Patient-specific biodegradable implant in pediatric craniofacial surgery

Patient-specific implants made of 3D printed bioresorbable polymers at the point-of-care: material, technology, and scope of surgical application

BACKGROUND

Bioresorbable patient-specific additive-manufactured bone grafts, meshes, and plates are emerging as a promising alternative that can overcome the challenges associated with conventional off-the-shelf implants. The fabrication of patient-specific implants (PSIs) directly at the point-of-care (POC), such as hospitals, clinics, and surgical centers, allows for more flexible, faster, and more efficient processes, reducing the need for outsourcing to external manufacturers. We want to emphasize the potential advantages of producing bioresorbable polymer implants for cranio-maxillofacial surgery at the POC by highlighting its surgical applications, benefits, and limitations.

METHODS

This study describes the workflow of designing and fabricating degradable polymeric PSIs using three-dimensional (3D) printing technology. The cortical bone was segmented from the patient's computed tomography data using Materialise Mimics software, and the PSIs were designed created using Geomagic Freeform and nTopology software. The implants were finally printed via Arburg Plastic Freeforming (APF) of medical-grade poly (L-lactide-co-D, L-lactide) with 30% β-tricalcium phosphate and evaluated for fit.

RESULTS

3D printed implants using APF technology showed surfaces with highly uniform and well-connected droplets with minimal gap formation between the printed paths. For the plates and meshes, a wall thickness down to 0.8 mm could be achieved. In this study, we successfully printed plates for osteosynthesis, implants for orbital floor fractures, meshes for alveolar bone regeneration, and bone scaffolds with interconnected channels.

CONCLUSIONS

This study shows the feasibility of using 3D printing to create degradable polymeric PSIs seamlessly integrated into virtual surgical planning workflows. Implementing POC 3D printing of biodegradable PSI can potentially improve therapeutic outcomes, but regulatory compliance must be addressed.

Titanium or Biodegradable Osteosynthesis in Maxillofacial Surgery? In Vitro and In Vivo Performances

Osteosynthesis systems are used to fixate bone segments in maxillofacial surgery. Titanium osteosynthesis systems are currently the gold standard. However, the disadvantages result in symptomatic removal in up to 40% of cases. Biodegradable osteosynthesis systems, composed of degradable polymers, could reduce the need for removal of osteosynthesis systems while avoiding the aforementioned disadvantages of titanium osteosyntheses. However, disadvantages of biodegradable systems include decreased mechanical properties and possible foreign body reactions. In this review, the literature that focused on the in vitro and in vivo performances of biodegradable and titanium osteosyntheses is discussed. The focus was on factors underlying the favorable clinical outcome of osteosyntheses, including the degradation characteristics of biodegradable osteosyntheses and the host response they elicit. Furthermore, recommendations for clinical usage and future research are given. Based on the available (clinical) evidence, biodegradable copolymeric osteosyntheses are a viable alternative to titanium osteosyntheses when applied to treat maxillofacial trauma, with similar efficacy and significantly lower symptomatic osteosynthesis removal. For orthognathic surgery, biodegradable copolymeric osteosyntheses are a valid alternative to titanium osteosyntheses, but a longer operation time is needed. An osteosynthesis system composed of an amorphous copolymer, preferably using ultrasound welding with well-contoured shapes and sufficient mechanical properties, has the greatest potential as a biocompatible biodegradable copolymeric osteosynthesis system. Future research should focus on surface modifications (e.g., nanogel coatings) and novel biodegradable materials (e.g., magnesium alloys and silk) to address the disadvantages of current osteosynthesis systems.

Biological Characterization of Polymeric Matrix and Graphene Oxide Biocomposites Filaments for Biomedical Implant Applications: A Preliminary Report

Carbon nanostructures application, such as graphene (Gr) and graphene oxide (GO), provides suitable efforts for new material acquirement in biomedical areas. By aiming to combine the unique physicochemical properties of GO to Poly L-lactic acid (PLLA), PLLA-GO filaments were produced and characterized by X-ray diffraction (XRD). The in vivo biocompatibility of these nanocomposites was performed by subcutaneous and intramuscular implantation in adult Wistar rats. Evaluation of the implantation inflammatory response (21 days) and mesenchymal stem cells (MSCs) with PLLA-GO took place in culture for 7 days. Through XRD, new crystallographic planes were formed by mixing GO with PLLA (PLLA-GO). Using macroscopic analysis, GO implanted in the subcutaneous region showed particles' organization, forming a structure similar to a ribbon, without tissue invasion. Histologically, no tissue architecture changes were observed, and PLLA-GO cell adhesion was demonstrated by scanning electron microscopy (SEM). Finally, PLLA-GO nanocomposites showed promising results due to the in vivo biocompatibility test, which demonstrated effective integration and absence of inflammation after 21 days of implantation. These results indicate the future use of PLLA-GO nanocomposites as a new effort for tissue engineering (TE) application, although further analysis is required to evaluate their proliferative capacity and viability.

