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Du X, Zhou Y, Schümperlin D, Laganenka L, Lee SS, Blugan G, Hardt WD, Persson C, Ferguson SJ. Fabrication and characterization of sodium alginate-silicon nitride-PVA composite biomaterials with damping properties. J Mech Behav Biomed Mater 2024; 155:106579. [PMID: 38749266 DOI: 10.1016/j.jmbbm.2024.106579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 03/22/2024] [Accepted: 05/08/2024] [Indexed: 05/28/2024]
Abstract
Silicon nitride is utilized clinically as a bioceramic for spinal fusion cages, owing to its high strength, osteoconductivity, and antibacterial effects. Nevertheless, silicon nitride exhibits suboptimal damping properties, a critical factor in mitigating traumatic bone injuries and fractures. In fact, there is a scarcity of spinal implants that simultaneously demonstrate proficient damping performance and support osteogenesis. In our study, we fabricated a novel sodium alginate-silicon nitride/poly(vinyl alcohol) (SA-SiN/PVA) composite scaffold, enabling enhanced energy absorption and rapid elastic recovery under quasi-static and impact loading scenarios. Furthermore, the study demonstrated that the incorporation of physical and chemical cross-linking significantly improved stiffness and recoverable energy dissipation. Concerning the interaction between cells and materials, our findings suggest that the addition of silicon nitride stimulated osteogenic differentiation while inhibiting Staphylococcus aureus growth. Collectively, the amalgamation of ceramics and tough hydrogels facilitates the development of advanced composites for spinal implants, manifesting superior damping, osteogenic potential, and antibacterial properties. This approach holds broader implications for applications in bone tissue engineering.
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Affiliation(s)
- Xiaoyu Du
- Institute for Biomechanics, ETH Zurich, Zurich, Switzerland.
| | - Yijun Zhou
- Division of Biomedical Engineering, Department of Materials Science and Engineering, Uppsala University, Uppsala, Sweden
| | | | - Leanid Laganenka
- Institute of Microbiology, Department of Biology, ETH Zurich, Zurich, Switzerland
| | - Seunghun S Lee
- Institute for Biomechanics, ETH Zurich, Zurich, Switzerland; Department of Biomedical Engineering, Dongguk University-Seoul, Seoul, South Korea
| | - Gurdial Blugan
- Laboratory for High Performance Ceramics, Empa, Swiss Federal Laboratories for Materials Science and Technology, Dubendorf, Switzerland
| | - Wolf-Dietrich Hardt
- Institute of Microbiology, Department of Biology, ETH Zurich, Zurich, Switzerland
| | - Cecilia Persson
- Division of Biomedical Engineering, Department of Materials Science and Engineering, Uppsala University, Uppsala, Sweden
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2
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He L. Biomaterials for Regenerative Cranioplasty: Current State of Clinical Application and Future Challenges. J Funct Biomater 2024; 15:84. [PMID: 38667541 PMCID: PMC11050949 DOI: 10.3390/jfb15040084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2024] [Revised: 03/18/2024] [Accepted: 03/26/2024] [Indexed: 04/28/2024] Open
Abstract
Acquired cranial defects are a prevalent condition in neurosurgery and call for cranioplasty, where the missing or defective cranium is replaced by an implant. Nevertheless, the biomaterials in current clinical applications are hardly exempt from long-term safety and comfort concerns. An appealing solution is regenerative cranioplasty, where biomaterials with/without cells and bioactive molecules are applied to induce the regeneration of the cranium and ultimately repair the cranial defects. This review examines the current state of research, development, and translational application of regenerative cranioplasty biomaterials and discusses the efforts required in future research. The first section briefly introduced the regenerative capacity of the cranium, including the spontaneous bone regeneration bioactivities and the presence of pluripotent skeletal stem cells in the cranial suture. Then, three major types of biomaterials for regenerative cranioplasty, namely the calcium phosphate/titanium (CaP/Ti) composites, mineralised collagen, and 3D-printed polycaprolactone (PCL) composites, are reviewed for their composition, material properties, and findings from clinical trials. The third part discusses perspectives on future research and development of regenerative cranioplasty biomaterials, with a considerable portion based on issues identified in clinical trials. This review aims to facilitate the development of biomaterials that ultimately contribute to a safer and more effective healing of cranial defects.
