaxillofacial-cervical tumors, Digital design, Personalized three-dimensional printing technology

How to cite this article:
Guo Z, Li C, Ling B, Gong Z. Clinical application of digital design combined with personalized three-dimensional printing technology in the treatment of deep oromaxillofacial-cervical tumors. Digit Med 2021;7:3

How to cite this URL:
Guo Z, Li C, Ling B, Gong Z. Clinical application of digital design combined with personalized three-dimensional printing technology in the treatment of deep oromaxillofacial-cervical tumors. Digit Med [serial online] 2021 [cited 2023 Mar 29];7:3. Available from: http://www.digitmedicine.com/text.asp?2021/7/1/0/331948

Introduction

Oral and maxillofacial tumors, with a rising incidence rate during the recent decades, are the most common in the head-and-neck region which seriously threatens the health of patients because of their high invasion and poor prognosis.^[1] While multidisciplinary comprehensive treatment takes surgery as the principle thing, complete removal of the primary lesion is essential for a better prognosis. Nonetheless, that several complex anatomical and functional subunits in head and neck area make the lesion location hard to be exposed and difficult to finish radical excision, especially for junior and inexperienced surgeon.

Nowadays, digital medical technology and computer-aided medical procedures are increasingly being applied in the field of craniomaxillofacial surgery, particularly the application of digital design combined with three-dimensional (3D) printing.^[2] This novel technology has greatly promoted the progress of tumor treatment, which can effectively raise diagnostic accuracy, lower the difficulty of surgery, and reduce postoperative complications; thereby it is improving the efficiency as well as success rate of surgery.^[3],[4] Among its numerous advantages, it would be beneficial from realization of transforming the virtual information into a real model by preimaging the data preoperatively. The position of tumor and its adjacent relationship with the surrounding important anatomical structures can be completely and accurately reflected on this model.^[5] At present, unfortunately, the clinical research of this technology combined with surgery in the treatment of oral and maxillofacial deep tumors is still very limited.

The purpose of this study is to retrospectively analyze the clinical data processed by the digital design associated with personalized 3D printed techniques for curing patients with deep oral and maxillofacial tumors, to better show the superiority of this kind of technology.

Patients and Methods

Patients

This was a retrospective, observational clinical study involving nine patients in total. All patients were recruited from the Outpatient of Oncological Department of Oral and Maxillofacial Surgery, Xinjiang Medical University Affiliated First Hospital, between June 2017 and March 2021. The protocol of the study was approved by the Ethics Committee, Stomatological School of Xinjiang Medical University, Xinjiang Medical University Affiliated First Hospital, and the informed consents were signed by all the patients. All the data generated or analyzed during this study are included in this published article.

The inclusion criteria were as follows: (1) Patients suffered from deep oral-maxillofacial-cervical tumors who had not accepted any previous treatment; (2) Patients were willing to receive relevant digital medical strategy; and (3) The general condition was acceptable for radical reconstruction operation under general anesthesia.

Preoperative preparation

To find out the exact location of the mass and adjacent relationship with peripheral blood vessels, nerves, and other tissues, we arranged plain and enhanced computed tomography (CT) scan for patients as well as performed CT angiography (CTA) and magnetic resonance imaging (MRI) examinations, respectively. The comprehensive preoperative laboratory tests were also ready for the surgery.

Computer-aided surgical design

Computer-aided design was carried out according to the three-imaging data. Using advanced 3D medical image processing software, including Mimics software version 19.0 (Materialise Inc., Leuven, Flanders Brabant, Belgium), 3-matic software version 9.0 (Materialise Inc., Leuven, Flanders Brabant, Belgium), Maya 2020 (Autodesk Inc., San Rafael, California, USA), the solid model was reconstructed in the computer and the surgical plan was formulated, which was available for surgical treatment under the guidance of navigation. The specific operation as follows: (1) All the imaging data were collected and organized intactly; (2) Sorted data were imported into Mimics software (Materialise Inc., Leuven, Flanders Brabant, Belgium) as DICOM files to process; (3) Significantly, threshold segmentation concerning on CTA images was commanded to extract the information from the bone, blood vessel, and skin tissue; (4) The digital model was reconstructed using threshold value; (5) Importantly, find the relative coordinate position of the required cutaneous guide vessels and mark it; (6) Skin and marker coordinates were input into 3-matic software (Materialise Inc., Leuven, Flanders Brabant, Belgium) to construct bone marker laminate; and (7) The model comprising of scaffold and skeletal marks determined the pattern of final digital guide [Figure 1].

Figure 1: Protocol of digital design combined with personalized three-dimensional printing technology in the treatment of deep oromaxillofacial-cervical tumors.

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During the operation and follow-up

The 3D printed solid model was brought into the operating room, the body surface location of the tumor as well as the trajectory of its accompanying blood vessels were drawn according to the model. Certainly, with this solid model, the whole surgical procedure was operated under the aid of navigation.

The signs such as healing of the operation area, whether relapse, occurrence of infection, recovery of the function of dentognathic system, and restoration of aesthetic appearance were evaluated through the subsequent visit trimonthly.

