Is Polyetheretherketone an Effective Alloplastic Material in Comparison to Titanium in Calvarial Reconstruction.

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.

Successful prosthetic salvage of a suboptimal autogenous auricular reconstruction with digital technologies: A report of 3 challenging treatments.

The surgical reconstruction of congenitally missing or malformed ears is challenging and involves complicated surgeries. Ear shape, position, and skin color will likely be compromised in patients with relative anatomic symmetry, and it is easier to reproduce these features with a prosthesis. This article describes the prosthetic reconstruction of 3 patients who had received failed or suboptimal surgical reconstruction of their missing or deformed ears. Challenging characteristics included limited soft-tissue availability, skeletal hypoplasia with prominent concavity defect, and bilaterally missing ears with abnormally low hairline. Three-dimensional planning using a software program was used to determine the ideal implant locations and mirror the contralateral ear. The mirrored ear was 3-dimensionally printed with a stereolithography printer. The skin color was reproduced digitally by using the Spectromatch Pro system.

Contemporary Review on Craniectomy and Cranioplasty; Part 1: Decompressive Craniectomy.

ABSTRACT: This paper aims to review clinical benefits of decompressive craniectomy (DC) in both adult and paediatric populations; its indications and factors contributing to its postoperative success. The Glasgow Outcome Scale and the Modified Rankin Scale are the most commonly used scales to assess the long-term outcome in patients post DC. In adult traumatic brain injury patients, 2 randomized clinical trials were carried out; DECRA (Decompressive Craniectomy in Diffuse Traumatic Brain Injury) and RESCUEicp (Randomised Evaluation of Surgery with Craniectomy for Uncontrollable Elevation of inter cranial pressure) employing collectively 555 patients. Despite the differences in these trials, their initial results affirm DC can lead to reduced mortality and more favorable outcomes. In ischemic stroke adult patients, different clinical trials of HAMLET (Dutch trial of Hemicraniectomy after middle cerebral artery infarction with life-threatening Edema), DESTINY (German trial of Decompressive Surgery for the treatment of Malignant Infarct of the Middle Cerebral Artery), and DECIMAL (French trial of Decompressive Craniectomy in Malignant Middle Cerebral Artery Infarcts) suggested that DC improves survival compared with best medical management, but with an increased proportion of treated individuals surviving with moderate or severe disability. With regard to the size of bone to be removed, the larger the defect the better the results with a minimum diameter of 11 to 12 cm of bone flap. Cranioplasty timing varies and ranges from 6 weeks to more than 12 months post DC, depending on completion of medical treatment, clinical recovery, resolution of any infection, and an evaluation of soft tissues at the defect site.

Contemporary Review on Craniectomy and Cranioplasty; Part 2: Material Selection and Plate Manufacture.

ABSTRACT: Cranioplasty materials include metals (ie, titanium); ceramics (ie, hydroxyapatite); polymers (ie, poly-methyl-metha-acrylate [PMMA]); and plastics (ie, polyether ether ketone). This paper aims to review their advantages and drawbacks. No ideal material currently exist, however, titanium implants are universally agreed to have lower infection rates than those reported for hydroxyapatite and PMMA implants; thus justifying their current wide use. These implants can be manufactured conventionally from medical grade titanium alloy Ti64 (titanium-aluminum-vanadium) in the form of plates ranging in thickness from 0.5 to 0.7 mm thick, or following the computer-aided design/manufacture principle. Surface finish of these implants is best achieved by electroplating.

Developing an In-house Interdisciplinary Three-Dimensional Service: Challenges, Benefits, and Innovative Health Care Solutions.

Three-dimensional printing (3DP) technologies have been employed in regular medical specialties. They span wide scope of uses, from creating 3D medical models to design and manufacture of Patient-specific implants and guidance devices which help to optimize medical treatments, patient education, and medical training. This article aims to provide an in-depth analysis of factors and aspects to consider when planning to setup a 3D service within a hospital serving various medical specialties. It will also describe challenges that might affect 3D service development and sustainability and describe representative cases that highlight some of the innovative approaches that are possible with 3D technology. Several companies can offer such 3DP service. They are often web based, time consuming, and requiring special call conference arrangements. Conversely, the establishment of in-house specialized hospital-based 3D services reduces the risks to personal information, while facilitating the development of local expertise in this technology. The establishment of a 3D facility requires careful consideration of multiple factors to enable the successful integration with existing services. These can be categorized under: planning, developing and sustaining 3D service; 3D service resources and networking workflow; resources and location; and 3D services quality and regulation management.