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Affiliation(s)
- Lizhe He
- Key Laboratory of 3D Printing Process and Equipment of Zhejiang Province, School of Mechanical Engineering, Zhejiang University, Hangzhou 310028, China
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3
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Li H, Hao J, Liu X. Research progress and perspective of metallic implant biomaterials for craniomaxillofacial surgeries. Biomater Sci 2024; 12:252-269. [PMID: 38170634 DOI: 10.1039/d2bm01414a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
Craniomaxillofacial bone serves a variety of functions. However, the increasing number of cases of craniomaxillofacial bone injury and the use of selective rare implants make the treatment difficult, and the cure rate is low. If such a bone injury is not properly treated, it can lead to a slew of complications that can seriously disrupt a patient's daily life. For example, premature closure of cranial sutures or skull fractures can lead to increased intracranial pressure, which can lead to headaches, vomiting, and even brain hernia. At present, implant placement is one of the most common approaches to repair craniomaxillofacial bone injury or abnormal closure, especially with biomedical metallic implants. This review analyzes the research progress in the design and development of degradable and non-degradable metallic implants in craniomaxillofacial surgery. The mechanical properties, corrosion behaviours, as well as in vitro and in vivo performances of these materials are summarized. The challenges and future research directions of metallic biomaterials used in craniomaxillofacial surgery are also identified.
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Affiliation(s)
- Huafang Li
- School of Materials Science and Engineering, University of Science and Technology Beijing, Beijing, 100083, China.
| | - Jiaqi Hao
- School of Materials Science and Engineering, University of Science and Technology Beijing, Beijing, 100083, China.
| | - Xiwei Liu
- Lepu Medical Technology Co., Ltd, Beijing 102200, China
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4
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Liu Y, Yi N, Davies R, McCutchion P, Ghita O. Powder Bed Fusion Versus Material Extrusion: A Comparative Case Study on Polyether-Ether-Ketone Cranial Implants. 3D PRINTING AND ADDITIVE MANUFACTURING 2023; 10:941-954. [PMID: 37886420 PMCID: PMC10599438 DOI: 10.1089/3dp.2021.0300] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/28/2023]
Abstract
As the choice of additive manufacturing (AM) technologies is becoming wider with reliable processes and a wider range of materials, the selection of the right technology to fabricate a certain product is becoming increasingly difficult from a technical and cost perspective. In this study polyether-ether-ketone cranial implants were manufactured by two AM techniques: powder bed fusion (PBF) and fused filament fabrication (FFF) and their dimensional accuracy, compression performance, and drop tower impact behavior were evaluated and compared. The results showed that both types of specimens differed from the original computer-aided design; although the origin of the deviation was different, the PBF samples were slightly inaccurate owing to the printing process where the accuracy of the FFF samples was influenced by postprocessing and removal of the scaffolds. The cranial implants fabricated using the FFF method absorbed more energy during the compression and impact tests in comparison with the PBF process. The failure mechanisms revealed that FFF samples have a higher ability to deform and a more consistent failure mechanisms, with the damage localized around the puncture head region. The brittle nature of the PBF samples, a feature observed with other polymers as well, led to complete failure of the cranial implants into several pieces.
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Affiliation(s)
- Yaan Liu
- Engineering, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, United Kingdom
| | - Nan Yi
- Engineering, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, United Kingdom
| | - Richard Davies
- Engineering, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, United Kingdom
| | - Paul McCutchion
- Engineering, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, United Kingdom
| | - Oana Ghita
- Engineering, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, United Kingdom
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5
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Liu J, He H, Tang L, Peng Y, Mu J, Lan L, Chen C, Dong Z, Cheng L. Comparison of the effect of bone induction with different exercise modes in mice. Biomed Mater Eng 2022; 33:365-375. [PMID: 35180103 DOI: 10.3233/bme-211341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUD The calcium phosphate biomaterials have excellent bone inductivity, exercise can promote the bone formation of biomaterials in animals, but it is not clear which exercise mode is better. OBJECTIVE To explore the effect of different exercise modes on osteoinduction by calcium phosphate-based biomaterials which were implanted in mice. METHOD The collagen-thermosensitive hydrogel-calcium phosphate (CTC) composite was prepared and transplanted in the thigh muscle of mice, then all mice were divided randomly into four groups (n = 10): the uphill running group, the downhill running group, the swimming group and the control group (conventional breeding). Ten weeks later, the samples were harvested, fixed, decalcified, embedded in paraffin and stained with hematoxylin and eosin (H&E), and then the osteoinduction phenomenon was observed and compared through digital slice scanning system. The area percentage of new bone-related tissues and the number of osteocytes and chondrocytes were counted and calculated. Lastly, the immunohistochemistry of type I collagen (ColI) and osteopontin (OPN) was performed to identify the new bone tissues. RESULTS The area percentage of new bone-related tissues and the number of osteocytes and chondrocytes were positively correlated; ordering from most to least of each group were as followings: the uphill running group > the swimming group > the downhill running group > the control group. The immunostaining of ColI and OPN results showed that both of the two proteins were identified in the new bone tissues, indicating that the CTC composite could induce ectopic bone formation in mice, especially training for uphill running and swimming. CONCLUSION Our results show that uphill running or swimming is a form of exercise that is beneficial to osteogenesis. According to this, we propose treatment with artificial bone transplantation to patients who suffer from bone defects. Patients should do moderate exercise, such as running uphill on the treadmill or swimming.
