Osseointegration of 3D-printed titanium implants with surface and structure modifications.

BACKGROUND: The purpose of this study was to establish a mechanical and histological basis for the development of biocompatible maxillofacial reconstruction implants by combining 3D-printed porous titanium structures and surface treatment. Improved osseointegration of 3D-printed titanium implants for reconstruction of maxillofacial segmental bone defect could be advantageous in not only quick osseointegration into the bone tissue but also in stabilizing the reconstruction. METHODS: Various macro-mesh titanium scaffolds were fabricated by 3D-printing. Human mesenchymal stem cells were used for cell attachment and proliferation assays. Osteogenic differentiation was confirmed by quantitative polymerase chain reaction analysis. The osseointegration rate was measured using micro computed tomography imaging and histological analysis. RESULTS: In three dimensional-printed scaffold, globular microparticle shape was observed regardless of structure or surface modification. Cell attachment and proliferation rates increased according to the internal mesh structure and surface modification. However, osteogenic differentiation in vitro and osseointegration in vivo revealed that non-mesh structure/non-surface modified scaffolds showed the most appropriate treatment effect. CONCLUSION: 3D-printed solid structure is the most suitable option for maxillofacial reconstruction. Various mesh structures reduced osteogenesis of the mesenchymal stem cells and osseointegration compared with that by the solid structure. Surface modification by microarc oxidation induced cell proliferation and increased the expression of some osteogenic genes partially; however, most of the markers revealed that the non-anodized solid scaffold was the most suitable for maxillofacial reconstruction.

Temporomandibular joint morphology in Korean using cone-beam computed tomography: influence of age and gender.

OBJECTIVES: The purpose of this study was to investigate the condylar morphology and position of Koreans using cone-beam computed tomography (CBCT) images. Analyzing the mean values of this study with reference to left and right sides, gender, and age will help to understand the size of the condyle and glenoid fossa, condylar morphology, and temporomandibular joint (TMJ) symmetry for establishing the standard temporomandibular joint structures of Koreans and then design the standard temporomandibular joint prosthesis for Koreans. RESULTS: There was no significant result in the condyle size, condyle axis angle, joint space, fossa depth, and mandibular body size between the left and right sides (p > 0.05). On the other hand, the mediolateral width of the condyle and mandibular body size show significantly different with the gender (P < 0.05). Also, significant differences were found in condyle size, joint space, fossa depth, and mandibular body size according to age groups (p < 0.05). CONCLUSIONS: Condylar position and morphology vary according to side, age, and gender. The results of this study are expected to help in customizing a treatment for the patients who need TMJ reconstruction by predicting the TMJ morphology according to age and gender and design the standard temporomandibular joint prosthesis for the Koreans.

Bone Conduction Capacity of Highly Porous 3D-Printed Titanium Scaffolds Based on Different Pore Designs.

In porous titanium scaffolds manufactured via 3D printing, the differences in bone formation according to pore design and implantation period were studied. Titanium scaffolds with three types of different pore structures (Octadense, Gyroid, and Dode) were fabricated via 3D printing using the selective laser melting method. Mechanical properties of scaffolds were investigated. Prepared specimens were inserted into both femurs of nine rabbits and their clinical characteristics were observed. Three animals were sacrificed at the 2nd, 4th, and 6th weeks, and the differences in bone formation were radiologically and histologically analyzed. The percentage of new bone and surface density in the pore structure were observed to be approximately 25% and 8 mm2/mm3, respectively. There was no difference in the amount of newly formed bone according to the pore design at 2, 4, and 6 weeks. In addition, no differences in the amount of newly formed bone were observed with increasing time within the same pore design for all three designs. During the 6-week observation period, the proportion of new bones in the 3D-printed titanium scaffold was approximately 25%. Differences in bone formation according to the pore design or implantation period were not observed.

Bioprinting on 3D Printed Titanium Scaffolds for Periodontal Ligament Regeneration.

