Xiaojun Chen (Orcid ID: 0000-0002-0298-4491)

Accepted Article
The Development of Computer-aided Patient-Specific Template Design Software
for 3D printing in Cranio-Maxillofacial Surgery
Afaque Rafique Memon1#, Dongyuan Li1#, Junlei Hu1, Enpeng Wang1, Dingzhong Zhang1 and
Xiaojun Chen1,2,3*
1Institute
of Biomedical Manufacturing and Life Quality Engineering, State Key Laboratory of
Mechanical System and Vibration, School of Mechanical Engineering, Shanghai Jiao Tong
University, Shanghai, China.
2Institute of Medical Robotics, Shanghai Jiao Tong University
3EngineeringResearch Center of Digital Medicine and Clinical Translation, Ministry of
Education, China
#
Afaque Rafique Memon and Dongyuan Li contribute equally to this work.

*Address correspondence to:

Xiaojun Chen, PhD, Professor

Room 805, School of Mechanical Engineering, Shanghai Jiao Tong University, Dongchuan Road
800, Minhang District, Shanghai, China

Post Code: 200240

E-mail: xiaojunchen@163.com

Tel: (+86) 21-34204851

Fax: (+86) 21-34206847

Abstract:

The patient-specific templates for osteotomy often have complex surface features. Using current
commercial software to design such templates is quite complicated, tedious and unrepeatable. In
this study, a novel surgical planning system for oral and maxillofacial surgery named
EasyTemplate is developed, aiming to help doctors shorten the modeling time and assure the
reliability in template design.

In the simplified design process of an osteotomy guide, the main plate can be formed efficiently
using a surface offsetting algorithm, which is based on iso-surface extraction and oriented

This article has been accepted for publication and undergone full peer review but has not been through
the copyediting, typesetting, pagination and proofreading process, which may lead to differences between
this version and the Version of Record. Please cite this article as doi: 10.1002/rcs.2243.

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 bounding box. Thereafter, the cutting grooves can be generated automatically. EasyTemplate has
Accepted Article
been successfully applied in clinical cases. A complicated surgical guide could be built
accurately in about 10 minutes. Compared with commercially available software, lower time cost
and simpler design process were achieved, moreover, the time cost is one-third or even less.

Keywords: Surgical template, Cranio-Maxillofacial Surgery, Computer-aided surgery

1. Introduction:
Basically, a surgical template is a guide which is useful for implant placement, bone
repositioning, osteotomy, tumor resetting and finding the accurate position of the implant
prosthesis [1]. The previous manufacturing of the surgical template relied upon the manual
structure and assembling techniques for the most part. However, these methods were
unrepeatable, nonstandard and time-consuming. With the popularity of Computer-Aided Design
and Computer-Aided Manufacturing (CAD/CAM), additive manufacturing of specific templates
guiding the osteotomy and repositioning has become a useful alternative to the intermediate
splint technique [2]. Meanwhile, the medical field is growing rapidly in terms of Computer-
Aided Surgical procedures to obtain more accurate data in 3 dimensions and to manufacture it
accordingly, with the help of 3D design software [3].

For patients with cranial-maxillofacial injuries or large mandibular defects, accurate

reconstruction of the mandible can be quite challenging in consideration of the functional and
aesthetic consequences [4]. An acceptable recreation needs to fulfill various criteria such as: to
establish an aesthetic facial architecture, to preserve both masticationary function and respiration,
and to allow an intelligible speech. Even most experienced surgeons can be challenged to meet
all these criteria as well as by defects requiring multiple osteotomies or with soft tissue defects
[5]. Recent developments in CAD/CAM have allowed doctors to attempt more accurate
operations and reconstructions with improved intraoperative efficiency [6 - 7]. Computer-aided
surgical template design and manufacture has already been used to guide doctors in making an
efficient osteotomy and moving bony segments as planned in software [8]. Furthermore, several
researchers have already revealed the use of CAD/CAM templates for mandibular distractor
Osteogenesis (DO) [09 - 12].