A Novel Technique to Secure the Skull Post in a Thin Skull Allowing for Surgical Navigation in Infants

Several surgical procedures have been described to correct the deformities associated with craniosynostosis. To simplify the prediction of results, virtual planning techniques and image-guided surgery have been used. Digital planning can be transferred to the operating room using osteotomy and cutting guides or surgical navigation. We describe a novel bone fixation method that allows for anchoring of a cranial dynamic reference frame (DRF) in a steady manner. DRF can be used for registration and as a reference for surgical navigation in an infant's skull. We describe this novel technique to overcome the problems of DRF fixation on an infant's thin and weak calvarium. We fixed the DRF to the cranium using this new system. A 6-hole X-shaped miniplate was placed using 5 screws, leaving 1 of the central holes free. The self-drilling screw that anchors the DRF in position was placed in the free central hole, avoiding calvarial bone breakage and allowing for surgical navigation. To the best of our knowledge, the present study is the first report of this DRF anchorage modification for surgical navigation during surgery of craniosynostosis in an infant.

[CAD/CAM Revolution in Craniofacial Reconstruction]

CAD/CAM Revolution in Craniofacial Reconstruction Abstract. The face is an important part of the personality and at the same time fulfils a variety of tasks. Aesthetics and function form a unique unit. The formation of the field of oral and maxillofacial surgery began in the first decades of the last century. It includes the prevention, diagnosis, therapy and rehabilitation of diseases, injuries, malformations and changes of the complex structures of the face, oral cavity, jaw and teeth. In the meantime, oral and maxillofacial surgery has arrived in the 21st century. Today's oral and maxillofacial surgery is a link between medicine and dentistry and a protagonist in the implementation of digital workflows in clinical care. Individual solutions with patient-specific implants are the rule, computer-assisted techniques support the surgeon in the planning and performing of surgical procedures. This article intends to give you an insight into how our patients benefit from advanced technologies.

Recent advances in the reconstruction of cranio-maxillofacial defects using computer-aided design/computer-aided manufacturing

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.

Effect of Injection Molding Melt Temperatures on PLGA Craniofacial Plate Properties during In Vitro Degradation

The purpose of this article is to present mechanical and physicochemical properties during in vitro degradation of PLGA material as craniofacial plates based on different values of injection molded temperatures. Injection molded plates were submitted to in vitro degradation in a thermostat bath at 37 ± 1°C by 16 weeks. The material was removed after 15, 30, 60, and 120 days; then bending stiffness, crystallinity, molecular weights, and viscoelasticity were studied. A significant decrease of molecular weight and mechanical properties over time and a difference in FT-IR after 60 days showed faster degradation of the material in the geometry studied. DSC analysis confirmed that the crystallization occurred, especially in higher melt temperature condition. DMA analysis suggests a greater contribution of the viscous component of higher temperature than lower temperature in thermomechanical behavior. The results suggest that physical-mechanical properties of PLGA plates among degradation differ per injection molding temperatures.

Effect of Injection Molding Melt Temperatures on PLGA Craniofacial Plate Properties during In Vitro Degradation

The purpose of this article is to present mechanical and physicochemical properties during in vitro degradation of PLGA material as craniofacial plates based on different values of injection molded temperatures. Injection molded plates were submitted to in vitro degradation in a thermostat bath at 37 ± 1°C by 16 weeks. The material was removed after 15, 30, 60, and 120 days; then bending stiffness, crystallinity, molecular weights, and viscoelasticity were studied. A significant decrease of molecular weight and mechanical properties over time and a difference in FT-IR after 60 days showed faster degradation of the material in the geometry studied. DSC analysis confirmed that the crystallization occurred, especially in higher melt temperature condition. DMA analysis suggests a greater contribution of the viscous component of higher temperature than lower temperature in thermomechanical behavior. The results suggest that physical-mechanical properties of PLGA plates among degradation differ per injection molding temperatures.