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Geroski T, Kovačević V, Nikolić D, Filipović N. From imaging to personalized 3D printed molds in cranioplasty. Med Eng Phys 2024; 130:104215. [PMID: 39160013 DOI: 10.1016/j.medengphy.2024.104215] [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: 02/24/2024] [Revised: 06/30/2024] [Accepted: 07/31/2024] [Indexed: 08/21/2024]
Abstract
Cranioplasty is the surgical repair of a bone defect in the skull resulting from a previous operation or injury, which involves lifting the scalp and restoring the contour of the skull with a graft made from material that is reconstructed from scans of the patient's own skull. The paper introduces a 3D printing technology in creating molds, which are filled with polymethyl methacrylate (PMMA) to reconstruct the missing bone part of the skull. The procedure included several steps to create a 3D model in an STL format, conversion into a G-code which is further used to produce the mold itself using a 3D printer. The paper presents our initial experience with 5 patients who undergone cranioplasty utilizing 3D printed molds. Making a patient-specific model is a very complex process and consists of several steps. The creation of a patient-specific 3D model loading of DICOM images obtained by CT scanning, followed by thresholding-based segmentation and generation of a precise 3D model of part of the patient's skull. Next step is creating the G-code models for 3D printing, after which the actual models are printed using Fused Deposition Modeling printer and PLA material. All surgeries showed good match of the missing bone part and part created using 3D printed mold, without additional steps in refinement. In such a way, 3D printing technology helps in creating personalized and visually appealing bone replacements, at a low cost of the final product.
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Affiliation(s)
- Tijana Geroski
- Faculty of Engineering, University of Kragujevac, Sestre Janjić 6, Kragujevac 34000, Serbia; Bioengineering Research and Development Centre (BioIRC), Prvoslava Stojanovića 6, Kragujevac 34000, Serbia.
| | - Vojin Kovačević
- Center for Neurosurgery, Clinical Centre Kragujevac, Zmaj Jovina 30, Kragujevac 34000, Serbia; Faculty of Medical Sciences, Department of Surgery, University of Kragujevac, Svetozara Markovića 69, Kragujevac 34000, Serbia
| | - Dalibor Nikolić
- Bioengineering Research and Development Centre (BioIRC), Prvoslava Stojanovića 6, Kragujevac 34000, Serbia; Institute for Information Technologies, Jovana Cvijića bb, Kragujevac 34000, Serbia
| | - Nenad Filipović
- Faculty of Engineering, University of Kragujevac, Sestre Janjić 6, Kragujevac 34000, Serbia; Bioengineering Research and Development Centre (BioIRC), Prvoslava Stojanovića 6, Kragujevac 34000, Serbia
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McGinnity-Hamze G, Hatamleh MM. Is Polyetheretherketone an Effective Alloplastic Material in Comparison to Titanium in Calvarial Reconstruction. J Craniofac Surg 2024; 35:1517-1522. [PMID: 38814081 DOI: 10.1097/scs.0000000000010335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 05/01/2024] [Indexed: 05/31/2024] Open
Abstract
INTRODUCTION AND AIM Polyetheretherketone (PEEK) and titanium (Ti) cranioplasty implants ideal outcomes are good esthetics, long-term stability, and protection of the fragile brain tissue. However, it is unclear whether PEEK implants can offer an equal alternative to Ti implants. This work aimed to critically review papers and case series published on both Ti and PEEK Cranioplasty regarding complications, clinical outcomes, ease of use, esthetics, manufacture and availability, cost and time-saving factors, postoperative quality of life (QOL), as well as their suitability for the fronto-orbito region reconstruction. METHODS PubMed database was sourced for published literature in the period 2007 to the end of 2023; a further manual search for articles was carried out on the reference lists of each paper. RESULTS A total of 48980 papers were found during the initial search, but only 33 articles met the inclusion criteria. A total of 6023 cranial implants, with 3879 being Ti and 1205 PEEK. Titanium was the material of choice in over 64.4% of cases; however, Ti has been in application for many years compared to PEEK. Out of the 33 papers, there was 27 retrospective cohort/analysis/case series and reviews: 1 meta-analysis, 2 systematic reviews and 3 randomized control trials. Four articles commented on the QOL, 15 on esthetics, 7 discussed cost and time-saving without measurable variables, and 7 articles looked explicitly at the complex fronto-orbito region, of which 49% were primary 1-stage surgical reconstructions, 54% were reconstructed with PEEK and 7% Ti (CAD/CAM). CONCLUSION There is no absolute consensus for the preference of either material, however, in the fronto-orbito region, PEEK is the material of choice for ease of use, esthetics, and time-saving. However, there are no long-term studies on PEEK cranioplasty, and fewer in comparison with Ti implants. Further research is required in this field. No reliable or measurable data was found to determine the QOL, esthetics, cost, or time-saving elements.
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Affiliation(s)
- Gráinne McGinnity-Hamze
- Cranio-Maxillofacial Prosthetics Unit, Department of Oral and Maxillofacial Surgery, King's College Hospital NHS Foundation Trust, London, UK
| | - Muhanad M Hatamleh
- Department of Allied Dental Sciences, Faculty of Applied Medical Sciences, Jordan University of Science and Technology, Irbid, Jordan
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Anele C, Balogun S, Ezeaku C, Ajekwu T, Omon H, Ejembi G, Komolafe E. Titanium mesh cranioplasty for cosmetically disfiguring cranio-facial tumours in a resource limited setting. World Neurosurg X 2024; 23:100362. [PMID: 38533234 PMCID: PMC10963312 DOI: 10.1016/j.wnsx.2024.100362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 02/22/2024] [Accepted: 03/01/2024] [Indexed: 03/28/2024] Open
Abstract
Background The aesthetic reconstruction of disfiguring cranio-facial defects after tumour excision can be quite challenging to the neurosurgeon with limited resources. The choice of cranioplasty implant, intraoperative technicalities and the patients' postoperative appearance are critical considerations in management. There are a number of synthetic materials available for cranioplasty, however, the customised implants are not readily available in our practice setup. They are also mostly constructed and contoured after the bony defect has been created or require sophisticated software construction pre-operatively. Methods Eight patients with cranio-facial tumour pathologies who presented to our neurosurgical service, and had titanium mesh cranioplasty for the correction of cosmetically disfiguring cranio-facial tumours. Results There were 6 females, and 2 male patients respectively, with an age range between 28 and 74years. The histological diagnoses were meningioma, frontal squamous cell carcinoma, fibrous dysplasia, frontal mucocoele, cemeto-ossifying fibroma, osteoma, and naso-ethmoidal squamous cell carcinoma. The patient with naso-ethmoidal squamous cell carcinoma had post-operative subgaleal empyema which was amenable to incision and drainage procedure. The patient with a frontal cemento-ossifyng fibroma had a transient immediate post-operative mechanical ptosis, which resolved completely in 3months. All of the total eight patients (100%) had satisfactory cosmetic outlook at a minimum follow up period of 1month post-operatively (Numeric Rating Scale of at least 7/10). One of the patients required a revision surgery on account of implant displacement. Conclusion Cranioplasty is a common reconstructive neurosurgical procedure. It is important to the neurosurgeon for its neuro-protective function, and in the restoration of intra-cranial CSF dynamics. However, the cosmetic outlook appears to be more important to patients in the absence of pain and/or neurological deficits. Titanium mesh reconstruction is commonly used globally, and is becoming the preferred choice in low resource settings.
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Affiliation(s)
- C.O. Anele
- Neurological Surgery Division, Department of Surgery, Obafemi Awolowo University Teaching Hospital Complex, Ile Ife, Osun State, Nigeria
| | - S.A. Balogun
- Neurological Surgery Division, Department of Surgery, Obafemi Awolowo University Teaching Hospital Complex, Ile Ife, Osun State, Nigeria
| | - C.O. Ezeaku
- Neurological Surgery Division, Department of Surgery, Obafemi Awolowo University Teaching Hospital Complex, Ile Ife, Osun State, Nigeria
| | - T.O. Ajekwu
- Neurological Surgery Division, Department of Surgery, Obafemi Awolowo University Teaching Hospital Complex, Ile Ife, Osun State, Nigeria
| | - H.E. Omon
- Neurological Surgery Division, Department of Surgery, Obafemi Awolowo University Teaching Hospital Complex, Ile Ife, Osun State, Nigeria
| | - G.O. Ejembi
- Neurological Surgery Division, Department of Surgery, Obafemi Awolowo University Teaching Hospital Complex, Ile Ife, Osun State, Nigeria
| | - E.O. Komolafe
- Neurological Surgery Division, Department of Surgery, Obafemi Awolowo University Teaching Hospital Complex, Ile Ife, Osun State, Nigeria
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Iratwar S, Roy Chowdhury S, Pisulkar S, Das S, Agarwal A, Bagde A, Paikrao B, Quazi S, Basu B. Comprehensive functional outcome analysis and importance of bone remodelling on personalized cranioplasty treatment using Poly(methyl methacrylate) bone flaps. J Biomater Appl 2024; 38:975-988. [PMID: 38423069 DOI: 10.1177/08853282241235884] [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] [Indexed: 03/02/2024]
Abstract
Cranioplasty involves the surgical reconstruction of cranial defects arising as a result of various factors, including decompressive craniectomy, cranial malformations, and brain injury due to road traffic accidents. Most of the modern decompressive craniectomies (DC) warrant a future cranioplasty surgery within 6-36 months. The conventional process of capturing the defect impression and polymethyl methacrylate (PMMA) flap fabrication results in a misfit or misalignment at the site of implantation. Equally, the intra-operative graft preparation is arduous and can result in a longer surgical time, which may compromise the functional and aesthetic outcomes. As part of a multicentric pilot clinical study, we recently conducted a cohort study on ten human subjects during 2019-2022, following the human ethics committee approvals from the participating institutes. In the current study, an important aspect of measuring the extent of bone remodelling during the time gap between decompressive craniectomy and cranioplasty was successfully evaluated. The sterilised PMMA bone flaps were implanted at the defect area during the cranioplasty surgery using titanium mini plates and screws. The mean surgery time was 90 ± 20 min, comparable to the other clinical studies on cranioplasty. No signs of intra-operative and post-operative complications, such as cerebrospinal fluid leakage, hematoma, or local and systemic infection, were clinically recorded. Importantly, aesthetic outcomes were excellent for all the patients, except in a few clinical cases, wherein the PMMA bone flap was to be carefully customized due to the remodelling of the native skull bone. The extent of physiological remodelling was evaluated by superimposing the pre-operative and post-operative CT scan data after converting the defect morphology into a 3D model. This study further establishes the safety and efficacy of a technologically better approach to fabricate patient-specific acrylic bone flaps with improved surgical outcomes. More importantly, the study outcome further demonstrates the strategy to address bone remodelling during the patient-specific implant design.