Currently, there are many commercial software packages available for template design such as
Imageware, UniGraphics (UG), Pro/Engineer, Geomagics Studio, Para form, STTIM100, ICEM
Surf and many more. However, these softwares all share the common disadvantages in surgical
template design, such as complex modeling process, high learning cost and low repeatability.
Chen et al. revealed that the traditional CAD software packages available in the market were not
dedicated to surgical template design because the usage may be too complicated and difficult for
a medical doctor to learn [13 - 15]. Using unspecialized software to design a customized
osteotomy template for corrective osteotomy may be extraordinary time-consuming. Oka et al.,
for instance, have invested many days using Magics RP to design such templates [16]. In

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 addition, doctors are unable to use software that requires engineering background to build a
Accepted Article
model. Therefore, it is necessary to develop specialized software and to study the key algorithms
for surgical template design in Computer-aided cranial-maxillofacial surgery.

To solve this problem, a design software called EasyTemplate for 3D printed templates in
Cranio-Maxillofacial Surgery is developed in this study. The development of software function
is based on some classical open source libraries for computer graphics and geometry algorithms,
including Visualization Toolkit (VTK, http://www.vtk.org/) and Computational Geometry
Algorithms Library (CGAL, https://www.cgal.org/). The user interface (UI) is built up by Qt (a
cross-platform tool for UI development, http://qt-project.org/). The developed software
EasyTemplate runs smoothly on a PC with Intel Core i7 with a 1G discrete GPU, 2.50 GHz CPU,
8 GB memory and a 64-bit Windows 10 operating system.

This specialized software is simple and efficient enough to design useful surgical templates. It
can also effectively facilitate the design of patient-specific maxillofacial templates for doctors.
The key algorithms on template design include multiplanar cutting, surface offsetting, automatic
groove generation and repositioning guide generation, which have been developed and optimized.
In comparison with the current commercial software, EasyTemplate has a more simplified and
time-saving modeling process. Meanwhile, for the person who does not have much relevant
experience, the usage of EasyTemplate is more foolproof and easier to learn.

2. Methods
Many relative algorithms are utilized in EasyTemplate to realize the whole process of template
modelings such as a surface offset algorithm based on directed bounding box, automatic
osteotomy groove generation algorithm based on implicit function cutting and the automatic
generating algorithm of repositioning template based on the spatial position transformation
solution. On the basis of the key algorithms mentioned above, surgical templates can be built
easily even by a beginner following these steps:

Initially, the reconstruction of a 3D model is adopted through 3D reconstruction software using

the patient's computed tomography (CT) scan data. Then, based on the original model, the
planned model could be designed using preoperative planning software. Finally, specific
templates, guiding the osteotomy and repositioning, will be designed by EasyTemplate with
several steps.

To build an osteotomy guide template, firstly, the basic surface and fixing area on the origin
model should be selected. After using a surface offsetting function of the template design
software to extract the feature of the original bone surface, a designer could conveniently obtain
the basic joint plate and upper occlusal plate, which fit the bone surface well. Regarding the
design of osteotomy groove and fixed hole on the template, the automatic groove generation and
hole punching functions are effective methods. Finally, Boolean operations are needed to
combine the separated parts together.

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 Regarding the repositioning connection template, this software uses the inverse solution
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algorithm of 3D space model movement to replace the complex position movement in the
traditional design process. Before the design starts, a planned model should be built as a
reference, and following the same modeling steps above, designers need to select a basic surface
and obtain planned planes. Thereafter, according to the planned model, a translation matrix (M)
is computed out to connect the upper part and lower part. Finally, to obtain a reposition
connection template with fixed punching holes, surface offsetting and hole punching should still
be implemented. The full workflow and steps are described in Figure 1 and the key algorithms
involved are described below.

Figure 1 The main design workflow of osteotomy(left) and repositioning template(right)

2.1 Preoperative Planning:

In this study, the design of the surgical template is mainly for the correction and repair of
mandibular distortion. The operation needs to plan the cutting path and the correct position of the
bone block according to the patient's CT tomographic image. Through preoperative planning,
doctors can obtain a personalized surgical plan by analyzing and processing the image data of the
lesions before surgery. In the orthognathic operation planning, the maxilla should be extracted
for reduction simulation. Compared with the complex cutting method in traditional CAD

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 software, this section introduces a multiplanar cutting algorithm, which is more effective and
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convenient for preoperative planning of the clinical case.

