Cad Cam Construction of Surgical Imolant for Craniofaical Implant

Computer-aided design andmanufacturing construction of a surgicaltemplate for craniofacial implantpositioning to support a definitive nasalprosthesis

Leonardo CioccaMassimiliano FantiniFrancesca De CrescenzioFranco PersianiRoberto Scotti

Authors’ affiliations:Leonardo Ciocca, Maxillo-Facial Prosthodontics,Section of Prosthodontics, Department of Oral Science,Alma Mater Studiorum University of Bologna, Bologna,ItalyMassimiliano Fantini, Francesca De Crescenzio,Virtual Reality and Simulation Laboratory, IIEngineering Faculty, Alma Mater StudiorumUniversity of Bologna, Forlı, ItalyFranco Persiani, II Engineering Faculty, Alma MaterStudiorum University of Bologna, Forlı, ItalyRoberto Scotti, Oral and Maxillo-Facial Rehabilitation,Section of Prosthodontics, Department of Oral Science,Alma Mater Studiorum University of Bologna, Bologna,Italy

Corresponding author:Dr Leonardo CioccaVia S. Vitale 5940125 BolognaItaly.Tel.: þ 39 051 208 8145Fax: þ 39 051 22 5208e-mail: [email protected]

Key words: CAD–CAM, craniofacial implants, nasal prosthesis, rapid prototyping, virtual surgery

Abstract:

Aim: To design a surgical template to guide the insertion of craniofacial implants for nasal prosthesis

retention.

Materials and methods: The planning of the implant position was obtained using software for virtual

surgery; the positions were transferred to a free-form computer-aided design modeling software and

used to design the surgical guides. A rapid prototyping system was used to 3D-print a three-part

template: a helmet to support the others, a starting guide to mark the skin before flap elevation, and a

surgical guide for bone drilling. An accuracy evaluation between the planned and the placed final

position of each implant was carried out by measuring the inclination of the axis of the implant

(angular deviation) and the position of the apex of the implant (deviation at apex).

Results: The implant in the glabella differed in angulation by 7.781, while the two implants in the

premaxilla differed by 1.86 and 4.551, respectively. The deviation values at the apex of the implants

with respect to the planned position were 1.17 mm for the implant in the glabella and 2.81 and

3.39 mm, respectively, for those implanted in the maxilla.

Conclusions: The protocol presented in this article may represent a viable way to position craniofacial

implants for supporting nasal prostheses.

Computer-aided design and manufacturing

(CAD–CAM) technology is developing rapidly

in the field of maxillofacial prosthetics. In recent

articles, we described protocols for elaborating

and rapidly prototyping molds for auricular pros-

theses for a patient who required ablative surgery

of the external ear for tumor removal (Ciocca et

al. 2007a, 2007b) and for a patient affected by

Treacher Collins syndrome (Ciocca et al. 2010a,

2010b). However, these previous reports did not

discuss the problem of identifying the bone avail-

able for craniofacial implant insertion. Osseoin-

tegrated implants have various advantages over

either adhesive or spectacle-retained devices for

the reconstruction of an ablated nose (Ciocca

et al. 2010a, 2010b). They provide better retention

of the prosthesis, so that it is properly positioned

and the patient can wear it more confidently. The

prosthesis can be made thinner, with feathered

edges that blend with the skin, which offers the

patient improved esthetics. Preoperative planning

with the maxillofacial surgeon and the prostho-

dontist is vital for optimal outcomes: today, the

virtual planning of the craniofacial implant inser-

tion and the rapid prototyping of the surgical

template requires the collaboration of the CAD–

CAM specialist engineer. Many articles have

described computerized technology without con-

sidering this important step and the procedure

required for the correct positioning of craniofacial

implants within the external volume of an ear or

nasal prosthesis (Nusinov & Gay 1980; Manko-

vich et al. 1986; Girod et al. 1995; Beumer et al.

1998; Coward et al. 1999; Penkner et al. 1999;

Runte et al. 2002; Cheah et al. 2003a, 2003b;

Hecker 2003; Kubon & Anderson 2003; Lemon

et al. 2003; Reitemeier et al. 2004; Mardini et al.

2005).

Typically, the available bone in the glabella and

the premaxilla is the major factor that determines

implant position for retention of nasal prosthesis.