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Affiliation(s)
- Juan Liu
- School of Basic Medicine, Chengdu University, Chengdu, China
| | - Hongyan He
- School of Basic Medicine, Chengdu University, Chengdu, China
| | - Lu Tang
- Affiliated Hospital and Clinical College, Chengdu University, Chengdu, China
| | - Yu Peng
- School of Basic Medicine, Chengdu University, Chengdu, China
| | - Junyu Mu
- School of Basic Medicine, Chengdu University, Chengdu, China
| | - Liang Lan
- School of Basic Medicine, Chengdu University, Chengdu, China
| | - Cheng Chen
- School of Basic Medicine, Chengdu University, Chengdu, China
| | - Zhihong Dong
- School of Mechanical Engineering, Chengdu University, Chengdu, China
| | - Lijia Cheng
- School of Basic Medicine, Chengdu University, Chengdu, China
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Sharma N, Aghlmandi S, Dalcanale F, Seiler D, Zeilhofer HF, Honigmann P, Thieringer FM. Quantitative Assessment of Point-of-Care 3D-Printed Patient-Specific Polyetheretherketone (PEEK) Cranial Implants. Int J Mol Sci 2021; 22:8521. [PMID: 34445228 PMCID: PMC8395180 DOI: 10.3390/ijms22168521] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Revised: 07/26/2021] [Accepted: 08/05/2021] [Indexed: 12/18/2022] Open
Abstract
Recent advancements in medical imaging, virtual surgical planning (VSP), and three-dimensional (3D) printing have potentially changed how today's craniomaxillofacial surgeons use patient information for customized treatments. Over the years, polyetheretherketone (PEEK) has emerged as the biomaterial of choice to reconstruct craniofacial defects. With advancements in additive manufacturing (AM) systems, prospects for the point-of-care (POC) 3D printing of PEEK patient-specific implants (PSIs) have emerged. Consequently, investigating the clinical reliability of POC-manufactured PEEK implants has become a necessary endeavor. Therefore, this paper aims to provide a quantitative assessment of POC-manufactured, 3D-printed PEEK PSIs for cranial reconstruction through characterization of the geometrical, morphological, and biomechanical aspects of the in-hospital 3D-printed PEEK cranial implants. The study results revealed that the printed customized cranial implants had high dimensional accuracy and repeatability, displaying clinically acceptable morphologic similarity concerning fit and contours continuity. From a biomechanical standpoint, it was noticed that the tested implants had variable peak load values with discrete fracture patterns and failed at a mean (SD) peak load of 798.38 ± 211.45 N. In conclusion, the results of this preclinical study are in line with cranial implant expectations; however, specific attributes have scope for further improvements.
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Affiliation(s)
- Neha Sharma
- Clinic of Oral and Cranio-Maxillofacial Surgery, University Hospital Basel, CH-4031 Basel, Switzerland; (N.S.); (H.-F.Z.)
- Medical Additive Manufacturing Research Group (Swiss MAM), Department of Biomedical Engineering, University of Basel, CH-4123 Allschwil, Switzerland;
| | - Soheila Aghlmandi
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital Basel, CH-4031 Basel, Switzerland;
| | - Federico Dalcanale
- Institute for Medical Engineering and Medical Informatics, University of Applied Sciences and Arts North-Western Switzerland, CH-4132 Muttenz, Switzerland; (F.D.); (D.S.)
| | - Daniel Seiler
- Institute for Medical Engineering and Medical Informatics, University of Applied Sciences and Arts North-Western Switzerland, CH-4132 Muttenz, Switzerland; (F.D.); (D.S.)
| | - Hans-Florian Zeilhofer
- Clinic of Oral and Cranio-Maxillofacial Surgery, University Hospital Basel, CH-4031 Basel, Switzerland; (N.S.); (H.-F.Z.)
| | - Philipp Honigmann
- Medical Additive Manufacturing Research Group (Swiss MAM), Department of Biomedical Engineering, University of Basel, CH-4123 Allschwil, Switzerland;
- Hand Surgery, Cantonal Hospital Baselland, CH-4410 Liestal, Switzerland
- Amsterdam UMC, Department of Biomedical Engineering and Physics, University of Amsterdam, Amsterdam Movement Sciences, NL-1105 Amsterdam, The Netherlands
| | - Florian M. Thieringer
- Clinic of Oral and Cranio-Maxillofacial Surgery, University Hospital Basel, CH-4031 Basel, Switzerland; (N.S.); (H.-F.Z.)
