technical issues of image guided surgery · implant insertion after ... research directions for...
TRANSCRIPT
![Page 1: Technical Issues of Image Guided Surgery · Implant insertion after ... Research directions for Computer Aided Surgery ... W. Birkfellner. W. Birkfellner Acknowledgments Dept. of](https://reader034.vdocument.in/reader034/viewer/2022042020/5e7782abd88a7a1efc66852f/html5/thumbnails/1.jpg)
Technical Issues of Image Guided Surgery
W. Birkfellner
Digital Image Processing Laboratory, Center for Biomedical Engineering and Physics
Medical University Vienna
W. Birkfellner
![Page 2: Technical Issues of Image Guided Surgery · Implant insertion after ... Research directions for Computer Aided Surgery ... W. Birkfellner. W. Birkfellner Acknowledgments Dept. of](https://reader034.vdocument.in/reader034/viewer/2022042020/5e7782abd88a7a1efc66852f/html5/thumbnails/2.jpg)
W. Birkfellner
ImageGuided CMFSurgery
An incomplete list of systems...
ARTMA Virtual Patient RoboDent System DenX IGI System Drill Guides (Materialise, T. Fortin et al.) Modification of
commercial systems like the BrainLAB suite or the Medtronic TREON
... and VISIT
![Page 3: Technical Issues of Image Guided Surgery · Implant insertion after ... Research directions for Computer Aided Surgery ... W. Birkfellner. W. Birkfellner Acknowledgments Dept. of](https://reader034.vdocument.in/reader034/viewer/2022042020/5e7782abd88a7a1efc66852f/html5/thumbnails/3.jpg)
Reviving old VHS Tapes: VISIT in action
W. Birkfellner et al., IEEE Trans Med Imaging. 19(6):616620, 2000W. Birkfellner et al., Clin Oral Implants Res. 12(1):6978, 2001F. Watzinger et al., Plast Reconstr Surg. 107(3):659667, 2001A. Wagner et al., Clin Oral Implants Res. 14(3):340348, 2003
![Page 4: Technical Issues of Image Guided Surgery · Implant insertion after ... Research directions for Computer Aided Surgery ... W. Birkfellner. W. Birkfellner Acknowledgments Dept. of](https://reader034.vdocument.in/reader034/viewer/2022042020/5e7782abd88a7a1efc66852f/html5/thumbnails/4.jpg)
Challenges from a technical point of view
• Imaging – CT protocols & handling of artefacts• Patient – to image registration• Image processing issues – visualization & segmentation• Hardware for imageguided CMF surgery• Workflow optimization • What's about to come ?• Nontechnical challenges ...
W. Birkfellner
![Page 5: Technical Issues of Image Guided Surgery · Implant insertion after ... Research directions for Computer Aided Surgery ... W. Birkfellner. W. Birkfellner Acknowledgments Dept. of](https://reader034.vdocument.in/reader034/viewer/2022042020/5e7782abd88a7a1efc66852f/html5/thumbnails/5.jpg)
Imaging
W. Birkfellner
• CT is the modality of choice for dental and CMF surgery
• Streak artefacts stem from the reconstruction process and are difficult to avoid or to be removed• Pantomography is strongly dependent on patient positioning due to the strong perspective and the tomographic distortion of the image• CBCT introduces other artefacts such as truncation and ring artefacts
![Page 6: Technical Issues of Image Guided Surgery · Implant insertion after ... Research directions for Computer Aided Surgery ... W. Birkfellner. W. Birkfellner Acknowledgments Dept. of](https://reader034.vdocument.in/reader034/viewer/2022042020/5e7782abd88a7a1efc66852f/html5/thumbnails/6.jpg)
W. Birkfellner
Artefacts in CBCT
Truncation and ring artefacts are common ...
