Biomaterials for Regenerative Cranioplasty: Current State of Clinical Application and Future Challenges.

Acquired cranial defects are a prevalent condition in neurosurgery and call for cranioplasty, where the missing or defective cranium is replaced by an implant. Nevertheless, the biomaterials in current clinical applications are hardly exempt from long-term safety and comfort concerns. An appealing solution is regenerative cranioplasty, where biomaterials with/without cells and bioactive molecules are applied to induce the regeneration of the cranium and ultimately repair the cranial defects. This review examines the current state of research, development, and translational application of regenerative cranioplasty biomaterials and discusses the efforts required in future research. The first section briefly introduced the regenerative capacity of the cranium, including the spontaneous bone regeneration bioactivities and the presence of pluripotent skeletal stem cells in the cranial suture. Then, three major types of biomaterials for regenerative cranioplasty, namely the calcium phosphate/titanium (CaP/Ti) composites, mineralised collagen, and 3D-printed polycaprolactone (PCL) composites, are reviewed for their composition, material properties, and findings from clinical trials. The third part discusses perspectives on future research and development of regenerative cranioplasty biomaterials, with a considerable portion based on issues identified in clinical trials. This review aims to facilitate the development of biomaterials that ultimately contribute to a safer and more effective healing of cranial defects.

Surgical treatment of feline intracranial meningiomas: a retrospective study of 26 cases.

BACKGROUND: Surgical excision is the treatment of choice for feline intracranial meningioma. OBJECTIVES: To report clinical findings, complications, and outcomes following surgery for feline intracranial meningioma. METHODS: Medical records (01/2000-01/2017) of cats that underwent surgical excision of an intracranial meningioma at our institution were reviewed. Patient data included signalment, clinical signs, surgical technique, complications, histopathologic diagnosis, survival time, and owners' answers to a satisfaction questionnaire. Survival was assessed using the Kaplan-Meier method and log-rank test. RESULTS: Twenty-six cats were included in this study. The exact cause of death was known in 17 cases and was not related to meningioma in 9/17 cases. Overall median survival time was 881 days (95% confidence interval 518; 1248). The age of the cat did not influence survival (p = 0.94) or the occurrence of complications (p = 0.051). Complications occurred in 13/24 cats, including dramatic complications in 4/24 cats. Most complications appeared in the first 24 hours post-surgery (12/13). Males had more postoperative complications (p = 0.042), including more seizures (p = 0.016). Cats with cranioplasty had fewer complications (p = 0.021). Clinical recurrence was confirmed in 3 out of 17 cats. Recurrence-free survival time was 826 days. Most owners (12/14) were satisfied with the outcome. CONCLUSIONS: Surgical treatment of intracranial meningioma in cats was associated with a long median survival time but also with a high rate of minor and major postoperative complications, including early postoperative seizures. Cranioplasty may reduce complications. Age at the time of surgery had no effect on outcomes.

Cranioplasty is not required in the reconstruction of small combined scalp and calvarial defects.

BACKGROUND: Treatment of scalp malignancies may include the need for craniectomy. The decision to perform cranioplasty is not straightforward and is frequently subjective. The purpose of this study was to assess the clinical outcomes after reconstruction of complex scalp and calvarial defects by comparing patients with and without cranioplasty. METHODS: Retrospective review of the clinical records of a consecutive series of patients who underwent scalp soft tissue reconstruction after craniectomy for malignancy or osteoradionecrosis between 2014 and 2022 at Royal Melbourne Hospital was conducted. Demographics, previous treatments, surgical details, and post-operative complications were assessed. Traumatic injuries and decompressive craniectomies were excluded. Minimum follow-up of 6 months. RESULTS: Thirty-seven patients were included in the study. Indications for surgery included skin malignancies, osteoradionecrosis, or both. There was one reconstructive failure (in the non-cranioplasty group). Infection and metalware exposure were common complications in patients who underwent cranioplasty (38.5%). No patient developed neurological symptoms subsequent to craniectomy. One patient needed revision surgery due to esthetic reasons (cranioplasty group). Transposition flaps were associated with more complications and revision procedures. CONCLUSION: Combined scalp and calvarial defects pose a difficult reconstructive challenge. Stable soft tissue coverage is more reliably achieved with free flap reconstruction. Cranioplasty is not always mandatory and should be reserved for cases with a very large bony defect or when the defect is located in a cosmetically sensitive area.

