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Clinical application of cinematic rendering in maxillofacial fractures

Open AccessPublished:June 06, 2022DOI:https://doi.org/10.1016/j.ijom.2022.05.003

      Abstract

      The purpose of this study was to evaluate the clinical application of cinematically rendered reconstructions of maxillofacial fractures. Ten surgeons and eight radiologists were shown three-dimensional images of 25 different patient cases, generated using both the volume rendering (VR) technique and the cinematic rendering (CR) technique. They were asked to mark the site of the fracture on the three-dimensional images and record the time this activity took. The effectiveness of the reconstructions to communicate with patients was assessed through the opinions of the surgeons and radiologists, as well as 25 patients. Subjective evaluations of the clinical value of the images were performed by the 18 surgeons and radiologists using a 10-item questionnaire. The percentages of correctly identified fractures of the nasal bone (P = 0.034), fracture dislocation (P < 0.001), and free bone fragments (P < 0.001) were significantly higher for CR images when compared to VR images, and identification took an average of 20.81 seconds for CR and 27.48 seconds for VR (P < 0.001). CR images were found to be more beneficial for communication with patients and scored higher for the display of fracture dislocation and free bone fragments than VR images (P < 0.05). CR images were found to have high clinical value in the visualization of maxillofacial fractures.

      Keywords

      Maxillofacial fractures occur as a result of a variety of traumatic injuries, including falls from height, traffic accidents, and interpersonal violence.
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      Surgeons need to evaluate the degree of skeletal disruption revealed by three-dimensional (3D) imaging when planning the initial treatment of a maxillofacial fracture. Images reformatted from computed tomography (CT) scans, especially using the volume rendering (VR) technique, are of great value in the assessment of facial trauma. However, VR, the most commonly used technique for 3D reconstructions in clinical practice, is based on ray casting and local lighting model principles, but neglects complex light paths, resulting in more artificial appearing images. Cinematic rendering (CR), a novel 3D reconstruction technique, has recently been used to model the real-life physical propagation of light, which allows for realistic shadowing and the creation of highly detailed, photorealistic 3D images based on the acquired traditional CT and magnetic resonance imaging (MRI) data.
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      Forensic 3D visualization of CT data using cinematic volume rendering: a preliminary study.
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      Berger et al.
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      Is CT-based cinematic rendering superior to volume rendering technique in the preoperative evaluation of multifragmentary intraarticular lower extremity fractures?.
      reported that the CR technique is superior to the VR technique in the visualization of multi-fragmentary intra-articular lower extremity fractures and ankle sprains. However, studies to determine the clinical value of the CR technique when applied to maxillofacial fractures have not yet been published.
      The purpose of this study was to evaluate the clinical application of CR reconstructions of maxillofacial fractures using subjective assessment criteria and to compare its clinical value with that of VR reconstructions.

      Materials and methods

      Participants and patient cases

      This was a retrospective study involving the analysis of anonymized data. Ethical approval was provided by the Ethics Committee of Guizhou Provincial People’s Hospital, and the requirement to obtain individual informed consent was waived. Maxillofacial surgeons and radiologists at Guizhou Provincial People’s Hospital, China, were randomly requested to participate in the study. In total, 10 maxillofacial surgeons (five chief physicians and five attending physicians) and eight radiologists (two chief physicians and six attending physicians) agreed to participate. The maxillofacial surgeon participants had no previous experience with the VR technique. Subsequently, 25 patient cases were identified (13 male, 12 female; mean age 40.76 ± 18.48 years). These patients had been diagnosed with maxillofacial fractures and underwent CT examination during treatment at Guizhou Provincial People’s Hospital, China, between November 2020 and February 2021.