Diagnosis and treatment planning are multi-dis-

ciplinary, and the use of new CAD–CAM tech-

nologies may improve implant-supported

prosthetic rehabilitation. Borderline patients

may be studied during the diagnostic phase using

Date:Accepted 5 August 2010

To cite this article:Ciocca L, Fantini M, De Crescenzio F, Persiani F, Scotti R.Computer-aided design and manufacturing construction of asurgical template for craniofacial implant positioning tosupport a definitive nasal prosthesis.Clin. Oral Impl. Res. 22, 2011; 850–856.doi: 10.1111/j.1600-0501.2010.02066.x

850 c� 2010 John Wiley & Sons A/S

mailto:[email protected]

the virtual simulation of the surgery, avoiding

surgical over-treatments or reducing more aggres-

sive surgeries (Van Steenberghe et al. 2005; Balshi

et al. 2006; Lal et al. 2006; Rosenfeld et al. 2006).

However, no attempt has been made to guide

the position of craniofacial implants using a

prosthetic virtual simulation regarding the final

rehabilitation of the nose or a rapidly prototyped

surgical template derived from this process. This

article describes the computer-aided design and

rapid prototyping of surgical template for the

prosthetically guided insertion of craniofacial

implants.

Material and methods

A 58-year-old man presenting with a total loss of

the nose due to a gunshot was scheduled for a

definitive nasal prosthesis, anchored on osseoin-

tegrated craniofacial implants (Fig. 1).

CT scan elaboration with NobelGuide

The CT data were uploaded into NobelGuide

software (Nobel Biocare, Kloten, Switzerland)

and elaborated to plan the implant surgery in

the nasal region, where a sufficient quantity of

available bone was present. Two implants were

positioned in the premaxillary area in the nasal

floor and one in the glabellar region. The length

of the implants was 11.5 mm and the diameter

was 3.75 mm. After positioning the implants, the

frontal, lateral, and upper orthographic views

(with and without the skeletal region of interest)

were collected as JPG images (Fig. 2).

CT and laser scanner data integration

The CT data were uploaded into Amira 3.1.1

software (Mercury Computer Systems, Chelms-

ford, MA, USA) and elaborated to reconstruct the

3D digital model of the skull surface by setting

the same threshold value used in NobelGuide

(276 Hounsfield Unit [HU]). The 3D digital

model of the skin surface was also obtained by

setting a suitable threshold value. Both models

were achieved semi automatically by threshold-

based segmentation, contour extraction, and sur-

face reconstruction. This process is particularly

useful for distinguishing between soft tissues and

skeletal structures. Moreover, to augment the

obtained region of the face, CT data were inte-

grated with laser scanner data that had been

collected previously for designing and manufac-

turing the eyeglasses-supported provisional nasal

prosthesis. In that instance, a laser scanner

(NextEngine Desktop 3D Scanner; NextEngine,

Santa Monica, CA, USA) was used to acquire the

facial skin surface from five (left, right, frontal,

upper, lower) different perspectives, covering a

wider area of the face with respect to CT data

acquisition focusing just on the nasal defect. As

usual in reverse engineering post-processing, the

five scans have been carefully aligned and merged

to obtain the final digital model of the patient’s

entire face. Skin surfaces from CT and laser

scanner data were both imported into Rapidform

XOS2 (INUS Technology, Seoul, Korea) and re-

gistration process was carried out for data inte-

gration into a single coordinate system. Three

pairs of corresponding reference points were se-

lected on both skin surfaces (CT and laser scan-

ner) for an initial rough alignment. When

Fig. 2. Frontal, lateral, and upper views (with and without the skeletal region of interest) by NobelGuide.

Fig. 1. Initial anatomy.

Ciocca et al �CAD–CAM construction of a surgical template for craniofacial implant positioning

c� 2010 John Wiley & Sons A/S 851 | Clin. Oral Impl. Res. 22, 2011 / 850–856

performing this operation, the first selected shell

(skin surface from laser scanner data) was moved

to the second selected shell (skin surface from

CT data). The refinement of the alignment was

performed semiautomatically using iterative

closest points (ICP)-based fine registration. To

evaluate the accuracy of the registration process,

a surface deviation analysis between CT and

laser scanner data was performed, yielding a

distance mean value of o1 mm. The color

map visualization of the surface deviation ana-

lysis is shown in Fig. 3: the regions with higher

deviation were localized around the mouth and

the residual left nasal ala, probably due to

different facial expressions during the two data

acquisition sessions. After the registration pro-

cess, the skin surface acquired from the laser

scanner was simply used to replace the skin

surface reconstructed from CT data integration

between skull surface from CT and skin surface

from laser scanner (Fig. 4).