By picking up a series of points on the model through clicking, arbitrary cutting tracks can be
formed based on a curve cutting algorithm. According to the cutting curve, the closed area that
fits the curve is calculated then the cutting process can be converted into multiplanar cutting, and
a more accurate cutting result will be obtained.

Figure 2 The virtual clipping of the maxillary bone

Figure 2A shows a single plane cutting model. Figure 2B shows a triangular section. Then, by
intersecting two adjacent cut sections of each cut section (as shown in Figure 2C), all the
triangularized sections are intercepted, so that only the model within the cutting range is retained.
Figure2D shows the final cut result. The surface of the free maxillary model is closer to the
actual cut surface of the model.

The entire workflow of preoperative planning is as follows. First, the normal vectors of all
triangular faces are computed and stored in Cells List. Then, the planned plane is obtained by
finding equal normal vectors in the list. In the end, osteotomy guide templates are designed
according to the planned plane. After the successful design of a planned plane model, an
algorithm is used to determine the cutting plane. The pseudo-code to determine the cutting plane
is given below.

Algorithm 1: Determine Cutting Plane

Require: CellsList of mesh, Threshold, e1 ,PCellsList of plane,e2

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 Ensure: n, P2 , P3
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function Obtian Plane( CellsList, Threshold)
for each Cell in CellsList do
ni ← GetNormal(e1 ,e2 )
NormalList ← ni
end for
for each ni in Normallist do
for each ni+1 in Normallist do
if ni == ni+1 then
n ← ni
PCellsList ← n
end if
end for
end for
return PCelllist
end function

2.2 Surface Offsetting:

Surface offsetting helps to generate the basic plate of the osteotomy template for further design.
Firstly, the curve cutting method is applied to extract the fitted surface of the origin model. Then
the surface offsetting function can be used to thicken the extracted surface. A common method of
surface offsetting is to move the surface by a certain distance in the direction of the lateral
surface of the bone. The direction of movement can be uniquely determined by the weighted
average of the normal vectors of triangular faces around the points. Regarding complex surfaces,
the calculation time would be inevitably long. At the same time, due to the large curvature
change of the cranial-maxillofacial surface, the model generated by the algorithm is often
inaccurate in the direction of migration, which fails to meet the needs of users.

In this study, a surface offsetting algorithm based on the iso-surface extraction algorithm is
proposed to solve this problem. The algorithm combines the oriented bounding box tree
(OBBTree) and the isosurface extraction algorithm, effectively reducing the running time of the
algorithm, and the accuracy of the model is also guaranteed to a certain extent.

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 Figure 3 Oriented bounding box of random points. By calculating the eigenvalues and eigenvectors of the point set
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covariance matrix, the geometric center and the principal axis of the oriented bounding box is obtained.

For the determination of the oriented bounding box in the three-dimensional space, a three-
dimensional convex hull, assume it has n triangles, set as and , , represent the
three vertices of the triangle. The area of the whole convex hull can be expressed as:

=∑ (1)

The weighted average value of the centroid coordinates of the triangle is:

= ∑ (2)

According to equations (1) and (2), the 3×3 covariance matrix C of a polyhedral convex hull can
be constructed by the following equation:

!
, − = ∑ #9 + & & + ' ' + ( ( )* − + (3)
"

In equation (3), the superscript k represents the first k triangles, the superscript M on behalf of
the entire polyhedral convex hull, the subscripts i and j refer to the corresponding component.
The formula represents the three-dimensional point set the information of a polyhedron convex
hulled in space. By diagonalizing the matrix, the corresponding eigenvectors and corresponding
eigenvalues of the matrix can be obtained. In the eigenvalues, the vector corresponding to the
maximum value is the principal direction of the directional bounding box. By projecting all
points on the polyhedral convex hull into the unit vector of the directional bounding box, the
maximum length ,-./ and minimum length ,- could be obtained. Then, the half-length of the
bounding could be expressed as equation (4):
! !
0234 50267
, .01 = (4)
"

And the center of the bounding box is shown in equation (5), where 8 indicates the unit vector.
! !
0234 50267
= ∑" "
8 (5)

The base surface of the basic plate is extracted from the original model by the surface extraction
algorithm according to actual needs based on Marching Cubes (MC) algorithm. After obtaining
the base surface, surface offsetting should follow these steps: (1) Establish the grid of bounding
box of basic surface, distributed sampling points into space; (2) To reduce the time of computing
the shortest distance, the vtkOBBTree algorithm is used to divide the basic surface into multiple
oriented bounding boxes (OBB); (3) Compute every node’s signed shortest distance to basic
surface mesh; (4) Obtain the offsetting surface with the MC algorithm. The design method and
the outcome are illustrated in Figure 5.