![Page 7: Technical Issues of Image Guided Surgery · Implant insertion after ... Research directions for Computer Aided Surgery ... W. Birkfellner. W. Birkfellner Acknowledgments Dept. of](https://reader034.vdocument.in/reader034/viewer/2022042020/5e7782abd88a7a1efc66852f/html5/thumbnails/7.jpg)
Quantitative CT
Homolka P, Beer A, Birkfellner W et al. Radiology, 224(1): 24752, (2002)
W. Birkfellner
![Page 8: Technical Issues of Image Guided Surgery · Implant insertion after ... Research directions for Computer Aided Surgery ... W. Birkfellner. W. Birkfellner Acknowledgments Dept. of](https://reader034.vdocument.in/reader034/viewer/2022042020/5e7782abd88a7a1efc66852f/html5/thumbnails/8.jpg)
Planning in VISIT
• Planning of implant channels based on available bone volume and density is rather straightforward• For extraoral implants, a more sophisticated interface is necessary
W. Birkfellner
![Page 9: Technical Issues of Image Guided Surgery · Implant insertion after ... Research directions for Computer Aided Surgery ... W. Birkfellner. W. Birkfellner Acknowledgments Dept. of](https://reader034.vdocument.in/reader034/viewer/2022042020/5e7782abd88a7a1efc66852f/html5/thumbnails/9.jpg)
W. Birkfellner
Tracking & Registrationa Link to the Real World
• Registration: Finding a transformation between the coordinate system of a volume image and the real world• Tracking: Maintaining that registration by measuring motion in 3D by
• optical tracking• electromagnetic probe• alternative techniques
W. Birkfellner et al., Med Phys 25(11):22422248,1998W. Birkfellner et al., IEEE Trans Med Imaging. 17(5):737742, 1998J. Hummel et al., Med Phys 29(10):22052212, 2002
![Page 10: Technical Issues of Image Guided Surgery · Implant insertion after ... Research directions for Computer Aided Surgery ... W. Birkfellner. W. Birkfellner Acknowledgments Dept. of](https://reader034.vdocument.in/reader034/viewer/2022042020/5e7782abd88a7a1efc66852f/html5/thumbnails/10.jpg)
Key issues in Tracking
W. Birkfellner
• Accuracy and resolution: Optical trackers are rather accurate and still superior to EM probes• Reliability: A free line of sight for an optical tracker always be maintained• Handling: Trackers are cumbersome in general; passive systems have a higher acceptance rate than active (=wired) systems, but are less robust.• Sterilizability: Autoclavation of electronics is difficult, ETO is expensive and timeconsuming
![Page 11: Technical Issues of Image Guided Surgery · Implant insertion after ... Research directions for Computer Aided Surgery ... W. Birkfellner. W. Birkfellner Acknowledgments Dept. of](https://reader034.vdocument.in/reader034/viewer/2022042020/5e7782abd88a7a1efc66852f/html5/thumbnails/11.jpg)
Patient to Image Registration
Point to point registration (Horn) using at least three markers and a point probeerror 0.7 +/ 0.15 mm
Birkfellner W, Solar P, Gahleitner A et al, Clin Oral Implants Res 12(1):6978, (2001)
W. Birkfellner
![Page 12: Technical Issues of Image Guided Surgery · Implant insertion after ... Research directions for Computer Aided Surgery ... W. Birkfellner. W. Birkfellner Acknowledgments Dept. of](https://reader034.vdocument.in/reader034/viewer/2022042020/5e7782abd88a7a1efc66852f/html5/thumbnails/12.jpg)
Some experiences
Minimally invasive insertion of titanium microscrews is feasible; the markers stay stable for several weeks Increasing the number of markers beyond 3 screws does not influence registration accuracy Exact localisation of screwhead centroids is necessary Mobility of mucosa in atrophic patients caused inaccuracies when using splinttype solutions, even if residual dentition is available
W. Birkfellner
![Page 13: Technical Issues of Image Guided Surgery · Implant insertion after ... Research directions for Computer Aided Surgery ... W. Birkfellner. W. Birkfellner Acknowledgments Dept. of](https://reader034.vdocument.in/reader034/viewer/2022042020/5e7782abd88a7a1efc66852f/html5/thumbnails/13.jpg)
Image Processing:Segmentation
W. Birkfellner
Segmentation is not exact – Identification of surfaces depends on algorithms used