Virtual planning transfer

In Rhino 3.0 (Robert McNeel & Associates,

Seattle, WA, USA), the frontal, lateral, and upper

images, without the skeletal region of interest,

collected by NobelGuide, were imported as back-

ground bitmaps in the corresponding views

(scaled to match each other and located in space,

so they all lined up). In each of the three views,

background bitmaps were used as a guide to trace

over the construction lines for the axis of the

three implants. The Crv2View command (curves

from two views) was used to create the axis of the

three implants in 3D space by selecting the

corresponding construction lines in two views.

The implants were modeled as cylinders (dia-

meter 3.75 mm and height 11.5 mm) and placed

in 3D space according to the relative axis and the

background bitmaps (Fig. 5a). For this kind of

construction, just two views are necessary, but

using three views avoid eventually problems due

to overlapping of reference features in the images.

Digital models of skull surfaces from CTand skin

surfaces from laser scanner were also imported for

referencing in 3D space. After replacing back-

ground bitmaps with the images, with the skele-

tal region of interest, collected by NobelGuide,

both digital models were moved, overlapping the

skull surface with respect to the new background

in each view (Fig. 5b).

Designing the template

Once all the models had been imported into

Rhino, a template with surgical guides for im-

plants placement, as planned previously, was

designed. It was developed in three parts: a

main template for referencing on the patient’s

head and two interchangeable overhanging surgi-

cal guides. The main template was designed as a

customized helmet by the offset (5 mm) of the

frontal–upper part of the 3D digital model of the

scanned face to ensure a correct matching with

the head of the patient. A dovetail joint was

added in the front for connecting the two surgical

guides, both provided with guide cylinders. The

first surgical guide was designed just to mark the

skin corresponding to the implants’ axis before

surgically cutting the soft tissues, while the

second one was developed to guide the drilling

of the bone for implant placement (Fig. 6).

Rapid prototyping of the template

The helmet template and the two interchange-

able overhanging surgical guides were directly

manufactured using a 3D soluble support tech-

nology rapid prototyping system (Stratasys, Eden

Prairie, MN, USA). The working principle is

based on fused deposition modeling by acryloni-

trile butadiene styrene plastic material (ABS

P400) and soluble support material to sustain

the prototype under construction. By this pro-

cess, prototypes are built up layer by layer (thick-

ness 0.254 mm) with two available filling

options: solid and sparse. In the first case, each

section of the model is completely filled with

ABS material. In the second one, the interior part

of the model is replaced with a honeycomb

structure. Solid fills are stronger and heavier,

while sparse fills are weaker and lighter, saving

material and speeding up the build process.

Therefore, the digital models were exported in

solid to layer format and directly prototyped in a

single work session, choosing the sparse fill

option for the helmet template and the solid fill

option for the overhanging guides to obtain

stronger elements. The process was completed

by washing the models in an agitation system

with a hot soapy water bath to remove all the

support material for hands-free model completion

(Fig. 7). Table 1 shows the amount and cost of the

ABS and the support material consumed.

Fig. 4. Skull surface from CT data (left), skin and skull surfaces from CT data (center), and integration between the skull

surface from CT data and skin surface from laser scanner data (right).

Fig. 3. Skin surface from CT data (left), laser scanner data (center), and surface deviation analysis between CT and laser

scanner data (right).