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Affiliation(s)
- Sandeep Iratwar
- Department of Neurosurgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Wardha, India
| | | | - Shweta Pisulkar
- Department of Prosthodontics, Crown & Bridge, Sharad Pawar Dental College, Datta Meghe Institute of Higher Education & Research, Wardha, India
| | - Soumitra Das
- Material Research Centre, Indian Institute of Science, Bangalore, India
| | - Akhilesh Agarwal
- Bio-Innovation cell, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Wardha, India
| | - Ashutosh Bagde
- Faculty of Engineering Technology, Biomedical Engineering/and Research Scientist, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Wardha, India
| | - Balaji Paikrao
- Department of Mechanical Engineering, Visvesvaraya National Institute of Technology, Nagpur, India
| | - Syed Quazi
- Department of Community Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Wardha, India
| | - Bikramjit Basu
- Material Research Centre, Indian Institute of Science, Bangalore, India
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Çakın H, Yildirim Y, Ozsoy U. Demonstration of Cosmetic Improvement After Cranioplasty Using a Personalized 3D-Printed Mold for Creating Polymethylmethacrylate Implants With a Simplified Process. World Neurosurg 2024; 182:100-104. [PMID: 37995992 DOI: 10.1016/j.wneu.2023.11.076] [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: 10/16/2023] [Accepted: 11/16/2023] [Indexed: 11/25/2023]
Abstract
BACKGROUND Although personalized polymethylmethacrylate (PMMA) implant production molds for cranioplasty are costly and time-consuming, they allow for better-quality implants. The researchers quantitatively tested the contribution of simplified, low-cost techniques to cosmetic improvement. METHODS PMMA prosthesis was placed in a 25-year-old male patient due to osteolysis in the bone flap removed after decompression surgery. A single-sided mold was three-dimensional (3D) printed before the surgery, and the prosthesis was produced during the surgery. In addition, the change in cranial asymmetry was evaluated using a 3D surface scanner after surgery. RESULTS The mold took half an hour to design and 5 hours to print. The mold cost about 2 dollars. The root means square (RMS) value measured to determine cranial asymmetry decreased from 5.4 mm to 2.8 mm postoperatively. The patient stated that he was pretty satisfied with the cosmetic result. CONCLUSIONS Simple design techniques developed can offer low-cost, fast-design alternative solutions with satisfactory cosmetic results for low-income countries and patients.
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Affiliation(s)
- Hakan Çakın
- Department of Brain and Neurological Surgery, Akdeniz University, Faculty of Medicine, Antalya, Turkey
| | - Yilmaz Yildirim
- Department of Anatomy, Akdeniz University, Faculty of Medicine, Antalya, Turkey
| | - Umut Ozsoy
- Department of Anatomy, Akdeniz University, Faculty of Medicine, Antalya, Turkey.
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Zhang J, Zhuang Y, Sheng R, Tomás H, Rodrigues J, Yuan G, Wang X, Lin K. Smart stimuli-responsive strategies for titanium implant functionalization in bone regeneration and therapeutics. MATERIALS HORIZONS 2024; 11:12-36. [PMID: 37818593 DOI: 10.1039/d3mh01260c] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/12/2023]
Abstract
With the increasing and aging of global population, there is a dramatic rise in the demand for implants or substitutes to rehabilitate bone-related disorders which can considerably decrease quality of life and even endanger lives. Though titanium and its alloys have been applied as the mainstream material to fabricate implants for load-bearing bone defect restoration or temporary internal fixation devices for bone fractures, it is far from rare to encounter failed cases in clinical practice, particularly with pathological factors involved. In recent years, smart stimuli-responsive (SSR) strategies have been conducted to functionalize titanium implants to improve bone regeneration in pathological conditions, such as bacterial infection, chronic inflammation, tumor and diabetes mellitus, etc. SSR implants can exert on-demand therapeutic and/or pro-regenerative effects in response to externally applied stimuli (such as photostimulation, magnetic field, electrical and ultrasound stimulation) or internal pathology-related microenvironment changes (such as decreased pH value, specific enzyme secreted by bacterial and excessive production of reactive oxygen species). This review summarizes recent progress on the material design and fabrication, responsive mechanisms, and in vitro and in vivo evaluations for versatile clinical applications of SSR titanium implants. In addition, currently existing limitations and challenges and further prospective directions of these strategies are also discussed.
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Affiliation(s)
- Jinkai Zhang
- Department of Oral & Cranio-Maxillofacial Surgery, Shanghai Ninth People's Hospital, College of Stomatology, Shanghai Jiao Tong University School of Medicine; National Clinical Research Center for Oral Diseases; Shanghai Key Laboratory of Stomatology & Shanghai Research Institute of Stomatology; Research Unit of Oral and Maxillofacial Regenerative Medicine, Chinese Academy of Medical Sciences, Shanghai 200011, China.
| | - Yu Zhuang
- Department of Oral & Cranio-Maxillofacial Surgery, Shanghai Ninth People's Hospital, College of Stomatology, Shanghai Jiao Tong University School of Medicine; National Clinical Research Center for Oral Diseases; Shanghai Key Laboratory of Stomatology & Shanghai Research Institute of Stomatology; Research Unit of Oral and Maxillofacial Regenerative Medicine, Chinese Academy of Medical Sciences, Shanghai 200011, China.
| | - Ruilong Sheng
- CQM-Centro de Quimica da Madeira, Universidade da Madeira, Campus da Penteada, 9020-105, Funchal, Madeira, Portugal.
| | - Helena Tomás
- CQM-Centro de Quimica da Madeira, Universidade da Madeira, Campus da Penteada, 9020-105, Funchal, Madeira, Portugal.
| | - João Rodrigues
- CQM-Centro de Quimica da Madeira, Universidade da Madeira, Campus da Penteada, 9020-105, Funchal, Madeira, Portugal.
| | - Guangyin Yuan
- School of Materials Science and Engineering, Shanghai Jiao Tong University, Shanghai 200240, China.
| | - Xudong Wang
- Department of Oral & Cranio-Maxillofacial Surgery, Shanghai Ninth People's Hospital, College of Stomatology, Shanghai Jiao Tong University School of Medicine; National Clinical Research Center for Oral Diseases; Shanghai Key Laboratory of Stomatology & Shanghai Research Institute of Stomatology; Research Unit of Oral and Maxillofacial Regenerative Medicine, Chinese Academy of Medical Sciences, Shanghai 200011, China.
| | - Kaili Lin
- Department of Oral & Cranio-Maxillofacial Surgery, Shanghai Ninth People's Hospital, College of Stomatology, Shanghai Jiao Tong University School of Medicine; National Clinical Research Center for Oral Diseases; Shanghai Key Laboratory of Stomatology & Shanghai Research Institute of Stomatology; Research Unit of Oral and Maxillofacial Regenerative Medicine, Chinese Academy of Medical Sciences, Shanghai 200011, China.
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Kim YC, Lee SJ, Woo SH, Yang S, Choi JW. A Comparative Study of Titanium Cranioplasty for Extensive Calvarial Bone Defects: Three-Dimensionally Printed Titanium Implants Versus Premolded Titanium Mesh. Ann Plast Surg 2023; 91:446-455. [PMID: 37713150 DOI: 10.1097/sap.0000000000003663] [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: 09/16/2023]
Abstract
OBJECTIVE This study compared the complications and symmetry outcomes between 3-dimensionally printed titanium implants and premolded titanium mesh in patients with extensive calvarial bone defects. METHODS This retrospective analysis included patients with calvarial defects >50 cm2 undergoing cranioplasty who received either a 3-dimensionally printed titanium implant manufactured by selective laser melting techniques (N = 12) or a premolded titanium mesh customized onto a 3-dimensionally printed skull template (N = 23). Complications including intracranial infection, hardware extrusion, wound dehiscence, and cerebrospinal fluid leaks were investigated. Predictive factors affecting complications were investigated to identify the odds ratios in univariate and multivariate analyses. The symmetry was assessed by calculating the root mean square deviation, which showed the morphological deviation of the selected area compared with the mirrored image of the contralateral region. RESULTS The overall complication rate was 26.1% (6/23 patients) in the premolded titanium group and 16.7% (2/12 patients) in the 3-dimensionally printed group. The reoperation rates did not differ significantly between the 2 groups (3-dimensionally printed group, 16.7%, versus premolded group, 21.7%). In multivariate analysis, only the number of previous cranial operation was significantly associated with the complication rate (odds ratio, 2.42; 95% confidence interval, 1.037-5.649; P = 0.041). The mean ± SD of the root mean square deviation was significantly smaller in the 3-dimensionally printed group (2.58 ± 0.93 versus 4.82 ± 1.31 mm, P < 0.001). CONCLUSIONS The 3-dimensionally printed titanium implant manufactured by the selective laser melting technique showed comparable stability and improved symmetry outcomes compared with the conventional titanium mesh in the reconstruction of extensive calvarial defects.
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Affiliation(s)
- Young Chul Kim
- From the Department of Plastic and Reconstructive Surgery, University of Ulsan College of Medicine, Asan Medical Center
| | - Seok Joon Lee
- From the Department of Plastic and Reconstructive Surgery, University of Ulsan College of Medicine, Asan Medical Center
| | - Soo Hyun Woo
- Department of Plastic and Reconstructive Surgery, College of Medicine, Chung-Ang University, Seoul
| | | | - Jong Woo Choi
- From the Department of Plastic and Reconstructive Surgery, University of Ulsan College of Medicine, Asan Medical Center
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Dewey MJ, Collins AJ, Tiffany A, Barnhouse VR, Lu C, Kolliopoulos V, Mutreja I, Hickok NJ, Harley BAC. Evaluation of bacterial attachment on mineralized collagen scaffolds and addition of manuka honey to increase mesenchymal stem cell osteogenesis. Biomaterials 2023; 294:122015. [PMID: 36701999 PMCID: PMC9928779 DOI: 10.1016/j.biomaterials.2023.122015] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 01/06/2023] [Accepted: 01/14/2023] [Indexed: 01/21/2023]
Abstract
The design of biomaterials to regenerate bone is likely to increasingly require modifications that reduce bacterial attachment and biofilm formation as infection during wound regeneration can significantly impede tissue repair and typically requires surgical intervention to restart the healing process. Further, much research on infection prevention in bone biomaterials has focused on modeling of non-resorbable metal alloy materials, whereas an expanding direction of bone regeneration has focused on development of bioresorbable materials. This represents a need for the prevention and understanding of infection in resorbable biomaterials. Here, we investigate the ability of a mineralized collagen biomaterial to natively resist infection and examine how the addition of manuka honey, previously identified as an antimicrobial agent, affects gram positive and negative bacterial colonization and mesenchymal stem cell osteogenesis and vasculature formation. We incorporate manuka honey into these scaffolds via either direct fabrication into the scaffold microarchitecture or via soaking the scaffold in a solution of manuka honey after fabrication. Direct incorporation results in a change in the surface characteristics and porosity of mineralized collagen scaffolds. Soaking scaffolds in honey concentrations higher than 10% had significant negative effects on mesenchymal stem cell metabolic activity. Soaking or incorporating 5% honey had no impact on endothelial cell tube formation. Although solutions of 5% honey reduced metabolic activity of mesenchymal stem cells, MSC-seeded scaffolds displayed increased calcium and phosphorous mineral formation, osteoprotegerin release, and alkaline phosphatase activity. Bacteria cultured on mineralized collagen scaffolds demonstrated surfaces covered in bacteria and no method of preventing infection, and using 10 times the minimal inhibitory concentration of antibiotics did not completely kill bacteria within the mineralized collagen scaffolds, indicating bioresorbable scaffold materials may act to shield bacteria from antibiotics. The addition of 5% manuka honey to scaffolds was not sufficient to prevent P. aeruginosa attachment or consistently reduce the activity of methicillin resistant staphylococcus aureus, and concentrations above 7% manuka honey are likely necessary to impact MRSA. Together, our results suggest bioresorbable scaffolds may create an environment conducive to bacterial growth, and potential trade-offs exist for the incorporation of low levels of honey in scaffolds to increase osteogenic potential of osteoprogenitors while high-levels of honey may be sufficient to reduce gram positive or negative bacteria activity but at the cost of reduced osteogenesis.