      Study design and assessment

      The CT images used in this analysis were obtained with a Siemens SOMATOM Force CT scanner (Siemens Healthcare, Forchheim, Germany), with 196 × 0.6 mm collimation (slice thickness of 1 mm), a tube rotation time of 0.25 seconds, 120 kV tube voltage, 180 mAs reference tube current, a convolution Nuclear Hr36, layer spacing at 0.7 mm, and CARE Dose 4D turned on. The patient was placed in a supine position with the head advanced and hands at the sides of the body. The scanning range was from the top of the skull to the lower edge of the mandible. After scanning, the thin layer data were transferred to a Siemens post-processing workstation (syngo.via, VB20B version; Siemens Healthcare). In each case, for both CR and VR images, datasets were transferred to an external workstation with prototype software installed (syngo.via Frontier, version 1.4.5; Siemens Healthcare). Both CR and VR reconstructions were created with similar opacity settings, field of view (FOV), and perspective.
      The CR or VR reconstructions were then randomly shown to the 10 maxillofacial surgeons and eight radiologists. In order to reduce the memory effect with the reconstruction images, the maxillofacial surgeons and radiologists were shown another set of reconstructions after a period of at least 2 weeks. To rate the diagnostic capacity of the reconstructions, they were asked to mark the fracture site on the 3D images and compare them with the gold standard of radiological diagnosis made by radiologists. They were also asked to note down the time it took to do this activity. The effectiveness of the reconstructions was assessed by recording the surgeons’ and radiologists’ opinions about which reconstruction they found to depict the fracture more clearly and more photorealistically, as well as which they would prefer to show patients. In addition, 25 patients were asked to choose which image made it easier to understand the fracture with the help of surgeons.
      With reference to the research by Elshafei et al.
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      and Berger et al.,
      • Berger F.
      • Ebert L.C.
      • Kubik-Huch R.A.
      • Eid K.
      • Thali M.J.
      • Niemann T.
      Application of cinematic rendering in clinical routine CT examination of ankle sprains.
      a 10-item questionnaire was designed for this study based on the characteristics of maxillofacial fractures, in order to subjectively rate the clinical value of CR and VR reconstructions. The questions were designed to be answered on a typical five-point Likert scale, ranging from 1 for ‘strongly disagree’ to 5 for ‘strongly agree’ (the questionnaire on which the participants recorded their responses is shown in Supplementary Material File S1).

      Statistical analysis

      The statistical analysis was performed using IBM SPSS Statistics version 20.0 (IBM Corp., Armonk, NY, USA). The main results are presented as the mean ± standard deviation or as frequency data. The time it took to mark the fracture site and the percentage of correctly identified fractures were computed as the diagnostic capacity of the reconstructions. These data were analysed using the paired t-test and χ2 test to evaluate the differences between CR and VR reconstructions. Furthermore, the kappa value was calculated to examine the consistency of the two techniques. The frequency of the 3D reconstructions to present to the patient, to depict the fracture more clearly, and to present the anatomical structures more realistically were measured using Fisher’s exact test and the χ2 test. The subjective evaluation scores of the clinical value of both techniques were analysed using the Wilcoxon matched‑pairs signed‑rank test and the independent t-test. Statistical significance was considered as two-sided P < 0.05.

      Results

      Diagnostic capacity of CR and VR reconstructions

      All 18 participants evaluated the 25 patient cases and completed a total of 450 case evaluations. As shown in Table 1, Most zygoma, maxilla, mandible, and orbital bone fractures were depicted correctly on both CR and VR images, independent of the reconstruction technique used. The percentage of fractures depicted correctly in both CR and VR reconstructions was not statistically significant (P > 0.05) except in the nasal bone. The percentage of nasal bone fractures depicted correctly in both CR and VR reconstructions was relatively low and was found to be statistically significant (P < 0.05). CR images were found to be significantly superior to VR images in depicting whether the broken end of a fracture was dislocated (P < 0.001) and whether there were free bone fragments around the broken end (P < 0.001) (Fig. 1). In addition, the participants showed good consistency in finding the fractures in the different 3D reconstruction images, with the kappa value ranging from 0.61 to 1.00. Furthermore, the average time to mark the fracture site and thus make the diagnosis was significantly shorter on the CR images than on the VR images (an average of 20.81 seconds versus 27.48 seconds; P < 0.001) (Fig. 2).
      Table 1Number of fractures detected using CR and VR reconstructions.
      Fracture siteClinical diagnosis, nCR, n/N (%)VR, n/N (%)P-valueKappa-value
      Nasal bone15215/270 (79.6%)188/270 (69.6%)0.034 *0.66
      Maxilla20307/360 (85.3%)311/360 (86.4%)0.4430.94
      Mandible10104/180 (57.8%)104/180 (57.8%)0.8161.00
      Zygoma15256/270 (94.8%)256/270 (94.8%)0.7020.61
      Orbital bone15248/270 (91.9%)248/270 (91.9%)0.9900.80
      Fault end dislocation20332/360 (92.2%)255/360 (70.8%)< 0.001 *0.78
      Bone fragments20326/360 (90.6%)260/360 (72.2%)< 0.001 *0.83
      CR, cinematic rendering; VR, volume rendering. *P < 0.05, significant.
      Fig. 1
      Fig. 1Comparison of computed tomography (CT), cinematic rendering (CR), and volume rendering (VR) reconstructions. The case of a 25-year-old male patient with multiple fractures of the left zygoma, dislocation of the broken end, and free fragments, demonstrated using (a) CT, (b) CR, and (c) VR techniques.
      Fig. 2
      Fig. 2Time required to make a diagnosis. CR, cinematic rendering; VR, volume rendering. * P < 0.001.

