The "springform" technique in cranioplasty: custom made 3D-printed templates for intraoperative modelling of polymethylmethacrylate cranial implants.

ABSTRACT

BACKGROUND: Manual moulding of cranioplasty implants after craniectomy is feasible, but does not always yield satisfying cosmetic results. In contrast, 3D printing can provide precise templates for intraoperative moulding of polymethylmethacrylate (PMMA) implants in cranioplasty. Here, we present a novel and easily implementable 3D printing workflow to produce patient-specific, sterilisable templates for PMMA implant moulding in cranioplastic neurosurgery. METHODS: 3D printable templates of patients with large skull defects before and after craniectomy were designed virtually from cranial CT scans. Both templates - a mould to reconstruct the outer skull shape and a ring representing the craniectomy defect margins - were printed on a desktop 3D printer with biocompatible photopolymer resins and sterilised after curing. Implant moulding and implantation were then performed intraoperatively using the templates. Clinical and radiological data were retrospectively analysed. RESULTS: Sixteen PMMA implants were performed on 14 consecutive patients within a time span of 10 months. The median defect size was 83.4 cm2 (range 57.8-120.1 cm2). Median age was 51 (range 21-80) years, and median operating time was 82.5 (range 52-152) min. No intraoperative complications occurred; PMMA moulding was uneventful and all implants fitted well into craniectomy defects. Excellent skull reconstruction could be confirmed in all postoperative computed tomography (CT) scans. In three (21.4%) patients with distinct risk factors for postoperative haematoma, revision surgery for epidural haematoma had to be performed. No surgery-related mortality or new and permanent neurologic deficits were recorded. CONCLUSION: Our novel 3D printing-aided moulding workflow for elective cranioplasty with patient-specific PMMA implants proved to be an easily implementable alternative to solely manual implant moulding. The "springform" principle, focusing on reconstruction of the precraniectomy skull shape and perfect closure of the craniectomy defect, was feasible and showed excellent cosmetic results. The proposed method combines the precision and cosmetic advantages of computer-aided design (CAD) implants with the cost-effectiveness of manually moulded PMMA implants.