TYPE Editorial

PUBLISHED 08 August 2022

DOI 10.3389/fonc.2022.960545

Editorial: Virtual surgical

OPEN ACCESS planning and 3d printing in
EDITED BY
Guolan Lu,
Stanford University, United States
head and neck tumor resection
REVIEWED BY
Andrey Finegersh,
and reconstruction
Stanford, United States

*CORRESPONDENCE Yu-xiong Su 1*, Florian M. Thieringer 2, Rui Fernandes 3

Yu-xiong Su
[email protected] and Sat Parmar 4
SPECIALTY SECTION 1
Division of Oral and Maxillofacial Surgery, Faculty of Dentistry, The University of Hong Kong,
This article was submitted to Hong Kong, Hong Kong SAR, China, 2 Department of Oral and Maxillofacial Surgery, University
Surgical Oncology, Hospital of Basel, Basel, Switzerland, 3 Department of Oral and Maxillofacial Surgery, College of
a section of the journal Medicine - Jacksonville, University of Florida, Jacksonville, FL, United States, 4 Department of Oral
Frontiers in Oncology and Maxillofacial Surgery, University Hospitals Birmingham NHS Foundation Trust,
Birmingham, United Kingdom
RECEIVED 03 June 2022
ACCEPTED 27 July 2022
PUBLISHED 08 August 2022
KEYWORDS
CITATION
computer-assisted surgery, virtual surgical planning, 3d printing, patient-specific
Su Y-x, Thieringer FM, Fernandes R
and Parmar S (2022) Editorial: Virtual implant, head and neck surgery, maxillofacial surgery, reconstruction, free flap
surgical planning and 3d printing in
head and neck tumor resection
and reconstruction.
Front. Oncol. 12:960545.
doi: 10.3389/fonc.2022.960545 Editorial on the Research Topic
COPYRIGHT
Virtual surgical planning and 3D printing in head and neck tumor
© 2022 Su, Thieringer, Fernandes and
Parmar. This is an open-access article
resection and reconstruction
distributed under the terms of the
Creative Commons Attribution License
(CC BY). The use, distribution or
reproduction in other forums is
permitted, provided the original During the past two decades, we have witnessed rapid development of technology in
author(s) and the copyright owner(s) the field of surgery. With the advancement of virtual surgical planning and medical three-
are credited and that the original
publication in this journal is cited, in
dimensional (3D) printing (additive manufacturing), computer-assisted surgery (CAS)
accordance with accepted academic has revolutionized head and neck surgery and craniofacial surgery, leading to a new era of
practice. No use, distribution or “digitalization and precision surgery” (1). CAS may refer to one or a combination of the
reproduction is permitted which does
not comply with these terms. following technologies: virtual surgical planning, navigation, 3D modelling, patient-
specific surgical template/cutting guides, patient-specific implants, virtual reality (VR)/
augmented reality (AR)/mixed reality (MR), and artificial intelligence (AI).
CAS consists of three phases (Figure 1). The first phase is the preoperative phase of
virtual surgery and 3D-printing of patient-specific devices. While commercial services
are currently available, in-house virtual surgical planning and 3D printing at the point-
of-care have become increasingly popular in privileged centers (2, 3). Meanwhile, open-
source software provides an alternative in low-resource settings (Ritschl et al.). The
second phase is the intraoperative phase of precision-enhanced real surgery using
patient-specific devices, navigation, and/or VR/AR/MR. The third phase is the
postoperative phase of accuracy analysis, which is optional but beneficial in providing
feedback for the surgical execution of preoperative planning (4). Evidence on the benefits
of using CAS for head and neck reconstruction has been accumulating. Earlier,
publications usually focused on technical aspects, and case reports or series with a low

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Su et al. 10.3389/fonc.2022.960545

