Medical 3D Players: When Millimeters Matter

Sebastian De Boodt  00:03 

Welcome to 3D Players. The podcast where we explore personalization in healthcare through advancements in 3D technology. We'll talk to leaders championing more predictable and sustainable patient care. I'm Sebastian De Boodt, joined by my co-host, Pieter Slagmolen. Today's discussion will center on standard and personalized devices, artificial intelligence, and engineering in personalized healthcare. Our guest, Dr. Thomas Kofod, is Chair of the Department of Oral and Maxillofacial Surgery at Rig's Hospital in Denmark, where his team focuses on corrective and reconstructive surgery, as well as computer assisted surgery. He's a strong believer in personalized care, having treated more than 1,000 patients with personalized devices. And he uses 3D planning with 100% of his patients! Welcome, Thomas, you're one of the biggest supporters of personalized care whom we know of so we’re very excited that you can join us today. 

Dr Kofod  00:57 

Thank you very much for having me.  

Sebastian De Boodt  01:00 

Thomas, I am curious, can you take us back to the first patient you ever treated with a personalized device? How was that experience? 

Dr Kofod  01:07 

I believed in the beginning that it would be something that we would do for specialized cases. But so, the first case we did was a craniofacial case in which we planned a front orbital advancement. That first surgery changed the way we look at cranial facial surgery. And we have planned all cases since then, simple or complex. So I think actually, what it is, is that you opened your eyes, for not to say how poor, but despite the fact that you do your very best, the quality of care that you can deliver using personalized planning and implants and guides, it just shows it’s very effective, that you can't do it without. And if you are to be honest to yourself, you have to realize that quite early. Therefore also the change of discussing whether you do it in some cases, or you do it in all cases is quite easy, I think.  

Sebastian De Boodt  01:53 

Maybe for the listeners, those not experts in your domain, can you explain what that procedure entails? In layman's terms? 

Dr Kofod  01:59 

Yes, it's a correction of the shape and the potential size of the cranium of children, who are born with a growth anomaly in which the growth stones of the cranium fused during birth, and therefore they have a constriction of their cranium and the volume in which their brain can develop. It's not a rare disease, but it's a fairly rare disease. And it can be either simple or complex in which more of these growth stones, which are called sutures, are closed. 

Pieter Slagmolen  02:29 

What was then the primary motivation for you to choose on this particular case patient specific over standard device? 

Dr Kofod  02:36 

In this case, it actually was the computer system. The ability to plan and design guides and osteotomies in which we could develop a treatment plan and treatment for this child. Prior to this, it was more or less handheld; you were moving bone still, but some osteotomy still there was no pre-planning. So despite the fact that in many years, we have done pre-planning in reconstructive surgery, and we've used to steer this graphic models for painting plates, then it was the first time we actually did pass judgments prior to the surgery on the cranium. So we all the small bone cuts?? costs, everything was guided, and we're able to reposition this using resorbable osteosynthesis. And with the experience, we have now developed together with good colleagues, engineering colleagues, a very nice chosen set up for personalized care in these children. We can actually develop a nice design, we have guides, both for the actual bone cutting on the cranium, but also for the repositioning of these bone paths. And most of all, trying to change the care of these patients by starting the change where we actually blow up a balloon inside the cranium. Therefore we can measure the changes possible with the cabinet too, and that hasn't been possible before. Because nobody knew what they were doing. Actually, we were moving bone. And it looked fairly nice. But nobody knew planned volume prior to the surgery.

Sebastian De Boodt  04:02 

So it’s actually, since then, also changing the kind of procedures that you're doing? 

Dr Kofod  04:07 

Sure, I mean, there's no going back, you see immediately A shorter surgery that is more precise surgery is more precise, and more predictable. And of course, they have the ages of six to nine months old. And it's a very strong tool to be able to tell parents that we are going to correct the child's head, your child's head, and it's going to be this plan. I mean, it's much easier to discuss the actual treatment with patients, not just parents, to children, this disease but in general. 

Pieter Slagmolen  04:38 

So you're describing that the impact of using this personalized approach is not only on yourself as a physician–being better prepared–but it's also on how the patient and their parents in their family can go into the surgery, right? 