The three-dimensional (3D) cell-printing technique has been identified as a new biofabrication platform because of its ability to locate living cells in pre-defined spatial locations with scaffolds and various growth factors. Osseointegrated dental implants have been regarded as very reliable and have long-term reliability. However, host defense mechanisms against infections and micro-movements have been known to be impaired around a dental implant because of the lack of a periodontal ligament. In this study, we fabricated a hybrid artificial organ with a periodontal ligament on the surface of titanium using 3D printing technology. CEMP-1, a known cementogenic factor, was enhanced in vitro. In animal experiments, when the hybrid artificial organ was transplanted to the calvarial defect model, it was observed that the amount of connective tissue increased. 3D-printed hybrid artificial organs can be used with dental implants, establishing physiological tooth functions, including the ability to react to mechanical stimuli and the ability to resist infections.

Risk of rod fracture according to cross-link position in pedicle subtraction osteotomy (PSO): A finite element study.

PURPOSE: The purpose of this study is to investigate the effect of the cross-link position on the rod fracture phenomenon during pedicle subtraction osteotomy (PSO) surgery using finite element model (FEM). METHODS: A three-dimensional finite element model of a lumbar spine with sagittal imbalance was constructed using computed tomography data of a 65-year-old female patient. After simulating the standard PSO at the L4 level, we constructed four models, specifically a model without a cross-link and three models with a cross-link at three different sites. The peak von Mises stress (PVMS) of the rod around the PSO site was measured after applying physiological loads (flexion, extension, axial rotation, and lateral bending) in each model. RESULTS: The measured PVMS outcomes at the PSO site were 135.8, 135.9, 208.9, and 384.7 MPa for model 1, 2, 3, and 4 during flexion, and 180.0, 180.1, 210.1, and 445.7 MPa during extension. These results show that when the cross-link is located at the PSO site, the rod stress at the PSO site increases significantly during flexion and extension. As the cross-link moved away from the PSO site, the effect on the rod stress decreased. When the cross-link was placed two levels away from the PSO site, the rod stress was scarcely affected. CONCLUSION: When the cross-link during PSO surgery was positioned two levels away from the PSO site, the risk of rod fracture did not increase.

Cross-link is a risk factor for rod fracture at pedicle subtraction osteotomy site: A finite element study.

BACKGROUND: We aim to investigate using finite element model (FEM) whether the use of a cross-link is a risk factor for rod fracture at the pedicle subtraction osteotomy (PSO) site. METHODS: The geometry and dimensions of the FEM were obtained from a high-resolution computed tomography scan data of a 65 years old female patient with spinal sagittal imbalance. The intact model was modified to place PSO on the L4 spine. A cross-link was placed at the PSO site. A multisegment spinal fusion model from L1 to the pelvis was used to compare and analyze the peak von Mises stress (PVMS) values of the implants. A compressive follower load of 400 N was added to the validated intact lumbar spinal model in the follower load path direction. RESULTS: After PSO surgery, the PVMS of the rod was significantly increased during flexion and extension at the PSO site. With the cross-link at the PSO site, the PVMS of the rod was further significantly increased during flexion and extension. CONCLUSION: The cross-link at the PSO site increased the risk of rod facture, especially during flexion and extension stress.

The Formation of Extragraft Bone Bridging after Anterior Cervical Discectomy and Fusion: A Finite Element Analysis.

