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Original article

Virtual surgical planning and three-dimensional printing for the

treatment of comminuted zygomaticomaxillary complex fracture
M. Longeac a, A. Depeyre a, B. Pereira c, I. Barthelemy a,b, N. Pham Dang a,b,*
a
Departement of Oral and Maxillo Facial Surgery, Plastic and Reconstructive Surgery, Estaing Hopital, CHU de Clermont Ferrand, Université Clermont
Auvergne, 1, place Lucie-Aubrac, 63000 Clermont-Ferrand, France
b
UMR Inserm/UdA, Neuro-Dol, Trigeminal Pain and Migraine, BP 10448, 63000 Clermont-Ferrand, France
c
Department of Clinical Research and investigation, 58, rue Montalembert, CHU de Clermont-Ferrand, Université Clermont-Auvergne, 63003 Clermont-
Ferrand, France

A R T I C L E I N F O S U M M A R Y

Article history: Objective: the objective of the study is to evaluate the interest of advanced computer technology,
Received 22 April 2020 including virtual surgical planning, three-dimensional modeling and pre-bended titanium plate and
Accepted 11 May 2020 mesh in the treatment of comminuted zygomaticomaxillary complex fractures.
Material and methods: A total of 19 patients were included. In the study group (n = 6) surgery was
Keywords: combined with preoperative planning including mirroring and bending of the titanium plates and mesh
Zygomaticomaxillary complex on a 3D model. In the control group (n = 13) plates and mesh were bended on the patient during the
Computer-assisted surgery
surgery. Patient characteristics, clinical outcomes, orbital volumes, zygoma projection and complica-
3-Dimensional printing
Plates
tions were recorded.
Results: After surgery, the orbital volume and the zygoma projection variations between injured side and
unaffected side were compared. Orbital volume variation was 2.1 mL [1.5; 4.0] in the control group and
0.4 mL [0.1; 1.0] in the study group. Zygoma projection variation was 0.2 cm in the control group and
0.1 cm in the study group. Orbital volume restoration (P = 0.004) and zygoma symmetrisation (P = 0.04)
were significantly better when titanium plates and meshes were pre-bent on a stereolithographic model.
Conclusion: This study confirms the interest of surgical planification using 3D models to improve
treatment of midface trauma.
C 2020 Elsevier Masson SAS. All rights reserved.

1. Introduction Computer-assisted surgery (CAS) and 3D printing have now

become an essential part of the workflow in several fields of oral
Fractures of the zygomaticomaxillary complex (ZMC) are and maxillofacial surgery, especially in complex reconstructive
among the most common injuries encountered in craniomaxillo- surgery [6–8]. Using advanced open-source software packages, the
facial trauma [1]. If untreated, they can cause both functional surgeon is now able to employ 3D segmentation and mirroring
(diplopia, enophthalmos, limitation of mouth opening) and tools, which are highly effective in mimicking the pre-traumatized
cosmetic (facial asymmetry, loss of zygomatic projection) impair- anatomy at a low cost.
ments [2]. Despite major technical improvement in the 20th The aim of this study is to compare the results of traditional surgery
century, the reduction and osteosynthesis of ZMC fractures are not and of computer technology using a 3D printing model to pre-bend
always easy in comminuted fractures. Management of these titanium plates in restoration of orbital volume and facial symmetry in
fractures has relied mainly on the surgeon’s experience. Results for the initial management of patients with comminuted ZMC fractures.
facial contour, symmetry and functional aspect are sometimes
disappointing [3–5].
2. Patients and methods

2.1. Study design and sample

* Corresponding author at: Departement of Oral and Maxillo Facial Surgery,
Plastic and Reconstructive Surgery, Estaing Hopital, CHU de Clermont Ferrand,
Université Clermont Auvergne, 1, place Lucie-Aubrac, 63000 Clermont-Ferrand,
This is an observational retrospective human subjects’ study
France. approved by the French University Bioethics Committee; IRB number
E-mail address: nphamdang@[Link] (N. Pham Dang). was 00005921.

[Link]
2468-7855/ C 2020 Elsevier Masson SAS. All rights reserved.