FIGURE 1
Schematic diagram of three phases of computer-assisted jaw reconstruction, including preoperative phase of computer panning and 3D
printing, intraoperative phase of precision-enhanced surgery with the use of patient-specific devices, and postoperative phase of feedback of
surgical execution by accuracy analysis.

level of evidence. Recently, an increasing number of studies have suboptimal for open access, such as the sinonasal, midface,
provided a higher level of evidence regarding clinical efficacy, and intraorbital (Taboni et al., Sahovaler et al., Yang et al.,
surgical accuracy, clinical outcomes, and oncology safety. These Garcia-Sevilla et al., Tang et al., Tel et al., Wu et al., Ha et al.).
studies have advanced scientific research on CAS. Recently in Tang et al. considered MR and surgical navigation had
some hospitals, virtual surgical planning and 3D printing for jaw complementary advantages in tumor resection, thus the
reconstruction have become routine clinical practices. combination of both was recommended. These new
The Research Topic of “virtual surgical planning and 3D technologies enhance the accuracy of tumor excision and
printing in head and neck tumor resection and reconstruction” increase oncological safety, while reducing the invasiveness
aims to collect the most recent evidence to popularize this of surgery.
cutting-edge technology in clinical practice. Altogether, 26 For reconstruction, computed tomography (CT)
manuscripts from 185 contributing authors have been angiography is widely used for perforator mapping in virtual
published on this Research Topic in Frontiers in Oncology surgical planning (Knitschke et al.).The AR-based protocol has
and Frontiers in Surgery. We are excited to see that these been used to assist fibula flap skin paddle harvesting on a 3D-
publications cover the most advanced developments and reveal printed phantom (Cercenelli et al.). AI-enabled CT
future research directions in this field. segmentation has also shown its advantages over manual
segmentation during computer planning (5). Most recently,
3D printed bone scaffolds with tissue engineering have been
Combination of CAS with the new used in jaw reconstruction, which highlights a promising
emerging technologies minimally invasive approach in the future (6 ). A
multidisciplinary research group in Basel used an engineered,
Traditionally, CAS uses surgical guides to transfer virtual vascularized, prefabricated bone graft for the reconstruction of
surgical planning into real surgery. The use of patient-specific maxillary defects. Although bone resorption was identified, this
surgical plates further enhances surgical accuracy and clinical technique demonstrated the safety and feasibility of composite
outcomes. In recent years, an increasing number of researchers graft engineering for the repair of complicated head and neck
have combined the use of new emerging technologies, such as defects (Ismail et al.).
VR, AR, MR, navigation, AI, and tissue engineering, in
computer-assisted head and neck reconstruction, showing that
technological innovation is still the driving force in surgery.
These new technologies have been used to assist tumor resection Accuracy and clinical
and reconstruction. outcomes of CAS
For tumor resection, AR with navigation is advantageous in
delineating tumor extension, thus helping achieve negative CAS not only enhances surgical efficiency but also improves
surgical margins, especially in anatomical locations that are clinical outcomes, including the accuracy of surgery (7, 8) Chen

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Su et al. 10.3389/fonc.2022.960545