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Accepted Article

Figure 4 The offsetting surface design procedure and results

Figure 4 shows the process of obtaining the base plate model from the surface to the thickening.
The red sample points represent the sample points with a positive distance symbol, while the
blue sample points represent the sample points with a negative distance symbol. The output
yellow model is the thickened joint plate obtained by the algorithm. After n cycles, the algorithm
can calculate the distance field distribution of the sampling point, which can effectively avoid the
distance field calculation of the point outside the directed bounding box, thus reducing the
amount of calculation and speeding up the running speed of the algorithm.

2.3 Generation of Osteotomy Guide:

In orthognathic surgery, osteotomy grooves are used to fix the direction of movement of the
scalpel and ensure that the cutting location conforms to preoperative planning results during
osteotomy. To prevent vibration that makes the cutting path deviate from the planned direction
during the operation of the scalpel, it is necessary to design a 1 mm thick step around the
osteotomy groove. According to the individual needs of patients, the design of osteotomy guides
varies from person to person, meanwhile, the design process can be awfully complicated and
cumbersome in present commercial 3D design software for inexpert designers. An osteotomy
guide used in common orthognathic surgery is shown in Figure 5.

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Accepted Article

Figure 5 Osteotomy guide

Therefore, this study proposes a method for automatic generation of a complete osteotomy slot.
(1) Obtain the central plane position information in the Y direction of the groove according to the
planning model, and generate a rectangular parallelepiped plate from the plane information. The
thickness of the plate is the same as the required groove width. (2) According to the range
position information of the grooves input by the user in the X direction, accurate position
information of the long plate for grooving on both sides is obtained. Then, the long plate is
modified by plane cutting. The normal vector 9: of the cutting plane is calculated by the normal
vector 90 of the long plate cross the normal vector 9; of the center point of a basic plane as
Equation 6, and the coordinates of the points P(x,y,z) on the plane can be obtained by moving
center point C(x,y,z) following Equation 5, where l is the length of the long plate.

9 : = 9 0 × 9; (6)
= − 0.4,9: (7)
(3) After the main model of the osteotomy guide and the long plate for grooving, the surface
model of the thickened plate around the groove is calculated by using the distance field stereo
cutting algorithm. (4) The surface model is stretched to a certain thickness to generate a thick
plate. After the Boolean algorithm is applied to merge the thick plate and the main body model,
the long plate is used to cut the summed model to finally obtain the required model.

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Accepted Article

Figure 6 Illustration of automatic osteotomy groove generation procedure

The design procedure is shown in Figure 6. After the osteotomy pits are generated automatically,
planar and curved cutting methods are required to modify the base guide template, meanwhile,
while the position of the fixing hole is determined, punch the fixing hole. Then, the methods of
drawing and stretching are used to generate the upper occlusal plate, take the center surface of
the skull as the base surface, and draw a sketch and extrude to generate an intermediate
connecting template. Finally, the Boolean summation operation is applied to complete the design
of the entire osteotomy guide.

2.4 Repositioning connection Template:

The repositioning connection template is used to connect the corrected mandible after the
osteotomy. An appropriate connection guide needs to fit the surface of the main bone and the
corrected bone well. In osteotomy operation, the connection guide and osteotomy guide are often
used together, so the design process of connecting guide template is related to the osteotomy
guide, and corresponding design needs to be made according to the planning plane information
and the actual planning position during the design process. However, in the process of using
traditional 3D model software to design the connecting guide template, the connection between
guide templates is not taken into account, which results in the need to manually adjust the
position for calibration. A connecting guide used in common orthognathic surgery is shown in
Figure 7.

