NemoFAB

The module of orthognathic surgery is divided in two interfaces: one interface

for surgery preparation of the case and other interface for surgery planning. We
begin with the first five steps which belong to preparation steps which are the
following:

NEMOFAB - ORTHO/ORTHOGNATHIC VOLUME

PREPARATION
This interface covers the first five steps from the orthognathic surgery module,
these steps are shown at the toolbar using the next buttons: Orientation,
Records, Segmentation, Osteotomies and 3D Ceph.

Orientation
Orientation is the first step for treatment planning in orthognathic surgery. There
are different opinions of the surgeons for doing head orientation. This wizard
presents four different options to cover the most important ways of head
orientation:

 Import and align the Models

 Automatic Orientation

 Orientation Manual

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  Orientation Photos

Import and align the Models

The import of the models is at the first step of the orientation process. Digital
dental models give substantial information to the surgeon for the orientation
process. Also, the digitalization of the models is mandatory in case a surgical
splint is going to be designed. They will be imported and aligned on the skull of
the patient. The models can be imported following protocol below.

In the following video, we can see all the steps of the Import Models panel:

Import Models Module

In the image below, we can see the result of this panel:

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Automatic Orientation

After pressing Automatic orientation, a new dialog is opened to build Skin

mesh.

Doctor presses Ok button and Skin mesh will be built.

We have to note that this orientation option is mainly used for orthognathic
cases.

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This orientation is based on the measurements taken during the clinical exam of
the patient. We can see all the steps of the Automatic Orientation on the next
video:

Orientation Module

We can see the result of it in the next image.

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Manual Orientation

The Orientation Menu allows to establish a correct position of the patient's

head through the dicom volume. This orientation will be the one used by the
software as the established position for treatment planning. It includes a tab
entitled Manual Orientation that will allow us to place the models in the same
position as marked by each of the views (right (R), left (L), inferior (I) and
anterior (A). In this way, the model will move accurately and appropriately into
the position marked further on, with the positioning icons that will appear in the
lower right-hand corner at the end of the orientation process.

In the following video, we can see how to do the Manual Orientation of the
Volume:

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Orientation Module

Volume Resizing

In each of the views in this screen (Axial, Sagittal, Coronal and 3D) a blue
frame will appear, initially marking the edges of the maximum cube framing the
entire volume of the tomography. The aim is to reduce this cube, so that it only
contains the valid region for planning.

In the following video, we can see how to do the Resize the Volume:

Orientation Module

And the result of both orientation and Resizing in the image below.

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Photo Orientation

Using the frontal, lateral and submentovertex photos as references the surgeon
can orient the head of the patient in the 3 planes of the space.

We can follow the steps shown in the next video and see how to choose photos
from Records:

Orientation Module

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And the result of the photo orientation in the image below.

Records

Thru this wizard the surgeon can produce additional records convenient for the
diagnosis, presentation and reporting of the case.

3D Photo mapping

The frontal facial photo can be mapped on the skin segmented in the CT or
CBCT of the head of the patient.

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We can follow the steps of how to map the photo shown in the next video:

Records Module

And the result of the photo orientation in the image below.

Import 3D Photo file

NemoFAB allows to import and align 3D photos files produced by 3D digital

cameras. The format supported is OBJ. The mapping of the 3D photo file on the
skin segmented surface is done using the mesh alignment tools of the
NemoFAB kernel.

In this functionality to Import 3D Photo file, this manual shows 3D mesh from a
patient.

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We can follow the steps of how to import a photo shown in the next video:

Records Module

The image below, shows an example of the result.

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Build X-Rays

In this step, the surgeon can produce lateral, frontal and panoramic virtual x-
rays.

Lateral and frontal X-rays are generated automatically by the software.

To build the panoramic X-ray we have to adjust first the axial plane, we press in
the letter O in the keyboard leave it press and then grab the end of the red circle
with the cursor and move it in the sagittal plane in order to find a central view
between the arches.

In the next video we can see how to generate all the X-rays:

Records Module

And we can see the X-rays generated in the image below.

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Dental Nerves

Process to add right and left dental nerves to the anatomical structures. It is
necessary for orthognathic surgery to know where the dental nerves are and not
collide with them.

The option to add and build dental nerves can be found at Build XRays panel:

In the next video we can see how to add the dental nerves:

Records Module

And we can see the dental nerves in the panoramic view shown in the next
image.

