Virtual Planning for Mandibular Reconstruction Surgery with Mimics Enlight CMF

Starting a case and preparing the anatomy

1. Importing images
   • Click on 'From Images' and locate the directory with the DICOM images of the skull and lower leg
   • Select the images to see a preview of the series
   • Click 'Open' to continue with the selected images
   • Click on 'Reconstruction Planner' to start planning
   • Indicate which scan belongs to which anatomy
   • (Optional) Check DICOM information by right-clicking on the image series and selecting 'Image Information'  
2. Segmenting the skull
   • Click on the skull option
   • Adjust the threshold if necessary (default is set for bone tissue)
   • Click 'Apply' to continue  
   • Use the Erase tool to remove any unwanted voxels in 2D or 3D
   • Separate the mandible using the Split tool: first mark the skull in a few slices, then do the same with the mandible
   • Click 'Finish' to generate the 3D skull and mandible models
3. Segmenting the soft tissue
   • Repeat the same segmentation steps for the soft tissue
   • Use the Erase tool to remove unnecessary parts
4. Segmenting the tibia and vessels
   • Lower the threshold for better artery visibility
   • Edit the segmentation if needed
   • Use the Split tool to separate the fibula, tibia, and vessels
   • Indicate if we are working with the left or right leg

Requesting automatic segmentation 

1. Load the images 
   • Click on 'From Images' and locate the directory with the DICOM images of the skull 
   • Log in to the Mimics Flow platform by clicking the button in the top right corner of the window. 
   • Fill out the ‘Title’ field with a name for the case and, optionally, fill out the remaining information 
2. Click on ‘Create case and request segmentation’ 
   •  Select the corresponding algorithm. In this case, select ‘CMF Reconstruction’ 
   • Click ‘Request segmentation’ 
3. Open the case once it’s done 
   • Click on ‘Sync and open’ in the pop-up window after the automatic segmentation has finished. 

(Optional) Identifying the nerves

1. Place points on the mental foramen and mandibular foramen to re-slice the image
2. Trace the nerve by placing points along the nerve canal
3. Repeat for both sides

Setting the natural head position

1. Indicate the Frankfurt horizontal plane:   
   • Place points in each ear canal
   • Place points on the inferior border of each orbit
2. Adjust the position of the skull in the three orthogonal views

Performing osteotomies

1. Click 'Add cut' and indicate at least two points on the mandible to create an osteotomy plane. Adjust the plane if needed, and repeat for the second cut. Make sure that the orange side of the planes is facing the area that needs to be removed.
2. Select 'Split' to perform the osteotomy and highlight the part to be removed

Planning the reconstruction

1. Mirror the healthy side 
   • Hide the skull by going to the object list and clicking on the eye next to it
   • Mirror the healthy side and hide the part of the mandible to be removed
2. Create the fibula segments 
   • Click 'Create Segments' and place points to draw the segments. Double-click on the last point, or press Esc when done.
   • Adjust their positioning to match the healthy anatomy; if needed, fine-tune how the segments are placed against each other in the fibula

Simulating implant placement

1. Set the desired implant height and diameter
2. Place points on the segments to indicate the position of the implants.
3. (Optional) Click and drag the control points of the cylinders around to change their orientation.

Report generation

1. Click ‘Report’ to generate a report in PowerPoint format, after specifying the output directory.

Note: This workflow is for demonstration purposes. Always consult with a trained healthcare professional for actual surgical planning.