La chirurgia guidata dalle immagini(IGS) è usata in numerosi settori della chirurgia. Un innovativo sistema di navigazione chiamato Implanav è stato sviluppato dall'Università di Bologna insieme alla ditta BresMedical per consentire al chirurgo di monitorare in tempo reale le strutture anatomiche, durante il posizionamento degli impianti in campo maxillo-facciale. L'obbiettivo dello studio è di valutare in vitro ed in vivo le potenzialità e la precisione di questo sistema. / Image-Guided Surgery (IGS) is used in a variety of medical procedures. An innovative system called ImplaNav has been developed by University of Bologna and BresMedical for oral and maxillofacial surgical navigation, in order to generate three-dimensional volumetric representations of the maxillofacial area, which allow surgeons to evaluate a patient's anatomy before surgery and assist in planning for the placement of implants in appropriate , ideal or preferred positions. The objective of this study is to evaluate the accuracy of the ImplaNavTM software and registration tools by presenting results obtained deploying the system in-vitro and in-vivo cases. The investigation focuses on how the surgical guidance, by way of visualization of a surgeon's instrument via optical tracking offered by the ImplaNavTM system, generates an immediate feedback on the possible misplacement or positioning of a dental implant.

The aim of this PhD thesis " Simulation Guided Navigation in cranio- maxillo- facial surgery : a new approach to Improve intraoperative three-dimensional accuracy and reproducibility during surgery ." was at the center of its attention the various applications of a method introduced by our School in 2010 and has as its theme the increase of interest of reproducibility of surgical programs through methods that in whole or in part are using intraoperative navigation. It was introduced in Orthognathic Surgery Validation a new method for the interventions carried out according to the method Simulation Guided Navigation in facial deformities ; was then analyzed the method of three-dimensional control of the osteotomies through the use of templates and cutting of plates using the method precontoured CAD -CAM and laser sintering . It was finally proceeded to introduce the method of piezonavigated surgery in the various branches of maxillofacial surgery . These studies have been subjected to validation processes and the results are presented . / Obiettivo di questa tesi di Dottorato “Simulation Guided Navigation in cranio-maxillo-facial surgery: a new approach to improve intraoperative three-dimensional accuracy and reproducibility during surgery.” ha avuto al centro delle proprie attenzioni le varie applicazioni di una metodica introdotta dalla ns. Scuola nel 2010 e che ha come tema di interesse l’aumento delle riproducibilità dei programmi chirurgici mediante metodiche che in toto o in parte utilizzano il navigatore intraoperatorio. Si è introdotto in Chirurgia Ortognatica un nuovo Metodo di Validazione per gli interventi effettuati secondo la metodica Simulation Guided Navigation nelle malformazioni facciali ; si è poi analizzata la metodica di controllo tridimensionale delle osteotomie mediante l’utilizzo delle dime di taglio e delle placche premodellate mediante metodica CAD-CAM e sinterizzazione laser. Si è infine proceduto ad introdurre la metodica di chirurgia piezonavigata alle varie branche di chirurgia maxillo-facciale. Tali studi sono stati sottoposti a processi di validazione ed i risultati vengono presentati.