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Accepted Article

Figure 7 Connection guide

In this study, the design of the connecting guide and osteotomy guide are combined, and the
reverse solution algorithm of three-dimensional space model movement is used to replace the
complex position movement in the traditional design process. At the same time, the design steps
of the connecting guide are simplified by using the rational transfer of the plane equation and the
position coordinate information of the retaining hole, to improve the design efficiency of the
connecting guide.

The spatial motion matrix of the rigid body can be obtained by combining the position
movement matrix with the rotation matrix in x, y, z directions. Because the scaling of the spatial
model is not involved in the process of bone block correction, and the deformation of the bone
block itself does not need to be considered, the problem of solving the spatial position
transformation of the bone block can be transformed into a kinematic solution problem. The
spatial motion of the model is essentially the coordinate system movement before and after the
model, so the motion matrix from coordinate system A to Coordinate system B can be raised to
solve this problem:

Based on solving the spatial position transformation of the model, this study simplifies the
tedious operation process of traditional design methods. The algorithm also realized the function
of automatically generating the base surface of the repositioning guide template and the fixed
hole. To decrease the injury of the patient during surgery, the method uses the position
information of the upper fixed hole directly into the design of the repositioning connection
template. This makes it possible to automatically generate fixed holes. The basic idea of the
auto-generated repositioning connecting template is shown in Figure 8.

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Accepted Article

Figure 8 Illustration of automatic repositioning guide generation procedure

Figure 8 shows the basic surface cutting, spatial transformation matrix solution, surface splice,
surface offsetting and the generation of fixed holes. The blue model is the mandible model of the
patient, the dark green and blue model is the result after orthognathic surgery planning, and the
green model is the designed connection template.

3. Results
A general framework of the surgical guide template design was introduced and several
algorithms were proposed including multiplanar cutting, surface offsetting, osteotomy pits and
repositioning guide templates which are generated automatically. A design software named
EasyTemplate was developed using Microsoft Visual Studio 2017 (Microsoft, Washington, USA)
in the Biomedical Manufacturing and Life Quality Engineering Laboratory of Shanghai Jiao
Tong University. Several clinical cases of customized guide template design were conducted
using EasyTemplate.

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Accepted Article

Figure 9 Main Interface of the EasyTemplate Software

Figure 9 is the main interface of our customized surgical template design software
“EasyTemplate”. While the designed guide template model is used in clinical applications, a
comparison was made between traditional software (including Mimics Geomagics Studio, UG
together) and EasyTemplate. For example, the user cannot design complicated shapes using
Geomagic studio as it does not have some special functions. Additionally, you cannot undo your
mistakes more than one step if you want to revert your changes. Meanwhile, Solidworks also has
limited features in terms of surgical template design. The process is complicated, requires
multiple Boolean operations, and takes a long time. Compared with the above commercial
softwares, EasyTemplate comes with more effective and convenient features as it is specialized
for surgical template design.

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Accepted Article

Figure 10 A and B show the Osteotomy guides, and C and D show the repositioning guides

The design of the two clinical cases is shown in Figure 10. For comparison, five such models
have been designed by both traditional software and EasyTemplate. Different from
EasyTemplate, the design process of surgical templates using traditional software, such as
Geomagic Studio and 3D-matic, is complicated. For example, to obtain a cutting guide, firstly,
the surface extraction and offsetting functions are applied to build the initial template. Then, the
appropriate reference planes are needed to stretch the convex hulls which are necessary to
generate osteotomy grooves. Finally, the fixed holes and some other auxiliary structures are
obtained using the functions of surface extraction, offsetting and Boolean operations. The
average time to complete the same steps of the template design process with different software
and algorithm is shown in table 1.

In terms of a better result, template design with EasyTemplate is more efficient than traditional
software. EasyTemplate is more targeted to the design of guide plates required for orthognathic
surgery during system development. Many ordinary repetitive operations are reduced. Therefore,
EasyTemplate reduces the requirements of experience for designers and makes it easier to design
more accurate surgical templates in a shorter time. The time cost is reduced by about two-thirds.

Up to now, totally five clinical cases have been successfully conducted with the help of
EasyTemplate in the template design process. For a patient with a misaligned mandible, the
offset bone block needs to be corrected by orthognathic surgery. Intraoperatively, an osteotomy
guide was used to assist in cutting off the misplaced bone, thereafter, a repositioning guide was

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 applied to connect the corrected mandibular block and the main bone block. Figure 11A and B
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respectively show the application of an osteotomy guide and repositioning guide.