- Medical Additive Manufacturing Research Group (Swiss MAM), Department of Biomedical Engineering, University of Basel, CH-4123 Allschwil, Switzerland;
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Chamrad J, Marcián P, Cizek J. Beneficial osseointegration effect of hydroxyapatite coating on cranial implant - FEM investigation. PLoS One 2021; 16:e0254837. [PMID: 34280226 PMCID: PMC8289038 DOI: 10.1371/journal.pone.0254837] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Accepted: 07/04/2021] [Indexed: 11/18/2022] Open
Abstract
A firm connection of the bone-implant-fixation system is of utmost importance for patients with cranial defects. In order to improve the connection reliability, the current research focuses on finding the optimal fixation method, as well as selection of the implant manufacturing methods and the used materials. For the latter, implementation of bioactive materials such as hydroxyapatite or other calcium phosphates has also been considered in the literature. The aim of this study was to investigate the effect of gradual osseointegration on the biomechanical performance of cranial Ti6Al4V implants with a deposited HA coating as the osseointegration agent. This effect was assessed by two different computational approaches using finite element method (FEM) modeling. The values of key input parameters necessary for FEM were obtained from experimental plasma spray deposition of HA layers onto Ti6Al4V samples. Immediately upon implantation, the HA layer at the bone-implant contact area brought only a slight decrease in the values of von Mises stress in the implant and the micro-screws when compared to a non-coated counterpart; importantly, this was without any negative trade-off in other important characteristics. The major benefit of the HA coatings was manifested upon the modeled osseointegration: the results of both approaches confirmed a significant reduction of investigated parameters such as the total implant displacements (reduced from 0.050 mm to 0.012 mm and 0.002 mm while using Approach I and II, respectively) and stresses (reduced from 52 MPa to 10 MPa and 1 MPa) in the implanted components in comparison to non-coated variant. This is a very promising result for potential use of thermally sprayed HA coatings for cranial implants.
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Affiliation(s)
- Jakub Chamrad
- Department of Solid Mechanics, Mechatronics and Biomechanics, Brno University of Technology, Brno, Czech Republic
- * E-mail:
| | - Petr Marcián
- Department of Solid Mechanics, Mechatronics and Biomechanics, Brno University of Technology, Brno, Czech Republic
| | - Jan Cizek
- Institute of Plasma Physics of the Czech Academy of Sciences, Prague, Czech Republic
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8
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Lewin S, Kihlström Burenstam Linder L, Birgersson U, Gallinetti S, Åberg J, Engqvist H, Persson C, Öhman-Mägi C. Monetite-based composite cranial implants demonstrate long-term clinical volumetric balance by concomitant bone formation and degradation. Acta Biomater 2021; 128:502-513. [PMID: 33857696 DOI: 10.1016/j.actbio.2021.04.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 04/01/2021] [Accepted: 04/07/2021] [Indexed: 01/14/2023]
Abstract
The use of calcium phosphates (CaPs) as synthetic bone substitutes should ideally result in a volumetric balance with concomitant bone formation and degradation. Clinical data on such properties is nevertheless lacking, especially for monetite-based CaPs. However, a monetite-based composite implant has recently shown promising cranial reconstructions, with both CaP degradation and bone formation. In this study, the volumetric change at the implant site was quantified longitudinally by clinical computed tomography (CT). The retrospective CT datasets had been acquired postoperatively (n = 10), in 1-year (n = 9) and 3-year (n = 5) follow-ups. In the 1-year follow-up, the total volumetric change at the implant site was -8 ± 8%. A volumetric increase (bone formation) was found in the implant-bone interface, and a volumetric decrease was observed in the central region (CaP degradation). In the subjects with 2- or 3-year follow-ups, the rate of volumetric decrease slowed down or plateaued. The reported degradation rate is lower than previous clinical studies on monetite, likely due to the presence of pyrophosphate in the monetite-based CaP-formulation. A 31-months retrieval specimen analysis demonstrated that parts of the CaP had been remodeled into bone. The CaP phase composition remained stable, with 6% transformation into hydroxyapatite. In conclusion, this study demonstrates successful bone-bonding between the CaP-material and the recipient bone, as well as a long-term volumetric balance in cranial defects repaired with the monetite-based composite implant, which motivates further clinical use. The developed methods could be used in future studies for correlating spatiotemporal information regarding bone regeneration and CaP degradation to e.g. patient demographics. STATEMENT OF SIGNIFICANCE: In bone defect reconstructions, the use of calcium phosphate (CaP) bioceramics ideally results in a volumetric balance between bone formation and CaP degradation. Clinical data on the volumetric balance is nevertheless lacking, especially for monetite-based CaPs. Here, this concept is investigated for a composite cranial implant. The implant volumes were quantified from clinical CT-data: postoperatively, one year and three years postoperatively. In total, -8 ± 8% (n = 9) volumetric change was observed after one year. But the change plateaued, with only 2% additional decrease at the 3-year follow-up (n = 5), indicating a lower CaP degradation rate. Osseointegration was seen at the bone-implant interface, with a 9 ± 7% volumetric change after one year. This study presented the first quantitative spatiotemporal CT analysis of monetite-based CaPs.