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Affiliation(s)
- Marley J Dewey
- Dept. of Materials Science and Engineering, University of Illinois Urbana-Champaign, Urbana, IL, 61801, USA
| | - Alan J Collins
- Carl R. Woese Institute for Genomic Biology, University of Illinois Urbana-Champaign, Urbana, IL, 61801, USA
| | - Aleczandria Tiffany
- Dept. of Chemical and Biomolecular Engineering, University of Illinois Urbana-Champaign, Urbana, IL, 61801, USA
| | - Victoria R Barnhouse
- Dept. of Bioengineering, University of Illinois Urbana-Champaign, Urbana, IL, 61801, USA
| | - Crislyn Lu
- School of Chemical Sciences, University of Illinois Urbana-Champaign, Urbana, IL, 61801, USA
| | - Vasiliki Kolliopoulos
- Dept. of Bioengineering, University of Illinois Urbana-Champaign, Urbana, IL, 61801, USA
| | - Isha Mutreja
- Department of Restorative Science, Minnesota Dental Research Center for Biomaterials and Biomechanics, University of Minnesota, Minneapolis, MN, 55455, USA
| | - Noreen J Hickok
- Department of Orthopaedic Surgery, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA 19107, USA
| | - Brendan A C Harley
- Dept. of Materials Science and Engineering, University of Illinois Urbana-Champaign, Urbana, IL, 61801, USA; Carl R. Woese Institute for Genomic Biology, University of Illinois Urbana-Champaign, Urbana, IL, 61801, USA; Dept. of Chemical and Biomolecular Engineering, University of Illinois Urbana-Champaign, Urbana, IL, 61801, USA; Dept. of Bioengineering, University of Illinois Urbana-Champaign, Urbana, IL, 61801, USA; Cancer Center at Illinois, University of Illinois Urbana-Champaign, Urbana, IL, 61801, USA.
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Lo AY, Yu RP, Raghuram AC, Cooper MN, Thompson HJ, Liu CY, Wong AK. Tissue Expanders in Staged Calvarial Reconstruction: A Systematic Review. Arch Plast Surg 2022; 49:729-739. [PMID: 36523916 PMCID: PMC9747287 DOI: 10.1055/s-0042-1751104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 03/25/2022] [Indexed: 12/15/2022] Open
Abstract
Cranioplasties are common procedures in plastic surgery. The use of tissue expansion (TE) in staged cranioplasties is less common. We present two cases of cranioplasties with TE and systematically review literature describing the use of TE in staged cranioplasties and postoperative outcomes. A systematic review was performed by querying multiple databases. Eligible articles include published case series, retrospective reviews, and systematic reviews that described use of TE for staged bony cranioplasty. Data regarding study size, patient demographics, preoperative characteristics, staged procedure characteristics, and postoperative outcomes were collected. Of 755 identified publications, 26 met inclusion criteria. 85 patients underwent a staged cranioplasty with TE. Average defect size was 122 cm 2 , and 30.9% of patients received a previous reconstruction. Average expansion period was 14.2 weeks. The most common soft tissue closures were performed with skin expansion only (75.3%), free/pedicled flap (20.1%), and skin graft (4.7%). The mean postoperative follow-up time was 23.9 months. Overall infection and local complication rates were 3.53 and 9.41%, respectively. The most common complications were cerebrospinal fluid leak (7.1%), hematoma (7.1%), implant exposure (3.5%), and infection (3.5%). Factors associated with higher complication rates include the following: use of alloplastic calvarial implants and defects of congenital etiology ( p = 0.023 and 0.035, respectively). This is the first comprehensive review to describe current practices and outcomes in staged cranioplasty with TE. Adequate soft tissue coverage contributes to successful cranioplasties and TE can play a safe and effective role in selected cases.
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Affiliation(s)
- Andrea Y. Lo
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine of University of South California, Los Angeles, California
| | - Roy P. Yu
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine of University of South California, Los Angeles, California
| | - Anjali C. Raghuram
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine of University of South California, Los Angeles, California
| | - Michael N. Cooper
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine of University of South California, Los Angeles, California
| | - Holly J. Thompson
- Wilson Dental Library, Herman Ostrow School of Dentistry of University of South California, Los Angeles, California
| | - Charles Y. Liu
- Department of Neurological Surgery, Keck School of Medicine of University of South California, Los Angeles, California
| | - Alex K. Wong
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine of University of South California, Los Angeles, California,Division of Plastic Surgery, City of Hope National Medical Center, Duarte, California,Address for correspondence Alex K. Wong, MD 1500 East Duarte RoadDuarte, CA 91010
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10
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Partial nasal bone reconstruction with acrylic bone cement: experimental study. THE EGYPTIAN JOURNAL OF OTOLARYNGOLOGY 2022. [DOI: 10.1186/s43163-022-00329-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Abstract
Background
The aim of this study was to evaluate the effectiveness of acrylic bone cement in partial nasal bone reconstruction.
Methods
This study was conducted using nine New Zealand rabbits. The left nasal bones of the rabbits were included in the experimental group, and the right nasal bones were evaluated as the control group. The partial bone segments on the bilateral nasal bones were marked and removed symmetrically. A synthetic graft material made of acrylic bone cement was placed in experimental group, and the partial bone segment removed from the right side was placed in control group as an autograft. All rabbits were sacrificed at the end of the 28th day. Samples were taken from the grafts and from the surrounding soft tissues for histopathological examination. Acute inflammation, chronic inflammation, vascularization, fibrosis, foreign body reaction, bone proliferation, and the presence of empty lacunae were evaluated under a light microscope for both groups.
Results
Surrounding soft tissue on synthetic and autograft were the same in terms of chronic inflammation. There was no statistically significant difference for vascularization, fibrosis, and foreign body reaction. Synthetic graft and autograft were the same in terms of chronic inflammation, fibrosis, and bone proliferation. There was no statistically significant difference for vascularization, foreign body reaction, and presence of empty lacunae (p > 0.05).
Conclusion
This study showed no significant differences between the use of acrylic bone and the use of an autograft for partial nasal bone reconstruction in terms of graft or tissue healing. Acrylic bone cement may therefore serve as a good alternative for nasal bone reconstruction.
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Thimukonda Jegadeesan J, Baldia M, Basu B. Next-generation personalized cranioplasty treatment. Acta Biomater 2022; 154:63-82. [PMID: 36272686 DOI: 10.1016/j.actbio.2022.10.030] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 10/10/2022] [Accepted: 10/13/2022] [Indexed: 12/14/2022]
Abstract
Decompressive craniectomy (DC) is a surgical procedure, that is followed by cranioplasty surgery. DC is usually performed to treat patients with traumatic brain injury, intracranial hemorrhage, cerebral infarction, brain edema, skull fractures, etc. In many published clinical case studies and systematic reviews, cranioplasty surgery is reported to restore cranial symmetry with good cosmetic outcomes and neurophysiologically relevant functional outcomes in hundreds of patients. In this review article, we present a number of key issues related to the manufacturing of patient-specific implants, clinical complications, cosmetic outcomes, and newer alternative therapies. While discussing alternative therapeutic treatments for cranioplasty, biomolecules and cellular-based approaches have been emphasized. The current clinical practices in the restoration of cranial defects involve 3D printing to produce patient-specific prefabricated cranial implants, that provide better cosmetic outcomes. Regardless of the advancements in image processing and 3D printing, the complete clinical procedure is time-consuming and requires significant costs. To reduce manual intervention and to address unmet clinical demands, it has been highlighted that automated implant fabrication by data-driven methods can accelerate the design and manufacturing of patient-specific cranial implants. The data-driven approaches, encompassing artificial intelligence (machine learning/deep learning) and E-platforms, such as publicly accessible clinical databases will lead to the development of the next generation of patient-specific cranial implants, which can provide predictable clinical outcomes. STATEMENT OF SIGNIFICANCE: Cranioplasty is performed to reconstruct cranial defects of patients who have undergone decompressive craniectomy. Cranioplasty surgery improves the aesthetic and functional outcomes of those patients. To meet the clinical demands of cranioplasty surgery, accelerated designing and manufacturing of 3D cranial implants are required. This review provides an overview of biomaterial implants and bone flap manufacturing methods for cranioplasty surgery. In addition, tissue engineering and regenerative medicine-based approaches to reduce clinical complications are also highlighted. The potential use of data-driven computer applications and data-driven artificial intelligence-based approaches are emphasized to accelerate the clinical protocols of cranioplasty treatment with less manual intervention and shorter intraoperative time.
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Affiliation(s)
| | - Manish Baldia
- Department of Neurosurgery, Jaslok Hospital and Research Centre, Mumbai, Maharashtra 400026, India
| | - Bikramjit Basu
- Materials Research Centre, Indian Institute of Science, CV Raman Road, Bangalore, Karnataka 560012, India; Centre for Biosystems Science and Engineering, Indian Institute of Science, Bangalore, Karnataka 560012, India.