Please cite this article in press as: Longeac M, et al. Virtual surgical planning and three-dimensional printing for the treatment of
comminuted zygomaticomaxillary complex fracture. J Stomatol Oral Maxillofac Surg (2020), [Link]
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Nineteen patients with unilateral comminuted ZMC fractures

associated with orbital volume change were included in the study.
All were admitted to the department of oral and maxillofacial
surgery, CHU Estaing (Clermont-Ferrand, France) between Febru-
ary 2014 and November 2016.
Patients were divided into two groups: a control group
composed of a consecutive cohort of 13 patients treated by
conventional surgery, and a study group composed of a consecu-
tive cohort of 6 patients assigned to computer-assisted treatment.
The outcomes, facial symmetry and orbital volume measured
on computed tomography before and after surgery were compared
between the two groups. Patient follow-up after surgery was
6 months.
Inclusion criteria were:

 comminuted unilateral ZMC fracture with associated orbital

fracture, including lateral orbital or orbital floor fractures;
 age older than 18 years;
 no history of previous or associated craniofacial trauma.

2.2. Treatment

All patients were operated under general anaesthesia within

15 days following the trauma. Subciliary, intraoral and eyebrow
incisions were made to expose the fractures. Zygomatic reduction
was achieved with titanium plates and 5 mm screws (SYNTHES1
Matrix Midface 0.8 mm or MEDARTIS MODUS1 2.0). Orbital floor
reconstruction was done with titanium orbital meshes (SYN- Fig. 2. The resulted 3D model printed with the Flashforge1 Pro Creator, fracture
lines and bone defects are drawn on the model. The titanium plates and mesh are
THES1, Matrix Midface 0.3 mm) or with a PDS plate (ETHICON1
shaped according to the patient’s specific anatomy.
ZX5, 0.25 mm). In the study group, titanium meshes and plates
were pre-bent according to a 3D stereolithographic model.
Outcome measures comprised: orbital volume and facial
symmetry, complications and rate of secondary surgery.
2.3. Preoperative planning procedure
The orbital volumes were measured double-blind in millilitres
by a maxillofacial surgeon and a radiologist using OsiriX1 MD.
CT data were imported in DICOM files into the 3D slicer
Manual segmentation was used to delineate the boundaries of the
software (Kitware1, N-Y, USA) to create a stereolithographic (STL)
orbit. A line connecting lateral and medial orbital rim landmarks on
file. It was exported in Meshmixer software (Autodesk1, USA). The
each slice defined the anterior limit. The posterior limit was set at
position of the middle sagittal plane of the skull was established by
the opening of the optic foramen into the orbit. The most superior
marking three points (sella, nasion and subspinal) to mirror the
and inferior axial slices were confirmed by sagittal plane auto-
uninjured side to the fractured side (Fig. 1). The resulting virtual
location on a sagittal-plane view. The computed ROI volume tool
model was printed (Flashforge1 Pro Creator). Titanium plates and
was used to automatically calculate volumes of the total selected
mesh were shaped according to the model and sterilized (Fig. 2).
regions.
ZMC symmetry was measured according to the method of Furst
2.4. Study variables and outcome parameters et al. [9]. We selected the axial image slice where the zygomatic
arches appeared to be thickest. Three landmarks were then
Study variables were epidemiological data and sequelae at identified:
6 months (diplopia, enophthalmos, sensory disorder of the infra-
orbital nerve, loss of zygomatic projection and limitation of mouth  axial midline: from the vertical plate of the ethmoid to the
opening). midline of the clivus (skull base);

Fig. 1. CT data are imported in DICOM files into the 3D slicer software (Kitware1, N-Y, USA) to create a stereolithographic (STL) file. The STL file is exported in Meshmixer
software (Autodesk1, USA). The position of the middle sagittal plane of the skull established by marking three points (sella, nasion and subspinal) (A), after removal of the
injured side (B), after mirroring (C).

Please cite this article in press as: Longeac M, et al. Virtual surgical planning and three-dimensional printing for the treatment of
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Table 1
Patients characteristics, cause of injury and type of implant.