Dr Kofod  04:50 

It's affects all of us. So, it's a change in the way we think we can plan all surgeries. It's not something we developed during surgery and there is no excuse not to plan prior to surgery. There is no good excuse why you shouldn't plan! If you come up with something that doesn't fit, then it's your insufficient plan. I mean, you can plan everything. So, it's not just to say it puts pressure on the team to develop, and to figure out both the plan, but also within that plan, a rescue plan for oncology, for example. It's just our ability. But I think in general, everything can be built, but it still is a clinical decision: what determines the surgery, what it should be, but it's built on a strong collaboration with especially engineers, and then it changes the full team and how we treat patients. 

Sebastian De Boodt  05:39 

Again, going back to the more early days, let's say, and maybe you can also explain, like how many years ago that was, just to get a little bit of an idea, what were some of the hurdles and challenges back then? 

Dr Kofod  05:49 

It's a little like this, that if we go really back, I started in this specialty, and I was cutting steel through graphical models back in the end of the 1990s. We were building models, we were cutting still something but the idea that we were then just ordering a model with no real knowledge of what to put in, what was the size of a tumor, which needed to be resected. But then we just cut the model, and we tried around and bended plates, but having the ability to operate on the patient prior to the actual operation and plan several outcomes and figure out what is the best possible outcome for this patient. Now with the planning phase, we still go back to 2012–13, in which we started with computer-assisted surgery. But, now you could say, in this way as we have (already) done it. And then of course, there's a big change by the use of patient specific implants when they came around. So still, it was improved care. But it was not the real change, because the real change came with personalized implants. Of course you can produce guides in many ways, but (it). becomes even more–you could say visible–our ability to actually perform those changes that we need on the skeletal level without patient specific implants; we can bend plates, we can do a lot of things, and we can come fairly close. But the precision in which we can treat now with patient specific implants is totally different to what it used to be. 

Sebastian De Boodt  07:15 

It's finally, let's say, the first time you can actually do, what you really would like... 

Dr Kofod  07:21 

We all thought we were doing a great job. In general, you're doing a great job, but it's just, we're not doing a perfect job and so much closer, much closer to perfection in terms of precision. Yeah, if it's the right plan, and the right implants are produced, then it can come very close to perfection in order to reconstruct correct craniums. 

Sebastian De Boodt  07:42 

Can you explain like, what's the difference between a good and a perfect surgery is for patients? 

Dr Kofod  07:47 

In many corrective surgeries, we move jaws around in order to correct either two jaws being too long behind, or too long forward, or having a asymmetric face. And if we're doing a real good job back then, then the precision on the positioning of the offhand sizes was a couple of millimeters—a millimeter and a half to two millimeters in any direction. It would be a midline being off by two millimeters. Now, if that midline precision would be closer to under two millimeters in any direction with the patients. So I mean, it goes without saying it's extremely more precise. 

Pieter Slagmolen  08:23 

And the reason that that precision is important in, specifically in, cranial surgery is that mostly because of the aesthetic impact of such precision?  

Dr Kofod  08:31 

Well, it's well, it's just not the aesthetic. If you operate on lengthening legs, we all have a shorter and longer leg, and we wouldn't even know. So, until (it’s) a couple of centimeters, it doesn't really bother us. But if we put a hair between our teeth, we can feel that we have a hair—so say 50,000, 5000th of a line is extremely thin. And we can feel that. The precision needed in the correction of craniums is much higher. 

Pieter Slagmolen  08:58 

That's an interesting view. And maybe I'll jump to something I wanted to ask later. But is that also the reason that you believe that personalized care is so much more advanced in the cranial maxillofacial space than it is maybe in other domains? Because of that sensitivity? 