PURPOSE: The aim of this randomized clinical trial is to compare 2 different approaches for Guided Bone Regeneneration (GBR) in posterior region of atrophic mandibles regarding: I) the amount of vertical bone regeneration, II) the type and frequencies of surgical and healing complications, III) the implants primary stability and the osseointegration rate. MATERIAL AND METHODS: Forty partially edentulous patients with atrophic posterior mandible, who require a three-dimensional bone regeneration and an implant-prosthetic rehabilitation, were treated according the following protocol. Patients were randomly divided into two study group: 20 patients were treated with non-resorbable d-PTFE titanium-reinforced membranes (group A); and 20 patients with titanium mesh covered by cross-linked collagen membranes (group B). All patients received two or more double variable thread tapered implants and a mixture of autogenous bone and bone allograft according to one-stage GBR approach. In each group were evaluated the amount of vertical bone regeneration and the insertion torque value (IT) and implant stability quotient (ISQ) of all implants. In addition, all complications were analyzed, distinguishing between “surgical” and “healing” complications. RESULTS: The vertical bone regeneration was 4.3 ± 1.2 mm in the group A and 4.2 ± 1.1 in the group B. 99% of implants showed an optimal primary stability with insertion torque values > 35 Ncm and ISQ values > 60. All implants achieved a successful osseointegration. In the group A, surgical and healing complication rates were 5.0% and 15.9% respectively, In the group B, complication rates were 15.0% and 21.1% respectively. CONCLUSIONS: The preliminary results of this RCT suggested that both GBR approaches are predictability and effectiveness for the restoration of atrophic posterior mandible. Double variable thread tapered implants permitted to achieve an adequate primary stability in order to perform an one-stage GBR approach. / PURPOSE: The aim of this randomized clinical trial is to compare 2 different approaches for Guided Bone Regeneneration (GBR) in posterior region of atrophic mandibles regarding: I) the amount of vertical bone regeneration, II) the type and frequencies of surgical and healing complications, III) the implants primary stability and the osseointegration rate. MATERIAL AND METHODS: Forty partially edentulous patients with atrophic posterior mandible, who require a three-dimensional bone regeneration and an implant-prosthetic rehabilitation, were treated according the following protocol. Patients were randomly divided into two study group: 20 patients were treated with non-resorbable d-PTFE titanium-reinforced membranes (group A); and 20 patients with titanium mesh covered by cross-linked collagen membranes (group B). All patients received two or more double variable thread tapered implants and a mixture of autogenous bone and bone allograft according to one-stage GBR approach. In each group were evaluated the amount of vertical bone regeneration and the insertion torque value (IT) and implant stability quotient (ISQ) of all implants. In addition, all complications were analyzed, distinguishing between “surgical” and “healing” complications. RESULTS: The vertical bone regeneration was 4.3 ± 1.2 mm in the group A and 4.2 ± 1.1 in the group B. 99% of implants showed an optimal primary stability with insertion torque values > 35 Ncm and ISQ values > 60. All implants achieved a successful osseointegration. In the group A, surgical and healing complication rates were 5.0% and 15.9% respectively, In the group B, complication rates were 15.0% and 21.1% respectively. CONCLUSIONS: The preliminary results of this RCT suggested that both GBR approaches are predictability and effectiveness for the restoration of atrophic posterior mandible. Double variable thread tapered implants permitted to achieve an adequate primary stability in order to perform an one-stage GBR approach.

Aim: We present a newly designed, localiser-free, head-mounted system featuring augmented reality (AR) as an aid to maxillofacial bone surgery, and assess the potential utility of the device by conducting a feasibility study and validation. Also, we implement a novel and ergonomic strategy designed to present AR information to the operating surgeon (hPnP). Methods: The head-mounted wearable system was developed as a stand- alone, video-based, see-through device in which the visual features were adapted to facilitate maxillofacial bone surgery. The system is designed to exhibit virtual planning overlaying the details of a real patient. We implemented a method allowing performance of waferless, AR-assisted maxillary repositioning. In vitro testing was conducted on a physical replica of a human skull. Surgical accuracy was measured. The outcomes were compared with those expected to be achievable in a three-dimensional environment. Data were derived using three levels of surgical planning, of increasing complexity, and for nine different operators with varying levels of surgical skill. Results: The mean linear error was 1.70±0.51mm. The axial errors were 0.89±0.54mm on the sagittal axis, 0.60±0.20mm on the frontal axis, and 1.06±0.40mm on the craniocaudal axis. Mean angular errors were also computed. Pitch: 3.13°±1.89°; Roll: 1.99°±0.95°; Yaw: 3.25°±2.26°. No significant difference in terms of error was noticed among operators, despite variations in surgical experience. Feedback from surgeons was acceptable; all tests were completed within 15 min and the tool was considered to be both comfortable and usable in practice. Conclusion: Our device appears to be accurate when used to assist in waferless maxillary repositioning. Our results suggest that the method can potentially be extended for use with many surgical procedures on the facial skeleton. Further, it would be appropriate to proceed to in vivo testing to assess surgical accuracy under real clinical conditions. / Obiettivo: Presentare un nuovo sistema indossabile, privo di sistema di tracciamento esterno, che utilizzi la realtà aumentata come ausilio alla chirurgia ossea maxillo-facciale. Abbiamo validato il dispositivo. Inoltre, abbiamo implementato un nuovo metodo per presentare le informazioni aumentate al chirurgo (hPnP). Metodi: Le caratteristiche di visualizzazione del sistema, basato sul paradigma video see-through, sono state sviluppate specificamente per la chirurgia ossea maxillo-facciale. Il dispositivo è progettato per mostrare la pianificazione virtuale della chirurgia sovrapponendola all’anatomia del paziente. Abbiamo implementato un metodo che consente una tecnica senza splint, basata sulla realtà aumentata, per il riposizionamento del mascellare superiore. Il test in vitro è stato condotto su una replica di un cranio umano. La precisione chirurgica è stata misurata confrontando i risultati reali con quelli attesi. Il test è stato condotto utilizzando tre pianificazioni chirurgiche di crescente complessità, per nove operatori con diversi livelli di abilità chirurgica. Risultati: L'errore lineare medio è stato di 1,70±0,51mm. Gli errori assiali erano: 0,89±0,54mm sull'asse sagittale, 0,60±0,20mm sull'asse frontale, e 1,06±0,40mm sull'asse craniocaudale. Anche gli errori angolari medi sono stati calcolati. Beccheggio: 3.13°±1,89°; Rollio: 1,99°±0,95°; Imbardata: 3.25°±2,26°. Nessuna differenza significativa in termini di errore è stata rilevata tra gli operatori. Il feedback dei chirurghi è stato soddisfacente; tutti i test sono stati completati entro 15 minuti e lo strumento è stato considerato comodo e utilizzabile nella pratica. Conclusione: Il nostro dispositivo sembra essersi dimostrato preciso se utilizzato per eseguire il riposizionamento del mascellare superiore senza splint. I nostri risultati suggeriscono che il metodo può potenzialmente essere esteso ad altre procedure chirurgiche sullo scheletro facciale. Inoltre, appare utile procedere ai test in vivo per valutare la precisione chirurgica in condizioni cliniche reali.

