Modern Facial Reconstructive Surgery - Computer design, 3D printing and custom implants. - EMF 2026

[applause] Hi. Um, I'll just make sure you can see what I can see. Good. Uh, so my name is Adam. Um, I'm originally from the south coast and I am a doctor. Clue is in the title. Um, I did a lot of my training in the south in London and then I met my wife who's from the northeast. So, we moved to the northeast. Those little dots on the map are where I've done all of my training in the northeast. Uh when I'm not collecting bits of paper, I'm a keen runner and a keen gardener. And yeah, the rest of the time I'm stuck in work. Um how long did it take? Uh so I had a slightly weird I did three years of undergrad, three years of medicine, and then everyone has to do a couple years of foundation training to do what I do. I then had to go do a dental degree which took 3 years and then my specialist training took six years which is just about to finish next week. [laughter] Um so what am I doing next? I'm not getting any more degrees. Um I've done enough of that and hopefully there's a consultant job somewhere. Um yeah, that's how it feels to finish finally. [laughter] Uh it took a lot of work. Anyway, um disclaimers. I am a UK oral and maxacial surgery specialty traininee. I'm fully registered with the general medical and dental councils. I'm not a 3D printing technician or engineer. So I can't tell you anything technical about how things are printed or what the computers are doing. Um it's in the title as a clue, but there will be some images that you might not like. And I have previously received some funding from one of the companies I mentioned in my talk. There are lots of other companies that do the same thing. They just have nice material which is why I've used them. and they're not paying me to talk about them today, sadly. Um, and then all of the images are taken, none of them are patients that I've worked with, so no one should recognize themselves up here. Um, I'd rather if there wasn't any photography or recordings from the audience, and I will be doing a Q&A either outside or if I can find it in the Q&A tent afterwards. Um, so what is an oral and max facial surgeon? Has anyone actually met one before unless unless you know me already? [laughter] Um, so we are the specialty that is the bridge between dentistry and medicine. You have to be a doctor and a dentist to enter specialist training, but there are lots of dentists working with us. So if you've had your wisdom teeth removed in a hospital setting or you've had a broken bone in your face, you've probably met one of us. Um, there are oral surgeons out there who do deal purely with teeth and our dentists. and we have a bit of overlap with ENT or ear nose and throat surgeons and plastic surgeons, but we kind of limit ourselves to the clavicle up unless we're doing reconstruction. Um, just a quick anatomy recap for those of you that didn't spend a million years in university. Um, I'm going to be talking mainly about the mandible, which is your lower jaw, this green bone, and a bit about the migilla, which is your top jaw, this red bone. Um, so how do we get the images that we need to make our 3D models of patients? Uh so CT scans so we have an X-ray device that moves around the patient that we know what energy the X-ray is when it leaves the X-ray source and then we measure the energy when it gets the other side and that builds up a clever 3D picture in slices of the patient. So this image on the right is a slice through someone's top jaw with the roots of the teeth visible and the spine visible at the back. It is not very helpful in isolation. So it's much easier for me to look at and definitely for you to look at when we ask the computer to do clever things and say can you reconstruct these 5 mm slices you've made into a 3D image and this is a completely normal face just for reference. So what can we do with it? So trauma cases so broken bones and if I mention a fracture I'm talking about a broken bone. If I mention a broken bone I'm talking about a fracture. Um so this is an example of a trauma case which has been CT scan. So, this is a thin atrophic mandible cuz when you lose all your teeth, your body says, "Oh, I don't need all that bone anymore. We'll get rid of it." Which makes the bone thin and weak. This means it needs a big chunky heavy plate which takes ages to bend up and is really stiff. Um, and if you've got a crumbly old patient with no teeth, you don't want to be spending more time doing their operation than you have to cuz longer anesthetics increase the risks of the actual procedure and the risk of complications. So, what they've done on the computer is they've segmented the fracture, which is why it's colorcoded. They've then put the fracture back together digitally and printed it. And this bottom image, what you can see is they've printed the model off and they've spent time before they went to surgery bending up the plate, sent it off to be sterilized. So when they come back to do the operation, they put some little stabilizing plates on cuz it's waving all over the place. It's difficult. Which lets them put the big chunky plate that bent on and if the plate fits your bones in the right place and then you take the stabilizing