Advances in virtual surgical planning (VSP) and computer-aided design/computer-aided manufacturing continue to transform the management of craniomaxillofacial surgical care. There has been a demonstrable shift toward fully personalized surgical care in postablative head and neck reconstruction, orthognathic and temporomandibular joint surgeries, and in surgery for congenital and acquired anomalies. Surgical management of facial trauma exhibits timing and budgetary challenges that have delayed the adoption of VSP into common practice in the area. This review explores the scope, advantages, and evolution of VSP in craniomaxillofacial trauma, with an emphasis on the authors’ institutional integration of VSP in management of facial trauma.
Key points
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Virtual surgical planning (VSP) continues to change the landscape of craniomaxillofacial surgery to enhance outcomes, improve precision, and reduce operative time.
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VSP use in facial trauma has been limited due to time and budgetary constraints; however, with technological advances, these limitations are becoming less prevalent.
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Advances in cost and access have the potential to offer the same benefits of VSP to patients undergoing treatment of facial trauma.
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As the use of VSP in treating facial trauma increases, application of VSP in facial trauma will continue to be explored.
Abbreviations
| 3D | three dimensional |
| AR | augmented reality |
| CAD/CAM | computer-aided design/computer-aided manufacturing |
| CT | computed tomography |
| FHS | free hand surgery |
| IN | intraoperative navigation |
| LOS | length of hospital stay |
| PEKK | polyetherketoneketone |
| PSIs | patient-specific implants |
| TMJ | temporomandibular joint |
| VR | virtual reality |
| VSP | virtual surgical planning |
Introduction
Virtual surgical planning (VSP) and computer-aided design/computer-aided manufacturing (CAD/CAM) have transformed the current landscape of craniomaxillofacial surgical care, shifting toward fully personalized surgical care in postablative head and neck reconstruction, orthognathic and temporomandibular joint (TMJ) surgeries, as well as other congenital and acquired anomalies. , A recent study demonstrated that 88.6% of surveyed surgeons currently use VSP, with a significant increase in surgical exposure during training for those in practice for less than 10 years. The role of VSP in facial trauma is a frontier less explored, but in recent years, it has been gaining attention for the potential benefits it affords the patients with facial trauma. This review specifically explores the scope and evolution of VSP in craniomaxillofacial trauma, highlighting integration of VSP in facial trauma for patients at the authors’ home institution.
Evolution of virtual surgical planning technology
Early adoption of CAD from 1999 to 2004 was a rudimentary phase in developing virtual surgical technologies as accuracy and opportunities for use began to emerge. Key developments included custom CAD systems for orthodontic and orthognathic planning with submillimeter accuracy, early planning tools for craniosynostosis that reduced operative time and transfusion needs, the introduction of navigation systems such as VectorVision for guided treatment of vascular malformations, and the Surgical Segment Navigator surface scanner. ,,,
VSP gained broader clinical use and improved precision between 2005 to 2014. In this phase of adaptation and development, several areas of oral and maxillofacial surgery began to implement this new technology. Specifically, multimodal imaging was incorporated for surgical management of synovial chondromatosis, piloting computer-assisted surgery for TMJ disorders. SurgiCase cranio-maxillofacial (CMF) was used for fibula reconstruction of mandibular defects with very high accuracy. , VSP was also being used in soft tissue analysis to evaluate outcomes from periodontal and orthognathic surgery. Wermker and colleagues used optical scans before and after orthognathic surgery to quantify both soft tissue changes and resultant symmetry. In a study by Zuhr and colleagues, the utilization of superimposed presurgical and postsurgical optical scans were used to evaluate and quantitatively compare techniques to determine soft tissue root coverage 1 year postoperatively. These advances allowed for an unprecedented level of accuracy. With continued improvements in these technologies, the clinical utility and scope of VSP in oral and maxillofacial surgery grew quickly.
From 2015 to 2024, VSP experienced a rapid integration of emerging technologies. Three dimensional (3D) planning improved soft-tissue prediction accuracy in orthognathic surgery, while artificial intelligence significantly accelerated and automated segmentation with greater than 90% accuracy. , Several efforts became directed at improving processing time that limited case turnaround time. , Mixed-reality systems such as HoloLens2 enhanced intraoperative visualization, and recent innovations—robot-guided laser osteotomies and highly precise patient-specific plates—achieved submillimeter trueness and minimized deviation from the virtual plan. , In 2024, Che and colleagues compared outcomes of patient-specific plating comparing VSP to traditional methods as it pertains to mandible fractures. This study found that there were no significant differences in outcome of the 10 VSP and 10 traditional surgery subjects. Remarkably, however, this study did show that no subjects in the VSP group experienced new postsurgical paresthesia secondary to the surgery, where 3 of the 10 traditional surgery patients exhibited new paresthesia following surgical repair, suggesting that VSP may afford some advantage in nervous protection. Ongoing reductions in plate turnaround time, along with the integration of in-house CAD/CAM, continue to enhance the feasibility of VSP in trauma settings.