Total, Control group Study group, P

n = 19 n = 13 n=6

Male, n(%) 15 (79.0) 10 (76.9) 5 (83.3) 0.76

Overall age 38.4  14.9 36.4  14.8 42.7  15.5 0.31
Right side, n (%) 6 (31.6) 4 (30.8) 2 (33.3) 0.91
Cause of injury
Traffic accident 3 (15.8) 2 (15.4) 1 (16.7) 1.00
Fall 3 (15.8) 2 (15.4) 1 (16.7) 1.00
Interpersonal violence 5 (26.3) 3 (23.1) 2 (33.3) 0.65
Sport 7 (36.8) 5 (38.5) 2 (33.3) 0.83
Other 1 (5.3) 1 (7.7) 0 (0) 1.00
Orbital floor implant
Titanium mesh, (n%) 9 (47.4) 3 (23.1) 6 (100)
PDS, (n%) 10 (52.6) 10 (76.9) 0 (0)

Fig. 3. Landmarks to measure ZMC symmetry. Point A: the most anterolateral point
of the zygomatic complex, point L: the most lateral point of the curve of the
zygomatic arch, axial midline: from the vertical plate of the ethmoid to the midline 3.2. Orbital volume restoration (Table 2)
of the clivus (skull base) was measured according to the method of Furst et al.
[9]. We selected the axial image slice where the zygomatic arches appeared to be
thickest. Three landmarks were then identified: Using these, we measured the
Preoperative mean orbital volume of the uninjured orbit
anterior zygomatic complex width (distance between axial midline and point A), (OVUpro) was 23.7  2.3 mL in the control group and
the posterior zygomatic complex width (distance between axial midline and point 23.9  3.1 mL in the study group with no significant difference
L) and the zygomatic complex projection (distance between points A and L). between the two (P = 0.76). Mean orbital volume of the uninjured
orbit (OVU) was comparable in the two groups (P = 0.82) and also in
 point A: the most anterolateral point of the zygomatic complex; the same group before and after surgery (P = 0.16). Measurement of
 point L: the most lateral point of the curve of the zygomatic arch. orbital volume is a repeatable and reproducible method.
Preoperative mean orbital volume of the injured orbit (OVIpro)
We measured the anterior zygomatic complex width (distance in the control group was 26.3  2.6 mL with an increase in volume of
between axial midline and point A), the posterior zygomatic complex 2.6 mL compared to the other side. In the study group it was
width (distance between axial midline and point L) and the zygomatic 26.8  2.9 mL with an increase in volume of 2.8 mL. Variation in
complex projection (distance between points A and L) (Fig. 3). preoperative orbital volume between the uninjured and injured sides
ranged from 2.6 to 2.8 mL (P = 0.51). The control group and the study
2.5. Statistical analysis group were comparable in terms of trauma.
Postoperative mean orbital volume of the injured orbit (OVIpo)
Statistical analyses were performed using Stata software in the control group was 25.8  2.42 mL with a mean decrease of
version 13 (StataCorp, College Station, TX). The tests were two- 0.8 mL [ 1.5; 1.2] and 24.2  3.3 mL in the study group with a
sided with the type-I error set at 5%. The continuous data were decrease in volume of 2.3 ml [ 2.5; 2.1]. Postoperatively, reduction
expressed as the mean  standard deviation (SD) or median of the orbital volume was statistically higher in the study group
[interquartile range], according to the statistical distribution. The (P = 0.03).
assumption of normality was assessed with the Shapiro–Wilk’s test. After surgery, comparison of the volume of the restored orbit
The comparisons between groups were performed using Student t- and that of the contralateral orbit showed a variation of 2.1 mL
test or Mann-Whitney test when assumptions required for the t-test [1.5; 4.0] in the control group and 0.4 mL [0.1; 1.0] in the study
were not met. The homoscedasticity was analyzed using Fisher- group with a statistical difference between the two (P = 0.004).
Snedecor test. The comparisons concerning categorical data were Orbital volume restoration was significantly better when titanium
realized using Chi2 or Fisher’s exact test. For paired comparisons, meshes were pre-bent on a stereolithographic model.
Student paired t-test or Wilcoxon test were applied.
3.3. ZMC symmetry (Table 3)