Flap Design for Cranial Reconstruction: An Analysis of Craniectomy and Cranioplasty Incisions.

Background: The surgical approach for cranial reconstruction is influenced by the presence of pre-existing scar tissue. Scars that lie within the vicinity of cranial defect require modification. Purpose: The present study was conducted to analyse co-relation between craniectomy scar and cranioplasty incision. Materials and Methods: A retrospective evaluation of 70 patients who were divided into three groups based on location of cranioplasty incision line was done. In group I, incision was located parallel and outside the scar; group II, incision was located over the scar; and group III, mixed and criss-cross incision was present. The primary outcome variable of interest was to analyse co-relation between craniectomy and cranioplasty incisions. Results: There were 45 cases of group I, 15 cases of group II and 10 cases of group III. Thirty-three patients had defect on left side, 26 had on right side, and 10 had bifrontal defect. No significant association was noted between the site and cranioplasty incision (Chi2 = 9.155, p = 0.433 and likelihood ratio = 9.487, p = 0.394). Conclusion: Well-vascularized broad-based scalp flap that provides adequate exposure and located on healthy bone irrespective of pre-existing craniectomy scar forms the mainstay of successful cranial reconstruction.

Is cranioplasty the optimal treatment for contralateral subdural effusion after decompressive craniectomy?: a case report.

Introduction and importance: Contralateral subdural effusion (CSDE) is a rare complication secondary to decompressive craniectomy (DC), which can lead to encephalocele and neurologic deterioration. The authors report a case that confirm the existence of unidirectional membrane valve, and cranioplasty is an effective treatment for CSDE. Case presentation: The authors reported a case of 43-year-old female was diagnosed with ruptured intracranial aneurysm and treated with interventional embolization. She underwent DC because of postoperative cerebral infarction subsequently. Her conscious state deteriorated accompanied by encephalocele in postoperative 2 week. A craniocerebral computed tomography (CT) confirmed the diagnosis of CSDE with cerebral hernia. A compression bandaging of the skull defect was applicated, whereas, her conscious state progressive deteriorated. She was transferred to the author's hospital where she underwent burr-hole drainage and clinical symptom has been improved. However, a relapse of CSDE was observed after the removal of drainage tube. Continuous lumbar drainage was employed, and which was ineffective for CSDE in this case. Finally, she underwent cranioplasty, with the help of drainage of subdural effusion, CSDE was completely resolved. Clinical discussion: CSDE is occasionally observed in patients after DC. Intracranial pressure (ICP) gradient and unidirectional membrane valve are the possible mechanisms of CSDE. At present, there is no optimal therapy for CSDE. For symptomatic CSDE patients, one or more treatment measures should be applicated. Conclusion: Cranioplasty is one of the curative and optimal method to treat symptomatic CSDE patients, early cranioplasty combined with burr-hole drainage should be performed for conservative treatment failed and intractable cases.

The free anterolateral thigh flap substituted for a pedicled biparietal flap in reconstructing complex frontal defect.

Complex scalp defects involving soft and hard tissues pose challenges for plastic surgeons. The solution for each defect must depend on various factors and even the technical development of the infrastructure. We present a case study in which the patient had a significant total frontal defect. The first surgery was a bi-parietal flap as a salvage option to cover the defect. However, aesthetic satisfaction was not achieved. The second surgery used the anterolateral thigh flap to enhance the aesthetic result, and the placement of titanium mesh was an appropriate choice. This case may be an example of how different solutions can lead to variable results and what needs to be considered when dealing with complex scalp defects.