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12
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iPSC-neural crest derived cells embedded in 3D printable bio-ink promote cranial bone defect repair. Sci Rep 2022; 12:18701. [PMID: 36333414 PMCID: PMC9636385 DOI: 10.1038/s41598-022-22502-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 10/17/2022] [Indexed: 11/06/2022] Open
Abstract
Cranial bone loss presents a major clinical challenge and new regenerative approaches to address craniofacial reconstruction are in great demand. Induced pluripotent stem cell (iPSC) differentiation is a powerful tool to generate mesenchymal stromal cells (MSCs). Prior research demonstrated the potential of bone marrow-derived MSCs (BM-MSCs) and iPSC-derived mesenchymal progenitor cells via the neural crest (NCC-MPCs) or mesodermal lineages (iMSCs) to be promising cell source for bone regeneration. Overexpression of human recombinant bone morphogenetic protein (BMP)6 efficiently stimulates bone formation. The study aimed to evaluate the potential of iPSC-derived cells via neural crest or mesoderm overexpressing BMP6 and embedded in 3D printable bio-ink to generate viable bone graft alternatives for cranial reconstruction. Cell viability, osteogenic potential of cells, and bio-ink (Ink-Bone or GelXa) combinations were investigated in vitro using bioluminescent imaging. The osteogenic potential of bio-ink-cell constructs were evaluated in osteogenic media or nucleofected with BMP6 using qRT-PCR and in vitro μCT. For in vivo testing, two 2 mm circular defects were created in the frontal and parietal bones of NOD/SCID mice and treated with Ink-Bone, Ink-Bone + BM-MSC-BMP6, Ink-Bone + iMSC-BMP6, Ink-Bone + iNCC-MPC-BMP6, or left untreated. For follow-up, µCT was performed at weeks 0, 4, and 8 weeks. At the time of sacrifice (week 8), histological and immunofluorescent analyses were performed. Both bio-inks supported cell survival and promoted osteogenic differentiation of iNCC-MPCs and BM-MSCs in vitro. At 4 weeks, cell viability of both BM-MSCs and iNCC-MPCs were increased in Ink-Bone compared to GelXA. The combination of Ink-Bone with iNCC-MPC-BMP6 resulted in an increased bone volume in the frontal bone compared to the other groups at 4 weeks post-surgery. At 8 weeks, both iNCC-MPC-BMP6 and iMSC-MSC-BMP6 resulted in an increased bone volume and partial bone bridging between the implant and host bone compared to the other groups. The results of this study show the potential of NCC-MPC-incorporated bio-ink to regenerate frontal cranial defects. Therefore, this bio-ink-cell combination should be further investigated for its therapeutic potential in large animal models with larger cranial defects, allowing for 3D printing of the cell-incorporated material.
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13
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Gonzalez Matheus I, Hutmacher DW, Olson S, Redmond M, Sutherland A, Wagels M. A Medical-Grade Polycaprolactone and Tricalcium Phosphate Scaffold System With Corticoperiosteal Tissue Transfer for the Reconstruction of Acquired Calvarial Defects in Adults: Protocol for a Single-Arm Feasibility Trial. JMIR Res Protoc 2022; 11:e36111. [PMID: 36227628 PMCID: PMC9614622 DOI: 10.2196/36111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 04/26/2022] [Accepted: 06/20/2022] [Indexed: 11/26/2022] Open
Abstract
Background Large skull defects present a reconstructive challenge. Conventional cranioplasty options include autologous bone grafts, vascularized bone, metals, synthetic ceramics, and polymers. Autologous options are affected by resorption and residual contour deformities. Synthetic materials may be customized via digital planning and 3D printing, but they all carry a risk of implant exposure, failure, and infection, which increases when the defect is large. These complications can be a threat to life. Without reconstruction, patients with cranial defects may experience headaches and stigmatization. The protection of the brain necessitates lifelong helmet use, which is also stigmatizing. Objective Our clinical trial will formally study a hybridized technique's capacity to reconstruct large calvarial defects. Methods A hybridized technique that draws on the benefits of autologous and synthetic materials has been developed by the research team. This involves wrapping a biodegradable, ultrastructured, 3D-printed scaffold made of medical-grade polycaprolactone and tricalcium phosphate in a vascularized, autotransplanted periosteum to exploit the capacity of vascularized periostea to regenerate bone. In vitro, the scaffold system supports cell attachment, migration, and proliferation with slow but sustained degradation to permit host tissue regeneration and the replacement of the scaffold. The in vivo compatibility of this scaffold system is robust—the base material has been used clinically as a resorbable suture material for decades. The importance of scaffold vascularization, which is inextricably linked to bone regeneration, is underappreciated. A variety of methods have been described to address this, including scaffold prelamination and axial vascularization via arteriovenous loops and autotransplanted flaps. However, none of these directly promote bone regeneration. Results We expect to have results before the end of 2023. As of December 2020, we have enrolled 3 participants for the study. Conclusions The regenerative matching axial vascularization technique may be an alternative method of reconstruction for large calvarial defects. It involves performing a vascularized free tissue transfer and using a bioresorbable, 3D-printed scaffold to promote and support bone regeneration (termed the regenerative matching axial vascularization technique). This technique may be used to reconstruct skull bone defects that were previously thought to be unreconstructable, reduce the risk of implant-related complications, and achieve consistent outcomes in cranioplasty. This must now be tested in prospective clinical trials. Trial Registration Australian New Zealand Clinical Trials Registry ACTRN12620001171909; https://tinyurl.com/4rakccb3 International Registered Report Identifier (IRRID) DERR1-10.2196/36111
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Affiliation(s)
- Isabel Gonzalez Matheus
- Department of Plastic & Reconstructive Surgery, Princess Alexandra Hospital, Queenland, Australia.,Herston Biofabrication Institute, Herston, Australia.,The Australian Centre for Complex Integrated Surgical Solutions, Translational Research Institute, Woolloongabba, Australia.,School of Medicine, University of Queensland, Brisbane, Australia
| | - Dietmar W Hutmacher
- Regenerative Medicine Institute of Health and Biomedical Innovation, Queensland University of Technology, Kelvin Grove, Australia
| | - Sarah Olson
- Department of Neurosurgery, Princess Alexandra Hospital, Woolloongabba, Australia
| | - Michael Redmond
- Herston Biofabrication Institute, Herston, Australia.,Department of Neurosurgery, Royal Brisbane & Women's Hospital, Herston, Australia
| | - Allison Sutherland
- The Australian Centre for Complex Integrated Surgical Solutions, Translational Research Institute, Woolloongabba, Australia
| | - Michael Wagels
- Department of Plastic & Reconstructive Surgery, Princess Alexandra Hospital, Queenland, Australia.,Herston Biofabrication Institute, Herston, Australia.,The Australian Centre for Complex Integrated Surgical Solutions, Translational Research Institute, Woolloongabba, Australia.,School of Medicine, University of Queensland, Brisbane, Australia
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14
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Ji T, Yao P, Zeng Y, Qian Z, Wang K, Gao L. Subgaleal Effusion and Brain Midline Shift After Cranioplasty: A Retrospective Study Between Polyetheretherketone Cranioplasty and Titanium Cranioplasty After Decompressive Craniectomy. Front Surg 2022; 9:923987. [PMID: 35937601 PMCID: PMC9351718 DOI: 10.3389/fsurg.2022.923987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 06/10/2022] [Indexed: 11/21/2022] Open
Abstract
Cranioplasty with polyetheretherketone (PEEK) has recently shown better cerebral protection performance, improved brain function, and aesthetic contour compared with titanium mesh. However, whether patients undergoing PEEK cranioplasty tend to develop subgaleal effusions remains elusive. This retrospective study included patients who underwent cranioplasty with PEEK implants or titanium mesh after decompressive craniectomy between July 2017 and July 2020. Patient information, including general information, location, size of the defect, subgaleal depth, and brain midline shift was collected and statistically analyzed. There were 130 cases of cranioplasty, including 35 with PEEK implants and 95 with a titanium mesh. Patients who underwent cranioplasty with a PEEK implant had a higher subgaleal effusion rate than those who underwent cranioplasty with titanium mesh (85.71% vs. 53.68%, P < 0.001), while a midline shift >5 mm was more frequently observed in the PEEK group than in the titanium group (20% vs. 6.3%, P = 0.021). The PEEK material was the only factor associated with subgaleal effusion after cranioplasty (OR 5.589, P = 0.002). Logistic regression analysis further showed that age was a protective factor against midline shift in the PEEK cranioplasty group (OR 0.837, P = 0.029). Patients who underwent cranioplasty with PEEK implants were more likely to develop severe subgaleal effusion and significant brain midline shifts than those with titanium mesh implants.
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Affiliation(s)
- Tao Ji
- Department of Neurosurgery, Shanghai Tenth People's Hospital, Tongji University, Shanghai, China
| | - Peiwen Yao
- School of Clinical Medicine, Nanjing Medical University, Nanjing, China
| | - Yu Zeng
- Department of Neurosurgery, Shanghai Tenth People's Hospital, Tongji University, Shanghai, China
| | - Zhouqi Qian
- Department of Neurosurgery, Shanghai Tenth People's Hospital, Tongji University, Shanghai, China
| | - Ke Wang
- Department of Neurosurgery, Shanghai Tenth People's Hospital, Tongji University, Shanghai, China
- Correspondence: Liang Gao Ke Wang
| | - Liang Gao
- School of Clinical Medicine, Nanjing Medical University, Nanjing, China
- Correspondence: Liang Gao Ke Wang
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15
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Hubbe U, Beiser S, Kuhn S, Stark T, Hoess A, Cristina-Schmitz H, Vasilikos I, Metzger MC, Rothweiler R. A fully ingrowing implant for cranial reconstruction: Results in critical size defects in sheep using 3D-printed titanium scaffold. BIOMATERIALS ADVANCES 2022; 136:212754. [PMID: 35929289 DOI: 10.1016/j.bioadv.2022.212754] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 02/23/2022] [Accepted: 03/06/2022] [Indexed: 06/15/2023]
Abstract
Current alloplastic materials such as PMMA, titanium or PEEK don't show relevant bone ingrowth into the implant when used for cranioplasty, ceramic implants have the drawback being brittle. New materials and implant designs are urgently needed being biocompatible, stable enough for cranioplasty and stimulating bone formation. In an in vivo critical size sheep model circular cranial defects (>2.4 cm) were covered with three different types of a 3D-printed porous titanium scaffolds with multidirectional, stochastically distributed architecture (uncoated scaffold, hydroxyapatite-coated scaffold, uncoated scaffold filled with a calcium phosphate bone cement paste containing β-TCP granules). An empty titanium mesh served as control. Among the different investigated setups the hydroxyapatite-coated scaffolds showed a surprisingly favourable performance. Push-out tests revealed a 2.9 fold higher force needed in the hydroxyapatite-coated scaffolds compared to the mesh group. Mean CT density at five different points inside the scaffold was 2385HU in the hydroxyapatite-coated group compared to 1978HU in the uncoated scaffold at nine months. Average lateral bone ingrowth after four months in the hydroxyapatite-coated scaffold group was up to the implant center, 12.1 mm on average, compared to 2.8 mm in the control group covered with mesh only. These properties make the investigated scaffold with multidirectional, stochastically distributed structure superior to all products currently on the market. The study gives a good idea of what future materials for cranioplasty might look like.