3. Results Measurements of the contour of the zygoma were made after

surgery. Mean zygomatic posterior width of the uninjured-side
3.1. Patient data (UWP) was 6.06  0.25 cm in the control group and 5.99  0.25 cm
in the study group. The same measurements were made of the
A total of 19 patients were included in the study (15 males and zygoma anterior width with comparable size in the two groups.
4 females). Thirteen were treated before February 2016 (conven- Mean zygomatic posterior width of the injured-side (IPW) was
tional surgery group) and 6 after February 2016 with pre-bent 6.35  0.27 cm in the control group and 6.31  0.33 cm in the study
plates (study group). Age ranged between 19 and 69 years in the group, with no statistical difference between groups. The variation in
conventional group (mean 36.4  14.8 years) and between 25 and posterior width between the uninjured and injured sides was 0.3 cm
66 years in the study group (mean 42.7  15.5 years). Patient in each group, with a statistically significant persistent difference
demographics and cause of injury are given in Table 1. (P = 0.001 to 0.03). Mean zygomatic anterior width of the uninjured
Patient characteristics in the two groups were similar (gender side (AWU) was 4.73  0.29 cm in the control group and
distribution [P = 0.76], overall age [P = 0.31]) as was distribution of 4.63  0.15 cm in the study group. It was respectively
the main causes of fractures. 4.73  0.35 cm and 4.82  0.23 cm on the injured side (AWI). The
In the control group, Titanium meshes were used for 3/13 difference in anterior width in the control group between injured and
(23.1%) and PDS plates for 10/13 (76.9%) patients. In the study uninjured sides was 0.2 [0.1; 0.3] and 0.1 [0.1; 0.3] in the study group,
group, titanium meshes were used for all 6 patients. with no statistical difference between the two. Use of pre-bent

Please cite this article in press as: Longeac M, et al. Virtual surgical planning and three-dimensional printing for the treatment of
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Table 2
Mean injured and uninjured orbital volumes (mL) for subjects before and after surgery in the study and control groups and differences between volumes with P values
reported.

Orbital volume (OV) (mL) Total, n = 19 Control group, n = 13 Study group, n = 6 P-value

OVUpro 23.8  2.5 23.7  2.3 23.9  3.1 0.76

OVUpo 23.7  2.4 23.6  2.2 23.8  3.1 0.82
p (OVUpro-OVUpo) 0.16 0.25 0.48
OVIpro 26.5  2.7 26.3  2.6 26.8  2.9 0.86
OVUpro – OVIpro 2.6 [1.7; 3.0] 2.6 [1.7; 3.0] 2.8 [2.1; 3.0] 0.51
OVIpo 25.3  2.7 25.8  2.4 24.2  3.3 0.36
OVIpo – OVIpro 1.4 [ 2.4; 0.7] 0.8 [ 1.5; 1.2] 2.3 [ 2.5; 2.1] 0.03
P (OVIPO-OVIpro) 0.02 0.33 0.003
OVUpo – OVIpo 1.5 [0.4; 3.0] 2.1 [1.5; 4.0] 0.4 [0.1; 1.0] 0.004

OVUpro: preoperative orbital volume of the uninjured orbit; OVIpro: preoperative orbital volume of the uninjured orbit; OVUpo: postoperative orbital volume of the
uninjured orbit; OVIpo: postoperative orbital volume of the injured orbit; OVUpro-OVIpro: volume difference between orbital volume of the uninjured side and orbital
volume of the injured side before surgery; OVIpo – OVIpro: volume difference between orbital volume of the injured side after surgery and orbital volume of the injured side
before surgery; OVUpo-OVIpo: volume difference between orbital volume of the uninjured side and orbital volume of the injured side after surgery.

Table 3
Mean injured and uninjured ZMC measurements (cm) for subjects before and after surgery in the study and control groups and differences between each side and each group
with P-values reported.