Survey of Ocular Prosthetics Rehabilitation in the United Kingdom, Part 2: Anophthalmic Patients' Satisfaction and Acceptance.

AIM: Ocular prostheses are integral for anophthalmic patients. Part 1 of this study reported that patients' aetiology, opinions, and attitudes significantly affected their prosthetic eyes experience. Part 2 investigates the patient satisfaction and acceptance in light of some of the aetiological demographics reported in Part 1. METHODOLOGY: One hundred sixty questionnaires were delivered to anophthalmic patients attending oculoplastic clinic. Etiological aspects presented in the questionnaire were disseminated in part 1. Patient satisfaction was assessed through 8 closed-end statements reflecting aspects concerning patient's views on prosthesis comfort and appearance; patient's expectations, self-esteem, and perception; and cooperation with ocularist. Each statement had 3 categories as agree, moderately agree, and disagree. A total of 126 questionnaires were returned (response rate was 78.8%). Data was analyzed using SPSS software. Association coefficients and correlations between variables were also analyzed. RESULTS: Total number of responses for the 8 statements was 888, averaging of 111 (expected 126) respondent per statement. Overall, 95.4% of our patients agreed with all satisfaction statements presented echoing very high satisfaction rate with their ocular prosthetics. Having an eye replacement that covers the defect is associated with high satisfaction among patients regardless of ocular prosthetic type. Patient acceptance of prosthesis in relation to employment status was high but not the same among the different categories (P > 0.05). High satisfaction with ocular prosthetics was prevalent among both genders, but there were no statistically significant differences in percentages of agreement in all statements (P > 0.05). Satisfaction and acceptance with ocular prosthetics was the same among all age groups of 12 to 85 years old (P > 0.05). CONCLUSIONS: The patient satisfaction is associated with the interplay of different variables that is related to ocular prosthesis design and its ability to disguise disfigurement (ie, prosthesis shape, resemblance to existing contra-lateral eye, etc.); patients themselves (ie, gender, age, occupation, marital status, etc); and psychological well-being and social support provided. Anophthalmic patients of the north west of England are significantly happy with their ocular prosthetic rehabilitation and support they receive from their regional hospital. Ocular prosthetics enhances their psychological well-being and social interaction and factors like patients' sex, age, employment status, and type of ocular prosthesis have no effect on their acceptance and satisfaction.

Novel Treatment Planning of Hemimandibular Hyperplasia by the Use of Three-Dimensional Computer-Aided-Design and Computer-Aided-Manufacturing Technologies.

RATIONALE AND AIM: Hemimandibular hyperplasia is characterized by an obvious overgrowth in the size of the mandible on one side, which can extend up to the midline causing facial asymmetry. Surgical resection of the overgrowth depends heavily on the skill and experience of the surgeon. This report describes a novel methodology of applying three-dimensional computer-aided-design and computer-aided-manufacturing principles in improving the outcome of surgery in 2 mandibular hyperplasia patients. METHODOLOGY: Both patients had their cone beam computer tomography (CBCT) scan performed. CMF Pro Plan software (v. 2.1) was used to process the scan data into virtual 3-dimensional models of the maxilla and mandible. Head tilt was adjusted manually by following horizontal reference. Facial asymmetry secondary to mandibular hypertrophy was obvious on frontal and lateral views. Simulation functions were followed including mirror imaging of the unaffected mandibular side into the hyperplastic side and position was optimized by translation and orientation functions. Reconstruction of virtual symmetry was assessed and checked by running 3-dimensional measurements. Then, subtraction functions were used to create a 3-dimensional template defining the outline of the lower mandibular osteotomy needed. Precision of mandibular teeth was enhanced by amalgamating the CBCT scan with e-cast scan of the patient lower teeth. 3-Matic software (v. 10.0) was used in designing cutting guide(s) that define the amount of overgrowth to be resected. The top section of the guide was resting on the teeth hence ensuring stability and accuracy while positioning it. The guide design was exported as an .stl file and printed using in-house 3-dimensional printer in biocompatible resin. CONCLUSION: Three-dimensional technologies of both softwares (CMF Pro Plan and 3-Matic) are accurate and reliable methods in the diagnosis, treatment planning, and designing of cutting guides that optimize surgical correction of hemimandibular hyperplasia at timely and cost-effect manner.