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Affiliation(s)
- U Hubbe
- Department of Neurosurgery, Faculty of Medicine, University of Freiburg, Breisacher Str. 64, Freiburg 79106, Germany.
| | - S Beiser
- Department of Neurosurgery, Faculty of Medicine, University of Freiburg, Breisacher Str. 64, Freiburg 79106, Germany.
| | - S Kuhn
- Stryker Leibinger GmbH & Co. KG, Bötzinger Straße 41, Freiburg 79111, Germany.
| | - T Stark
- Stryker Leibinger GmbH & Co. KG, Bötzinger Straße 41, Freiburg 79111, Germany.
| | - A Hoess
- INNOTERE GmbH, Meissner Str. 191, Radebeul, 01445, Germany
| | - H Cristina-Schmitz
- Division of Experimental Surgery, Center for Experimental Models and Transgenic Services, Germany; Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany.
| | - I Vasilikos
- Department of Neurosurgery, Faculty of Medicine, University of Freiburg, Breisacher Str. 64, Freiburg 79106, Germany.
| | - M C Metzger
- Department of Oral and Maxillofacial Surgery, Faculty of Medicine, University of Freiburg, Hugstetter Straße 55, Freiburg 79106, Germany.
| | - R Rothweiler
- Department of Oral and Maxillofacial Surgery, Faculty of Medicine, University of Freiburg, Hugstetter Straße 55, Freiburg 79106, Germany.
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16
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Voss JO, Kasselmann S, Koerdt S, Rendenbach C, Fischer H, Jöhrens K, Czabanka M, Schmidt-Bleek K, Duda GN, Heiland M, Raguse JD. Treatment options for critical size defects - Comparison of different materials in a calvaria split model in sheep. BIOMATERIALS ADVANCES 2022; 136:212788. [PMID: 35929320 DOI: 10.1016/j.bioadv.2022.212788] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 03/24/2022] [Accepted: 04/01/2022] [Indexed: 06/15/2023]
Abstract
Bone defects of the craniofacial skeleton are often associated with aesthetic and functional impairment as well as loss of protection to intra- and extracranial structures. Solid titanium plates and individually adapted bone cements have been the materials of choice, but may lead to foreign-body reactions and insufficient osseointegration. In contrast, porous scaffolds are thought to exhibit osteoconductive properties to support bone ingrowth. Here, we analyse in critical size defects of the calvaria in sheep whether different bone replacement materials may overcome those remaining challenges. In a critical size defect model, bilateral 20 × 20 × 5-mm craniectomies were performed on either side of the sagittal sinus in 24 adult female blackheaded sheep. Bony defects were randomised to one of five different bone replacement materials (BRMs): titanium scaffold, biodegradable poly(d,l-lactic acid) calcium carbonate scaffold (PDLLA/CC), polyethylene 1 (0.71 mm mean pore size) or 2 (0.515 mm mean pore size) scaffolds and polymethyl methacrylate (PMMA)-based bone cement block. Empty controls (n = 3) served as references. To evaluate bone growth over time, three different fluorochromes were administered at different time points. At 3, 6 and 12 months after surgery, animals were sacrificed and the BRMs and surrounding bone analysed by micro-CT and histomorphometry. The empty control group verified that the calvaria defect in this study was a reliable critical size defect model. Bone formation in vivo was detectable in all BRMs after 12 months by micro-CT and histomorphometric analysis, except for the non-porous PMMA group. A maximum of bone formation was detected in the 12-months group for titanium and PDLLA/CC. Bone formation in PDLLA/CC starts to increase rapidly between 6 and 12 months, as the BRM resorbs over time. Contact between bone and BRM influenced bone formation inside the BRM. Empty controls exhibited bone formation solely at the periphery. Overall, porous BRMs offered bone integration to different extent over 12 months in the tested calvaria defect model. Titanium and PDLLA/CC scaffolds showed remarkable osseointegration properties by micro-CT and histomorphometric analysis. PDLLA/CC scaffolds degraded over time without major residues. Pore size influenced bone ingrowth in polyethylene, emphasising the importance of porous scaffold structure.
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Affiliation(s)
- Jan Oliver Voss
- Department of Oral and Maxillofacial Surgery, Charité Universitätsmedizin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Augustenburger Platz 1, 13353 Berlin, Germany; Berlin Institute of Health (BIH), Anna-Louisa-Karsch-Straße 2, 10178 Berlin, Germany.
| | - Svenja Kasselmann
- Department of Oral and Maxillofacial Surgery, Charité Universitätsmedizin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Augustenburger Platz 1, 13353 Berlin, Germany; Department of Veterinary Medicine, Institute of Veterinary Anatomy, Freie Universität Berlin, Koserstraße 20, 14195 Berlin, Germany.
| | - Steffen Koerdt
- Department of Oral and Maxillofacial Surgery, Charité Universitätsmedizin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Augustenburger Platz 1, 13353 Berlin, Germany.
| | - Carsten Rendenbach
- Department of Oral and Maxillofacial Surgery, Charité Universitätsmedizin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Augustenburger Platz 1, 13353 Berlin, Germany.
| | - Heilwig Fischer
- Department of Oral and Maxillofacial Surgery, Charité Universitätsmedizin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Augustenburger Platz 1, 13353 Berlin, Germany; Berlin Institute of Health (BIH), Anna-Louisa-Karsch-Straße 2, 10178 Berlin, Germany; Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany.
| | - Korinna Jöhrens
- Institute of Pathology, University Hospital Carl Gustav Carus, Fetscherstr. 74, 01307, TU Dresden, Dresden, Germany.
| | - Marcus Czabanka
- Department of Neurosurgery, Universitätsmedizin Frankfurt am Main, Schleusenweg 2-16, 60590 Frankfurt am Main, Germany.
| | - Katharina Schmidt-Bleek
- Julius Wolff Institute and Berlin Institute of Health Centre for Regenerative Therapies, Berlin Institute of Health at Charité Universitätsmedizin, Augustenburger Platz 1, 13353 Berlin, Germany.
| | - Georg N Duda
- Julius Wolff Institute and Berlin Institute of Health Centre for Regenerative Therapies, Berlin Institute of Health at Charité Universitätsmedizin, Augustenburger Platz 1, 13353 Berlin, Germany.
| | - Max Heiland
- Department of Oral and Maxillofacial Surgery, Charité Universitätsmedizin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Augustenburger Platz 1, 13353 Berlin, Germany.
| | - Jan-Dirk Raguse
- Department of Oral and Maxillofacial Surgery, Charité Universitätsmedizin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Augustenburger Platz 1, 13353 Berlin, Germany; Fachklinik Hornheide, Department of Oral and Maxillofacial Surgery, Dorbaumstraße 300, 48147 Münster, Germany.
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17
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Zhao Y, Wang Z, Zhao J, Hussain M, Wang M. Additive Manufacturing in Orthopedics: A Review. ACS Biomater Sci Eng 2022; 8:1367-1380. [PMID: 35266709 DOI: 10.1021/acsbiomaterials.1c01072] [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: 11/30/2022]
Abstract
Additive manufacturing is an advanced manufacturing manner that seems like the industrial revolution. It has the inborn benefit of producing complex formations, which are distinct from traditional machining technology. Its manufacturing strategy is flexible, including a wide range of materials, and its manufacturing cycle is short. Additive manufacturing techniques are progressively used in bone research and orthopedic operation as more innovative materials are developed. This Review lists the recent research results, analyzes the strengths and weaknesses of diverse three-dimensional printing strategies in orthopedics, and sums up the use of varying 3D printing strategies in surgical guides, surgical implants, surgical predictive models, and bone tissue engineering. Moreover, various postprocessing methods for additive manufacturing for orthopedics are described.
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Affiliation(s)
- Yingchao Zhao
- Xiangya School of Medicine, Central South University, No.172 Yinpenling Street, Tongzipo Road, Changsha 410013, China
| | - Zhen Wang
- Xiangya School of Medicine, Central South University, No.172 Yinpenling Street, Tongzipo Road, Changsha 410013, China
| | - Jingzhou Zhao
- Department of Chemical & Biomolecular Engineering, National University of Singapore, 4 Engineering Drive 4, Singapore 117585, Singapore
| | - Mubashir Hussain
- Postdoctoral Innovation Practice, Shenzhen Polytechnic, No.4089 Shahe West Road, Xinwei Nanshan District, Shenzhen 518055, China
| | - Maonan Wang
- Department of Chemical & Biomolecular Engineering, National University of Singapore, 4 Engineering Drive 4, Singapore 117585, Singapore
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18
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Castrisos G, Gonzalez Matheus I, Sparks D, Lowe M, Ward N, Sehu M, Wille ML, Phua Y, Medeiros Savi F, Hutmacher D, Wagels M. Regenerative matching axial vascularisation of absorbable 3D-printed scaffold for large bone defects: A first in human series. J Plast Reconstr Aesthet Surg 2022; 75:2108-2118. [PMID: 35370116 DOI: 10.1016/j.bjps.2022.02.057] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 12/10/2021] [Accepted: 02/22/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND We describe the first clinical series of a novel bone replacement technique based on regenerative matching axial vascularisation (RMAV). This was used in four cases: a tibial defect after treatment of osteomyelitis; a calvarial defect after trauma and failed titanium cranioplasty; a paediatric tibial defect after neoadjuvant chemotherapy and resection of Ewing sarcoma; and a paediatric mandibular deficiency resulting from congenital hemifacial microsomia. METHOD All patients underwent reconstruction with three-dimensional (3D)-printed medical-grade polycaprolactone and tricalcium phosphate (mPCL-TCP) scaffolds wrapped in vascularised free corticoperiosteal flaps. OUTCOME Functional volumes of load-sharing regenerate bone have formed in all cases after a moderate duration of follow-up. At 36 cm, case 1 remains the longest segment of load bearing bone ever successfully reconstructed. This technique offers an alternative to existing methods of large volume bone defect reconstruction that may be safe, reliable, and give predictable outcomes in challenging situations. It achieves this by using a bioresorbable scaffold to support and direct the growth of regenerate bone, driven by RMAV. CONCLUSION This technique may facilitate the reconstruction of bone defects previously thought unreconstructable, reduce the risk of long-term implant-related complications and achieve these outcomes in a hostile environment. These potential benefits must now be formally tested in prospective clinical trials.
