Journal of Cranio-Maxillo-Facial Surgery 41 (2013) e87ee90

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Journal of Cranio-Maxillo-Facial Surgery

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Clinical indication for intraoperative 3D imaging during open

reduction of fractures of the mandibular angle
Jan-Christoph Klatt a, *, M. Heiland b, S. Marx c, H. Hanken b, R. Schmelzle a, P. Pohlenz a
a
Department of Plastic and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, D-20246 Hamburg, Germany
b
Department of Oral and Maxillofacial Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
c
Hamburg Bergedorf, Alte Holstenstraße 12, D-21031 Hamburg, Germany

a r t i c l e i n f o a b s t r a c t

Article history: Purpose: This retrospective study investigated 3-dimensional (3D) imaging with intraoperative Cone-
Paper received 9 December 2011 Beam Computed Tomography (CBCT) in Mandibular Angle Fractures (MAF) treated by open reduction.
Accepted 16 November 2012 The aim of this study was to demonstrate the image quality of intraoperative CBCT in this region and the
benefit for the patients.
Keywords: Methods: 83 patients with 86 MAF were included in this study. 8 patients were female and 75 male.
Cone-beam tomography
Patient age ranged from 11 to 68 years (average age 26.8 years). All patients were examined with the
Lower jaw fractures
mobile CBCT scanner ARCADIS Orbic 3D (Siemens Medical Solutions, Erlangen, Germany) directly after
Angle fractures
Complications
surgical treatment of the MAF.
3D reconstruction Results: As a direct result of intraoperative CBCT four patients (5%) underwent intraoperative revision.
The intraoperative acquisition of the data sets was uncomplicated and in all cases it was possible to
effectively visualise and assess the MAF in 3D quality.
Conclusion: The results showed that intraoperative CBCT is a reliable imaging technique for real-time
intraoperative assessment of treated MAF. Use of the mobile 3D CBCT scanner is easy to integrate into
routine practice and offers the advantage that immediate revision surgery can be performed.
Ó 2012 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights
reserved.

1. Introduction The clinical applicability of CBCT in oral and maxillofacial surgery

The successful treatment of MAF using innovative surgical
techniques and fixation (Höfer et al., 2012; Jain et al., 2012) is
closely related to the development of diagnostic radiology
facilities. CBCT has enhanced the information available for pre-,
intra- and post-operative management in oral and maxillofacial
surgery.
Digital Volume Tomography (DVT) was first introduced in 1998
as a new investigative procedure in X-ray diagnostics in dental
practice, where it was immediately in competition with conven-
tional CT. This modified form of CT can be used to reconstruct the
complex anatomy of the face at different levels and to visualise the
facial bone without superimposed secondary images. In compar-
ison with CT, CBCT significantly lowers exposure to radiation and
minimises interference from metal artefacts (Schulze et al., 2004;
Heiland et al., 2004).
* Corresponding author. Tel.: þ49 40 7410 22777; fax: þ49 40 7410 55467.
E-mail address: klatt.jc@web.de (J.-C. Klatt).
continues to increase (De Vos et al., 2009; Jayaratne et al., 2010).
The benefits of intraoperative use of the combination of 3D
volume scanners and mobile C-arm scanners (SIREMOBIL Iso-C3D,
Siemens Medical Solutions, Erlangen, Germany) were first reported
in 2001. The mobile C-arm scanner (ARCADIS Orbic 3D, Siemens
Medical Solutions, Erlangen, Germany), which was developed for
use on the facial skull, was put into operation for the first time
worldwide in early 2005 in the Department of Oral and Maxillo-
facial Surgery, at the University Medical Centre Hamburg-
Eppendorf.
One of the main indications for intraoperative 3D imaging is the
need for immediate intraoperative analysis of the results of the
operation, so that the corrections required can be made immedi-
ately during surgery. Because of the relatively high post-surgical
complication rate for fractures in this region, the radiological
monitoring of therapy is of particular importance (Stone et al.,
1993; Iizuka et al., 1991; Soriano et al., 2005; Lamphier et al., 2003).
Conventional X-ray imaging, because two-dimensional, is of
limited value. CT is restricted to a narrow range of indications on
grounds of cost and the high exposure to radiation involved.

