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Table of Contents    
COMMENTARY
Year : 2021  |  Volume : 69  |  Issue : 3  |  Page : 618-619

Novel Solutions to Cranioplasty: From Exchange Cranioplasty to Synthetic Patient-Specific Implants


Professor of Neurosurgery, Department of Neurosurgery, AIIMS, Delhi, India

Date of Submission02-Jun-2021
Date of Decision02-Jun-2021
Date of Acceptance02-Jun-2021
Date of Web Publication24-Jun-2021

Correspondence Address:
Dr. Deepak Gupta
Department of Neurosurgery, AIIMS, Delhi 110029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.319242

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How to cite this article:
Gupta D. Novel Solutions to Cranioplasty: From Exchange Cranioplasty to Synthetic Patient-Specific Implants. Neurol India 2021;69:618-9

How to cite this URL:
Gupta D. Novel Solutions to Cranioplasty: From Exchange Cranioplasty to Synthetic Patient-Specific Implants. Neurol India [serial online] 2021 [cited 2021 Jul 28];69:618-9. Available from: https://www.neurologyindia.com/text.asp?2021/69/3/618/319242




Gopal S et al. in their publication entitled Customized and cost-effective 3D printed mould for cranioplasty: India's first single-centre experience has documented a cost-effective cranioplasty technique in 25 cases using CAD and 3D printing technology gives ideal cosmetic effect in patients where the autologous bone was not available (previous infection and flap resorption was noted in 72% cases).[1] The mean time to manufacture 3D printed template was <16 hrs. Authors obtained good outcomes in the visual analogue score for cosmesis (Mean VASC 8.2)

Partibhan et al. developed a prosthesis construct made up of polymethyl Metha acrylate from the replica of the custom template produced by Rapid Prototyping Technology, using the data of 3D-CT scan images and 2 mm CT cuts in 2004.[2]

Alloplastic reconstruction is routinely done in cases where the viable autologous bone is not available. A similar novel, economic, patient-specific, 3D printing-assisted and heat polymerized PMMA cranioplasty fabrication technique with an accuracy comparable to that of patient-specific titanium and PEEK cranioplasty was developed earlier too.[3]

We have guidelines on decompressive craniectomy, we have now living guidelines on TBI (traumatic brain injury) management for the past two and half decades, but we do not have any guidelines on Cranioplasty post decompressive craniectomy. A very high incidence of bone resorption and re-do cranioplasties noted in high volume trauma centres.[4] Lately, a group of experts discussed indications and technique, materials, timings, hydrocephalus and pediatric cranioplasties aiming to develop consensus-based evidence on cranioplasties.[5] The consensus group recommended the use of 3D planning techniques when available and usage of custom made implants for cosmetic results as bone grafts carry a high risk of resorption.[4] In children, autologous bone is preferred for all age groups[5],[6] [Figure 1]. However, in children more than three years of age, a synthetic material can be used if osteoconductive material is not available.
Figure 1: (a) 3D printed skull defect mould with customized final finished cranial PMMA prosthesis. (b) Virtual anatomic reconstruction 3D image of a said skull with cranial defect generated from DICOM data using 3D Slicer software. (c) Final mould after removal of unwanted parts of the mirrored model. The orange-coloured part is the part of mirrored model forming the base of the cranial defect to create the mould and the green part is the original virtual model. (d) 3D printed skull defect mould with customised final finished cranial PMMA prosthesis. (e) Intraoperative fit of the 3D customised PMMA cranioplasty implant on patients head. (f) Bifrontal PSI PEEK Cranioplasty showing development on CAD model, intraoperative pictures and final construct in situ. (g) Showing exchange cranioplasty using autologous bone in children

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PMMA (Polymethylmethacrylate) is a non-absorbable, radiolucent, inert, and common alloplastic material for cranioplasties. In resource strained setups, liquid PMMA (easily mouldable, inexpensive) is very commonly used for cranioplasties but associated with the issue of exothermic reaction during polymerisation, surgeon dependency of intraoperative preparation, toxic fumes release during preparation. 3D solid customised using CAD technology eliminates the disadvantage of liquid PMMA [Figure 1].

HA (Porous Hydroxyapatite) implants are both osteoconductive and biocompatible (absence of host immune reaction or systemic/local toxicities) but has a high risk of prosthesis fracture owing to their porous structure.

PSA-PEEK (Patient-Specific implant- Polyetheretheketone) 3D implant is inert, durable and mechanically sound cranioplasty material and gives excellent cosmetic fits but five times more expensive than PMMA/HA CP implants [Figure 1].



 
  References Top

1.
Gopal S, Rudrappa S, Sekar A, Preethish-Kumar V, Masapu D. Customized and Cost-Effective 3D Printed Mold for Cranioplasty: India's First Single Center Experience. Neurol India 2021;69:611-7.  Back to cited text no. 1
  [Full text]  
2.
Parthiban JKBC, Abirami O, Murugan AM, Radhakrishnan R. Custom cranioplasty using rapid prototyping technology. Neurol India 2004;52:520.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Lal B, Ghosh M, Agarwal B, Gupta D, Roychoudhury A. A novel economically viable solution for 3D printing-assisted cranioplasty fabrication. Br J Neurosurg 2020;34:280-3.  Back to cited text no. 3
    
4.
Basheer N, Gupta D, Mahapatra AK, Gurjar H. Cranioplasty following decompressive craniectomy in traumatic brain injury: Experience at level-I apex trauma centre. Ind J Neurotrauma 2010;7:139-44.  Back to cited text no. 4
    
5.
Iaccarino C, Kolias A, Adelson PD, Rubiano AM, Viaroli E, Buki A, et al. Consensus statement from the international consensus meeting on post-traumatic cranioplasty. Acta Neurochirurgica 2021;163:423-40.  Back to cited text no. 5
    
6.
Prasad GL, Gupta DK, Mahapatra AK, Borkar SA, Sharma BS. Surgical results of growing skull fractures in children: A single centre study of 43 cases. Childs Nerv Syst 2015;31:269-77.  Back to cited text no. 6
    


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