852 | Clin. Oral Impl. Res. 22, 2011 / 850–856 c� 2010 John Wiley & Sons A/S

Clinical procedure

The surgical template was tested on the patient,

and the insertion procedure was checked in rela-

tion to the dimensions of the drill and the hand

piece before surgical intervention (Fig. 8). The

patient underwent general anesthesia for the

surgery: before starting, the position of the surgi-

cal template was marked onto the skin with a

skin pencil to facilitate repositioning during the

second phase of the surgery. Then, the insertion

landmark points were pointed on the skin and

deeper, with a needle and dermographic ink, as a

guide for flap elevation (Fig. 9a, b). A plastic

surgery was executed to eliminate the left nasal

ala, still present as residual structure from the

first emergency surgery. When the skull bone

was exposed, the second surgical template was

fixed to the helmet and it was repositioned onto

the head according to the lines previously

marked. The surgical pilot drill was guided by

the holes of the templates and a pin was inserted

to test the inclination and the position with

respect to the available bone. The insertion of

implants (Branemark System RP TiUnite, Nobel

Biocare) was performed according to the conven-

tional protocol (Fig. 9c, d), and the flaps were

sutured covering the screw taps of the implants

(Fig. 9e).

Results

A CT scan was performed after the surgery to

verify the accuracy of the surgical protocol with

respect to the CAD–CAM planned design. In Fig.

Fig. 6. Design of the surgical template for implant positioning: helmet template (a),

starting guide to mark the skin (b), surgical guide to drill the bone in the glabellar

region (c), and surgical guide to drill the bone in the premaxillary area (d).

Fig. 7. Rapid prototyping of the surgical template for implant positioning: helmet template, starting guide to

mark the skin, and surgical guides to drill the bone (in the glabellar region and in the premaxillary area).

Table 1. Material cost

Surgical template elements ABSmaterial(cm3)

Supportmaterial(cm3)

Buildingtime

Cost ofmaterial(h)

Helmet template 98.45 116.30 14 h53 min

51.12

Surgical guide to mark the skin 8.82 4.60 1 h 20 min 4.29Surgical guide to drill the bone in theglabellar region

7.67 3.70 1 h 2 min 3.82

Surgical guide to drill the bone in thepremaxillary area

9.68 5.82 1 h 46 min 4.78

Total 124.62 130.42 19 h 1 min 64.01

Fig. 5. Virtual planning transfer (frontal and lateral views): implant modeling, according to background bitmaps (a) and skull

positioning, according to background bitmaps (b).



10 are shown the frontal and lateral views of the

radiographic control after implants placement to

support the nasal prosthesis. The presence of

previously placed implants for dental prosthesis

and the distribution of bullets due to the gunshot

can also be observed.

The post-operative CT data were uploaded into

Amira and elaborated to reconstruct the digital

model of the skull surface by setting the same

threshold value used previously (276HU), and the

3D digital models of the inserted implants were

reconstructed by setting a suitable threshold value.

The digital models were imported in Rapid-

form XOS2 and the registration process was

carried out by selecting three pairs of correspond-

ing reference points on both skull surfaces (pre-

and postsurgical intervention) for initial rough

alignment. The refinement of the alignment was

performed using ICP registration. The process for

pre- and postdata integration into the same co-

ordinate system allowed comparison of the

planned position with the real position of the

implants in Rhino environment (Fig. 11).

The accuracy between planned and placed was

quantitatively evaluated by measuring two para-

meters: the inclination of the axis of the implant

(angular deviation) and the position of the apex of

the implant (deviation at apex; Table 2). Because

the axes of planned and placed implants are repre-

sented by two straight lines in space that do not lie

in a plane, the angular deviation is evaluated as the

minor angle between two skew lines, defined as

either of the angles between any two lines parallel

to them and passing through a point in space.

The implant in the glabella differed in angula-

tion by 7.781, while the two implants in the

premaxilla differed by 1.86 and 4.551, respec-

tively. Consistent with literature data (Van

Steenberghe et al. 2003; Di Giacomo et al.

2005; Ozan et al. 2009) for accuracy when using

the CAD–CAM system during implant surgery,

the angle deviation was acceptable in terms of

safety and prosthetic implications. The deviation

values at the apex of the implants with respect to

the planned position were 1.17 mm for the im-

plant in the glabella and 2.81 and 3.39 mm,

respectively, for those implanted in the maxilla.

The position of the implants resulted in the mean

values of the data from the literature.

Discussion

Different computer-aided surgery systems har-

ness the advantages of optimal 3D diagnosis

and software-based planning by accurately trans-

ferring the virtual implant positions to the corre-

sponding anatomical patient’s sites. Since 1997,

different approaches for computer-assisted

implant planning have been available for oral

Fig. 8. Try-in of the surgical template on the patient and check of the insertion procedure.