OBJECTIVE: In addition to bone bridging inside a cage or graft (intragraft bone bridging, InGBB), extragraft bone bridging (ExGBB) is commonly observed after anterior cervical discectomy and fusion (ACDF) with a stand-alone cage. However, solid bony fusion without the formation of ExGBB might be a desirable condition. We hypothesized that an insufficient contact area for InGBB might be a causative factor for ExGBB. The objective was to determine the minimal area of InGBB by finite element analysis. METHODS: A validated 3-dimensional, nonlinear ligamentous cervical segment (C3-7) finite element model was used. This study simulated a single-level ACDF at C5-6 with a cylindroid interbody graft. The variables were the properties of the incorporated interbody graft (cancellous bone [Young's modulus of 100 or 300 MPa] to cortical bone [10000 MPa]) and the contact area between the vertebra and interbody graft (Graft-area, from 10 to 200 mm2). Interspinous motion between the flexion and extension models of less than 2 mm was considered solid fusion. RESULTS: The minimal Graft-areas for solid fusion were 190 mm2, 140 mm2, and 100 mm2 with graft properties of 100, 300, and 10000 MPa, respectively. The minimal Graft-areas were generally unobtainable with only the formation of InGBB after the use of a commercial stand-alone cage. CONCLUSION: ExGBB may be formed to compensate for insufficient InGBB. Although various factors may be involved, solid fusion with less formation of ExGBB may be achieved with refinements in biomaterials, such as the use of osteoinductive cage materials; changes in cage design, such as increasing the area of polyetheretherketone or the inside cage area for bone grafts; or surgical techniques, such as the use of plate/screw systems.

Cranioplasty Enhanced by Three-Dimensional Printing: Custom-Made Three-Dimensional-Printed Titanium Implants for Skull Defects.

The authors studied to demonstrate the efficacy of custom-made three-dimensional (3D)-printed titanium implants for reconstructing skull defects. From 2013 to 2015, 21 patients (8-62 years old, mean = 28.6-year old; 11 females and 10 males) with skull defects were treated. Total disease duration ranged from 6 to 168 months (mean = 33.6 months). The size of skull defects ranged from 84 × 104 to 154 × 193 mm. Custom-made implants were manufactured by Medyssey Co, Ltd (Jecheon, South Korea) using 3D computed tomography data, Mimics software, and an electron beam melting machine. The team reviewed several different designs and simulated surgery using a 3D skull model. During the operation, the implant was fit to the defect without dead space. Operation times ranged from 85 to 180 minutes (mean = 115.7 minutes). Operative sites healed without any complications except for 1 patient who had red swelling with exudation at the skin defect, which was a skin infection and defect at the center of the scalp flap reoccurring since the initial head injury. This patient underwent reoperation for skin defect revision and replacement of the implant. Twenty-one patients were followed for 6 to 24 months (mean = 14.1 months). The patients were satisfied and had no recurrent wound problems. Head computed tomography after operation showed good fixation of titanium implants and satisfactory skull-shape symmetry. For the reconstruction of skull defects, the use of autologous bone grafts has been the treatment of choice. However, bone use depends on availability, defect size, and donor morbidity. As 3D printing techniques are further advanced, it is becoming possible to manufacture custom-made 3D titanium implants for skull reconstruction.

Simultaneous Bimaxillary Surgery and Mandibular Reconstruction With a 3-Dimensional Printed Titanium Implant Fabricated by Electron Beam Melting: A Preliminary Mechanical Testing of the Printed Mandible.

A woman presented with a long history of mandibular defects posterior to the left lower first premolar caused by inadequate reconstruction after removal of a tumor on the left side of the mandible. In the frontal view, extreme facial asymmetry was apparent. The dental midline of the mandible was deviated 10 mm to the left compared with the dental midline of the maxilla, and all maxillary teeth were inclined to the left owing to dental compensation. There was an 8-mm maxillary occlusal cant relative to the maxillary first molar. Bimaxillary surgery using computer-assisted designed and computer-assisted manufactured devices without an intermediate occlusal splint was performed to align the maxilla and mandible at the correct position, and reconstructive surgery for the mandible using a 3-dimensional printed titanium mandible was concurrently performed. In particular, during the virtual mandible design, 2 abutments that enabled the prosthetic restoration were included in the mandible using a computer-assisted design program. This report describes the successful functional and esthetic reconstruction of the mandible using electron beam melting technology, an alternative technique for reconstruction of mandibles that did not undergo radiation therapy.