Session: Oral Abstract Session

CSI04 - Implementation of Immersive Virtual Reality and Augmented Reality in Temporomandibular Total Joint Replacement Using Biomet Stock Prosthesis - A Case Series

Saturday, March 11, 2023

4:05pm – 4:15pm CST

Figure 1. ImmersiveTouch’s Virtual Reality (VR) platform used for ideal placement of fossa and ramal prosthesis. Preoperative trial of Augmented Reality for superimposition of the surgical plan onto the patient's Skeletal Model. A, Posterior view of condylar prosthesis seated within the glenoid fossa depicting bony interferences. B, The required areas of bony reduction (purple) are displayed for well adaptation of the condylar prosthesis onto the lateral ramus. Proximity of the IAN (orange) to the bony osteotomy site is also demonstrated. C, Senior surgeon utilizing the ImmersiveTouch’s VR software for treatment planning. D, AR displays the osteotomy plane for condylar resection and areas of bony interference in preparation for placement of condylar prosthesis. E, AR guided placement of the condylar prosthesis and guided angulation and depth of the fixation screw holes. F, Interdental occlusion with condylar prosthesis seated in centric relation within the prosthetic fossa visualized via AR; this in turns with a surgeon’s tactical feedback of the occlusion provided enough information to correctly reconstruct the TMJ. Images provided courtesy of ImmersiveTouch, Inc.

Figure 2. Intraoperative use of ImmersiveTouch’s Augmented Reality platform for preparation of the fossa and ramal surgical sites and placement of stock prosthesis. A, Removal of bony interferences and drilling of fixation screw holes on lateral surface of zygomatic arch for fossa prosthesis insertion. B, Condylar osteotomy, lateral ramus bony interference reduction, and guided placement of fixation screw holes for condylar prosthesis insertion.

Figure 3. Superimposition analysis describing magnitude of discrepancy between preoperative surgical plan and actual positioning of the fossa and condylar components. Analysis demonstrates high correspondence. First patient, shown on A and B, displays an average difference of 1.780 ±0.218mm at the fossa and 0.933 ±0.216mm at the condyle. Second patient, shown on C and D, displays an average difference of 1.006 ±0.413mm at the fossa and 1.890 ±0.255 at the condyle. Images provided courtesy of ImmersiveTouch, Inc.

Oral Abstract Presenter(s)

Robert H. Liu, DMD

Oral & Maxillofacial Surgery Resident
Walter Reed National Military Medical Center
North Bethesda, Maryland

Disclosure(s): No financial relationships to disclose

Co-Author(s)

IN

Injamamul L. Niloy, DDS

Oral & Maxillofacial Surgery Resident
Walter Reed National Military Medical Center
Washington, District of Columbia

Disclosure information not submitted.
CY

Chang Min Richard Yim, DMD

Oral and Maxillofacial Surgery Attending
Walter Reed National Military Medical Center
Bethesda, Maryland

Disclosure information not submitted.
NP

Nikole Pham

Bethesda, Maryland

Disclosure information not submitted.

Abstract: Alloplastic temporomandibular joint replacement (TJR) is the definitive reconstructive option in patients with end-stage temporomandibular joint (TMJ) degenerative disease. FDA-approved Stock and Custom TJR prosthesis systems both benefit from preoperative virtual surgical planning for precise surgical osteotomies, reduction of interferences, and placement of selected prosthesis. Although challenging, the preoperative surgical plan traditionally has been converted onto the surgical field manually, with the use of surgical guides, or by using a dynamic navigation system1. The aim for this study is to demonstrate a workflow for the use of ImmersiveTouch’s Virtual Reality (VR) for surgical planning and Augmented Reality (AR) for implementation of total alloplastic TMJ joint replacement using Biomet Stock Prosthesis.

This prospective study included two patients who underwent TJR using Biomet stock prosthesis at the Walter Reed National Military Medical Center (Bethesda, MD) between May 2022 and August 2022. Preoperative facial computed tomography (CT) and three-dimensional (3D) magnetic reasoning imaging (MRI) of TMJ were co-located for combined visualization of both datasets in VR. A 3D reconstruction of both hard and soft tissue of the TMJ complexes were performed and key anatomic components and critical bony measurements were identified. Using immersive VR, surgical planning was performed by a senior surgeon. Planning included condylar resection, selection and positioning of appropriate Biomet Stock TMJ fossa and condylar prostheses, and identification of bony interferences. Surgical plan was translated onto the operative field using AR software and surgical guides. During surgery, an AR head-mounted display was used by the senior surgeon to superimpose the 3D model upon the patient’s facial bones in real time. AR provided in-situ guidance for condylar osteotomy, bony interference reduction, placement of fossa and condylar prosthesis, and drilling of fixation screw holes to the appropriate depth and angulation. AR simultaneously displayed critical anatomical information such as the inferior alveolar nerve and skull base location. The Biomet stock prosthesis was then fixated in place to the pre-drilled sites. Most critically, AR visualized real time patient’s interdental occlusion with the new prosthetic condyle seated in planned relation within the prosthetic fossa. This negated the need for intraoperative intermaxillary fixation (IMF). A postoperative CT scan was taken and superimposed onto the preoperative surgical plan to evaluate accuracy.

Superimposition analysis demonstrated high correspondence between the preoperative surgical plan and postoperative result. The average differences in the positioning of the condylar and fossa prosthesis were 1.252 ±0.269mm and 1.393 ±0.335mm respectively. The fossa and condylar prostheses were well adapted to the zygomatic arch and lateral ramus. Vital anatomic structures were not violated during the surgical procedures. All patients had stable and reproducible occlusion with significant improvement in TMJ functions.

Our study explored a novel use of Immersive VR and AR in surgical planning and placement of Biomet Stock prosthesis for TMJ Joint Replacement. Immersive VR allows the surgeon to visualize the anatomy of interest in detailed 3D hard and soft tissue virtual models as well as simulate surgical planning. Our study demonstrates that AR can transfer a virtual preoperative surgical plan to the operative field and reduce risks of injuring critical anatomic structures while maintaining sterility with potential to reduce valuable surgical time. This also eliminates the need for surgeons to switch focus onto an external monitor required with dynamic navigation2. Additionally, it allows for the flexibility to modify or correct the surgical course. AR has the advantage of requiring small surgical access contrary to the use of surgical guides2. Most importantly, it accurately visualizes the patient's occlusion during the insertion of prosthesis. By eliminating IMF, this significantly reduces cross-contamination, infection risks, and operative time and cost while increasing patient satisfaction.

Comments to Organizers:: Reference:
1. Zinser MJ, Sailer HF, Ritter L, Braumann B, Maegele M, Zöller JE. A paradigm shift in orthognathic surgery? A comparison of navigation, computer-aided designed/computer-aided manufactured splints, and "classic" intermaxillary splints to surgical transfer of virtual orthognathic planning. J Oral Maxillofac Surg. 2013 Dec;71(12):2151.e1-21. doi: 10.1016/j.joms.2013.07.007. PMID: 24237776.

2. Bussink T, Maal T, Meulstee J, Xi T. Augmented reality guided condylectomy. Br J Oral Maxillofac Surg. 2022 Sep;60(7):991-993. doi: 10.1016/j.bjoms.2022.01.008. Epub 2022 Feb 1. PMID: 35339300.