Fig. 9. Surgery: initial landmarking (a, b), implant positioning (c, d), and the flap suture (e).



implants (Ewers et al. 2004; Mupparapu & Singer

2004), but none have been useful for the insertion

of craniofacial implants. Moreover, although

several studies have been published on the accu-

racy of these models (Tal & Moses 1991;

DelBalso et al. 1994; White et al. 2001; Hatcher

et al. 2003), no data are available on the accuracy

of craniofacial implant positioning with respect to

the planned position.

This study presented a new protocol of con-

structing surgical templates for craniofacial im-

plants. Starting from a 3D system (NobelGuide,

Nobel Biocare), planning of the ideal position of

three craniofacial implants was carried out. The

spatial position of each implant, represented in

the NobelGuide, was transferred into CAD soft-

ware that allowed projection of the surgical tem-

plate. When the helmet and the inserts were

prototyped and sterilized, the patient was sched-

uled for surgery.

The main innovation in such a procedure was

the integration of CTand laser scanner data as the

starting point for the design of the surgical guide.

Coordinate systems integration from multimodal

devices has already been carried out for the gen-

eration of a craniofacial database (Suwardhi et al.

2005), but not for the purpose described in this

paper. To reduce the patient’s exposure to X-rays,

CT scanning should be focused on the effective

region of interest, while the completely safe 3D

laser scanning may cover a much wider area. Thus,

the CT scan, focused on the nasal defect, was

integrated with 3D laser scanning of the entire face

and head surface to design the customized helmet.

The main problem of such a surgical guide was

the stability: the helmet was designed on a rigid

and fixed frontal surface of the patient, while the

skin is resilient and mobile. Even if the glabella

landmark can be readily detected, minor pressure

on the template may dislocate it in a wrong

position. Taking care in positioning it with respect

to the three landmarks (two supra-ocular bone

arches and glabella) with no pressure on the skin,

the template position was accurately marked on

the frontal and lateral skin of the skull, so as to

reproduce the same position each time the tem-

plate was used. However, a bone pin retention

system will also be necessary in the future for

better stabilization of the template.

As result of this main problem, the implant in

the glabellar region was affected by an error in the

inclination in spite of a very good placement

position. The two implants in the premaxillary

area in the nasal floor were more internally

displaced with respect to the planned place due

to a slightly incorrect repositioning of the helmet

during the two-step drilling surgery. Moreover,

they were both inserted into the bone tissue less

in depth than planned.

The main advantages of this protocol are the use

of a CAD–CAM system to guide the implant

surgery and to project the implant position accord-

ing to prosthetic options. The first advantage

allows the surgeon to accurately plan the flap and

the plastic surgery: in the case reported here, for

example, a reduction in the thickness of the mu-

codermal flap in the floor of the nose was necessary

to obtain a correct emerging profile of the healing/

prosthetic abutments. The second advantage allows

the prosthodontist to take into account the pros-

thetic issues in terms of the inclination for a better

impression and accessibility for home hygienic

maintenance care around implants.

The main disadvantages are that it is consum-

ing and expensive due to the elaboration of the

surgical template. Moreover, the rapid prototyp-

ing equipment (software and 3D printer) may

represent a barrier.

Conclusions

The protocol presented here simplifies the im-

plant surgery for the insertion of craniofacial

implants to support a nasal prosthesis. The sur-

gical template can be rapidly manufactured using

CAD–CAM technology in combination with

other systems for virtual surgery. This protocol

facilitates a more accurate positioning of cranio-

facial implants than unguided surgery.

Fig. 10. Radiographic control after implants placement to support the nasal prosthesis (indicated by black arrows): (a) frontal

view; (b) lateral view. In the radiography can also be noticed the presence of previously placed implants for dental prosthesis

and the distribution of bullets due to the gunshot.

Fig. 11. Comparison between the planned (continuous line axis) and placed (dashed line axis) implant position to

quantitatively evaluate the accuracy: (a) frontal view; (b) lateral view.

Table 2. Values of accuracy measurements

Site Deviationat apex (mm)

Angulardeviation (1)

Glabella 1.17 7.78Maxilla 1 2.81 1.86Maxilla 2 3.39 4.55



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