Dr Kofod  09:12 

Well, in the specialty, there has been a tradition and need for real close planning. I think in general, you know that the precision needs to be much higher. But the idea that you actually pre-plan surgery has been there for orthognathic surgery, the correction of jaws, moving them back and forth. I mean, it's fairly the same way we have planned them for 50 years, the ability to do it in the computer comes with extra treatment, the science, and especially the translation into this. I mean, we have planned always and therefore we also advanced with the use of computers much faster than other specialties because you could say that was a culture and a tradition to go and see what were you supposed to do. If you go to orthopedics, well, now patient specific solutions are coming up, but it's more or less 10 years later than CMF. I think it comes with tradition and a culture which wants to improve care all the way. It's not that orthopedics doesn't want to improve care, but that has been an understanding on the possible changes with computer system surgery. 

Sebastian De Boodt  10:15 

Are there any lessons learned you think for those other in domains like orthopedics that can be had from CMF, too? 

Dr Kofod  10:22 

For sure. They don't need to go through a 10-year period in order to figure out what to do. But I think we need to be able to visualize what we're doing and that comes with improved software. Then I think it should be possible that we segment what doesn't matter, whether it's a fractal patient or oncological patient, because then we would need what we need to resect–of course, with the advanced future it will be that we actually can monitor growth of tumors–because then we would know how much we would resect, and the ability to then go into software in which you can visualize the tumor on one or two modalities, and do a surgical planning, and afterwards get a patient specific implant and a patient specific plan for a graft or just an implant. I mean, that ability they don't need to develop in our specialties. It's fully transferable into orthopedics, for tumor care, or for different... and I mean, what there isn't in CMF, is, I mean, done within neurosurgery. It’s not a CMF discipline, we do it combined with the neurosurgeons within maxillofacial traumatology clinics, with facial traumatology also done by neighboring specialties. And some of them have no tradition, but it will change these specialties to plastic surgery and EMT. And likewise for oncological care of head and neck tumors, it will change those specialties too, because there's no I mean, in the future, there'll be nobody who enters this kind of situation and doesn't ask people, “Could I see the plans for my operation?” So, I think there will be that need. 

Sebastian De Boodt  11:55 

Obviously, you're a big supporter of our slice planning and potentially also guides and implants. So yet, I guess also in the CMF domain, it's not that every physician is doing this, I'm assuming like, what do you think are the reasons for that, like what are still some of the bigger challenges that exists.

Dr Kofod  12:10 

There's always a discussion that planning is expensive, you shouldn't need to re-operate that many patients in order that it is much cheaper to do it right first time. There's a discussion, which is about pricing, and it is expensive. And when we changed from stainless steel wires onto plates, everybody thought it was too expensive. Now, everybody thinks it's fine with the pricing when we changed to resorbable osteo sensors, then everybody said, “Oh, it's expensive.” But when more and more people use them, the price goes down. And we have used two or three other 2D systems for planning orthognathic surgery. If we look at the time spent to cut plaster models, look at X-rays, trace X-rays in 2D in relation to do it in 3D, and with the possible outcome that it's not for discussion±—it's about moving money from one system to another system and understanding that change. And of course, we live in different societies all over the world. If it's an insurance-based healthcare system, they look to make an economical outcome for those owing the big insurance companies. But in general, it's true to say, that most of the patient specific implants of this kind used has been in a public hospital in Central Europe and a private practice somewhere in the ocean ethnics. It doesn't have to do with the setting we are in; it has to do with the actual understanding that this is a need. And of course, within CMF, it's like this, that our culture has been, that we think we should be cheap. I mean, every time a solution came up, we thought we should be cheap. I've seen neighboring specialties. Nobody thinks they should be cheap. I mean, everybody knows in spine surgery, it cost a fortune in pelvic surgery, it cost a fortune! So, we just need to realize that if we want to still going on being cheap, then actually we are not understanding the needs of our patients. Of course, we need to understand that change. It's not because it needs to be expensive. But of course, with a growing market, the price will go down. It's always like this. But in general, it's also about accepting that we are improving care and improved care costs money. 

Pieter Slagmolen  14:16 

Am I right in assuming that you believe that in the end, it's not more expensive? Maybe, that is more a shift from what we did traditionally towards new, more digital methods. But then in the end, the overall cost is not going up—that is maybe a misconception of people? 