![Page 14: Technical Issues of Image Guided Surgery · Implant insertion after ... Research directions for Computer Aided Surgery ... W. Birkfellner. W. Birkfellner Acknowledgments Dept. of](https://reader034.vdocument.in/reader034/viewer/2022042020/5e7782abd88a7a1efc66852f/html5/thumbnails/14.jpg)
Alternative techniques
W. Birkfellner
Surface registration: Highly dependent on the quality of surface segmentation and the presence of outliers
Surface scanning by laser ranging is hampered by the small visible area of the mucosa
Stab incisions are cumbersome, but give
good results
© by Tactile Technologies, IL
Schicho K, Seemann R, Cohen V et al. J Clin Periodontol. 34(11):9917, (2007)
![Page 15: Technical Issues of Image Guided Surgery · Implant insertion after ... Research directions for Computer Aided Surgery ... W. Birkfellner. W. Birkfellner Acknowledgments Dept. of](https://reader034.vdocument.in/reader034/viewer/2022042020/5e7782abd88a7a1efc66852f/html5/thumbnails/15.jpg)
Splint techniques
W. Birkfellner
© by DMFR, from Eggers G, Kress B, Rohde S, Mühling J.Dentomaxillofac Radiol. 38(1):2833, (2009)
Problematic in completely edentulous patients Residual elasticity of 2component molding materials is recognizable Segmentation of molding material and mucosa sometimes difficult
![Page 16: Technical Issues of Image Guided Surgery · Implant insertion after ... Research directions for Computer Aided Surgery ... W. Birkfellner. W. Birkfellner Acknowledgments Dept. of](https://reader034.vdocument.in/reader034/viewer/2022042020/5e7782abd88a7a1efc66852f/html5/thumbnails/16.jpg)
Surface Scanning
Has a long history in frameless stereotaxy Complicated for fully intraoral interventions
Result from the Medtronic FAZER surface digitizer – from Schicho K, Figl M, Seemann R et al. J Neurosurg, 106(4):7049, (2007)
Colchester AC, Zhao J, HoltonTainter KS et al. Med Image Anal, 1(1):7390, (1996)
W. Birkfellner
![Page 17: Technical Issues of Image Guided Surgery · Implant insertion after ... Research directions for Computer Aided Surgery ... W. Birkfellner. W. Birkfellner Acknowledgments Dept. of](https://reader034.vdocument.in/reader034/viewer/2022042020/5e7782abd88a7a1efc66852f/html5/thumbnails/17.jpg)
Tracking technologies for CMF & oral surgery
W. Birkfellner
32 implants, 5 patients after tumor resection and primary reconstruction
Accuracy: top 1.0 +/ 0.5 mm bottom 1.3 +/ 0.9 mm
Wagner A, Wanschitz F, Birkfellner W et al. Clin Oral Implants Res. 14(3):3408, (2003)
![Page 18: Technical Issues of Image Guided Surgery · Implant insertion after ... Research directions for Computer Aided Surgery ... W. Birkfellner. W. Birkfellner Acknowledgments Dept. of](https://reader034.vdocument.in/reader034/viewer/2022042020/5e7782abd88a7a1efc66852f/html5/thumbnails/18.jpg)
Challenges in tool design Sterilizable electronics are
cumbersome, autoclavation is difficult. Passive markers somewhat solve the problem and are handy, but provide less accurate results when being conatminated with blood Tool geometry (and size) is crucial
West JB, Maurer CR Jr. IEEE Trans Med Imaging. 23(5):53345, (2004)
W. Birkfellner
![Page 19: Technical Issues of Image Guided Surgery · Implant insertion after ... Research directions for Computer Aided Surgery ... W. Birkfellner. W. Birkfellner Acknowledgments Dept. of](https://reader034.vdocument.in/reader034/viewer/2022042020/5e7782abd88a7a1efc66852f/html5/thumbnails/19.jpg)
An early academic effort Hybrid Tracking
Birkfellner W, Watzinger F, Wanschitz F et al.IEEE Trans Med Imaging. 17(5):73742, (1998)
Combination of electromagnetic and optical sensors to overcome the drawbacks of both technologies
W. Birkfellner
![Page 20: Technical Issues of Image Guided Surgery · Implant insertion after ... Research directions for Computer Aided Surgery ... W. Birkfellner. W. Birkfellner Acknowledgments Dept. of](https://reader034.vdocument.in/reader034/viewer/2022042020/5e7782abd88a7a1efc66852f/html5/thumbnails/20.jpg)
Looking back Implant insertion 2000
W. Birkfellner