plates off and this is all done from the neck. So we're looking up underneath the patient. Uh ordinarily we do a lot of mandible fractures from inside the mouth. So if you break your jaw, don't worry about getting a big scar in your neck unless it's a horrific fracture. Um this is another example of a complex mandible fracture. This patient has teeth. Um so the observant ones there might notice that the fracture is in lots of different colors, which means it's broken into lots of different parts. In order to get control of all of these, we've got to do it from outside. Again, um and these metal bars on the teeth that you can see there are called arch bars. So, we need to fix the teeth in the right position to do the surgery. So, this is the wiring your jaw shut, which we might do during your operation, but not when we wake you up. Um, which means if your teeth are right when we fix your jaw, it doesn't matter if we get the bone slightly wrong, cuz you're the one who cares about how your teeth meet together, not whether the bone is millimeter accurate, your body will fill those bits in. Um, but getting a big long heavy plate when there's several bits moving around is difficult. Um, so there are things we can do on a printed model beforehand and on a computer. So we can make these little bits that fit on and wrap around bits of anatomy like holes where nerves come out and specifically shape bits of bone. We can then make holes in those which then make guides for where we need to drill our first holes which then allow us to fit the plate cuz imagine trying to get a long pre-bent plate like the last case onto bone that's in several pieces and covered in blood. Nightmare but good fun if you me. Um, and this is the finished result because we like scanning people afterwards. So, this person would be on a soft, sloppy diet for six weeks. You're not allowed to bite or chew anything while this is healing. Um, and then we probably see them three or four times during that period. And after 6 weeks, we're happy. We leave the plates forever unless they start poking through the gum or causing you problems cuz why would you have another operation if you don't need one? Um, and here's an example of what we can do if we involve cuz all the previous ones we can do in-house if we've got the right laboratory technicians and the right printers and things. If we don't have that, then we can ask a nice company to do it for us. And KLS Martin do a very nice job, but so does Synthes Striker and whatever other company you want to use. Um, so we scan our CT scan. We give the engineer a couple days to work on it and they come back and they say, "Oh, we've colorcoded the bits we think are broken and we're going to put them back together for you and we want you to check the position is right." So, I mean, they can do it quicker than 48 hours if you ask them nicely. Um, there you go. Perfect. If only surgery were that easy. Um, and then they can make the plates for us. They can either print them or fabricate them in other ways so that they will fit on one way. Um, this makes it look really simple because they're just like, bam, there's a plate. Uh, they're ignoring all of the soft tissue and actual surgery bits to getting the plate. Uh, what this is showing is they've etched the line of the fracture on the plate and they put these little locator tabs underneath so it definitely fits. And then they also show us where the screws are in relation to the big sensory nerve that runs runs in the jawbone. It's a bit embarrassing if you kebab that and the patient can't feel their lip and chin. Um, this is for really difficult cases. So, we don't do this every week. Um, we have little stock plates that we can just shove in for most people. It's another thing we do a lot of. So, this is quite a routine thing that happens in a lot of hospitals in our country is facial deformity surgery or orthnathic surgery. So, this is for patients that see the orthodontist and the orthodontist says, "I cannot fix this with braces alone. we think we need you to move the jaws into the right position so we can fix the bite. Um, so this is a typical patient. None of these patients need this operation. So they never come in and we go, "Thank goodness you're here. We need to give you an operation right away." There are lots of people who walk around looking like this. They function fine. They're very happy with their lives. It's very driven by what bothers the patient and what concerns them. And this is just an X-ray showing that, you know, the back teeth are top teeth are so far behind the bottom teeth that the orthodontist couldn't fix that with braces. And this is what patient looks like after they've had that sort of treatment. Um that's the same person. Um and then just for example, how do we get there? So we can go entirely from inside the mouth to do these operations. So for the top jaw and the bottom jaw, which means we don't have to give you a scar other than sometimes a tiny little nick between the eyes. So we can measure things off a screw we stick in there. Um, and the British Orthodontic Society have a lot of great information about this on their website and it's very difficult for me to explain or how do we cut them and move them around. So, they've