Dr Kofod  14:31 

I think, by far, that's true. I mean, of course, there'll be a short-term shift, and that the actual implant is more expensive. But if you see operation time shortened in theaters where they do free flap surgery, just using these kinds of guides and implants shortens three hours, and it's by far paying for the price of the guides and the implants and all of that. So for me, no doubt, it's also a change. In the old days, I was sitting in the morning cutting plaster, surgery, and tracing X rays. Now I have a daytime job screen, daytime planning with an engineer, and the outcome is much better. I'm changing, not doing three hours, an hour and a half cutting plaster and making models for, for pre-planning to surgery. Now we do something which is better. And of course, we buy some of that. And, of course, that has a price.  

Sebastian De Boodt  15:19 

You mentioned here the role of the engineer, I'd like to pick in on that a bit. Can you explain like, what engineer? What did they do exactly? What's the contribution of an engineer today in your procedures? 

Dr Kofod  15:29 

From the very beginning, in the early 90s, something late 90s, it was actually that we ordered a model, then they were producing a model, and we got the model. But now, it's a very close collaboration, mostly every day, and they take care of a lot of things that we need in computer assisted surgery. There's a lot of, you could say segmentation of data set pre-producing, ready for a planning session, we have now on-site planning. The possibility for that, we have done for many years: have these virtual planning meetings, we have pre-ordered, we have told them what kind of surgery we would like to perform, and therefore, they have made everything ready. And then we have online, you could say a planning session in which we align the face, as we have seen the face clinically, we go through the needed planning, the needed movements. And then post-planning, there's a lot of processing of building guides, building implants, and designing all of that. They do a lot of what doctors and lab technicians do. They produce a lot of this, it's done, of course now on a computer. But there's still a lot of manual work also still being done post-processing. But in general, this is the daily work, and they take care of a lot of the work that we were doing. It's our closest collaboration now, I think. 

Pieter Slagmolen  16:45 

What the listeners don't know is that you're a bit special in a way that you have your own engineer on site at this point in time. Can you explain what value that brings? Additionally, compared to maybe somebody who is remote, what's the difference for you in being able to have somebody to work with on a day-to-day basis? 

Dr Kofod  17:01 

It goes without saying, it's for this very long collaboration, I think it has changed our daily work. I mean, we planned a lot of patients, but we also develop care, we have developed a lot of different treatments, algorithms, modalities, designs, stuff like that. And that's much easier when you sit together. We can discuss different things, but the ability to change how we see what we'd like to do with a computer assisted surgery. And that collaboration, (it) goes without saying it's much easier with somebody on site. It's not that we haven't developed things together, doing you couldn’t through the screen. But it is something very different. 

Sebastian De Boodt  17:36 

We see also with the actual manufacturing, of production to 3D printing of personalized devices. Do you see this shift going on as something that was happening in companies exclusively towards hospitals doing this at the point of care? What do you think is the driver behind that shift? Is that also what you just mentioned, collaboration, or are there other things at play?

Dr Kofod  17:56 

There'll be a couple of ways. I think if you discuss what some hospitals will need, they would need something which is an onsite planning or printing facility for some products. I don't see metal implants being produced. I don't see the change towards resorbable new implants being produced at hospitals because of many good reasons. Among others, because this is potentially explosive and stuff like that. There's a lot of handling, which needs to be taken care of, what we need to understand is where we can meet each other best. For CMF, that for acute care, we would need somebody, we will need a printing facility to print orbital implant for an acute trauma day 1-2-3-4. But we can actually have personalized implant on day five or six. So, we will develop care. And if we couldn't have had an orbital implant day five for the reconstruction, of course, then we would need to have, you could say, it developed with the effort of logistics, (and) a lot of long term working relationships and understanding on what are the needs in order to treat patients, right? I mean, for oncology, we now can get reconstructions plate planned, produced, delivered with reasonable time in order to live up to the packages from oncological care. The same with the orbital implants. Of course, we can't have a patient specific implant produced within six hours, but we can have then somebody that can guide the shape of a standard implant, which would be second best and then the possibility to use navigation. Likewise, in order to control our treatment. 

