Customized alloplastic cranioplasty of large bone defects by 3D-printed prefabricated mold template after posttraumatic decompressive craniectomy: A technical note

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Abstract

Background:

Manufacturing of customized three-dimensional (3D)-printed cranioplastic implant after decompressive craniectomy has been introduced to overcome the difficulties of intraoperative implant molding. The authors present and discuss the technique, which consists of the prefabrication of silicone implant mold using additive manufacturing, also known as 3D printing, and polymethyl methacrylate (PMMA) implant casting.

Methods:

To reconstruct a large bone defect sustained after decompressive craniectomy due to traumatic brain injury (TBI), a 3D-printed prefabricated mold template was used to create a customized PMMA implant for cranial vault repair in five consecutive patients.

Results:

A superb restoration of the symmetrical contours and curvature of the cranium was achieved in all patients. The outcome was clinically and cosmetically favorable in all of them.

Conclusion:

Customized alloplastic cranioplasty using 3D-printed prefabricated mold for casting PMMA implant is easy to perform technique for the restoration of cranial vault after a decompressive craniectomy following moderate-to-severe TBI. It is a valuable and modern technique to advance manufacturing of personalized prefabricated cranioplastic implants used for the reconstruction of large skull defects having complex geometry. It is a safe and cost-effective procedure having an excellent cosmetic outcome, which may considerably decrease expenses and time needed for cranial reconstructive surgery.

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Most cited references 49

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3D modeling, custom implants and its future perspectives in craniofacial surgery

Jayanthi Parthasarathy (2014)

Custom implants for the reconstruction of craniofacial defects have gained importance due to better performance over their generic counterparts. This is due to the precise adaptation to the region of implantation, reduced surgical times and better cosmesis. Application of 3D modeling in craniofacial surgery is changing the way surgeons are planning surgeries and graphic designers are designing custom implants. Advances in manufacturing processes and ushering of additive manufacturing for direct production of implants has eliminated the constraints of shape, size and internal structure and mechanical properties making it possible for the fabrication of implants that conform to the physical and mechanical requirements of the region of implantation. This article will review recent trends in 3D modeling and custom implants in craniofacial reconstruction.

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Outcomes of cranial repair after craniectomy.

Victor Chang, M. F. Langlois, Asim Mahmood … (2010)

Hemicraniectomy is a commonly practiced neurosurgical intervention with a wide range of indications and clinical data supporting its use. The extensive use of this procedure directly results in more cranioplasties to repair skull defects. The complication rate for cranial repair after craniectomy seems to be higher than that of the typical elective craniotomy. This finding prompted the authors to review their experience with patients undergoing cranial repair. The authors performed a retrospective review of 212 patients who underwent cranial repair over a 13-year period at their institution. A database tracking age, presenting diagnosis, side of surgery, length of time before cranial repair, bone graft material used, presence of a ventricular shunt, presence of a postoperative drain, and complications was created and analyzed. The overall complication rate was 16.4% (35 of 213 patients). Patients 0-39 years of age had the lowest complication rate of 8% (p = 0.028). For patients 40-59 years of age and older than 60, complication rates were 20 and 26%, respectively. Patients who originally presented with traumatic injuries had a lower rate of complications than those who did not (10 vs 20%; p = 0.049). Conversely, patients who presented with tumors had a higher complication rate than those without (38 vs 15%; p = 0.027). Patients who received autologous bone graft placement had a statistically significant lower risk of postoperative infection (4.6 vs 18.4%; p = 0.002). Patients who underwent cranioplasty with a 0-3 month interval between operations had a complication rate of 9%, 3-6 months 18.8%, and > 6 months 26%. Pairwise comparisons showed that the difference between the 0-3 month interval and the > 6-month interval was significant (p = 0.007). The difference between the 0-3 month interval and the 4-6 month interval showed a trend (p = 0.07). No difference was detected between the 4-6 month interval and > 6-month interval (p = 0.35). The overall rate of complications related to cranioplasty after craniectomy is not negligible, and certain factors may be associated with increased risk. Therefore, when evaluating the need to perform a large decompressive craniectomy, the surgeon should also be aware that the patient is not only subject to the risks of the initial operation, but also the risks of subsequent cranioplasty.