![Page 21: Technical Issues of Image Guided Surgery · Implant insertion after ... Research directions for Computer Aided Surgery ... W. Birkfellner. W. Birkfellner Acknowledgments Dept. of](https://reader034.vdocument.in/reader034/viewer/2022042020/5e7782abd88a7a1efc66852f/html5/thumbnails/21.jpg)
Implant insertion after hemimaxillectomy
Sealing of the nasopharynx with an obturator prosthesis after radical resection of squamous cell carcinoma
W. Birkfellner
![Page 22: Technical Issues of Image Guided Surgery · Implant insertion after ... Research directions for Computer Aided Surgery ... W. Birkfellner. W. Birkfellner Acknowledgments Dept. of](https://reader034.vdocument.in/reader034/viewer/2022042020/5e7782abd88a7a1efc66852f/html5/thumbnails/22.jpg)
Restoration after ablative tumor resection
Surgical removal of an osteosarcoma in the mandible Implant insertion in a scapula flap after reconstruction
Wagner A, Wanschitz F, Birkfellner W et al. Clin Oral Implants Res. 14(3):3408, (2003)
W. Birkfellner
![Page 23: Technical Issues of Image Guided Surgery · Implant insertion after ... Research directions for Computer Aided Surgery ... W. Birkfellner. W. Birkfellner Acknowledgments Dept. of](https://reader034.vdocument.in/reader034/viewer/2022042020/5e7782abd88a7a1efc66852f/html5/thumbnails/23.jpg)
Minimally invasive implant insertion
Wittwer G, Adeyemo WL, Schicho K et al.Int J Oral Maxillofac Implants. 22(5):78590, (2007)
Comparison of VISIT and the Medtronic TREON system. Accuracy ranges from 0.6 +/ 0.5 to 1.0 +/ 0.5 mm for both systems
W. Birkfellner
![Page 24: Technical Issues of Image Guided Surgery · Implant insertion after ... Research directions for Computer Aided Surgery ... W. Birkfellner. W. Birkfellner Acknowledgments Dept. of](https://reader034.vdocument.in/reader034/viewer/2022042020/5e7782abd88a7a1efc66852f/html5/thumbnails/24.jpg)
W. Birkfellner
Medical AugmentedReality
W. Birkfellner et al., IEEE Trans Med Imaging. 21(8):991997, 2002F. Wanschitz et al., Clin Oral Implants Res. 13(6):610616, 2002W. Birkfellner et al., Phys Med Biol. 48(3):N4957, 2003M. Figl et al., IEEE Trans Med Imaging. 24(11):14921499, 2005
![Page 25: Technical Issues of Image Guided Surgery · Implant insertion after ... Research directions for Computer Aided Surgery ... W. Birkfellner. W. Birkfellner Acknowledgments Dept. of](https://reader034.vdocument.in/reader034/viewer/2022042020/5e7782abd88a7a1efc66852f/html5/thumbnails/25.jpg)
Technology of image injection
Birkfellner W, Figl M, Huber K et al. IEEE Trans Med Imaging.21(8):9917, (2002)
W. Birkfellner
![Page 26: Technical Issues of Image Guided Surgery · Implant insertion after ... Research directions for Computer Aided Surgery ... W. Birkfellner. W. Birkfellner Acknowledgments Dept. of](https://reader034.vdocument.in/reader034/viewer/2022042020/5e7782abd88a7a1efc66852f/html5/thumbnails/26.jpg)
Linking navigation and augmented reality
W. Birkfellner
![Page 27: Technical Issues of Image Guided Surgery · Implant insertion after ... Research directions for Computer Aided Surgery ... W. Birkfellner. W. Birkfellner Acknowledgments Dept. of](https://reader034.vdocument.in/reader034/viewer/2022042020/5e7782abd88a7a1efc66852f/html5/thumbnails/27.jpg)
Conclusions & OutlookResearch directions for Computer Aided Surgery in the CMFarea include
Technical developments concerning TRE … Developments for optimized workflow and cost including socioeconomic researchEvaluation of suitable clinical applications
W. Birkfellner
![Page 28: Technical Issues of Image Guided Surgery · Implant insertion after ... Research directions for Computer Aided Surgery ... W. Birkfellner. W. Birkfellner Acknowledgments Dept. of](https://reader034.vdocument.in/reader034/viewer/2022042020/5e7782abd88a7a1efc66852f/html5/thumbnails/28.jpg)
W. Birkfellner
Acknowledgments
Dept. of CranioMaxillofacial SurgeryDental School ViennaDept. of Diagnostic RadiologyMy Colleagues at the CBMTP… and R. Schulze and the IADMFR for inviting me!
[email protected]://www.zbmtp.meduniwien.ac.at/index.php?id=79