TMJ

In this step, we can produce the sagittal and coronal slices of the TMJ area.

Additionally, in this step a segmentation of the head of the condyles (right and
left) is automatically done in order to, posteriorly, facilitate the automatic
segmentation between the maxilla and mandible anatomical regions.

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In the next video we can see all the steps of the TMJ panel:

Records Module

And we can see the result in the image below.

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Airway

In this step, the program segments the airway volume. An algorithm of region
growth is used to produce it.

In the next video we can see all the steps of the Airway panel:

Records Module

And we can see the 3D structure of the Airway coloured with a scale of
centimeters in the image below.

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Import Lateral Photo

The Import Lateral Photo panel, which allows you to align the Xray with the
lateral foto selected.

In the next video we can see all the steps of the Import lateral photo:

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Records Module

And we can see the result in the image below.

Segmentation
The purpose of this wizard is to merge the crowns of the upper and lower
models with the segmented maxilla and mandible. The occlusal surfaces of the
teeth in the CT or CBCT have no definition and are scattered by the artifacts
produced by the metals of the brackets, arch wires and bands making them
useless for splint designing. The program must use the occlusal surfaces of the
models that show very good definition and no artifacts.

Upper model merge area

Upper model merge area and Lower model merge area panels are for
choosing the crown areas of the upper and lower models respectively to be
merged.

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In the following video, we can see how to do the Upper model merge area:

Segmentation Module

And the result can be seen in the image below.

Lower model merge area

User repeats the same process with lower model at Lower model merge area
panel.

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In the next video we can see all the steps of the Lower model merge area
panel:

Segmentation Module

And we can see the mesh obtained in the image below.

Merge models to volume

The last tab of this section is Merge models to volume, before building
mandible and maxilla by separate, condyles must be traced and segment
condyles.

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The steps that we need to follow to segment the structures are shown in the
video:

Segmentation Module

The result that we obtain can be seen in the image below.

Osteotomies
The first tab of this wizard, osteotomies, is for osteotomy design by the
surgeon.

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In the following video, we can see how to obtain the different osteotomies:

Osteotomies Module

And one example of an osteotomy can be seen in the image below.

Import segmented models

In Import Segmented Models panel, the surgeon should import the segmented
models (sectioned models with occlusal feasibility) and align them with the
segmental bone fragments of the maxilla and the mandible. This will benefit the
planning process making the occlusal adjustment automatic.

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In the next video we can see all the steps of the Import segmented models
panel:

Import Segmented Models Panel

And we can see the mesh imported aligned in the image below.

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3D Ceph
In this step, the surgeon will mark landmarks for a 3D cephalometric tracing.
Starting by choosing from the list of analysis the most convenient analysis for
doing the diagnosis and treatment plan and trace all the landmarks that the
analysis requires.

The steps that we need to follow in the 3D Ceph Module are shown in the video:

3D Ceph Module

The cephalometric points marked can be seen in the image below.

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After marking all the points, its possible to see al the points marked by clicking
on “Ceph 3D Analysis” the right lateral panel.

The “Position Setup” option allows the user to change how each point is
presented when he need to see it. In the following video we can see how the
process is done:

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NEMOFAB - ORTHOGNATHIC SURGERY DIAGNOSIS
AND PLANNING

The planning of an orthognathic surgery covers the last three steps from the
Arnett Orthognathic module, these steps are shown at the tool bar using the
next buttons:

 2D Ceph

 Treatment plan: is a menu with six options: Planning, Arnett treatment

plan (planning mandible first), Arnett treatment plan (planning maxilla
first), Arnett treatment plan (planning mandible first), , Arnett treatment
plan (planning maxilla first), Remove active surgical treatment plan.

 Splints

2D Ceph

In this first step from orthognathic surgery planning, the surgeon has the option
of producing a 2D Cephalometric tracing for analysis and treatment planning in
NemoCeph.

After Doctor selects this option a multi-image 2D cephalometric tracing is

produced. The multiple images are the lateral virtual x-rays produced in the
wizard 2 (records), step C.

The user will be given the option to export the 3D landmarks previously traced
in step 5 and choose which side he wants to export (right or left). The 2D
cephalometric document will be opened and ready to be traced using the
NemoCeph 2D module.

One of the benefits of doing the treatment plan in 2D is that most surgeons are
familiar with this kind of predictions, and they can do the vertical and horizontal

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movements easily in the 2D environment. This treatment plan can be imported
lately in the 3D treatment plan with great efficiency.