Survey of Ocular Prosthetics Rehabilitation in the United Kingdom, Part 1: Anophthalmic Patients' Aetiology, Opinions, and Attitudes.

PURPOSE: Ocular prostheses are constructed to aid cosmetic, functional, and psychological rehabilitation of anophthalmic patients. Part-1 of this study aimed to evaluate anophthalmic patients' opinions, attitudes, and experience about aspects related to their postfit ocular prostheses. METHODS: One hundred sixty questionnaires were delivered to anophthalmic patients inquiring about different information such as age, gender, occupation, eye-loss cause, prosthesis type, prosthesis-wearing frequency, prosthesis-cleaning frequency, and problems encountered. A total of 126 questionnaires were returned (response rate was 78.8%). Data was analyzed using SPSS software (P <0.05). RESULTS: The patients were 74 males and 52 females (57.55 years ±â€Š17.57). Almost 50% of the patients lost their eye due to trauma that was the highest among other causes (P <0.05). High proportion clean their prosthesis daily (37.4%) which was the highest among other cleaning regimes (P <0.05). Almost 30.3% experienced having problems with their prosthetic eye. Patients who clean their prosthetic eye every 6 months have experienced more problems (P <0.05). Majority of patients wear their prosthetic eyes 24 hours (92%) (P <0.05). Half of patients who received a prosthetic eye for the first time experienced problems with it (P <0.05) such as excess discharge (45%), infection (25%), and soreness (20%). However, the problems were independent of prosthesis-type (P >0.05). CONCLUSIONS: Trauma is the most common cause of anophthalmic patients in the North-West of England. Anophthalmic patients are likely to experience problems with their prosthetic eye if they have lost their natural eye due to disease; it is their first prosthesis; or if they clean it once every 6 months.

Simultaneous Computer-Aided Design/Computer-Aided Manufacture Bimaxillary Orthognathic Surgery and Mandibular Reconstruction Using Selective-Laser Sintered Titanium Implant.

This patient report describes simultaneous bimaxillary orthognathic surgery and mandibular reconstruction by means of three-dimensional (3D) planning, 3D printed biocompatible surgical wafers, and 3D selective-laser sintered titanium implant. A 26-year-old male patient presented with a left mandibular defect secondary to trauma. The whole body of the mandible on the left hand side was deficient with a narrow connection with the remaining left condyle. He had undergone orthodontic treatment for 18 months and was ready to undergo bimaxillary orthognathic surgery. Advanced cranio-maxillofacial software was used in processing his cone beam computer tomography scan data, and e-casts of his upper and lower dental arches. Bimaxillary surgery was planned with Le Fort 1 maxillary impaction and mandibular advancement to achieve a class 1 incisor relationship. Intermediate and final surgical wafers were designed following the planned movements and printed using biocompatible resin. The deficient left side of the mandible was reconstructed by means of mirror imaging the contra-lateral right side into the deficient left side with the aim of restoring normal facial symmetry. Biomedical software was then used in designing a reconstruction plate that connected the condylar head and the mandible following the planned bimaxillary surgery and mandibular continuity symmetry reconstruction. The plate was printed in titanium following state-of the-art selective laser sintering technology. The bimaxillary surgery and mandibular reconstruction were done simultaneously as planned along with an iliac-crest bone graft. This patient confirms the advantages of 3D computer-aided design/computer-aided manufacture technologies in optimizing clinical outcomes for cranio-maxillofacial reconstruction, especially when conducting two simultaneous clinical procedures.

Closed-eye orbital prosthesis: a clinical report.