made it into animations. This is the same movements. So, the top jaw needs to come forwards and the bottom jaw needs to go back, but they've chosen a very mild case for their animation for some reason. So, you can argue you don't need to do anything, but illustrates the principle quite well. Um, so usually they have at least two years of orthodontic treatment to align everything and put everything in the right position. Often makes things look worse because we're putting them into a position or asking the orthodontist to put them in the position which is ideal for after we've put the jaws in the right position. Patients have to be prepared to deal with that and see the orthodontist every 6 weeks and then we make cut in the top jaw, cut in the bottom jaw, move it and snap some little plates on and then leave it to heal for 6 weeks. So rather than someone doing the trauma to you, um we do it for you. Um and again, this makes it look really simple. Um but how do you do this? Cuz we could do this before we had 3D printers and technology. So we need to examine patients and take lots of measurements and we tend to split things into vertical thirds and horizontal fifths. And we look for asymmetries and one bit being larger than the other. And then we can take this X-ray and mark up all these landmarks and draw lots of clever lines and angles off it. And then we need to somehow take what your bite is. So this device is called a face bow. It sticks in your ear. You have to bite on a bit of wax. And that lets us mount on a model where your jaw is in relation to your skull base. We can then move the jaws around independently on the model. And we do the movement separately. So the top jaw will go first and then the bottom jaw. And then make us a little plastic wafer. And if we wire your teeth together with that plastic wafer in after we've separated the top jaw from the rest of your face, that'll be in the right position. And then once we've fixed that, we split your bottom jaw from the bit that has the jaw joints on it and put a different wafer in and that puts it in the final position, which is quite timeconuming for the lab, but it works very well. Um, and we some places we're still using these gooey impressions, which I presume everyone hates and a lot of people have had. You've had a mouthguard made, you've had braces. Uh, so again technology to the rescue. 3D cameras um can do this for us. And again, there are lots of companies that do this. I don't receive any money from Trios. They've just got the best video illustrating the principle. Um and how quickly they can do the equivalent of an impression. And you can do all sorts of things on this. It's not just for people having surgery. Um but the 3D camera, you just move it around the mouth, you fill in all the white space and the gaps, and you go, "Right, there's your bottom jaw. 10 seconds rather than 2 minutes of all that goo in your mouth." Um, and I'm I'm going to force you to watch the end because this shows quite a neat little thing they can do afterwards, which is very helpful to us because we want to know what your actual bite is before we move your jaws around and it has to be correct. Um, so we get them to scan the top jaw, which again is nice and quick. This is definitely the quickest machine of sh, but it's marketing material, so it's going to be perfect. And he probably doesn't need to scan the pink pallety bit in the middle, but he will just to prove a point. But might want to do that if you're making a denture. [snorts] And the last thing you do is if you get the patient to bite together cuz it now has those 3D models, but it doesn't know how they fit together and scan how the teeth are fitting together. Uh the computer program will put those together. So when you spend send them off um to be looked at, they go click. So you do it on one side and then that all gets turned into an STL file and printed and we can combine this with a CT scan. So how do I get to my next slide? A bit of workflow examples. We take photographs, measurements, videos, scans. We fuse the scan of your mouth with your CT scan. We then sit down and have a meeting with an engineer and we say they say we've put the simulated cuts on the jaws. Where do you want the teeth? We say put them here. And then they can make us some splints just like the ones the lab would make us, but it all comes in the post and has been printed rather than spending a lot of time in the lab. But you're just shifting the cost and the time elsewhere. And we can move we can spot things we don't really spot on conventional surgery. And we can move the jaw very precisely in whatever direction we want using 3D planning. Um and on sorry on the left um these are all three different patients. So the far side is that's before we've done anything to them. The middle picture is that's we've put the top jaw where it needs to go. And the bottom jaw is that's where we want the bottom jaw to go after we've fixed the top jaw. Um and then the other thing that the 3D planning gives us is quite nice is it tells us how the teeth might meet together, where the roots of the teeth are expected to be, so we don't chop those off when we're chopping the top jaw from the rest of your head. Um, and it tells us where things