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Affiliation(s)
- Susanne Lewin
- Department of Materials Science and Engineering, Uppsala University, Uppsala, Sweden.
| | - Lars Kihlström Burenstam Linder
- Department of Neurosurgery, Clinical Neurosciences, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
| | - Ulrik Birgersson
- Department of Neurosurgery, Clinical Neurosciences, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden; Department of Clinical Science, Intervention and Technology, Division of Imaging and Technology, Karolinska Institutet, Huddinge, Sweden; OssDsign, Uppsala, Sweden
| | - Sara Gallinetti
- Department of Materials Science and Engineering, Uppsala University, Uppsala, Sweden; OssDsign, Uppsala, Sweden
| | - Jonas Åberg
- Department of Materials Science and Engineering, Uppsala University, Uppsala, Sweden; OssDsign, Uppsala, Sweden
| | - Håkan Engqvist
- Department of Materials Science and Engineering, Uppsala University, Uppsala, Sweden
| | - Cecilia Persson
- Department of Materials Science and Engineering, Uppsala University, Uppsala, Sweden
| | - Caroline Öhman-Mägi
- Department of Materials Science and Engineering, Uppsala University, Uppsala, Sweden
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Lewin S, Fleps I, Neuhaus D, Öhman-Mägi C, Ferguson SJ, Persson C, Helgason B. Implicit and explicit finite element models predict the mechanical response of calcium phosphate-titanium cranial implants. J Mech Behav Biomed Mater 2020; 112:104085. [PMID: 33080431 DOI: 10.1016/j.jmbbm.2020.104085] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 08/14/2020] [Accepted: 09/08/2020] [Indexed: 11/29/2022]
Abstract
The structural integrity of cranial implants is of great clinical importance, as they aim to provide cerebral protection after neurosurgery or trauma. With the increased use of patient-specific implants, the mechanical response of each implant cannot be characterized experimentally in a practical way. However, computational models provide an excellent possibility for efficiently predicting the mechanical response of patient-specific implants. This study developed finite element models (FEMs) of titanium-reinforced calcium phosphate (CaP-Ti) implants. The models were validated with previously obtained experimental data for two different CaP-Ti implant designs (D1 and D2), in which generically shaped implant specimens were loaded in compression at either quasi-static (1 mm/min) or impact (5 kg, 1.52 m/s) loading rates. The FEMs showed agreement with experimental data in the force-displacement response for both implant designs. The implicit FEMs predicted the peak load with an underestimation for D1 (9%) and an overestimation for D2 (11%). Furthermore, the shape of the force-displacement curves were well predicted. In the explicit FEMs, the first part of the force-displacement response showed 5% difference for D1 and 2% difference for D2, with respect to the experimentally derived peak loads. The explicit FEMs efficiently predicted the maximum displacements with 1% and 4% difference for D1 and D2, respectively. Compared to the CaP-Ti implant, an average parietal cranial bone FEM showed a stiffer response, greater energy absorption and less deformation under the same impact conditions. The framework developed for modelling the CaP-Ti implants has a potential for modelling CaP materials in other composite implants in future studies since it only used literature based input and matched boundary conditions. Furthermore, the developed FEMs make an important contribution to future evaluations of patient-specific CaP-Ti cranial implant designs in various loading scenarios.
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Affiliation(s)
- Susanne Lewin
- Department of Materials Science and Engineering, Uppsala University, Uppsala, Sweden.
| | - Ingmar Fleps
- Institute for Biomechanics, ETH Zurich, Zurich, Switzerland
| | | | - Caroline Öhman-Mägi
- Department of Materials Science and Engineering, Uppsala University, Uppsala, Sweden
| | | | - Cecilia Persson
- Department of Materials Science and Engineering, Uppsala University, Uppsala, Sweden
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