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Long-term results following titanium cranioplasty of large skull defects.

Mario Cabraja, Martin Klein, Thomas-Nikolas Lehmann (2009)

Decompressive craniectomy is an established procedure to lower intracranial pressure. Therefore, cranioplasty remains a necessity in neurosurgery as well. If the patient's own bone flap is not available, the surgeon can choose between various alloplast grafts. A review of the literature proves that 4-13.8% of polymethylmethacrylate plates and 2.6-10% of hydroxyapatite-based implants require replacement. In this retrospective study of large skull defects, the authors compared computer-assisted design/computer-assisted modeled (CAD/CAM) titanium implants for cranioplasty with other frequently used materials described in literature. Twenty-six patients underwent cranioplasty with CAD/CAM titanium implants (mean diameter 112 mm). With the aid of visual analog scales, the patients' pain and cosmesis were evaluated 6-12 years (mean 8.1 years) after insertion of the implants. None of the implants had to be removed. Of all patients, 68% declared their outcomes as excellent, 24% as good, 0.8% as fair, and 0% as poor. There was no resulting pain in 84% of the patients, and 88% were satisfied with the cosmetic result, noting > 75 mm on the visual analog scale of cosmesis. All patients would have chosen cranioplasty again, stating an improvement in their quality of life by the calvarial reconstruction. Nevertheless, follow-up images obtained in 4 patients undergoing removal of meningiomas was only suboptimal. With the aid of CAD technology, all currently used alloplastic materials are suited even for large skull defect cranioplasty. Analysis of the authors' data and the literature shows that cranioplasty with CAD/CAM titanium implants provides the lowest rate of complications, reasonable costs, and acceptable postoperative imaging. Polymethylmethacrylate is suited for primary cranioplasty or for long-term follow-up imaging of tumors. Titanium implants seem to be the material of choice for secondary cranioplasty of large skull defects resulting from decompressive craniectomy after trauma or infarction. Expensive HA-based ceramics show no obvious advantage over titanium or PMMA.

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Author and article information

Contributors

Bruno Splavski

Goran Lakicevic

Marko Kovacevic

Damir Godec

Journal

Journal ID (nlm-ta): Surg Neurol Int

Journal ID (iso-abbrev): Surg Neurol Int

Title: Surgical Neurology International

Publisher: Scientific Scholar (USA )

ISSN (Print): 2229-5097

ISSN (Electronic): 2152-7806

Publication date Collection: 2022

Publication date (Electronic): 22 April 2022

Volume: 13

Electronic Location Identifier: 169

Affiliations

[1 ]Department of Neurosurgery, Sestre milosrdnice University Hospital Center, Zagreb, Croatia,

[2 ]Department of Neurosurgery, Mostar University Hospital, Mostar, Bosnia and Herzegovina, Osijek, Croatia

[3 ]Department of Neurosurgery, Osijek University Hospital Center, Osijek, Croatia

[4 ]Department of Technology, Chair of Polymer Processing, Faculty of Mechanical Engineering and Naval Architecture, University of Zagreb, Zagreb, Croatia.

Author notes

[* ] Corresponding author: Bruno Splavski, Department of Neurosurgery, Sestre milosrdnice University Hospital Center, Zagreb, Croatia. splavuno@ 123456gmail.com

Article

Publisher ID: 10.25259/SNI_1239_2021

DOI: 10.25259/SNI_1239_2021

PMC ID: 9062916

PubMed ID: 35509538

SO-VID: 7b16e8f7-6ce6-4a2d-af5d-ac4df83bfb24

License:

This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

Customized alloplastic cranioplasty of large bone defects by 3D-printed prefabricated mold template after posttraumatic decompressive craniectomy: A technical note

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Abstract

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Most cited references 49

3D modeling, custom implants and its future perspectives in craniofacial surgery

Outcomes of cranial repair after craniectomy.

Long-term results following titanium cranioplasty of large skull defects.

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