Figure 11 Clinical outcome of osteotomy guide and repositioning guide

4. Discussion
Computer-based planning for surgical template reconstructions has been progressively more
accepted worldwide because of its improved accuracy, convenience and the expected superior
patient outcomes. However, CAD/CAM technology is not new, the latest improvements in
resolution, image quality and decreased slice thickness obtained from CT scans, now allow for
increased accuracy of 3D modeling and more advanced surgical simulations [17-19].

The functions of commercially available software (such as UG, Pro/E, Solidworks and
Geomagics) are comprehensive but not very specific for maxillofacial template design. For
example, the design of the guide groove of the osteotomy guide requires multiple surface
extraction, stretching and Boolean operations in traditional commercial software, the design
takes quite a long time. In the design of the corrective connection guide template, it is necessary
to use Boolean operations to move the bone pieces and the original model to fuse the model, and
then extract the curved surface, thicken it in the offset, etc. The operation process is relatively
cumbersome and requires high requirement for the designer. The automatic generation algorithm
mentioned in this article can reduce the number of Boolean operations, which could effectively
speed up the design of the guide template and shorten the design cycle. Compared with
traditional commercial softwares such as Solidworks and 3D-matic, the time spent to design the
osteotomy grooves using EasyTemplate is one-third that of commercial software.

EasyTemplate can be a very useful alternative to commercially available softwares with an auto-
generated repositioning guide algorithm, reducing the difficulty to reverse modeling and to
provide basic shapes for designers. It also contains multiple functions so that ideal templates can
be designed through the software. During the surgery, it can also be combined with AR surgery

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 navigation [20] to achieve full computer-aided surgical procedures, which ensures digital and
Accepted Article
precise surgery.

5. Conclusion
With the growing need for individual templates, EasyTemplate can be a useful alternative to
traditional softwares. This software allows the auto-generation algorithm which helps to avoid a
tedious modeling process while providing basic shapes for designers. The new algorithm
implemented in the EasyTemplate allows multiple functions so that ideal templates could be
designed. Five orthognathic cases were conducted successfully based on the osteotomy templates
and repositioning templates designed by EasyTemplate.

Compared with other commercially available software, EasyTemplate has more effective
algorithms and a simpler design process. This software also reduces the requirement for
designers to build a patient-specific surgical template. The option is available in the future to
combine EasyTemplate software with preoperative planning software to improve the efficiency
of planning and design of surgical templates.

Funding Information

This work was supported by grants from National Key R&D Program of China
(2017YFB1302900), National Natural Science Foundation of China (81971709; M-0019;
82011530141), the Foundation of Science and Technology Commission of Shanghai
Municipality (19510712200; 20490740700), Shanghai Jiao Tong University Foundation on
Medical and Technological Joint Science Research (ZH2018ZDA15; YG2019ZDA06;
ZH2018QNA23), and 2020 Key Research project of Xiamen Municipal Government
(3502Z20201030).

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 Dear editors,

We would like to thank you for giving us a chance to resubmit the paper and thank
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the reviewers for giving us constructive suggestions which would help us to improve
the quality of the paper. Here we submit a new version of our manuscript (Previous
Number: RCS-20-0310) with the title “The Development of Computer-aided Patient-
Specific Template Design Software for 3D printing in Cranio-Maxillofacial Surgery”,
which has been modified according to the suggestions of reviewers. We mark all the
changes in red in the revised manuscript. We hope that the revisions are satisfactory.

Sincerely yours,

Xiaojun Chen, PhD, Professor

Room A-805, School of Mechanical Engineering, Shanghai Jiao Tong University,

Dongchuan Road 800, Minhang District, Shanghai, China

Post Code: 200240

E-mail: xiaojunchen@sjtu.edu.cn

Tel: (+86) 21-34204851

Fax: (+86) 21-34206847

This article is protected by copyright. All rights reserved.