like nerves and where overlaps and how things are going to move, which is quite helpful for doing the operation. Um, so you want to see some before and after pictures of people had this sort of treatment. Me too. Um, so left is before, right after. These are the same patient. So the top left, someone has had their bottom jaw more forwards cuz their bottom teeth would have been really far behind their top teeth. Couldn't fix that with orthodontist. So you bring the whole jaw forwards. might also be a good treatment for sleep apnnea in certain patients. And this person wasn't a fan of their gummy smile. So the top jaw is all gone upwards. Um so that's the sort of deformity. And then we get into cancer reconstruction. And I'm still doing good for time. I'm not going too quickly. Everyone's still with me. Good. Um, so this is where things get a bit challenging because unlike that operation where we can say we're going to do the same cuts every time and we're going to do the same movements with no control over where people get cancer or when they get cancer or when they decide to come and see us. So some people come very early and it's very small and you just remove it and you're like that's great. And some people come and it's massive and you think can we even get it out? And taking hands out leaves a big hole. You often can't leave a big hole without significantly affecting someone's appearance which has effects on their self-perception and the way they function and also their speech, swallowing, ability to enjoy food, uh, which is a massive part of your quality of life as well. So there's no point going, "Good news, I've removed the cancer but ruined your life." Um, because you probably won't thank me. And we also need to get these big holes to heal as quickly as possible because if they're going on to have chemotherapy, radiotherapy, anything else, you don't want any delays. Um and how do we get the tissue to fill the holes? Um so we do something called free tissue transfer or taking a free flap. So the idea is we take tissue with its own blood supply from elsewhere in your body and transplant it into your head and then we have to use a microscope and really tiny stitches or this device called a coupler to join the veins and arteries together in your neck. Um you learn on a chicken thigh. So this is a chicken thigh that's been inflated. You know those stringy bits on chicken that most people pick off before they cook them. There's little blood vessels in there. So that's um a chicken thigh on a CD ROM because it stops it sliding around with a 1 millm scale. And this is how everyone learns. So that's some tiny stitching with a millimeter. And then if you don't do well with millimeter scales, that's a 5 piece illustrating the size of the stitches we're doing. And then once you've learned a chicken thigh, you get to work on a live rat. And then you get let loose on people. So we don't just get to have a go. you'd be pleased to hear. Um, so this sort of flat, where is it? Is fairly forgiving because we can measure it before and sort of do two operations at the same time. And if it's a bit big or a bit small, you can trim it, you can stretch it, it's forgiving. Um, when you've got a cancer that's affecting the jawbone, like in the middle of this picture, and you have to put basically the whole jaw in the bin, it is difficult to sort of just bodgege together a new jaw from a bit that's a bone you've chopped off the leg. But that's what we used to do. Um so your fibula which is the outer leg bone in your lower leg um can be harvested with some perforating blood vessels and a bit of skin and fat. The bone itself and then a length of blood vessel for plumbing in which looks very pretty on a the diagram what we get in reality is something that looks a bit like this. Um and without any 3D printing or guides or being able to bend things in advance we end up with that big long chunky plate that you're doing a lot of trial and error bending. Oh no, that doesn't fit. Oh, we need to trim a bit here. It makes the operation take sort of 14 16 hours on a bad day, which is not very nice amount of time to be operating for. And then the longer you delay plum plumbing this in, which you have to do after you've fitted it, the less likely it is to work as well. And we want it to work cuz we want patients to heal. But this is an example of a freehand one. You can still do freehand ones. People still do. They they get good results. So it's not obsolete, but there's just different ways of doing things. Um, so we went back to 3D engineers or some people clever in the media and said, "Well, what if we want to take this? Can you turn that into something we could use by combining the scans together?" So, it looks a bit comical cuz they literally It's the same as me holding up a leg bone and going, "Oh, I think that fits there." But we get them to do it on the computer. We can get them to plan where the dental implants go and and that all looks good, but it doesn't really tell me where to cut. It just told me it could fit like that. Um, so I can thank my friends at Kessless Martin again for putting a nice video of how this done. And again, this ignores all of the dissection and surgery. They just kind of go, "Oh yeah, you can snap a