Recent advances in the reconstruction of cranio-maxillofacial defects using computer-aided design/computer-aided manufacturing
© The Author(s). 2018
Received: 30 December 2017
Accepted: 16 January 2018
Published: 5 February 2018
With the development of computer-aided design/computer-aided manufacturing (CAD/CAM) technology, it has been possible to reconstruct the cranio-maxillofacial defect with more accurate preoperative planning, precise patient-specific implants (PSIs), and shorter operation times. The manufacturing processes include subtractive manufacturing and additive manufacturing and should be selected in consideration of the material type, available technology, post-processing, accuracy, lead time, properties, and surface quality. Materials such as titanium, polyethylene, polyetheretherketone (PEEK), hydroxyapatite (HA), poly-DL-lactic acid (PDLLA), polylactide-co-glycolide acid (PLGA), and calcium phosphate are used. Design methods for the reconstruction of cranio-maxillofacial defects include the use of a pre-operative model printed with pre-operative data, printing a cutting guide or template after virtual surgery, a model after virtual surgery printed with reconstructed data using a mirror image, and manufacturing PSIs by directly obtaining PSI data after reconstruction using a mirror image. By selecting the appropriate design method, manufacturing process, and implant material according to the case, it is possible to obtain a more accurate surgical procedure, reduced operation time, the prevention of various complications that can occur using the traditional method, and predictive results compared to the traditional method.
The reconstruction of complex cranio-maxillofacial defects is challenging due to the unique anatomy, the presence of a vital structure, and the variety of deficits [1, 2]. The reconstruction of congenital or acquired cranio-maxillofacial defects due to congenital abnormalities, post-trauma, tumor resection, and infection requires both functional and esthetic considerations [3, 4].
Computer-aided design (CAD) is the process of creating, modifying, analyzing, or optimizing a design using computer system. Computer-aided manufacturing (CAM) is the process of planning, managing, or controlling manufacturing using computer system .
The advantages of CAD/CAM technology include improved accuracy of esthetic results, restoration of large and geometrically complex anatomical defects, reduction of operative times, more accurate fitting of implants, overcoming the disadvantages of autogenous bone grafts, and performing resection and reconstruction in one step [10, 11]. The 3D printing technique in the cranio-maxillofacial area surgery includes contour models that are accurate replicas of patient-specific anatomy, guides that are patient-specific templates that guide precise cutting and drilling, splints defined as the replica of the virtual post-operative position of the patient structure, and implants defined as three-dimensionally printed objects that are directly implanted in the patients [12, 13].
In this paper, we will discuss the manufacturing processes using CAD/CAM, implant materials, the workflow reconstructing the cranio-maxillofacial defects, and future directions of development.
The manufacturing processes
The manufacturing processes include subtractive manufacturing, which cuts off a piece of material to form the final shape, and additive manufacturing, which builds up the material by stacking . Subtractive manufacturing, the traditional machining technique has the disadvantage in that it is difficult to make complicated shapes by computer numerical control (CNC) milling and there is a lot of material waste .
There are various kinds of manufacturing processes. The manufacturing process should be selected with consideration of the material type, available technology, post-processing, accuracy, lead time, properties, and surface quality .
The ideal material is biocompatible, easy to shape, high strength, non-toxic, inexpensive, durable, radiolucent, and lightweight [8, 22]. However, no material satisfies these conditions [22–24]. Materials include non-resorbable materials such as titanium, polyethylene, polyether ether ketone (PEEK), and hydroxyapatite (HA) and absorbable materials such as poly-DL-lactic acid (PDLLA), polylactide-co-glycolide acid (PLGA), and calcium phosphate.
Titanium is the metal of choice for manufacturing implants. It has the advantages of high strength, biocompatibility, lightweight, corrosion resistance, and the potential for osseointegration [8, 25, 26]. However, it has the disadvantage of causing scatter artifacts in CT scans .
Polyethylene includes porous polyethylene (PPE) and ultra-high molecular weight polyethylene (UHMW-PE). PPE such as Medpor (Pufex Surgical Inc., College Park, GA, USA) was used for reconstruction of the orbital floor and augmentation of the facial area . PPE is very stable and easy to shape and has tissue ingrowth through its pores [29, 30]. However, there is a possibility of infection . UHMW-PE was used for reconstruction of orbit or temporomandibular joint by making PSIs using CAD/CAM [31, 32]. Because of a solid structure, UHMW-PE can have a lower infection rate than PPE . Polyethylene has the advantage of not producing artifact because of radiolucency in CT, but it also has a disadvantage that it is difficult to control implant position after surgery [3, 32].
PEEK was used to reconstruct various craniofacial bone defects including cranioplasty [23, 33]. PEEK has similar strength and elasticity to bone and is easy to modify . It is radiolucent in CT and offers more comfort to patients, with lower thermal conductivity and lighter weight than titanium. However, it had reports of infection and foreign body reaction .
HA is used as a biocompatible scaffolding material for bone tissue engineering . It is osteoconductive and non-resorbable and shows tissue in-growth in the presence of pores, with a strong capacity to bind both hard and soft tissues . Pure HA is low in viscosity and difficult to make complex shapes, but it can be overcome with custom-made HA using CAD/CAM [37, 38].
As absorbable implants, PDLLA and PLGA are commonly used, especially in pediatric craniofacial surgery . However, foreign body reaction and the weakness of materials such as screw fracture have been reported [40, 41]. There are cases in which calcium phosphate implants have been used for the reconstruction of cranio-maxillofacial defects . These printed calcium phosphate implants have good biocompatibility and suitable biodegradation and are similar to the mineral phase of the bone, so they do not cause artifacts or interference seen in other metallic alloplasts in CT or MRI. In addition, calcium phosphate implants show less mechanical performance than titanium but are suitable as a scaffold for bone tissue growth and can be loaded with bioactive protein or antibiotics.
The modeling software used for 3D printing includes Mimics (Materialise, Leuven, Belgium), SolidWorks (Dassault Systemes, Velizy-Villacoublay, France), Amira (FEI Visualization Sciences Group, Merignac, France), Rhino (Robert McNeel & Associates, Seattle, WA, USA), and SurgiCase CMF (Materialise, Leuven, Belgium). The printing software include ZPrinter and Projet (3D Systems, Rock Hill, SC, USA) and Alaris (Objet Limited, Rehovot, Israel) .
After performing virtual surgery, including resection and reconstruction in the pre-operative image, printing of a resection guide or fabrication of the template by printing the skull model with virtual surgery [49, 50]
After printing of the skull model reconstructed symmetrically using a mirror image of the unaffected side, pre-bending of the plate, using it as a template, or fabrication of the implant directly on the skull model [51–53]
After reconstruction symmetrically using a mirror image of the unaffected side and design of the 3D implant to fit precisely to the defect, fabrication of the PSI by transferring the PSI data to CAM software [3, 8, 32, 54–57]
Digital workflows are time consuming and cannot be used for emergency procedures such as immediate post-traumatic surgery . It takes from a few days to weeks to make the PSI outside the hospital . However, with the development of 3D printers, relatively inexpensive personalized 3D printers have been introduced and the accuracy has increased, making it possible to manufacture products inside the hospital, reducing the time required. In addition, the development of professional CAD software familiar to surgeons and minimally invasive surgical procedures will provide predictable results.
By selecting the appropriate design method, manufacturing process, and implant material according to the case, it is possible to obtain a more accurate procedure, reduced surgical time, the prevention of various complications that can occur using the traditional method, and predictive results compared to the traditional method.
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