 The following is a point-by-point response to the comments of the editor and
reviewers:
Accepted Article
# Reviewer 1

1. It would be good to compare the use of your method and the methods of the
commercial software in terms of the design time. In the discussion page 16 line 38 you
mention “the design takes a long time”. line 44 says “The automatic generation
algorithm mentioned in this article can effectively speed up the design of the guide
template and shorten the design cycle.” Please quantify this time and compare it to
the method that you propose.

Our responses:

Thanks for your suggestion. In the revised version, we have compared our
software with some other traditional commercial softwares like Geomagic Studio and
3D-matic, the time to design the templates using EasyTemplate is about one-third that
of commercial software. The detailed results regarding each operation step are shown
in Table 1.

Table 1 Comparison between traditional softwares and EasyTemplate

Geomagic
Functions 3D-matic(min) EasyTemplate(min)
Studio(min)
Obtain Osteotomy Grooves 14.8±3 13.2±3 4.5±1
Obtain Repositioning Template 15.6±4 12.1±3 4.8±2
Punching 4.4±2 3.4±1 1±0
Total Time 34.8±9 28.7±7 10.3±3
User Interaction Very complicated Complicated Easy

2.page 2

line 47 change: “designing process” into “design process” (do this also in the rest
of the paper, also for e.g. change “designing software” into “design software”.)

line 49 change: “using surface” into “using a surface”

This article is protected by copyright. All rights reserved.

 page 3

line 40 change “software available” into “software packages available”

Accepted Article
line 50 change “an instance” into “instance”

line 50 change “temples” into “templates”

page 4

line 16 change “the designing” into “the design”

line 16 change “template” into “templates”

line 17 change “designing includes,” into “design include:”

line 28 change “such as surface” into “such as a surface”

line 30 change “on spatial” into “on the spatial”

line 32 change “by an” into “by a”

line 36 change “of 3D skull” by “of a 3D skull”

line 45 change “feature of origin bone” by “feature of the origin bone”

page 5

line 45 change “obtain personalized” into “obtain a personalized”

page 6

line 32 change “In figure2 A is a” into “Figure 2A shows a”

… do the same for the naming of figures in what follows: e.g. “figure2 C” should
be “Figure 2C “

line 44 (2x) Should “planed plane model” not be “planned plane model”?

This article is protected by copyright. All rights reserved.

 page 7.

line 8 have “PCellsList” indented the same position as the previous line.
Accepted Article
line 18 change “of cutting” into “of the cutting”

line 19 change “Then, surface” into “Then the surface”

page 8

line 3 change “of oriented” into “of the oriented”

line 4 change “it has n triangle” into “it has n triangles”

line 15 “According to formular (1) and (2),the 3x3 …” into “According to

formulas (1) and (2), the 3x3 …” (leave a blank between the comma “,” and “the”)

line 36 change “, vtkOBBTree” into “, the vtkOBBTree”

line 38 change “box” into “boxes”

line 39 change “with MC algorithm” into “with the MC algorithm”

page 9

line 39 change “2.3 Generation of Osteotomy Groove:” into “2.3 Generation of

Osteotomy Grooves:”

line 49 change “Osteotomy groove” into “An osteotomy groove”

page 10

line 35 change “of long plate” into “of the long plate”

page 11

line 26 change “The procedure of automatic generate Osteotomy pits” into

“Illustration of automatic osteotomy pit generation procedure”

This article is protected by copyright. All rights reserved.

 page 12
Accepted Article
line 30 change “Then, the method of” into “Then, the methods of”

line 39 do not split “Automaticall” and “y” in Figure 7

line 55 change “A designing software” into “A design software”

page 15

line 30 change “The designing” into “The design”

line 33 change “designing process” into “design process”

page 16

line 46 and line 48 change “Many software” into “Much software”

line 47 change “and make it” into “and makes it”

line 47 change “template” into “templates”

line 51 change “in template designing process” into “in the template design
process”

page 17

line 6 change “designing” into “design”

line 11 change “This software allows auto generation algorithm which helps to
avoid tedious

modeling process” into “This software allows the auto generation algorithm which
helps to avoid a tedious modeling process”

line 16 change “basing” into “based”

line 20 change “simpler designing process” into “a simpler design process”

This article is protected by copyright. All rights reserved.

 line 22 change “for future” into “in the future”
Accepted Article
Our responses:

We have carefully corrected all of the grammatical errors in the article as you
suggested.