Results

Clinical information

All of nine patients were diagnosed with deep oromaxillofacial-cervical tumors, including 4 males and 5 females with a mean age of 48.5 years old (26–68-year-old), whose tumor size ranged from 1.5 cm × 2.2 cm to 3.5 × 4.2 cm. There were five cases characterized by oromaxillofacial osseous defect; 2 cases' primary lesions were adjacent to bone and 2 cases had no contact with maxillofacial bone; 7 cases were closely next to blood vessels of oral-maxillofacial-cervical region, while 2 were contactless. Aside from three cases located in the infratemporal fossa and 2 cases located in the infraorbital region, the remaining cases were distributed independently in maxillary sinus, retromolar triangle area, parapharyngeal space, and even cervical vascular space [Table 1].

Table 1: Clinical information of the patients.

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Surgical approach and histopathological type

The surgical approach was divided into two categories based on the direction: (1) Lateral approach: The condyle, zygomatic arch, or temporal bone were removed through an extended incision from auricle to anterior temporal (5 cases); (2) Anterior approach: Lateral nasal incision plus infraorbital incision (also well-known as the modified Weber-Fergusson incision) provided access to the nasal cavity and maxilla.

Postoperative follow-up

After successful operation assisted by digital surgical techniques on all of patients, we asked them to fulfil subsequent visit at the 1^st, 3^rd, 6^th, and 12^th months. During the follow-up period, one patient occurred postoperative infection, one patient arised limitation of mouth opening, one patient was found recurrence of osteosarcoma, and one patient was found recurrence of ameloblastoma. No other cacoethic symptoms were detected.

Typical case

A 59-year-old male was admitted to the Outpatient of Oncological Department of Oral and Maxillofacial Surgery, Xinjiang Medical University Affiliated First Hospital, due to a 2-month history of gradually limited mouth opening with concomitant pain. Radiological features revealed that a irregularly oval homogenous low-density signal confined to his right infratemporal fossa extending into the ipsilateral coracoid process of mandible, occupied by a large (3.4 cm × 2.2 cm), well-defined and solid lesion. In order to select an appropriate surgical approach to fully expose the field of vision, the digital navigation was arranged. The postoperative histopathology confirmed the diagnosis of basal cell adenoma using the special immunohistochemistry staining. The openness has been improved, and no signs of recurrence and symptoms of adverse complication were appeared during his follow-up period [Figure 2] and [Figure 3].

Figure 2: Typical case report.

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Figure 3: The solid model of three-dimensional printing.

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Discussion

There exists multitudinous important anatomical structures and complex functional subunits in the deep space of oral-maxillofacial-cervical region,^[6] for instance pterygovenous plexus, maxillary artery, hypoglossal nerve, facial nerve, vagus nerve and cervical vessels, and so on.^[7] It is difficult to discover because the growth of tumor is usually concealed in these deeply hidden spaces of the maxillofacial area. The misdiagnosed and delayed treatment consequently takes place from time to time, even though it is very crucial to strive for medical intervention in the early stage.^[8] Due to its vague boundary and obscure relationship with its surroundings, there is a high risk of hemorrhea and a big possibility of damaging contiguous important parts, so that the complete resection of the deep maxillofacial tumor is tough.^[9]

Depending on the continuous progress of science and technology, the development of digital medicine as a novel concept has evolved over the past three decades.^[10],[11] Among them, digital design combined with personalized 3D printing technology has the potential to revolutionize the field of cranio-maxillofacial and head and neck surgery in general.^[12] It is noteworthy that, additionally, this technology shows a great available value in preoperation evaluation and intra-operation navigation for curing deep oral and maxillofacial tumors.^[13] It rests on the simulative model reconstructed both entire physiological tissue and vital anatomical structure, the key of which is the imaging data (DICOM files) excavated from CT, CTA, and MRI materials.^[14] In this way, 3D images can be naturally converted into three-dimension using 3D visualization technique so as to make accurate preoperative evaluation and reasonable surgical plan.^[15] Simultaneously, 3D-printing can further extend its visualizing function to transform 3D images into the physical model in light of the program design of software with regard to reconstruction.^[16] Intraoperative navigation based on 3D printing model, which can guide the precise direction to avoid the significant anatomic landmarks in the deep of oral and maxillofacial region. Hence, the occurrence of postoperative complications becomes evitable, as well as the reinforcement of surgical effectiveness and security would be guaranteed.^[17]

Conclusion

To sum up, digital design combined with personalized 3D printed technology in the treatment of deep oral and maxillofacial and neck tumors could help surgeons to understand the location of tumors more precisely through the solid models, which is beneficial to improve the safe and correct implementation of deep tumor resection.

Acknowledgement

The deepest gratitude goes first and foremost to Prof. Gong for his constant guidance and encouragement in all aspects. Secondly, the cordial appreciation is for Dr. Li who drafted the manuscript, as well as provided language help, writing assistance and proof reading of this article. Last but not least, thanks a lot to Mr. Tao Zhang from Xinjiang Operation 3D Intelligence and Technology Co., Ltd, for his lecturing on relevant surveying and mapping software.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

This study was supported by grants from the Clinical Research Center of Shaanxi Province for Dental and Maxillofacial Diseases, College of Stomatology, Xi'an Jiaotong University. (XJKQHT(2021] 00035).

Conflicts of interest

Zhongcheng Gong is an Associate Editor of the journal. The article was subject to the journal's standard procedures, with peer review handled independently of this editor and his research groups.

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