One of the most challenging prostheses to fabricate is an acceptable orbital prosthesis. Successful reconstruction of the complex missing tissues, the globe, muscle, skin, and bony elements requires time and high levels of practical skill. A good match to the contralateral nondefect side will help mask the underlying defect and give the patient confidence to return to normal, routine life. The contralateral eye opening will commonly dictate the eye opening of such a prosthesis, but because of the expressive nature of the eye and its high levels of mobility, this can be difficult to achieve. This clinical report presents a patient who had an extended orbital exenteration and right maxillectomy to remove a maxillary squamous cell carcinoma. An alternative approach to constructing an orbital prosthesis was undertaken with the eye closed. Compared to the normal method of fabrication, this process was less complex and quicker, made the prosthesis less "staring," camouflaged the defect, and reduced the detection of the prosthesis because of movements in the remaining eye. The patient engaged in his routine daily life, which reinforced his self-esteem, confidence, and reintegration into the community.

Management of extensive frontal cranioplasty defects.

Cranioplasty is a medical technique to correct cranial bone defects. Depending on the size and location of the defect, a bone substitute can be used to replace the missing bone. Frontal bone defects are important to patients in terms of cosmetics because they are visible. Advances in computer design allow the production of customized implants with improved cosmetic and functional results. This report describes hybrid optimization of three-dimensional technological methods along with traditional methods toward the manufacture of deep-buried titanium implants, restoring frontal skull defects for 4 patients. A three-dimensional model was produced from the computed tomographic scan data of 3 patients using an in-house three-dimensional printer. A new approach was followed in treating the fourth patient. The defect was restored using preoperative scan before cranioplasty. These data were transported digitally into the defect skull to recreate the bone contour required, and a three-dimensional model was produced from the "new" digital model using the three-dimensional printer. Defect areas of the patients were large and measured 101.21 × 123.35 (vertical × horizontal) in average (mm). Conventional wax-up of the defect was carried to restore normal conformity. A titanium sheet (0.5 mm) was swaged into the desired shape; however, convexity of the defect area makes titanium swaging challenging, especially at the deep lateral undercuts. Making side flanges at reasonable lengths made it easy to swage without creasing. Three-dimensional models aided to produce accurately fitting plates. Finally, the sequential method of using both digital and manual procedures is a low-cost, reliable, accurate, and reproducible method.

A novel approach to immediate restoration of the cosmetic deformity after regional temporalis flap reconstruction of a maxillary defect: a case report.

Restoration of large maxillary defects can be achieved by using various muscle and bone flap transfers. Free muscle and bone transfer has become the reconstruction standard because it offers a combination of bone and soft tissues, which allows primary closure of the defect and secondary placement of dental implants for a full rehabilitation approach. If free tissue transfer is not a viable option, regional flaps such as temporalis muscle offer a viable alternative. This report presents a novel approach to immediate reconstruction of temporalis defects after muscle transfer to repair a maxillary defect. A custom-made titanium onlay was constructed preoperatively using a three-dimensional model of the patient to restore the absent muscle contour. The implant was placed at the same time as the muscle transfer. A good cosmetic outcome was achieved, and no postoperative complications were reported.

A fiber-reinforced composite prosthesis restoring a lateral midfacial defect: a clinical report.

This clinical report describes the use of a glass fiber-reinforced composite (FRC) substructure to reinforce the silicone elastomer of a large facial prosthesis. The FRC substructure was shaped into a framework and embedded into the silicone elastomer to form a reinforced facial prosthesis. The prosthesis is designed to overcome the disadvantages associated with traditionally fabricated prostheses; namely, delamination of the silicone of the acrylic base, poor marginal adaptation over time, and poor simulation of facial expressions.

Fracture resistance of teeth restored with different post systems: in vitro study.

OBJECTIVES: The objective of this study was to investigate fracture resistance and mode of failure of teeth restored with different prefabricated post systems. STUDY DESIGN: Thirty teeth were collected, sectioned 15 mm from the apex, root canal prepared, and randomly allocated into 3 groups as follows: glass fiber posts (group 1), carbon fiber posts (group 2), and Radix-Anchor titanium posts (group 3). Teeth were then restored with a composite core and tested using a universal testing machine at 10 mm/min cross-head speed. Mode of failure was identified as either reparable or irreparable (catastrophic). RESULTS: Mean values of fracture forces (N) for teeth restored with Radix posts (571.6) were statistically significantly higher than teeth restored with either carbon fiber (420.6) or glass fiber posts (393.9). There were 86.67% of fractures that were catastrophic in nature. CONCLUSIONS: Teeth restored with Radix-titanium posts were more resistant to fracture than those restored with either carbon or glass fiber posts. Most of the fracture modes were catastrophic in nature.