# Reviewer 2

1. The design process of the templates is emphasized in this paper and the structure
of the cutting guide has been shown clearly in Figure 5. However, the structure of the
connection guide is not very clear. More details and a similar figure should be provided.

Our responses:

Thanks for your valuable suggestion. We have added a figure to show the detailed
structure of a connection guide, which is used to connect the main bone and corrected
bone together after the osteotomy.

Figure 7 Connection guide

2. The information about the oriented bounding box is not clear enough. More
details are needed such as how to determine the half-length and center of the bounding
box.

Our responses:

This article is protected by copyright. All rights reserved.

 Half-length and midpoint coordinates are the key parameters reflecting the
characteristics of the oriented bounding box. These parameters can be calculated by
Accepted Article
projecting all points on the polyhedral convex hull into the unit vector of the directional

bounding box. The half-length of the bounding could be expressed as equation

(4):

= (4)

Where and represent the maximum length and minimum length.

And the center of the bounding box is shown in equation (5), where indicates the
unit vector.

=∑ (5)

3. The authors have compared EasyTemplate with some other softwares, proving
its reliability and efficiency of their algorithms. Although the modeling process of
EasyTemplate has already been discussed, the design process using other softwares
should also be briefly described.

Our responses:

To make the comparison result more convincing, we have added a brief description
regarding the design of surgical templates using traditional softwares as follows:

The design process of surgical templates using traditional softwares, such as

Geomagic Studio and 3D-matic, is complicated. For example, to obtain a cutting guide,
firstly, the surface extraction and offsetting functions are applied to build the initial
template. Then, the appropriate reference planes are needed to stretch the convex hulls
which are necessary to generate osteotomy grooves. Finally, the fixed holes and some
other auxiliary structures are obtained using the functions of surface extraction,
offsetting and Boolean operations.

4. The authors should also add a reference to their software for dental splint design
for orthognathic surgery and if it could be combined with their AR navigation system

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 for intraoperative implant placement:

Chen X, et al. Development of a computer-aided design software for dental splint in

Accepted Article
orthognathic surgery. Scientific reports. 2016 Dec 14;6:38867.

Chen X, et al. Development of a surgical navigation system based on augmented reality

using an optical see-through head-mounted display. Journal of biomedical informatics.
2015 Jun 1;55:124-31.

Our responses:

We have cited these two papers in the revised version.

# Reviewer 3

1. Very good paper as description. There is no evaluation of accuracy after

osteotomy, perhaps comparing the results with other templates. You should include the
number of patients where the new software has been applied. I'm wondering whether it
is commercially available.

Our responses:

Thanks for your suggestion. The purpose of this study is to save template design
time instead of accuracy improvement. Actually, there is no significant difference in
terms of accuracy between our surgical templates and traditional ones since the design
structures of ours are similar to others. According to the results reported in mandibular
angle osteotomy, the mean and maximal deviations between the simulated contour and
post-operative mandibular contour are around 1mm and 2mm respectively [1].

In the revised version, we also mentioned that 5 clinical cases have been
successfully conducted using EasyTemplate. We are sorry that the software is not
commercially available yet, however, the CFDA（China Food and Drug Administration）
certification procedure is underway. And we hope it can be approved soon, and then the
software can be commercialized.

[1] Ye N, Long H, Zhu S, Yang Y, Lai W, Hu J. (2015). The accuracy of computer

image-guided template for mandibular angle ostectomy. Aesthetic Plastic Surgery,
39(1), 117-123.

This article is protected by copyright. All rights reserved.

 # Reviewer 4

1. Gladly I received this manuscript for revision since judging by its title it could
Accepted Article
be an interesting work. However, before an actual revision can be done and
recommendations be made regarding improvements and the approval, the manuscript
needs to be rewritten and the language needs to be significantly improved, i.e. by proof
reading of a native speaker. In its current form the lack of structure and language errors
massively impair the comprehensibility and of the manuscript. Only afterwards can
recommendations regarding the manuscript’s contents be made.

Our responses:

We have carefully corrected the language errors in the article and it has been
proofread by a native English speaker.

This article is protected by copyright. All rights reserved.