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L’obbiettivo di una ricostruzione micro vascolare di mandibola è quello di assicurare al paziente il miglior risultato estetico e funzionale auspicabile. Ciò può essere conseguito utilizzando il lembo microvascolare di perone/cresta iliaca e una placca ricostruttiva in titanio che funga da guida nella fase di modellamento del lembo per ricreare un contorno parabolico il più possibile simile al profilo mandibolare originario del paziente. Il modellamento manuale ed artigianale intraoperatorio di una placca ricostruttiva è operatore dipendente ed anche in mani molto abili o ricorrendo a modelli anatomici stereolitografici non sempre risulta preciso quanto voluto e spesso non porta ai risultati postoperatori attesi e desiderati. Obbiettivo del nostro studio è stato pertanto, sfruttando le moderne tecnologie CAD-CAM, la produzione di placche ricostruttive “custom -made” progettate direttamente al computer ricreanti il profilo osseo originale del paziente. / This paper describes a new protocol for mandibular reconstruction. CAD/CAM technology was used to manufacture custom-made cutting guides for tumor ablation and reconstructive plates to support fibula free flaps in five patrients presenting oral tumour involving the mandibular bone. CT scan data from the patients were elaborated to produce a virtual surgical plan of mandibular osteotomy in safe tissue for complete ramus/body resection. The CAD/CAM procedure was used to construct a customized surgical device composed of a cutting guide and a titanium reconstructive bone plate. The cutting guide allowed the surgeon to precisely transfer the virtual planned osteotomy into the surgical environment. The bone plate, including in two cases a custom-made anatomical condylar prosthesis, was designed using the outer surface of the healthy side of the mandible to obtain an ideal contour and avoid the bone deformities present on the side affected by the tumor. Operation time was reduced in the demolition and reconstruction phases. Functional and aesthetic outcomes allowed patients to immediately recover their usual appearance and functionality. This new protocol for mandibular reconstruction using CAD/CAM to construct custom-made guides and plates may represent a viable way to reproduce the patient's anatomical contour, give the surgeon better procedural control, and reduce operation time.