Dimension (cm) Total, n = 19 Control group, n = 13 Study group, n = 6 P-value

Posterior width (PW)

Uninjured side (UPW) 6.04  0.24 6.06  0.25 5.99  0.25 0.42
Injured side (IPW) 6.34  0.28 6.35  0.27 6.31  0.33 0.83
P (UPW,IPW) 0.001 0.001 0.03
IPW-UPW 0.3[0.2;0.4] 0.3 [0.2; 0.3] 0.3[0.1; 0.5] 1.00
Anterior width (AW)
Uninjured side (UAW) 4.70  0.25 4.73  0.29 4.63  0.15 0.23
Injured side (IAW) 4.76  0.32 4.73  0.35 4.82  0.23 0.69
P (UAW, IAW) 0.34 1.00 0.006
IAW-UAW 0.2 [0.1; 0.3] 0.2 [0.1; 0.3] 0.1 [0.1; 0.3] 0.96
Projection (P)
Uninjured side (UP) 3.66  0.39 3.64  0.45 3.69  0.25 0.96
Injured side (IP) 3.76  0.48 3.76  0.55 3.76  0.29 0.60
P (uninjured-injured) 0.06 0.13 0.10
IP-UP 0.1 [0.1; 0.3] 0.2 [0.1; 0.4] 0.1 [0.0; 0.1] 0.04

PW: posterior width; AW: anterior width; P: projection; U: uninjured side; I: injured side.

titanium plates did not increase the quality of the reduction of the bent titanium plates on a 3D printing model. There was also a trend
anterior and posterior width of the zygoma. towards fewer complications and sequelae, and without an
Mean zygomatic projection on the uninjured side (PU) was increase in operating time.
3.64  0.45 cm in the control group and 3.69  0.25 cm in the study In recent years, there has been extensive literature available on
group. Mean zygomatic projection on the injured side (PI) was the use of 3D printing methods for the treatment of ZMC fractures.
3.76  0.55 cm in the control group and 3.76  0.29 cm in the study Yet, to be reliable, 3D printed models should be consistent with
group. The difference in projection between injured and uninjured patient reality. Choi et al. [10] found a mean deviation of 0.56%
sides was 0.2 cm in the control group and 0.1 cm in the study group, between the original dry skull and the 3D printed model, which is
with a statistically significant difference (P = 0.04). Use of pre-bent acceptable for the scheduling of surgical procedures. Moreover,
titanium plates increased the quality of the projection of the zygoma. only a few of the published studies used objective benchmarks and
many lacked a control group [11,7].
3.4. Complications and sequelae Owing to the complicated anatomy of the ZMC, the great
difficulty was in evaluating orbital volume and ZMC shape [12],
No intraoperative complications were recorded. Because of the which requires a standard orientation of the CT-scan slices
small sample size, analyses of each sequela did not provide a [13]. Values were measured twice, with no inter-observer
reasonable basis for drawing any definite conclusions. However, variation. There was no significant difference between the
when all complications and sequelae were analysed as a composite preoperative and postoperative orbital volumes of the uninjured
endpoint a significantly lower rate was evidenced in the study side (P = 0.16), which were similar to those obtained in the
group (P = 0.03) (Table 1). literature with the same measurement technique [12]. This
confirms the reliability and the repeatability of the technique.
To analyse ZMC symmetry, we used the method described by Furst
4. Discussion et al. [9], which allows the measurement of only anterior and
posterior width and projection, it does not take into account each
In the present study, the authors measured on preoperative and single point of the zygoma. To measure ZMC symmetry exhaus-
postoperative CT-scan the quality of reduction based on ZMC and tively, other studies have used surface-based matching techniques
orbital cavity marker points. The results indicated a statistically [2,14] that consist in mirroring of the unaffected side of the ZMC.
significant improvement in restoring orbital volume (P = 0.004) Both surfaces are then overlaid, creating an inter-surface distance
and zygoma projection (P = 0.04) with the use of meshes and pre- map representing the amount of symmetry between the two sides.

Please cite this article in press as: Longeac M, et al. Virtual surgical planning and three-dimensional printing for the treatment of
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Appendix A. Supplementary data Surg 2017;139(4):957–65.

Supplementary data associated with this article can be found, in

the online version, at [Link]

Please cite this article in press as: Longeac M, et al. Virtual surgical planning and three-dimensional printing for the treatment of
comminuted zygomaticomaxillary complex fracture. J Stomatol Oral Maxillofac Surg (2020), [Link]
mas.2020.05.009