Clinical applications in trauma
To successfully execute VSP for facial trauma cases, standardized general steps are involved. High-quality 3D imaging is a key starting point. Patients presenting to the trauma bay or emergency department with facial injuries often undergo computed tomography (CT) shortly after initial evaluation. When conventional CT is not available, cone beam CT performed in the clinic is also an acceptable alternative, offering less radiation exposure while generally providing adequate diagnostic information. These imaging datasets are imported into a specialized software, where fractured fragments are segmented and the repair is virtually planned. The 2 most employed techniques are virtual reduction, repositioning of the fractured segments, or mirroring the contralateral uninjured side to guide reconstruction. An example of this process of segmentation, reapproximation, and intraoperative plating of the mandible with a custom plate is depicted in Case 1 below (Case 1, Figs. 1 and 2 ).
(Case 1) The case VSP is shown, with the segments reapproximated into their ideal position to facilitate surgical planning and reconstructive plate fabrication.
( A , B ) (Case 1) The patient virtual plan depicted above, shown clinically with complete exposure of the fractured segments via a submandibular, extraoral approach. The subsequent photo reveals placement of the custom-designed plate onto the fractured mandible with the segments in near anatomic alignment following open reduction.
A virtual meeting is then held with the surgery team and an engineer from the selected VSP company where simulation of the repair is performed with manipulation of the digital imaging and communications in medicine (DICOM) files. A final dataset is representative of the expected outcome. From this, the desired plates, occlusal splints, cutting guides, and models are designed. , The customized components are then milled or printed using CAD/CAM technology. Patient-specific implants (PSIs) are useful for their ability to exactly follow the bony contours of the patient’s anatomy and eliminating the intraoperative time required for plate bending, but can result in challenges if intraoperative modifications are required. , They are also useful for areas of more complex anatomy and allow for novel plate designs. From an engineering standpoint, PSIs are milled from titanium, which reduces the risks of compressive and tensile forces of bending plates and allows for a thinner profile with the same strength. It has also been shown that in situations of more complex craniofacial trauma, a single large plate that reduces comminuted segments allows for better return to anatomic form compared to several small plates attempting to unify fragments with no underlying structure. PSI can make this increasingly achievable with unique plate design options. Custom-printed occlusal splints are particularly useful in situations of comminuted Le Fort fractures where realignment of the dentition can be challenging (Case 2, Figs. 3–10 ). Cutting guides allow surgeons to have bone-borne or tooth-borne titanium means of demarcating the ideal osteotomy for facilitating the desired outcome (Case 3, Figs. 11–18 ). Printed models are a useful teaching tool and can serve as a way for surgeons to prebend stock plates in preparation for or during surgery.
(Case 2) CT maxillofacial postprocessing after initial trauma: The patient was intubated at the time of the scan, as they were being evaluated and treated in the level 1 trauma bay. It is easy to visualize the extensive fractures that this patient has sustained secondary to this severe trauma.
(Case 2) Segmentation of fractures of anatomic subunits: Using the CT scan and specialized software, Proplan CMF, the fractured segments are identified and demarcated to allow for reconstruction. This allows for clear visualization of the borders to allow for simulated repair and subsequently allow for customized hardware design.
(Case 2) Virtual reduction of fractured subunits: This depicts the appropriate repositioning of the segmented, fractured subunits into the most ideal position. The edges of the segments are aligned and placed in the position to yield the outcome most like the position prior to the facial trauma.
(Case 2) Custom surgical guides with predrilling holes: Four guides in place to facilitate predrilling holes for final plating system.
(Case 2) Custom 3D-printed titanium plates: Five plates in place following the predrilled screw hole positions. Landmarks serve to distinguish specific plate for the appropriate orientation to reduce operative time and ensure appropriate placement.
(Case 2) Planning of surgical splint: The surgical splint serves as an occlusal guide based on the virtually planned occlusal result. These can be adjusted in parameters of occlusal depth and amount of buccal contour. This is a critical checkpoint in ensuring reestablishment of the appropriate occlusal relationship after trauma.
(Case 2) Final: This segmented but repaired image depicts the recapitulation of the significant facial fractures that nearly exactly replicates that of the VSP surgical plan.
( A , B ) (Case 2) CT Max postop: This figure obtained after surgery reveals the excellent reduction and final outcome of reduction of the numerous facial fractures and the successful implementation of VSP in managing facial trauma.
(Case 3) This patient sustained a bilateral left mandibular parasymphyseal fracture, Le Fort I fracture, ZMC complex fractures, and severely comminuted bilateral nasal, orbital, and ethmoidal fractures that are appreciated in this 3 dimensional reconstruction of the CT imaging.
(Case 3) Segmentation of fractures of anatomic subunits: Using the CT scan and specialized software, Proplan CMF, the fractured segments are identified and demarcated to allow for their reconstruction. This allows for clear visualization of the borders of each fracture to allow for simulated repair and subsequently allows for customized hardware design. In areas of more severe comminution, the largest segments are utilized for designing the customized plating system.
(Case 3) Virtual reduction of fractured subunits: This depicts the appropriate repositioning of the segmented, fractured subunits into the most ideal position. The edges of the segments are aligned and placed in the position to yield the outcome most similar to their position prior to the facial trauma.
(Case 3) Custom surgical guides with predrilling holes: Four guides in place to allow for predrilling holes for final plating system.
( A , B ) (Case 3) Custom 3D-printed titanium plates: Seven plates in place with the 5 following the predrilled screw hole positions. Landmarks serve to distinguish the intended location of the specific plate a provide an orientation marker for the appropriate placement to reduce operative time and ensure appropriate placement.
(Case 3) ( A ) Options for reducing this mandibular fracture are shown, with either bone-borne or ( B ) tooth-borne options.