1010-5182/$ e see front matter Ó 2012 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.jcms.2012.11.024
e88 J.-C. Klatt et al. / Journal of Cranio-Maxillo-Facial Surgery 41 (2013) e87ee90

This study investigates the intraoperative revision of mandib- a revision rate of 5%. The four intraoperative revision patients
ular angle fractures as a result of the additional information were all male.
acquired with the isocentric C-arm ARCADIS Orbic 3D. In one patient intraoperative 3D visualisation revealed that two
screws positioned near to the fracture were not securely fixed
2. Material and methods (Figs. 1 and 2). Without revision the risk of pseudarthrosis and
infection in this patient was high.
All 86 mandibular angle fractures in this study were stabilised by Two other patients were treated with a miniplate superiorly and
open reduction and rigid internal fixation with 2 miniplates as stan- a compression plate at the base of the lower jaw. 3D visualisation
dard protocol for the treatment of mandibular angle fractures in the intraoperatively showed that a large gap was visible between the
University Medical Centre Hamburg. The first plate is fixed on the linea pieces of the fracture with the high risk of pseudarthrosis and
oblique and the second plate (a dynamic compression plate/DCP) is occlusion dysfunction for the patient (Figs. 3 and 4).
placed at the base of the lower jaw via transbuccal minimally invasive In a double lower jaw fracture, intraoperative CBCT resulted in
approach. This was followed by an intraoperative 3D radiographic revision to correct the position of the miniplates and compression
examination using the C-arm system ARCADIS Orbic 3D performed plates because a large gap remained after rigid internal fixation
immediately in the operating room under sterile conditions. (Fig. 5). The revision was also necessary because of the high risk of
A high-voltage X-ray generator (40e110 kV) with a tube current pseudarthrosis and occlusal dysfunction.
of 23 mA and 900 image intensifier was used, attached to a monitor
with two 1900 screens. The design allows for orbital rotation of 190
with 95 over scan. The system’s fully-digital imaging chain with
1024  1024 pixels (1K2) combines an image intensifier for
recording with mu-metal shielding. There is no loss of processing,
presentation and documentation to the DICOM communication
(Digital Imaging and Communications in Medicine). The ARCADIS
Orbic 3D analysed the recordings during exposure and used EASY
(Enhanced Acquisition System) to optimise dose, brightness and
contrast. The model requires only 30 s for a standard scan of 50
images or 60 s for a 100-image scan. The CBCT technique used
produces a cone-shaped beam, which measures the area repre-
sented by obtaining projection data.
In the 3D image data set, a cube of about 12 cm3 in volume
(2563 voxels) and a voxel size of 0.47 mm, is calculated and dis-
played synchronously on the right monitor. The left monitor was
used simultaneously for comparison with previous images. The 3D
data sets were displayed in MPR (Multiplanar Reconstructions) in
coronal, sagittal and axial projections. The data can also be
visualised in VRT (Volume Rendering Technique) and SSD (Shaded
Surfaces Display) quality.
The foot switch simplifies operation of the device as do the laser
sights for the positioning of the fluoroscopy region at the isocenter. In
this system, the isocentric C-arm unit is significantly larger than that
of a standard C-arm. The rigid isocentric C-arm unit must be precisely Fig. 1. Fracture after third molar osteotomie and wrong reposition, sagittal view.

aligned to the patient. There can be no evasive movements without

loss of isocentricity (in the case of potential collisions between unit
and patient or environment for example) which means that collision
testing should be performed before fluoroscopy.
Intraoperatively acquired images were analysed for all the
patients in this study to assess whether intraoperative revision
under sterile conditions would avoid revision surgery and its
associated increased morbidity and risk of complications.