plate on and it's done." So the whole jawbone is going to be going because there's cancer, but you can't see on there. So they make us a cutting guide that clips exactly onto precise bit of the jaw. You can drill the holes for the plate and the screws in advance. And then the orange bit is the bit that is going off to be looked at under the microscope. open hopefully after so that's all the cancer's gone. They then take that fibula and they segment it up. So the white bits that are going in the bin means when we get rid of those it will fit exactly together. And again we pre-drilled the holes so that they all fit. And then it means you can get a really precise fit. And that is literally you can put the plate on on the leg and do all the cuts to the bone on the leg. Disconnect it, bring it up, put more screws in. Nine times out of 10 that just fits and you've saved about an hour and a half, two hours from your operation and you can go straight on to the fiddly bit under the microscope. And usually this can get turned around within two weeks. So you get your diagnosis, you get all your scans, we have a couple of meetings with the engineers and go, "Yep, we're happy. Please make that and we will be able to do it within a couple weeks." So it's not a long turnaround on these things. They've gotten quite quick at it. Um and then people are taking it a step further now. So they've said well when people get out the other side of their cancer treatment and they've lost all their teeth because they might be having radiotherapy. Um or you know they're just oral hygiene is not very good in a lot of cancer patients. What what how are they going to eat later? We want to put teeth back in. So now people are saying well we can plan the teeth in advance and we can put the implants in and we can get the restorations on in 3 months. So you wouldn't see this bottom bit in the patient. They're just lifting the lift down. So you can see and then they put that restoration on which isn't brilliantly color matched but lots of patients choose the bright white shiny color cuz they like it. And that's sort of what we can do. And then there's some other fun applications. I'm almost finished talking. So what if we can't really print anything cuz it's not going to help us. But we wanted to remove a tumor from sort of between the eyes. You don't want to just go blindly poking around in that area. There's important things we might want to keep. Um, so there's a few companies out there that make uh things that link up this CT scan that we have in advance. We've got a 3D camera. There's a bit that's screwed onto the patient and registered to some landmarks. And then we've got a pointer with some landmarks. And the 3D camera picks up those points. It's a bit like motion capture for like video games or animated characters. And then wherever we put the tip of that pointer will show up on the screen so we can see exactly where we're doing our surgery and how close we are to things we want to get rid of or keep. And then a former colleague of mine has been doing some research. Um, so Google Glasses and augmented reality. People are saying, "Well, that's great. We've made a plan, but we don't really know where all the blood vessels and other bits are, but we know where that is on the scan. If we use these clever things, could we overlay that onto surgery and make it better?" And this isn't really at the clinical application stage, but it might be the future. Um, so they can pretty much make whatever we want. So they can make various custom implants for orthogonic surgery. If you've got really difficult trauma cases, you can say, um, you know, I don't want to spend ages bending up lots of little fiddly plates or just want something that's going to fit, they can make that. If you're missing a big chunk of your bone off from your head or your skull after an injury, we can say, can you make a big bit of something that will get absorbed into the rest of the body in the long run? Um, and then the reconstruction plates we talked about. Um, it does save time. Whether it's necessarily better, it probably is for the cancer surgery, but then there's always problems like what if the cancer grows between planning the scan and doing the operation and you need to freehand things. So, the skills are still important. Um, and [laughter] for some of the orthographic cases, we've been doing it conventionally for years. People are very happy with the results. We might be able to plan it to like half a millimeter of accuracy with the 3D planning, but is the patient going to notice or care? Um, we don't know. Um, so of other things that are coming in quite clever as finite element analysis. So, it used to be like we will only make you this implant cuz this is the only implant we've tested. Now, we can say what have you made this? And then they'll run a little simulation based on the forces they think the jaw is going to be exposed to and they'll go, yeah, that's working. We'll make it. or they'll say that will never work. We won't make it for you. You need to redesign it. And that's my talk. Um I will take questions in the Q&A tent which I just need to find my way to cuz I've not been there yet. But anyone wants to speak to me, they can find me there. [applause]