Pieter Slagmolen  19:33 

That's an interesting view. So what you're seeing is that you have actually–probably because of technology advancements–you've had a lot more options now to have to do personalized because it's become fast enough for certain indications. Are there indications today where you still are forced, that's the way I would describe it, maybe forced to revert to a standard approach where you cannot rely on personalized and which cases are that, and why? 

Dr Kofod  19:57 

For example, (with) a gunshot wound, we would need to reconstruct the soft tissue damage and we will need to realign that mandible, then we would need a reconstruction plate. And we can't have that, I mean, prior to eight, nine days with a decent (outcome) but what it is then, we can have a model almost the day after, two days after, and then we can end a plate on that. And we can even have guides to do that, again, that's logistics and a huge change in the production which is guided towards the need of treating patients. Even with acute care, we still use computer assisted surgery, we still pre-bend the plate, we still guide the position—it's just that we can't have the implant produced with the same speed. So this is how it is. And I don't think we will have 6-24 hours implants. There will be a need in order to have, you could say, something to print, an open to print mandible, whether that's on site or with logistics within two days, I think that's how patient flow develops in the local setting. But for sure, there are a few things which still need to be able to happen. But they are hard to handle if you want a patient specific implant, but we can still use the planning and have patient specific, adapted, standard implants. And that's much better than no plan. 

Sebastian De Boodt  21:12 

Alright, it makes a lot of sense. 

Pieter Slagmolen   

To simplify your workflow to what you can do basically for specific indications. 

Sebastian De Boodt  21:22 

On the topic of trying to simplify, I'm going to shift a bit towards innovation, as well. We're very curious to hear your opinion on artificial intelligence. And I know Pieter was keen on asking that question. So sorry, Pieter, for stealing it. 

Pieter Slagmolen   

Oh, that's fine.  

Sebastian De Boodt   

Artificial Intelligence. You know, it's a big thing today. And it's already impacting quite a lot of things in terms of efficiency, and so on. But can you explain your vision on what role you think AI will play in making your planning smarter? And when would you trust yourself as a surgeon and a trained engineer versus an AI algorithm to kind of give you a suggestion? 

Dr Kofod  21:56 

Well, I think it will be fine with suggestions, I think to improve care. They would know which kind of osteotomies that, for example, me as a treating surgeon, how the design should be at the osteotomies, and of course, we should see them automatically. And then, it will be like this, that from the previous plans, if we put my plans on top of each other, they will potentially look quite alike. If we have a patient in which we pre-operatively know that these are the measurements that we would default to, and we can actually take them from, then of course we can do a pre-operative setting; this is how you would usually do it. And then–that's another discussion–then we always need to move them around. For me AI would be beneficial in order to say, well, “Thomas, do you think there's the care (so) this patient would look like what you usually do?” Or are there any different things? I think there'll be a lot of possible for advanced, you could see an improved workflow also, basically, on the engineering part, the same with the design. Okay, we usually do like this... Do you think that this design would be the same? If AI should be used wisely, I think that we can come ahead. But on a longer perspective, I would also see that we have, for example, airways defining the needs, we would need to have soft tissue defining the needs. So, in theory, when we have very good soft tissue algorithm from the airway from whatever, then in sleep apnea patients, we would let the knowledge there from “How do we open the airway?” and “How much it is needed would that be?” and we would get a suggestion that you will need to move maxilla mandible, let's say, 12 millimeters forward. You will need to have the higher bone being advanced this size. 

Sebastian De Boodt  23:38 

And that is then something that today is really difficult to do then, where you're looking... 