      Effectiveness of reconstructions to communicate with patients

      The majority of maxillofacial surgeons and radiologists stated a preference for showing patients CR images, and perceived CR images to depict the fracture site more clearly and to present the anatomical structures more realistically (Fig. 3). Moreover, most patients deemed that CR images were more beneficial to their understanding of fractures than VR images. The differences between CR and VR reconstructions regarding effectiveness to communicate with patients were found to be statistically significant (all P < 0.001; Table 2).
      Fig. 3
      Fig. 3Comparison of computed tomography (CT), cinematic rendering (CR), and volume rendering (VR) reconstructions for a patient with multiple fractures. The case of a 21-year-old male patient with multiple fractures of the right frontal bone, right temporal bone, bilateral nasal bone, upper jaw, mandible, and right zygomatic arch, dislocated and separated, and small bone fragment, using CT (a–d), CR (e, g), and VR (f, h) techniques.
      Table 2Effectiveness of CR and VR reconstructions to communicate with patients.
      ObjectEvaluation of image criteriaCR, n (%)VR, n (%)Both, n (%)χ2P-value
      SurgeonsFracture depicted more clearly237 (52.7)118 (26.2)95 (21.1)65.87< 0.001 *
      Image closer to anatomy239 (53.1)124 (27.6)87 (19.3)61.06< 0.001 *
      Preferred image to show patients248 (55.1)130 (28.9)72 (16)63.51< 0.001 *
      PatientsEasier to understand fractures19 (76)6 (24)0 (0)13.52< 0.001 *
      CR, cinematic rendering; VR, volume rendering. *P < 0.05, significant.

      Subjective evaluations of the clinical value of CR and VR reconstructions

      All 18 viewers subjectively rated the clinical value of CR and VR reconstructions. Most maxillofacial surgeons and radiologists thought that CR images could improve understanding of fractures, giving CR an average rating of 4.58 compared to 3.93 for VR images (P = 0.002). Further, they rated CR images 4.43 on average and VR images 3.74 on average for their ability to depict and aid in understanding of the maxillofacial anatomy (P = 0.004). In addition, this study found that CR visualization improved the depiction of fracture dislocation and free bone fragments, with participants giving an average rating of 4.50 to CR images and 3.78 to VR images (P = 0.001) (Table 3). These differences were found to be statistically significant. Furthermore, it was agreed that CR reconstructions may not have obvious advantages when deciding on the choice of treatment options and interdisciplinary consultation, intraoperative complications, and the time required to propose a treatment plan, when compared with VR reconstructions. Although the scores for CR images were higher than those for VR images for each item evaluated, the differences in scores were not found to be statistically significant (Fig. 4, Fig. 5).
      Table 3Subjective evaluations of the clinical value of CR and VR reconstructions; mean± SD values.
      Subjective evaluationsCRVRtP-value
      Images could help improve understanding of fractures4.58 ± 1.063.93 ± 0.490.850.002 *
      Images could help overall understanding of the facial anatomy4.28 ± 1.024.11 ± 0.580.680.51
      Images could help understanding of maxillofacial anatomical details, such as the frontal process of the maxilla4.43 ± 1.553.74 ± 0.640.890.004 *
      Images could help understanding of dislocation of the broken ends and bone fragments4.50 ± 1.263.78 ± 0.791.510.001 *
      Images could influence the choice of treatment options4.06 ± 0.803.89 ± 0.580.830.12
      Images could help reduce the time required to propose a treatment plan4.03 ± 1.123.94 ± 0.540.570.58
      Images could help increase confidence in choosing treatment options4.28 ± 0.673.94 ± 0.731.560.14
      Images could help reduce the time required for multidisciplinary consultations4.22 ± 0.654.00 ± 0.691.290.22
      Images could help reduce intraoperative complications by improving anatomical understanding4.18 ± 0.793.89 ± 0.681.320.21
      Images could help in the informed consent process4.22 ± 0.813.83 ± 0.711.940.07
      CR, cinematic rendering; VR, volume rendering; SD, standard deviation. *P < 0.05, significant.
      Fig. 4
      Fig. 4Subjective evaluations of the clinical value of cinematic rendering (CR) reconstructions. Key: (1) Images could help improve understanding of fractures. (2) Images could help overall understanding of the facial anatomy. (3) Images could help understanding of maxillofacial anatomical details, such as the frontal process of the maxilla. (4) Images could help understanding of dislocation of the broken ends and bone fragments. (5) Images could influence the choice of treatment options. (6) Images could help reduce the time required to propose a treatment plan. (7) Images could help increase confidence in choosing treatment options. (8) Images could help reduce the time required for multidisciplinary consultations. (9) Images could help reduce intraoperative complications by improving anatomical understanding. (10) Images could help in the informed consent process.
      Fig. 5
      Fig. 5Subjective evaluations of the clinical value of volume rendering (VR) reconstructions. Key: (1) Images could help improve understanding of fractures. (2) Images could help overall understanding of the facial anatomy. (3) Images could help understanding of maxillofacial anatomical details, such as the frontal process of the maxilla. (4) Images could help understanding of dislocation of the broken ends and bone fragments. (5) Images could influence the choice of treatment options. (6) Images could help reduce the time required to propose a treatment plan. (7) Images could help increase confidence in choosing treatment options. (8) Images could help reduce the time required for multidisciplinary consultations. (9) Images could help reduce intraoperative complications by improving anatomical understanding. (10) Images could help in the informed consent process.