3. Results

In the period from 05/2005 to 10/2008, eighty-three patients

with mandibular angle fractures underwent open reduction and
rigid internal fixation with intraoperative 3D X-ray assessment
under sterile conditions.
The group was made up of 41 patients with isolated MAF and 42
patients with a MAF and another fracture in combination. Three
patients had bilateral mandibular angle fracture, so 86 mandibular
angle fractures were seen in total. When the sex distribution with
the patient group is considered, 75 men (90%) and 8 women were
affected by this type of fracture. At the time of surgery the mean age
of the patients was 26.8 years (range 11e68 years).
Performed ARCADIS Orbic 3D X-ray findings resulted in 4 out
of 83 patients, requiring revision of their surgery giving Fig. 2. Fracture after third molar osteotomie and wrong reposition, axial view.
 J.-C. Klatt et al. / Journal of Cranio-Maxillo-Facial Surgery 41 (2013) e87ee90
Fig. 3. Gaping after osteosynthesis Patient 1, sagittal view.
Fig. 4. Gaping after osteosynthesis Patient 2, sagittal view.
The system used in this study shows all relevant information
about the angle of the jaw in an excellent 2D and 3D image quality
with high resolution and good contrast. In all cases, visualisation
allowed assessment of the fracture gap and the position of frag-
ments and screws. As very small metal artefacts are used in the
system, it is possible to assess the position of the plate and adjacent
structures very effectively. Also any medial gap in the lingual
cortex, after fixation and the position of screws in relation to the
inferior alveolar nerve can be visualised very well.
4. Discussion
It is difficult to assess the repositioning of the fracture after open
reduction and internal fixation, especially in the jaw angle. Also the
e89
Fig. 5. Result after revision of a wrong osteosynthesis, sagittal view.
trend towards minimally invasive surgical techniques has made it
difficult for the surgeon to obtain a direct view at the surgical site.
The advantages of this technique are not only the quality of the
imaging with high spatial resolution, the small space required and
the high mobility that can be achieved but also include the
reduction of acquisition and operational costs (Sukovic, 2003;
Eggers et al., 2007). Furthermore, the radiation exposure of staff
and patients as well as positioning time is lower than with other
similar systems (Hoelzle et al., 2001).
The ARCADIS Orbic 3D C-arm, based on the cone-beam tech-
nique, achieved a reduction in radiation dose and metal artefacts
compared with CT (Loubele et al., 2009; Silva et al., 2008; Chau and
Fung, 2009; Ludlow et al., 2006). The system provides excellent 2D
and 3D imaging quality of the bone structures of the human skull
(Fox et al., 2008).
The high-resolution multidimensional and superposition-free
images of both hard and soft tissue acquired using the technique,
justify the higher radiation dose required by CBCT (Korbmacher
et al., 2007). Volume tomography, for example, allows much
better assessment of the position of the mandibular nerve and
impacted third molar than a conventional panoramic view
(Ghaeminia et al., 2009).
The use of ARCADIS Orbic 3D C-arm is helpful particularly in
treatment of fracture of the mandible (Pohlenz et al., 2008). In this
study, inspection of the lingual corticalis, which is often difficult to
achieve, and fixation of the mandibular angle were possible to
a high quality. The improved scope for intraoperative inspection in
different planes means that any poor repositioning is very rapidly
evident.
The ability to optimise the operation by a faster and more
accurate real-time imaging (Quereshy et al., 2008) in conjunction
with the easy intraoperative handling of the device explains how it
is used to advantage in mandibular angle fracture surgery.
Also, the use of ARCADIS Orbic 3D C-arm in the area of the
mandibular condylar process showed that intraoperative revision
was required in 11.8% of patients (Klatt et al., 2011).
In another study between 2000 and 2010 the results of 579
postoperative 2D X-ray controls after maxillofacial trauma were
observed. In 16 cases (0.2%) the patients need a retreatment
because of the postoperative 2D X-ray control. In the same study
e90 J.-C. Klatt et al. / Journal of Cranio-Maxillo-Facial Surgery 41 (2013) e87ee90
a literature review of 1377 postoperative 2D X-ray controls after
maxillofacial trauma showed a retreatment in 0.7% of the patients.
The conclusion of the author is that a postoperative X-ray control is
not useful and lead to more costs, operation time and a higher
radiation dose for the patients with no medical indication (Van den
Bergh et al., 2011).
In the current study the rate of 5% intraoperative revision after
86 mandibular angel fractures occurred.
Intraoperative CBCT control is perhaps a new benchmark in
maxillofacial surgery.
The helpful diagnostic capabilities of ARCADIS Orbic 3D C-arm in
the mandibular angle region are particularly important. Revision
surgery in terms of a second procedure may be avoided because of
these intraoperative investigations. The quality of patient care is
improved and it also eliminates the need for additional post-
operative CT scans and the additional costs associated with
a second operation. This study underscores the important advan-
tage that potential complications from a second operation can be
avoided, as can the potential complications and long-term damage
from subsequent secondary interventions.
Although higher costs, longer operation time, additional radia-
tion dose and a higher risk of intraoperative infection arise by
intraoperative use of the ARCADIS Orbic 3D C-arm, we think that in
difficult cases the benefit of using intraoperative CBCT outweighs
its disadvantages.
Further investigations are needed to ascertain in which special
cases the higher radiation dose, the longer operation time, the
higher risk of intraoperative infection and the higher costs for the
patient is justified.
5. Conclusion
The results showed that intraoperative CBCT is a reliable
imaging technique for real-time intraoperative assessment of
treated MAF. Use of the mobile 3D CBCT scanner is easy to integrate
into routine practice and offers the advantage that immediate
revision surgery can be performed.
Although higher costs, longer operation time, additional radia-
tion dose and a higher risk of intraoperative infection arise by
intraoperative use of the ARCADIS Orbic 3D C-arm, we think that in
difficult cases the use of intraoperative CBCT is of benefit.
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