3D Treatment Plan
This chapter is compound by 3 plans:

 Standard Planning

 Arnett Classic Wizard

 Arnett treatment plan (planning maxilla first)

Standard Planning

In this wizard, the surgeon can complete his treatment plan for the patient.
There are the following steps:

By only using this step the surgeon can complete any orthognathic treatment
plan for the patient. Since the whole planning can be delivered on this wizard,
we will describe all the options available for this step.

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In the following videos, we can see how to perform the Standard Planning:

Standard Planning Module

And using morphing:

Morphing Planning Step

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Arnett Classic Wizard

This wizard has been designed by Dr. G. William Arnett and follows his
philosophy of treatment plan. There are the following steps:

Confirm Orientation

In this step, the surgeon can recheck that the orientation of the head done was
correct. The values of the orientation in the wizard 1 step A appear on the panel
for his review.

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Move Mandible

In this step, the program does all movements of the mandible. The movements
are automatically applied by selecting the Move Md to Final Occlusion check
and pressing Move button.

In the section A-P Movements, check the option Md11 Overbite to apply the
vertical movement (to close the distance between maxilla and mandible). Check
the option Md11 Overjet to apply the anterior/posterior movement. Check the
option Molar Overbite to rotate the mandible. The rotation can be selected to
Right side using R check or left side using L check. In the section Frontal
Movements. Check the option Md11 to facial midline to translate mandible
with a lateral movement. Check the option Level Md canines to facial
horizontal to rotate in the roll axis. Check Set yaw 77 to rotate the mandible in
the yaw axis. Check the option Freehand and set a value to rotate the
mandible.

The program informs the surgeon the distance from pogonion to a vertical line
passing through the lower incisor at the field Pog to incisor vertical.

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Mx Positioning

In this step, the program does the frontal movements of the maxilla. The frontal
movements are automatically applied by selecting the corresponding check box:

In the section Frontal Movements:

Check Align Midline and the maxilla is aligned with the midline of the skull
mesh. Check Level Mx canines to facial horizontal which produces a rotation
of the maxilla in the roll axis. Check Correct Mx yaw to rotate the mandible in
the yaw axis. Check the option Freehand and set a value to rotate the
mandible.

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Chin

In this panel, the chin osteotomy can be reoriented.

Orient Cd. Fragments

The right and left condylar bearing fragments can be adjusted in this step. They
can rotate in the 3 planes of space. Also, if the Generate Interference Structures
button is pressed, the software can build the interference mesh between the
condylar bearing fragment and the body of the mandible as long as they collide.

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Standard Planning

In this Standard Planning panel, the meshes of the osteotomies can be

modified for a final adjustment.

In this Standard Planning panel you can select Adjust to models Occlusion
option for the models by pressing the Actions... button.

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This panel includes a functionality to be able to show the distance between the
different meshes of the osteotomies with a color map, in this way being in
occlusion it will be possible to detect possible collisions between the teeth of the
lower and upper arch.

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Arnett treatment plan (planning maxilla first)

This treatment option allows the user to perform an Arnett Classic treatment
starting with the maxilla intervention instead of the mandible.

All the steps to follow are contemplated in the Arnett Classic Wizard workflow,
described previously in the Arnett Classic Wizard section.

Remove active surgical treatment plan

Using the third option of the menu is possible to delete the active treatment
plan. If the general treatment plan is selected first and then the Delete active
treatment plan option is selected, then the General plan will be deleted.

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If instead you were planning to use the Arnett treatment plan and then this
option Delete treatment plan is selected, then the Arnett treatment plan will be
deleted.

After selecting this option, the movements in the osteotomy meshes will be
eliminated and their initial position will be restored.

Create Reports
To generate a surgery report in PDF format, we just need to click in the icon of
the printer in the upper toolbar of the software or by pressing the Action…
button followed by the option Surgery PDF.

As a result, the system will create PDF with the treatment summary.

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Guides
Splints Design

Prepare Maxilla

Place and adjust the buccal and lingual points to the shape and depth required
for the splint.

The steps we need to follow for the preparation of the Maxilla are in the video:

Prepare Mx Step

Prepare Mandible

Place and adjust the buccal and lingual points to the shape and depth required:

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The steps we need to follow for the preparation of the Mandible are in the video:

Prepare Md Step

Build Splint (Intermediate)

At this panel Maxilla or Mandible can be selected, some parameters from splint
can be configured. After configuring it, the splint is built pressing Build Splint.