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Affiliation(s)
- George Castrisos
- Department of Plastic Surgery, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
| | - Isabel Gonzalez Matheus
- Department of Plastic Surgery, Princess Alexandra Hospital, Woolloongabba, QLD, Australia; The Herston Biofabrication Institute, Herston; The University of Queensland, Australia; Southside Clinical Division, School of Medicine, University of Queensland, Woolloongabba, Australia; The Australian Centre for Complex Integrated Surgical Solutions, Woolloongabba , Australia.
| | - David Sparks
- Department of Plastic Surgery, Princess Alexandra Hospital, Woolloongabba, QLD, Australia; Faculty of Engineering, Queensland University of Technology, Kelvin Grove, Australia; Southside Clinical Division, School of Medicine, University of Queensland, Woolloongabba, Australia
| | - Martin Lowe
- Department of Orthopaedic Surgery, Princess Alexandra Hospital, Woolloongabba QLD, Australia
| | - Nicola Ward
- Department of Orthopaedic Surgery, Princess Alexandra Hospital, Woolloongabba QLD, Australia
| | - Marjoree Sehu
- Southside Clinical Division, School of Medicine, University of Queensland, Woolloongabba, Australia; Infection Management Services, Princess Alexandra Hospital, Woolloongabba QLD, Australia
| | - Marie-Luise Wille
- Queensland University of Technology Node ARC Training Centre for Multiscale 3D Imaging, Modelling and Manufacturing, QLD, Australia; Queensland University of Technology, Institute of Health Biomedical Innovation, Australia
| | - Yun Phua
- Department of Plastic and Reconstructive Surgery, Queensland Children's Hospital, South Brisbane, QLD, Australia
| | - Flavia Medeiros Savi
- Department of Plastic and Reconstructive Surgery, Queensland Children's Hospital, South Brisbane, QLD, Australia; Queensland University of Technology, Institute of Health Biomedical Innovation, Australia
| | - Dietmar Hutmacher
- Queensland University of Technology Node ARC Training Centre for Multiscale 3D Imaging, Modelling and Manufacturing, QLD, Australia; Queensland University of Technology, Institute of Health Biomedical Innovation, Australia
| | - Michael Wagels
- Department of Plastic Surgery, Princess Alexandra Hospital, Woolloongabba, QLD, Australia; The Herston Biofabrication Institute, Herston; The University of Queensland, Australia; Southside Clinical Division, School of Medicine, University of Queensland, Woolloongabba, Australia; Department of Plastic and Reconstructive Surgery, Queensland Children's Hospital, South Brisbane, QLD, Australia; The Australian Centre for Complex Integrated Surgical Solutions, Woolloongabba , Australia
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Msallem B, Maintz M, Halbeisen FS, Meyer S, Sigron GR, Sharma N, Cao S, Thieringer FM. Biomechanical Evaluation of Patient-Specific Polymethylmethacrylate Cranial Implants for Virtual Surgical Planning: An In-Vitro Study. MATERIALS 2022; 15:ma15051970. [PMID: 35269201 PMCID: PMC8911603 DOI: 10.3390/ma15051970] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 02/19/2022] [Accepted: 03/01/2022] [Indexed: 02/06/2023]
Abstract
Cranioplasty with freehand-molded polymethylmethacrylate implants is based on decades of experience and is still frequently used in clinical practice. However, data confirming the fracture toughness and standard biomechanical tests are rare. This study aimed to determine the amount of force that could be applied to virtually planned, template-molded, patient-specific implants (n = 10) with an implant thickness of 3 mm, used in the treatment of a temporoparietal skull defect (91.87 cm2), until the implant cracks and finally breaks. Furthermore, the influence of the weight and porosity of the implant on its force resistance was investigated. The primary outcome showed that a high force was required to break the implant (mean and standard deviation 1484.6 ± 167.7 N), and this was very strongly correlated with implant weight (Pearson’s correlation coefficient 0.97; p < 0.001). Secondary outcomes were force application at the implant’s first, second, and third crack. Only a moderate correlation could be found between fracture force and the volume of porosities (Pearson’s correlation coefficient 0.59; p = 0.073). The present study demonstrates that an implant thickness of 3 mm for a temporoparietal skull defect can withstand sufficient force to protect the brain. Greater implant weight and, thus, higher material content increases thickness, resulting in more resistance. Porosities that occur during the described workflow do not seem to reduce resistance. Therefore, precise knowledge of the fracture force of polymethylmethacrylate cranial implants provides insight into brain injury prevention and serves as a reference for the virtual design process.
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Affiliation(s)
- Bilal Msallem
- Clinic of Oral and Cranio-Maxillofacial Surgery, University Hospital Basel, CH-4031 Basel, Switzerland; (B.M.); (N.S.); (S.C.); (F.M.T.)
- Medical Additive Manufacturing Research Group (Swiss MAM), Department of Biomedical Engineering, University of Basel, CH-4123 Allschwil, Switzerland;
| | - Michaela Maintz
- Medical Additive Manufacturing Research Group (Swiss MAM), Department of Biomedical Engineering, University of Basel, CH-4123 Allschwil, Switzerland;
| | - Florian S. Halbeisen
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital Basel, University of Basel, CH-4031 Basel, Switzerland;
| | - Simon Meyer
- Clinic of Oral and Cranio-Maxillofacial Surgery, University Hospital Basel, CH-4031 Basel, Switzerland; (B.M.); (N.S.); (S.C.); (F.M.T.)
- Medical Additive Manufacturing Research Group (Swiss MAM), Department of Biomedical Engineering, University of Basel, CH-4123 Allschwil, Switzerland;
- Correspondence:
| | - Guido R. Sigron
- Clinic of Oral and Cranio-Maxillofacial Surgery, Cantonal Hospital Aarau, CH-5001 Aarau, Switzerland;
| | - Neha Sharma
- Clinic of Oral and Cranio-Maxillofacial Surgery, University Hospital Basel, CH-4031 Basel, Switzerland; (B.M.); (N.S.); (S.C.); (F.M.T.)
- Medical Additive Manufacturing Research Group (Swiss MAM), Department of Biomedical Engineering, University of Basel, CH-4123 Allschwil, Switzerland;
| | - Shuaishuai Cao
- Clinic of Oral and Cranio-Maxillofacial Surgery, University Hospital Basel, CH-4031 Basel, Switzerland; (B.M.); (N.S.); (S.C.); (F.M.T.)
- Medical Additive Manufacturing Research Group (Swiss MAM), Department of Biomedical Engineering, University of Basel, CH-4123 Allschwil, Switzerland;
| | - Florian M. Thieringer
- Clinic of Oral and Cranio-Maxillofacial Surgery, University Hospital Basel, CH-4031 Basel, Switzerland; (B.M.); (N.S.); (S.C.); (F.M.T.)
- Medical Additive Manufacturing Research Group (Swiss MAM), Department of Biomedical Engineering, University of Basel, CH-4123 Allschwil, Switzerland;
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Histological Processing of CAD/CAM Titanium Scaffold after Long-Term Failure in Cranioplasty. MATERIALS 2022; 15:ma15030982. [PMID: 35160928 PMCID: PMC8839919 DOI: 10.3390/ma15030982] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 01/17/2022] [Accepted: 01/25/2022] [Indexed: 02/01/2023]
Abstract
Cranioplasty is a frequently performed procedure after craniectomy and includes several techniques with different materials. Due to high overall complication rates, alloplastic implants are removed in many cases. Lack of implant material osseointegration is often assumed as a reason for failure, but no study has proven this in cranioplasty. This study histologically evaluates the osteointegration of a computer-aided design and computer-aided manufacturing (CAD/CAM) titanium scaffold with an open mesh structure used for cranioplasty. A CAD/CAM titanium scaffold was removed due to late soft tissue complications 7.6 years after cranioplasty. The histological analyses involved the preparation of non-decalcified slices from the scaffold’s inner and outer sides as well as a light-microscopic evaluation, including the quantification of the bone that had formed over the years. Within the scaffold pores, vital connective tissue with both blood vessels and nerves was found. Exclusive bone formation only occurred at the edges of the implant, covering 0.21% of the skin-facing outer surface area. The inner scaffold surface, facing towards the brain, did not show any mineralization at all. Although conventional alloplastic materials for cranioplasty reduce surgery time and provide good esthetic results while mechanically protecting the underlying structures, a lack of adequate stimuli could explain the limited bone formation found. CAD/CAM porous titanium scaffolds alone insufficiently osseointegrate in such large bone defects of the skull. Future research should investigate alternative routes that enable long-term osteointegration in order to reduce complication rates after cranioplasty. Opportunities could be found in mechano-biologically optimized scaffolds, material modifications, surface coatings, or other routes to sustain bone formation.
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Chauhan D, Chattopadhyay P, Thakur A. Reconstruction of cranial defect with patient-specific implants: Four different cost-effective techniques. Natl J Maxillofac Surg 2022; 13:136-142. [PMID: 35911808 PMCID: PMC9326212 DOI: 10.4103/njms.njms_200_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Revised: 12/24/2020] [Accepted: 04/04/2021] [Indexed: 11/04/2022] Open
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22
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Okishev DN, Cherebylo SA, Konovalov AN, Chelushkin DM, Shekhtman OD, Konovalov NA, Okisheva EA, Kravchuk AD, Eliava SS. [Features of modeling a polymer implant for closing a defect after decompressive craniotomy]. ZHURNAL VOPROSY NEIROKHIRURGII IMENI N. N. BURDENKO 2022; 86:17-27. [PMID: 35170273 DOI: 10.17116/neiro20228601117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
BACKGROUND Individual polymer implants are widespread for bone reconstruction after decompressive craniectomy. Despite the availability of customized titanium products, various specialists and hospitals prefer polymer implants. OBJECTIVE To compare the methods of modeling and manufacturing the polymethylmethacrylate implants and identify the features affecting the quality of reconstruction. MATERIAL AND METHODS We analyzed 14 patients with extensive skull defects after installation of polymethyl methacrylate implants. Software used for modeling of individual implants by different specialists was compared. RESULTS Satisfactory reconstruction result was obtained in all cases. There were no infectious complications. The authors outlined certain important aspects for modeling of individual polymer products: local use of anatomical thickness of the implant, leaving safe spaces, prevention of temporal retraction, template-based resection before reconstruction. CONCLUSION To date, skull defect closure with polymeric materials remains relevant, and even has certain advantages over customized titanium products.
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Affiliation(s)
- D N Okishev
- Burdenko Neurosurgical Center, Moscow, Russia
| | - S A Cherebylo
- Institute for Problems of Laser and Information Technologies, Shatura, Russia
| | | | | | | | | | - E A Okisheva
- Sechenov First Moscow State Medical University, Moscow, Russia
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Reconstruction of the Occipital and Parietal Congenital Defect with 3D Custom-Made Titanium Prosthesis: A Case Report with Four and a Half Years of Follow-Up and a Brief Review of Literature. Case Rep Dent 2021; 2021:7027701. [PMID: 34721909 PMCID: PMC8550828 DOI: 10.1155/2021/7027701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 08/25/2021] [Indexed: 11/17/2022] Open
Abstract
Management of patients with congenital skull defects requires a multidisciplinary approach. Considering the defect's location and size, brain protection, and the cosmetic outcome makes such reconstructions challenging. Due to limited resemblance to skull contour and donor site morbidity of autogenous bone grafts, alloplastic materials are widely used for skull reconstructions. Titanium alloys have proper strength values, low infection rates, favorable osseointegration property, and excellent marginal adaptability when manufactured by computer-aided design (CAD) and computer-aided manufacturing (CAM). A 13-year-old female patient presented with congenital defects at the superior third of occipital bone and posterior thirds of the bilateral parietal bones. On CT scan, the exact size and shape of the defect were determined. Using CAD/CAM, a 3D virtual model of the prosthesis was designed and then printed with titanium alloy (TiAl6V4) via additive manufacturing method. The prosthesis was placed on the defect in a total surgery time of only 90 minutes. On 4.5 years of follow-up, the contour of the skull was ideal and the skin over the defect and neurologic status was intact. Due to their biocompatibility and rigidity, custom-made titanium prostheses are promising options for reconstructing complex skull defects.