      Discussion

      The diagnosis of a maxillofacial fracture usually needs a two-dimensional multiplanar reconstruction and a 3D reconstruction image created after post-processing of a CT scan.
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      CR is a novel 3D reconstruction technique that has recently come into use. It is based on a global illumination model, which takes the impact of all light rays on image reformation into account when producing the image, in order to achieve highly detailed, photorealistic 3D images.
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      In the present study, the value of CR reconstructions of maxillofacial fractures in clinical application was evaluated, and comparisons were made with VR reconstructions.
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      the present study showed that the time to make a diagnosis using a CR image was significantly reduced when compared to diagnosis using a VR image. This is most likely due to the fact that the CR technique uses a global illumination model, which improves understanding, perception, and the orientation of volumetric structures.
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      Most participants in this study found that CR images were a better choice for doctor–patient communication than VR images, and give a more photorealistic and clearer depiction of the anatomical structures, which is in agreement with the study by Berger et al.
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      . Of note, some radiologists chose ‘VR’ or ‘both CR and VR’ for communications purposes in this study, for the following reasons: (1) the radiologists had already used the VR technique in the past, and (2) the rendering speed and processing of CR is time-consuming, taking 5–30 seconds for rendering again when making a change to the CR image. Additionally, in this study, when patients were asked to choose which images made understanding fractures easier, the results showed that CR images were more beneficial for patients to understand their fractures than VR images, which is an important finding of this study. Thus, future application of the CR technique for maxillofacial surgeons may play an integral part in doctor–patient communication, treatment planning, and medical education in routine clinical practice.
      The criteria for assessing the clinical value of CR reconstructions are inconsistent. In the current study, on the basis of research by Elshafei et al.
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      Application of cinematic rendering in clinical routine CT examination of ankle sprains.
      a 10-item questionnaire was designed based on the characteristics of maxillofacial fractures to evaluate the clinical value of the CR technique in reconstructions of maxillofacial fractures. It was found that CR reconstructions may not have obvious advantages when deciding on the choice of treatment options or with regard to interdisciplinary consultation, intraoperative complications, or the time required to propose a treatment plan, when compared with VR reconstructions. This is most likely due to the fact that the CR technique has not yet been approved for clinical use and maxillofacial surgeons do not fully understand the advantages of the CR technique.
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      • Emekli U.
      Myositis ossificans traumatica of the medial pterygoid muscle after third molar tooth extraction: a case report and review of literature.
      . Significantly, the current study found that CR visualization improved the depiction of fracture dislocation and free bone fragments, with participants giving an average rating of 4.50 to CR images, which is in agreement with the study by Elshafei et al.
      • Elshafei M.
      • Binder J.
      • Baecker J.
      • Brunner M.
      • Uder M.
      • Weber G.F.
      • Grützmann R.
      • Krautz C.
      Comparison of cinematic rendering and computed tomography for speed and comprehension of surgical anatomy.
      This is an important finding of the current study.
      This study has several limitations worthy of consideration. First, the main aim of the current study was a general evaluation of CR imaging of maxillofacial fractures rather than an exploration of differences in visualization between different tissue types. Second, the benefit of the different types of reconstruction for communication was assessed by only 25 patients, so we can only speculate on the potential impact of CR images. The benefit to patients of routine clinical application of CR images remains to be determined. Third, this was a retrospective study, so there is an inevitable bias in the random selection of study cases. Thus, future research should focus on the potential impact of CR images on patients in doctor–patient communication.
      Overall, this study found that the visualization of maxillofacial fractures by cinematic rendering technique significantly shortened the diagnosis time, improved the depiction of fracture dislocation and bone fragments, and helped in the understanding of complex anatomical structures. Cinematic rendering imaging is beneficial in medical education, doctor–patient communication, and treatment planning.

      Acknowledgements

      We thank all of the participants for their assistance in this study.

      Funding

      This study was supported by Guiyang Science and Technology Project ( ZKXM[2020]4–1 ) and the Science and Technology Foundation of Guizhou Province ( QKHPTRC[2019]5803 ).

      Competing interests

      None.

      Ethical approval

      Ethical approval was provided by the Ethics Committee of Guizhou Provincial People’s Hospital.

      Patient consent

      The requirement to obtain individual informed consent was waived.

      Appendix A. Supplementary material

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