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A splint can be drilled with holes using button Drill Holes. After pressing it a tool
to drill mesh will be active.

The steps we need to follow to build the splint are in the video:

Build Splint Step

The image below, shows the resulted splint.

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Build Splint (Final)

Pressing arrows from Mouth opening, the mandible will be moved vertically.
After pressing Build splint button a new splint mesh is built between maxilla
and mandible.

User can add a label in splint mesh to specify patient-ID. The Label button can
be pressed to add label and configure text size, name, shape, etc.

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The steps are similar to the previous and can be seen in the same video:

Build Splint Step

The image below, shows the final splint.

The Final Splint Model can also be exported as an STL file, the instructions can
be seen in the following video:

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STL Export Files

Reshaping Guides

User selects Mandibular Guide option from the Guides menu and the
Mandibular Reshaping panel opens.

In the following video, we can see how to do the Reshaping of the mandible:

Reshaping Step

And one example of an osteotomy can be seen in the image below.

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Custom Plates

Plate

This panel is able to design plates using the manufacturer and model which
exist on the market for this purpose.

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The osteotomy meshes must be at occlusal position.

Firstly, the user will select a manufacturer and a model.

Second, a tool to draw plates will be active.

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Plates can be modified the size and moved by pressing on inferior yellow sphere.

Second custom plate is modified by pressing on inferior yellow sphere.

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After locking the second custom plate, it can be moved rigidly.

Adding a third custom plate

Adding a handle at third custom plate

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Exported mould from the third custom plate.

Screws added to the third custom plate after ending it.

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Screws added to the second custom plate after ending it.

Custom plate

This panel allows the users to design custom made plates defining the complete
geometry of the plate in accordance with the selected base mesh. The custom
plate is designed by the user instead of selecting the manufacturer and model.
Also, fixation screws can be added by selecting Manufacturer, Model and Screw
from the database.

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Second, the user will draw a custom board and press the end board to stop this
process.

The purple sphere will determine the position of the hole, it can be moved by
the user. Also, some green checkpoints will appear to transform the custom
plate.

Finally, by clicking End plate, the system will build the custom plate, adapted to
the surface of both meshes.

The image below shows an example of a Custom Plate.

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Plate Guides

This panel is able to design guides for the custom plates and plates before.
First, the user will select an osteotomy mesh and a base plate designed before.
Finally, the user will configure the guide and will build it. The guide will be added
into the meshes list to be exported.

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Osteotomy Guide

The Osteotomy Guides panel is used to design new custom plates connected to
splints using connectors. This panel contains the sections to:

 Selection and design guides, which are shown in the left image below.

 Connection guides and joining them, which are shown in the right image.

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In the Osteotomy guides panel, the selection of the osteotomy and its state are
selected from two lists. At the Base Plate section, the New button is pressed
and a new panel Plate Design is shown. At the Plate Design panel the button
Select Initial Model opens a meshes list panel to select one mesh. After
selecting the model, the Retention section will be enabled, direction will be
selected (a predefined one by pressing Choose Dir or the Camera Dir), and
the options to configure the surface should be defined.

After pressing Apply, the distances regarding the Undercuts can be shown.

By pressing Next a new panel will open to Select the Baseplate Area, on this
panel a tool to draw polylines in 3D mesh can be enabled.

The height, thickness and external smooth will be configured before generating
a base plate. The Select Baseplate Area button enables a tool to draw polylines
in 3D mesh. The user selects the area in the 3D mesh and presses Apply, then
a new intermediate plate mesh is built.

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Then the user is able to define perforations in the baseplate, if needed, and
press Build Baseplate to build the final mesh, when finished he closes the
Plate Design panel.

The user presses Create Guide after defining the Cut Width, Flaps Width and
Flaps Height, and the plate mesh is split using the plane which divides
osteotomy meshes.

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User selects one part of the splint and deletes it.

The next step is to design the splint, the user marks facial and lingual points at
maxilla or mandible mesh.

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Then the shape of the splint can be configured using: offset vestibular, offset
lingual and height. User presses the Build button, then the splint is built and
shown in 3D view.

User has three options to add bridges: classical, circular and rectangular
bridges. User adds the three types of bridges between plate design and splints.

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User is able to delete some parts of the splint before joining meshes.

User presses Join meshes button, the result is an unique mesh with splint, plate
design and connectors. This is called an osteotomy guide.

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