Dr Kofod  23:41 

Well, we’re on the borders of trying to discuss this and we do some segmentation and we move them. But we see the result post-operatively, but a little like starting the change of care in the correction of children's craniums on the craniosynostosis patients, then if we now know what we are doing, which changes we are and we know how much volume we are changing, then in 15 years, we would know, okay, this was enough. This is correct, because everybody is discussing correction versus over-correction. But what is over-correction, if you don't know what you are correcting, in order to be able to have that discussion, you need to plan something, and you need to be able to do that during surgery. And that doesn't really matter what's on top of the cranium, or it's moving to yours, unless we can trust and show that the position is correct. And these were the changes that we did. But then, of course, in sleep apnea patients knowing that we move them 12 millimeters and we know how the hyoid bone and the soft tissue the tongue palate moved, then we would know, “Okay, we don't need to move them, let's say 18 millimeters, but just 12 millimeters.” That would be the clever use of AI. Also that we improve care, not just on the movement of the skeleton, but actually foreseeing which changes are needed in order to change patient's life. I mean, these get rid of CPAP machines, they don't have strokes and different other things which is at a higher risk for sleep apnea patients, so a lot of these things and with increased demands on what's called “Insta-faces.” I mean, it's not because we need to go that way. But we need to have a discussion on how does this change aesthetic surgery in the future? There should, of course, be built patient specific implants for Aesthetic Surgery, likewise, these that we do for corrective surgeries, and this should be part of the care. And if I was having aesthetic surgery by somebody who was moving, or putting something on my face, for sure, I would love to see the implant and the changes needed. But we are not there yet. We will come there, again, with improved visualization of soft tissue, that will not be the change of care for aesthetic surgeons. Then they don't potentially need seven surgeries or seven procedures, but potentially one. 

Sebastian De Boodt  25:44 

If you look forward 20 years from now into potential better ways of treating patients. Is there anything that's impossible today that you would love to be reality, by the time that you can retire?

 

Dr Kofod  25:55 

For a lot of the things that I think will be needed is that we get rid of a lot of the lovely titanium that we put in patients now! I think we should need where's the need for permanent implant and where can be used resorbable implants and which part of the implant can resorb. We don't need to do additional surgeries, so the understanding, and really put pressure on that we have still development, despite the fact that we now have a good platform for moving things around is that we should make those implants disappear again. So that would be one thing that I think will need to change, we have some of the possible implants, but we need to develop new materials for new implants. There are still things, what I hope we can do, is that we can learn to visualize tumors better, and therefore also mark them and use the computer system surgery in order to make improved care. I hope that we can mark tumors and also their displacement on the soft tissue so that we can plan properly with radiotherapy. They will be in one solution, not in two solutions, I think what happens is that we have not enough or not good enough visualization, markings of tumors, and we therefore resect too little, too much. But the ability to see, visualize the tumor, make a perfect plan, having a fast care...then I think that will improve care and also (give) the highest survival of head and neck surgery, for example. Any surgery as such. And then of course, there is nothing that can be planned for elective surgery, I don't think there's a need not to use this kind of planning. The only thing is that you actually need is to treat fewer patients in order to become good at the surgery because you use your brains pre-op, and as it’s possible to use this information post-op. Any surgeon can make multiple plans planned for one surgery, and see how good we'll be at accomplishing this. And that knowledge needs, of course, with AI to go into the system, then this is a better design. At the moment, it is a little like we think that one design from a clinical perspective is good. We haven't been doing that for years, it works fine. From an engineering point of view, they think they know. But, it's good for a technical point of view. And, of course, that needs to meet somewhere in the middle. We actually know that this is a good design. For these reasons, we can go closer, for example, with screws towards teeth, because we actually agree that who is at risk, that's the patient. It's not the engineer trying to make sure that the screws don't come close! It's not the surgeon who is over-aggressive, but in a dilemma trying to make it work. And of course, there engineers and surgeons with like needs to meet and discuss these matters. So, it becomes real, what we're doing. 

Pieter Slagmolen  28:29 

Great. I think that's a perfect note, also to end on is the synergy between engineers and surgeons, which is a great part of your story. Thanks a lot for joining us, Thomas. I think that’s what I take away is your experience on the importance of surgical planning for cranial maxillofacial surgery. What I liked was how you described that you should probably stay away from potentially explosive technology within the hospitals and what innovations can bring Insta-faces in the future. That was all pretty interesting, so thanks a lot for sharing that. We really appreciate your insights with us on this 3D Players podcast, a podcast where we explore trends, insights, and innovations in personalized and sustainable health care. We’re your hosts, Sebastian De Boodt and Pieter Slagmolen. Thank you for listening. And please join us for the next edition!