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Hacherl CC, Patel NA, Jones K, Ruh NB, Gendreau JL, Abraham ME, Mammis A. Characterizing Adverse Events of Cranioplasty Implants After Craniectomy: A Retrospective Review of the Federal Manufacturer and User Facility Device Experience Database. Cureus 2021; 13:e16795. [PMID: 34513401 PMCID: PMC8405381 DOI: 10.7759/cureus.16795] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/31/2021] [Indexed: 11/08/2022] Open
Abstract
Introduction Cranioplasty is performed by placing an artificial plate in place of a patient's native skull bones to repair post-craniectomy defects after trauma. Implanted materials can range from titanium to synthetic polyether derivatives and are produced by multiple manufacturers. There are few studies characterizing complications associated with these cranioplasty plates to date. We aimed to quantify and categorize complications of these devices using a national federal database. Methods The Manufacturer and User Facility Device Experience (MAUDE) database was queried for all entries reported under the category "plate, cranioplasty, preformed, non-alterable" with the additional product code GXN between the time range from September 1, 2010, to September 1, 2020. After data extraction, each of the entries was screened for duplicates and tabulated into different categories of complications. Additionally, product information such as the plate manufacturer was extracted from each entry. Results The search yielded 329 unique event reports. The most frequent complications were infection (39%), followed by incorrectly fitting implants (30%) and implant breaks (6%). Other major complications included cerebrospinal fluid leakage and cerebral edema (5%), wound dehiscence (5%), and migration of hardware (3%). The brands associated with the most entries in the database were the Synthes (DePuy Synthes Companies, Massachusetts, United States) polyetheretherketone (PEEK) patient-specific implants (PSI) (57%), the Biomet (Zimmer Biome, Indiana, United States) hard tissue replacement-polyetherketoneketone (HTR-PEKK) patient-matched implant (PMI) (23%), and the AccuShape PEEK PSI (MedCAD, Dallas, USA) (5%). Conclusions Infection and improperly fitting implants appear to be the two most frequent complications of cranioplasty plates. The goals of future research should include the prevention of plate infections as well as improving techniques to custom-fit implantable devices.
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Affiliation(s)
| | - Neal A Patel
- Neurological Surgery, Mercer University School of Medicine, Savannah, USA
| | - Keri Jones
- Medicine, Dwight D. Eisenhower Army Medical Center, Augusta, USA
| | - Nikki B Ruh
- Medicine, Walter Reed National Military Medical Center, Bethesda, USA
| | | | - Mickey E Abraham
- Neurological Surgery, University of California San Diego, San Diego, USA
| | - Antonios Mammis
- Neurological Surgery, New York University Grossman School of Medicine, New York, USA
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Decision-Making in Adult Cranial Vault Reconstruction. Plast Reconstr Surg 2021; 148:109e-121e. [PMID: 34181619 DOI: 10.1097/prs.0000000000008058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
LEARNING OBJECTIVES After studying this article, the participant should be able to: 1. Define and classify different types of cranial defects 2. Compare both autologous and alloplastic options for reconstruction 3. Develop an optimal approach for cranial vault reconstruction in various clinical scenarios. SUMMARY Defects of the cranium result from various causes, including traumatic loss, neurosurgical intervention, skull tumors, and infection. Cranial vault reconstruction aims to restore both the structural integrity and surface morphology of the skull. To ensure a successful outcome, the choice of appropriate cranioplasty reconstruction will vary primarily based on the cause, location, and size of the defect. Other relevant factors that must be considered include adequacy of soft-tissue coverage, presence of infection, and previous or planned radiation therapy. This article presents an algorithm for the reconstruction of various cranial defects using both autologous and alloplastic techniques, with a comparison of their advantages and disadvantages.
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Translucent Customized Cranial Implants Made of Clear Polymethylmethacrylate: An Early Outcome Analysis of 55 Consecutive Cranioplasty Cases. Ann Plast Surg 2021; 85:e27-e36. [PMID: 33170582 DOI: 10.1097/sap.0000000000002441] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Large skull reconstruction, with the use of customized cranial implants, restores cerebral protection, physiologic homeostasis, and one's preoperative appearance. Cranial implants may be composed of either bone or a myriad of alloplastic biomaterials. Recently, patient-specific cranial implants have been fabricated using clear polymethylmethacrylate (PMMA), a visually transparent and sonolucent variant of standard opaque PMMA. Given the new enhanced diagnostic and therapeutic applications of clear PMMA, we present here a study evaluating all outcomes and complications in a consecutive patient series. METHODS A single-surgeon, retrospective, 3-year study was conducted on all consecutive patients undergoing large cranioplasty with clear PMMA implants (2016-2019). Patients who received clear PMMA implants with embedded neurotechnologies were excluded due to confounding variables. All outcomes were analyzed in detail and compared with previous studies utilizing similar alloplastic implant materials. RESULTS Fifty-five patients underwent cranioplasty with customized clear PMMA implants. Twenty-one (38%) were performed using a single-stage cranioplasty method (ie, craniectomy and cranioplasty performed during the same operation utilizing a prefabricated, oversized design and labor-intense, manual modification), whereas the remaining 34 (62%) underwent a standard, 2-stage reconstruction (craniectomy with a delayed surgery for cranioplasty and minimal-to-no implant modification necessary). The mean cranial defect size was 101.8 cm. The mean follow-up time was 9 months (range, 1.5-39). Major complications requiring additional surgery occurred in 7 patients (13%) consisting of 2 (4%) cerebrospinal fluid leaks, 2 (4%) epidural hematomas, and 3 (4%) infections. In addition, 3 patients developed self-limiting or nonoperative complications including 2 (4%) with new onset seizures and 1 (2%) with delayed scalp healing. CONCLUSIONS This is the first reported consecutive case series of cranioplasty reconstruction using customized clear PMMA implants, demonstrating excellent results with regard to ease of use, safety, and complication rates well below published rates when compared with other alloplastic materials. Clear PMMA also provides additional benefits, such as visual transparency and sonolucency, which is material specific and unavailable with autologous bone. Although these early results are promising, further studies with multicenter investigations are well justified to evaluate long-term outcomes.
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Cost-Effective Cranioplasty Utilizing 3D Printed Molds: A Canadian Single-Center Experience. Can J Neurol Sci 2021; 49:196-202. [PMID: 33818332 DOI: 10.1017/cjn.2021.57] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Cranioplasty is a commonly performed neurosurgical procedure used to repair defects of the cranial vault. For large defects, 3D printing allows for the creation of patient-specific synthetic cranioplasties. Although these implants provide excellent cosmetic results for patients, costs are quite high. This makes their routine use challenging in the current Canadian healthcare environment. The purpose of this study is to report our experience with a novel, cost-effective method for cranioplasty using desktop 3D printers to manufacture patient-specific molds to aid in the shaping of polymethyl methacrylate (PMMA) cranioplasty intraoperatively. METHODS A retrospective review of patients who underwent cranioplasty utilizing 3D printed custom molds was conducted at a single center between 2018 and 2020. Either a two-piece self-align or open-air mold was utilized. Material cost, as well as demographic, clinical, and radiologic data, was reviewed. A five-point ordinance scale was used to evaluate patient satisfaction with cosmesis. RESULTS Four patients had previous craniectomies with infected bone flaps, 2 patients had significant bony destruction from tumor invasion, and 1 patient had bone flap resorption. Three patients underwent an open-air mold technique with a Ti-mesh/PMMA-combined implant. The remaining 4 patients underwent two-piece mold with PMMA-only implant. All patients had 'Good' to 'Excellent' cosmetic outcome with one post-operative acute subdural hematoma and one post-operative infection. Two-piece mold resulted in improved cosmetic outcome and cost savings. CONCLUSIONS 3D printing can be used in a cost-effective manner to deliver good cranioplasty cosmesis. Wider adoption of this technique can result in significant healthcare cost savings without compromising patient outcome.
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Sun S, Jiao Z, Wang Y, Wu Z, Wang H, Ji Q, Liu Y, Wang Z, Zhang P. Porous polyetheretherketone microcarriers fabricated via hydroxylation together with cell-derived mineralized extracellular matrix coatings promote cell expansion and bone regeneration. Regen Biomater 2021; 8:rbab013. [PMID: 33763233 PMCID: PMC7975764 DOI: 10.1093/rb/rbab013] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 02/09/2021] [Accepted: 02/24/2021] [Indexed: 12/18/2022] Open
Abstract
Porous microcarriers have aroused increasing attention recently by facilitating oxygen and nutrient transfer, supporting cell attachment and growth with sufficient cell seeding density. In this study, porous polyetheretherketone (PEEK) microcarriers coated with mineralized extracellular matrix (mECM), known for their chemical, mechanical and biological superiority, were developed for orthopedic applications. Porous PEEK microcarriers were derived from smooth microcarriers using a simple wet-chemistry strategy involving the reduction of carbonyl groups. This treatment simultaneously modified surface topology and chemical composition. Furthermore, the microstructure, protein absorption, cytotoxicity and bioactivity of the obtained porous microcarriers were investigated. The deposition of mECM through repeated recellularization and decellularization on the surface of porous MCs further promoted cell proliferation and osteogenic activity. Additionally, the mECM coated porous microcarriers exhibited excellent bone regeneration in a rat calvarial defect repair model in vivo, suggesting huge potential applications in bone tissue engineering.