Il presente lavoro parte dalla descrizione dei processi di rimodellamento osseo mascellare a seguito della perdita di elementi dentari e la successiva riabilitazione mediante impianto dentale osteointegrato. Approfondiremo proprio i complessi aspetti dell’osteointegrazione su superfici implantari in titanio sia a livello micro che macroscopico. Nel campo dell’implantologia, infatti, il titanio risulta essere il materiale maggiormente impiegato in virtù della sua eccellente biocompatibilità e resistenza. Successivamente prenderemo in analisi i trattamenti di superficie implantare ad oggi più diffusi, lavorati prevalentemente a livello microscopico e infine confronteremo una sistematica trattata tradizionalmente con una innovativa trattata superficialmente a livello nanometrico. Il confronto avverrà in vivo, paragonando i risultati ottenuti clinicamente e radiograficamente tra le 2 sistematiche implantari, utilizzate per ripristinare la funzione masticatoria nei pazienti arruolati. / This paper starts from the description of the processes of the maxillary bone remodeling due to the loss of teeth and the subsequent rehabilitation by osseointegrated dental implants. We are deepening the complex features of osseointegration of titanium implant surfaces at both micro and macroscopic aspects. In fact in implantology the titanium appears to be the material most widely used because of its excellent biocompatibility and resistance. Subsequently we will analyze the implant surface treatments for today's most popular, worked mostly at the microscopic level and then will compare a treated traditionally system with an innovative surface treated at the nanometer level. The comparison will take place in vivo, by comparing the results obtained clinically and radiographically between the two implant systems, used to restore the masticatory function in patients enrolled.

Questo studio ha valutato l'efficacia di un approccio rigenerativo utilizzando cellule staminali mesenchimali (MSC) e uno scaffold di idrossiapatite pura e porosa (HA) progettata con tecnologia CAD-CAM per sostituire il condilo dell'articolazione temporomandibolare (ATM). Metodi.Uno scaffolds di HA con porosità totale del 70% è stato prototipato per sostituire i due condili temporomandibolari (sinistro e destro) dello stesso animale. MSC sono state ottenute dalla cresta iliaca ed espanse in coltura. Guide chirurgiche su misura sono state create e utilizzate per esportare la pianificazione virtuale delle linee di taglio dell'osso nell'ambiente chirurgico. Sei pecore sono state sacrificate a 4 mesi dopo l'intervento.Gli scaffold sono stati espiantati, campioni istologici sono stati preparati, ed è stata eseguota l'analisi istomorfometrica. Risultati.L'analisi della riduzione di porosità per apposizione di osso neoformato mostrata una differenza statisticamente significativa tra la formazione ossea nei condili carichi di MSC rispetto ai condili senza ( / This study evaluated the efficacy of a regenerative approach using mesenchymal stem cells (MSCs) and CAD-CAM customized pure and porous hydroxyapatite (HA) scaffolds to replace the temporomandibular joint (TMJ) condyle. Methods. Pure HAscaffolds with a 70%total porosity volumewere prototyped usingCAD-CAMtechnology to replace the two temporomandibular condyles (left and right) of the same animal. MSCs were derived from the aspirated iliac crest bone marrow, and platelets were obtained from the venous blood of the sheep. Custom-made surgical guides were created by direct metal laser sintering and were used to export the virtual planning of the bone cut lines into the surgical environment. Sheep were sacrificed 4 months postoperatively. The HA scaffolds were explanted, histological specimens were prepared, and histomorphometric analysis was performed. Results. Analysis of the porosity reduction for apposition of newly formed bone showed a statistically significant difference in bone formation between condyles loaded with MSC and condyles without (

Background: Piezoelectric instrumentation seems to offer 3 important advantages for cutting bone structures. Be more precise because it is produced by micro-vibrations from the cutting insert. Be safer because the ultrasonic frequency used does not affect soft tissue. Thirdly, the less invasive cutting action produces minor tissue damage and consequently probably a better healing Aim of the Study: The aim of this study is to evaluate the effectiveness of piezoelectric device capability in maxillo-facial surgery, in order to take advantage of these favourable capacity. Material and Methods: Considering the several potential application of the piezoelectric technology in Orthognathic, Oncologic and Extractive surgery, we would like to design protocols in order to verify how this new device can modify the surgical technique, the surgical time, the patients healing and its quality of life. Results: Due to the precise Piezosurgery cut, we can manage the Cad-Cam-Custom Made plates protocol in Oncologic Surgery and in Orthognatic Surgery increasing our percentage of comparison between the 3D preoperative plan and the surgical execution. We also found a better quality of life impaction in Patient who underwent and extractive surgery Conclusion: Piezosurgery device seems to be a strong surgical aid were safe and precise cut are needed and its capability to reduce the discomfort Patients need to be study in deep also in major surgery like Orthognatic and Oncologic surgery.