Image guided surgical navigation integrating "mirroring" computational planning based on intra-operative cone-beam CT imaging: a promising new approach for management of primary bilateral midfacial fractures.

Cosmetic and functional re-establishment following primary or secondary treatment of comminuted and complex midfacial fractures remains a challenge for surgeons. Computer Assisted Surgery (CAS) has revolutionized the conceptualization and approach to these reconstructions and has become a reliable part of the surgical armamentarium. Computer aided design/modeling (CAD/CAM) software that allows "mirroring" planning coupled to navigation systems has dramatically improved surgical strategies in reconstructive surgery of the craniomaxillofacial skeleton, particularly with respect to the prediction of suitable symmetric bone repositioning. So far, however, use of this approach has been limited to unilateral cases, with a non-fractured contralateral side being considered the condition sine qua non for the application of such a technique and the "mirroring" planning being performed on pre-operative CT imaging. We report a case of complex primary reconstruction in a patient presenting with bilateral midfacial fractures, using complete intra-operative sequence processing with a navigation system integrating "mirroring" computational planning based on a mobile C-arm cone-beam computed tomography (CBCT) scan with a flat-panel detector. To the best of our knowledge, no similar cases have yet been reported involving the use of this sequencing method in the primary management of bilateral midfacial fracture reconstruction.