et al., Möllmann et al., Kang et al.). The studies in this Research changes were summarized, which could help junior surgeons
Topic provide scientific data and evidence to support prevent unfavorable situations and rationalize contingency
the benefits of the new technology, including precise strategies in CAS (Antú nez-Conde et al.). These studies
tumor resection and satisfactory functional and aesthetic provide valuable experiences for beginners to learn and follow,
reconstruction outcomes. which can help shorten their learning curve.
Achieving surgical margin safety is of paramount
importance for treatment outcomes. Previous studies have
proved that predetermined resection margins during virtual Dental rehabilitation and functional
planning do not compromise adequate surgical margin and jaw reconstruction
oncologic outcome (9, 10). Wilkat et al. used navigation for
mapping intraoperative frozen sections, leading to accurate 3D With the use of virtual surgical planning and 3D printing in
localization of the margins, which could be further incorporated jaw reconstruction, we can achieve high surgical accuracy. This
into CT data for precise adjuvant radiotherapy planning. A contributes to not only facial contour but also dental
higher rate of residual-free resections was reported in the CAS rehabilitation, which is important to increase the quality of life
group than in the non-CAS group. Giannitto et al. used a 3D- after oncological surgery. Virtual surgical planning and 3D
printed specific tongue with ex vivo real-time magnetic printed patient-specific plates make simultaneous dental
resonance imaging to determine the orientation of the surgical implantation during osseous free flap reconstruction easier and
margins. Regarding the accuracy of reconstruction, Pu et al. more controllable (Antú nez-Conde et al.). The design of “three-
developed a lateral malleolus cap to overcome the sliding and in-one” fibula surgical guide incorporates three major functions,
rotational errors of fibula cutting guides and found that the including fibula segmentation, dental implantation, and
accuracy of simultaneous dental implants could reach the positioning of patient-specific plates, which greatly facilitates
accuracy of dental implants in native jaws. A preliminary the reconstructive surgery (11). Furthermore, with immediate
analysis showed that the postoperative soft tissue contour of loading, “Jaw-in-a-day” procedure can restore the teeth and
mid-face reconstruction was superior in the CAS group function at the same time of tumor resection, especially for
compared to that in the freehand group (Wang et al.). These benign cases (12). In recent years, intraoperative navigation and
studies provide solid evidence supporting the benefits of CAS in AR have been incorporated into surgery to facilitate dental
clinical practice. implantation in different bony flaps. The combination of AR
with dynamic navigation reduced the deviation of dental
implant in reconstructive patients with complex anatomical
structure (Ochandiano et al.) Good implant success rates and
Learning curve and change of optimal clinical outcomes of dental rehabilitation have been
surgical plan reported, which has laid the foundation for functional
jaw reconstruction.
One of the major criticisms of CAS is its lack of flexibility Alternatively, Korn et al. used a new design for patient-
during surgery. Although many concerns have been raised specific implant-borne dental rehabilitation in patients with
regarding the learning curve and changes in computer plans large maxillary defects. This approach avoids osseous free flap
during surgery, few studies have focused on this important topic surgery for jaw reconstruction, which shows that 3D printing
so far. We are delighted that this previously neglected issue has technology may have other revolutionary potential to change the
been addressed well in this Research Topic. future of surgery.
Zhu et al. used cumulative sum analysis to reveal a three-
stage learning curve of CAS with the use of patient-specific
implants, including the initial learning, plateau, and Summary
overlearning stages. Two independent studies performed in
Europe and Asia investigated surgical adherence and In summary, virtual surgical planning and medical 3D
unexpected changes in surgical plans (Ma et al., Pu et al.). printing are transforming head and neck surgery by increasing
With thoughtful preoperative planning and proper execution predictability and repeatability, improving efficiency, enhancing
of surgery, surgeons can minimize the rate of unexpected change resection and reconstruction accuracy, and facilitating dental
of surgical plans during surgery to as low as 5.6%, which has well rehabilitation and functional jaw reconstructions. With the
addressed the criticism. Four clinical scenarios of unexpected incorporation of other emerging technologies, such as AR,

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Su et al. 10.3389/fonc.2022.960545

MR, and AI, smarter and more intelligent surgery will become a Conflict of interest
reality in the near future.
The authors declare that the research was conducted in the
absence of any commercial or financial relationships that could
Author contributions be construed as a potential conflict of interest.

All authors listed have made a substantial, direct, and

intellectual contribution to the work and approved it Publisher’s note
for publication.
All claims expressed in this article are solely those of the
authors and do not necessarily represent those of their affiliated
Acknowledgments organizations, or those of the publisher, the editors and the
reviewers. Any product that may be evaluated in this article, or
We would like to thank all the authors’ contribution to this claim that may be made by its manufacturer, is not guaranteed
Research Topic and eBook. or endorsed by the publisher.

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