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Affiliation(s)
- Shuo Sun
- Department of Spine Surgery, The First Hospital of Jilin University, 1 Xinmin Street, Changchun 130021, China
- Key Laboratory of Polymer Ecomaterials, Changchun Institute of Applied Chemistry, Chinese Academy of Sciences, 5625 Renmin Street, Changchun 130022, China
| | - Zixue Jiao
- Key Laboratory of Polymer Ecomaterials, Changchun Institute of Applied Chemistry, Chinese Academy of Sciences, 5625 Renmin Street, Changchun 130022, China
| | - Yu Wang
- Key Laboratory of Polymer Ecomaterials, Changchun Institute of Applied Chemistry, Chinese Academy of Sciences, 5625 Renmin Street, Changchun 130022, China
| | - Zhenxu Wu
- Key Laboratory of Polymer Ecomaterials, Changchun Institute of Applied Chemistry, Chinese Academy of Sciences, 5625 Renmin Street, Changchun 130022, China
| | - Haowei Wang
- Department of Spine Surgery, The First Hospital of Jilin University, 1 Xinmin Street, Changchun 130021, China
| | - Qingming Ji
- Department of Spine Surgery, The First Hospital of Jilin University, 1 Xinmin Street, Changchun 130021, China
- Key Laboratory of Polymer Ecomaterials, Changchun Institute of Applied Chemistry, Chinese Academy of Sciences, 5625 Renmin Street, Changchun 130022, China
| | - Yi Liu
- Department of Spine Surgery, The First Hospital of Jilin University, 1 Xinmin Street, Changchun 130021, China
| | - Zongliang Wang
- Key Laboratory of Polymer Ecomaterials, Changchun Institute of Applied Chemistry, Chinese Academy of Sciences, 5625 Renmin Street, Changchun 130022, China
| | - Peibiao Zhang
- Key Laboratory of Polymer Ecomaterials, Changchun Institute of Applied Chemistry, Chinese Academy of Sciences, 5625 Renmin Street, Changchun 130022, China
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Takumi I, Akimoto M. Calcium Phosphate Cement "Space Fill-in" Augmentation in Autologous Cranioplasty for Large Cranial Defect: Additional Technical Consideration and Its Long-term Follow-up. Neurol Med Chir (Tokyo) 2021; 61:292-296. [PMID: 33642454 PMCID: PMC8048119 DOI: 10.2176/nmc.tn.2020-0363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
In the skull tumor surgery that requires a large cranial reconstruction, economical one-time surgery is challenging. Calcium phosphate paste (CPC) alone is not applied in the large defect. Other plastic fill-in materials have each drawback. Ready-made implants are costly. The authors present additional technique of CPC cranioplasty combined with mainstay autologous grafts for a large cranial defect. The combination of split rib grafts was augmented by CPC. Tenons were placed for the stability of grafts. Our newly additional technique is that CPC is filled in the small adjacent spaces of autografts, not applied as the simple on-lay graft. We introduced this method to a 57-year-old gentleman with left parietal expansile skull tumor. The aesthetics of the patient has been satisfactory, and there were no complaints about pain in the graft site. In the follow-up period of 8 years, both autologous grafts and CPC were well maintained without marked resorption. This patient could work as a farmer in this period. Our methods fulfilled the requirements of aesthetics and in-situ plasticity for a larger cranial defect.
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Affiliation(s)
- Ichiro Takumi
- Department of Neurosurgery, St. Marianna University School of Medicine
| | - Masataka Akimoto
- Department of Plastic Surgery, Nippon Medical School Chiba Hokuso Hospital
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30
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Surgical and Patient-Reported Outcomes in Patients With PEEK Versus Titanium Cranioplasty Reconstruction. J Craniofac Surg 2020; 32:193-197. [DOI: 10.1097/scs.0000000000007192] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Tecce MG, Othman S, Mauch JT, Nathan S, Tilahun E, Broach RB, Azoury SC, Kovach SJ. Complex oncologic resection and reconstruction of the scalp: Predictors of morbidity and mortality. Arch Craniofac Surg 2020; 21:229-236. [PMID: 32867412 PMCID: PMC7463124 DOI: 10.7181/acfs.2020.00206] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Accepted: 08/18/2020] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Oncologic resection of the scalp confers several obstacles to the reconstructive surgeon dependent upon patient-specific and wound-specific factors. We aim to describe our experiences with various reconstructive methods, and delineate risk factors for coverage failure and complications in the setting of scalp reconstruction. METHODS A retrospective chart review was conducted, examining patients who underwent resection of fungating scalp tumors with subsequent soft-tissue reconstruction from 2003 to 2019. Patient demographics, wound and oncologic characteristics, treatment modalities, and outcomes were recorded and analyzed. RESULTS A total of 189 patients were appropriate for inclusion, undergoing a range of reconstructive methods from skin grafting to free flaps. Thirty-three patients (17.5%) underwent preoperative radiation. In all, 48 patients (25.4%) suffered wound site complications, 25 (13.2%) underwent reoperation, and 47 (24.9%) suffered from mortality. Preoperative radiation therapy was an independent risk factor for wound complications (odds ratio [OR], 2.85; 95% confidence interval [CI], 1.1-7.3; p = 0.028) and reoperations (OR, 4.45; 95% CI, 1.5-13.2; p = 0.007). Similarly, the presence of an underlying titanium mesh was an independent predictor of wound complications (OR, 2.49; 95% CI, 1.1-5.6; p= 0.029) and reoperations (OR, 3.40; 95% CI, 1.2-9.7; p= 0.020). Both immunosuppressed status (OR, 2.88; 95% CI, 1.2-7.1; p= 0.021) and preoperative radiation therapy (OR, 3.34; 95% CI, 1.2-9.7; p= 0.022) were risk factors for mortality. CONCLUSION Both preoperative radiation and the presence of underlying titanium mesh are independent risk factors for wound site complications and increased reoperation rates following oncologic resection and reconstruction of the scalp. Additionally, preoperative radiation, along with an immunosuppressed state, may predict patient mortality following scalp resection and reconstruction.
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Affiliation(s)
- Michael G Tecce
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Sammy Othman
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Jaclyn T Mauch
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Shelby Nathan
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Estifanos Tilahun
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Robyn B Broach
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Saïd C Azoury
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Stephen J Kovach
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
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Delayed Infection Occurring Seventeen Years After Cranioplasty: Are Previously Implanted Materials Permanently Safe? J Craniofac Surg 2020; 31:472-474. [PMID: 31764555 DOI: 10.1097/scs.0000000000006052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Crainoplasty following decompressive craniotomy is widely applied clinically. Here, a 55-year-old male had clinical presentation of fever, headache, and ulceration at the anterior scalp of left ear, with 4 to 5 mL pus induction per day, where he accepted cranioplastic surgery 17 years ago using the material of medical silicone rubber. The results of experimental test and magnetic resonance imaging indicated a sign of infection. The authors reported a rarely delayed infection 17 years after cranioplastic surgery. The over long-term risks for the previously transplanted materials should be recognized.
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Latissimus Dorsi-Myocutaneous Flap in the Repair of Titanium Mesh Exposure and Scalp Defect After Cranioplasty. J Craniofac Surg 2020; 31:351-354. [PMID: 31764551 DOI: 10.1097/scs.0000000000006016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Titanium mesh was widely used for cranium defect repair but associated with high complication rates. In this study, the authors describe a method using latissimus dorsi-myocutaneous flap in the repair of titanium mesh exposure and scalp defect after cranioplasty, and the plate retaining is also achieved. Fifteen patients from April 2012 to May 2016 underwent this procedure, the age ranged from 32 to 62 years and 47 years old on average, and all the patient had plate exposure combined with surgical site infection and variation of scalp defect. All the patients had fully flap survive, and follow up ranged from 6 months to 24 months, 1 patient had titanium mesh re-expose and received additional operation to remove the plate. The free latissimus dorsi musculocutaneous flap could supply large size of bulky tissue coverage with good blood supply and strong anti-infection ability. This method was an option for retaining the titanium mesh and repairing the exposure for the mild infection with small size scalp defect patient.
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Free Flap Reconstruction of Complex Oncologic Scalp Defects in the Setting of Mesh Cranioplasty. J Craniofac Surg 2020; 31:1107-1110. [DOI: 10.1097/scs.0000000000006421] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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El Morsy OA, Barakat A, Mekhemer S, Mounir M. Assessment of 3-dimensional bone augmentation of severely atrophied maxillary alveolar ridges using patient-specific poly ether-ether ketone (PEEK) sheets. Clin Implant Dent Relat Res 2020; 22:148-155. [PMID: 32103625 DOI: 10.1111/cid.12890] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 11/27/2019] [Accepted: 02/12/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND This study aimed to analyze the effectiveness of virtually designed polyether-ether ketone (PEEK) sheets to delineate and maintains the three-dimensional patient's maxillary alveolar ridge. MATERIALS AND METHODS Fourteen patients (34 implants) with severely atrophied anterior maxillary alveolar ridges underwent rehabilitation using custom-made CAD/CAM PEEK sheets acting as a containment system for interpositional mix of particulate autogenous and xenogeneic bone graft, fixed by mono-cortical screws. Radiographic Assessment included measurements of linear changes in the vertical and horizontal dimensions on cross-sectional cuts of computed tomography (CBCT) using special software. RESULTS Wound healing was uneventful for all the patients except one patient that showed wound break down 2 weeks postoperatively, which did not affect the outcome of the procedure. CBCT scans were interpreted to compare the quantity of both vertical and horizontal bone preoperatively and 6 months postoperatively. Statistical analyses demonstrated a significant difference between the results of both time intervals, with a mean vertical and horizontal bone gain was 3.47 mm(±1.46) and 3.42 (±1.1) with a P-value of (.0001). The customized sheets were removed 6 months postoperative with the successful placement of dental implants. CONCLUSION The virtual planning of three-dimensional maxillary alveolar ridge augmentation utilizing patient-specific PEEK sheets deemed successful to restore the deficient ridge and to accommodate suitable size dental implants.
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Affiliation(s)
- Ola Alaa El Morsy
- Oral and Maxillofacial Surgery department, Future University, new Cairo, Egypt
| | - Ahmed Barakat
- Oral and Maxillofacial Surgery, Faculty of Dentistry, Cairo University.,Head of the Oral and maxillofacial surgery department, Future University, Cairo, Egypt
| | - Sameh Mekhemer
- Oral and Maxillofacial Surgery department, Future University, new Cairo, Egypt.,Oral and Maxillofacial Surgery, Faculty of Dentistry, Cairo University
| | - Mohamed Mounir
- Oral and Maxillofacial Surgery, Faculty of Dentistry, Cairo University
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Sharaf B, Asaad M, Banuelos J, Meaike J. Deformation of cranioplasty titanium mesh in a paediatric patient following head trauma. BMJ Case Rep 2019; 12:12/6/e230421. [PMID: 31189547 DOI: 10.1136/bcr-2019-230421] [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: 11/04/2022] Open
Abstract
Decompressive craniectomy is a life-saving procedure performed to treat intracranial hypertension caused by a variety of conditions. Subsequent cranioplasty reconstruction is needed for brain protection. Different alloplastic materials with different advantages and disadvantages are available for cranial reconstruction. We present the first case of a deformed titanium cranioplasty mesh in a paediatric patient following head trauma. Children who have undergone cranioplasty reconstruction should be counselled to wear a protective helmet when involved in contact sports or activities that may put their implant at risk of trauma.
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Affiliation(s)
- Basel Sharaf
- Department of Surgery, Division of Plastic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Malke Asaad
- Department of Surgery, Division of Plastic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Joseph Banuelos
- Department of Surgery, Division of Plastic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Jesse Meaike
- Department of Surgery, Division of Plastic Surgery, Mayo Clinic, Rochester, MN, USA
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