Letter to editor: Exploring complications following cranioplasty after decompressive hemicraniectomy: A retrospective bicenter assessment of autologous, PMMA and CAD implants.

This study presents a critical analysis of complications following cranioplasty (CP) after decompressive hemicraniectomy, focusing on autologous, polymethylmethacrylate (PMMA), and computer-aided design (CAD) implants. The analysis encompasses a retrospective bicenter assessment, evaluating factors influencing surgical outcomes and emphasizing the significance of material selection in minimizing postoperative complications. The study's comprehensive examination of complication rates associated with various implant materials contributes significantly to understanding CP outcomes. While polymethylmethacrylate (PMMA) and autologous bone flaps (ABFs) exhibited higher rates of surgical site infection (SSI) and explantation, a meta-analysis revealed a contrasting lower infection rate for polyether ether ketone (PEEK) implants. The study underscores the critical role of material selection in mitigating postoperative complications. Despite its strengths, the study's retrospective design, reliance on data from two centers, and limited sample size pose limitations. Future research should prioritize prospective, multicenter studies with standardized protocols to enhance diagnostic accuracy and treatment efficacy in CP procedures.

Personalized 3D-printed cranial implants for complex cranioplasty using open-source software.

Background: Cranioplasty is a routine neurosurgery treatment used to correct cranial vault abnormalities. Utilization of 3D printing technology in the field of cranioplasty involving the reconstruction of cranial defects emerged as an advanced possibility of anatomical reshaping. The transformative impact of patient-specific 3D printed implants, focuses on their remarkable accuracy, customization capabilities, and enhanced biocompatibility. Methods: The precise adaptation of implants to patient-specific anatomies, even in complex cases we presented, result in improved aesthetic outcomes and reduced surgical complications. The ability to create highly customized implants addresses the functional aspects of cranial defects and considers the psychological impact on patients. Results: By combining technological innovation with personalized patient care, 3D printed cranioplasty emerges as a transformative avenue in cranial reconstruction, ultimately redefining the standards of success in neurosurgery. Conclusion: 3D printing allows an excellent cranioplasty cosmesis achieved at a reasonable price without sacrificing patient outcomes. Wider implementation of this strategy can lead to significant healthcare cost savings.

CRANIOPLASTY WITH DIRECT REVASCULARIZATION IN HEMORRHAGIC MOYAMOYA DISEASE: 2-DIMENSIONAL OPERATIVE VIDEO.

Moyamoya disease is a progressive nonatherosclerotic stenosis of the terminal segments of the arteries of the Circle of Willis. Hemorrhagic presentation is a life-threatening condition, associated with an increased risk of rebleeding and ischemic events.1-7 We present the case of a 65-year-old woman with a right intracerebral hemorrhage who underwent emergency hematoma evacuation without bone flap replacement. The investigation confirmed the diagnosis of Moyamoya disease and demonstrated hypoperfusion of the right cerebral hemisphere. Late angiography depicted no transdural collaterals through the bone defect and demonstrated preservation of the superficial temporal artery (STA). Next, it was chosen to perform one-stage cranioplasty with direct revascularization. We detached the temporal fascia from the muscle and created a window through the fascia to give STA passage in a corridor through the temporal muscle until the brain's surface. Vascular anastomosis was performed with an interrupted suture line employing a 10-0 nylon thread. Flow within the right middle cerebral artery (MCA) was retrograde, coming from branches of the posterior cerebral artery (PCA), and the end-to-side anastomosis was placed to orientate the STA flow in the same direction as in the MCA. We used a custom-made titanium plate for the cranioplasty and gave enough room inferiorly for the course of STA. In the end, we sutured the temporal fascia to the titanium plate for a better cosmetic result. To avoid additional unnecessary procedures, the performance of direct revascularization during the cranioplasty is feasible and deserves additional investigation as a tool to prevent new hemorrhagic or ischemic events. Informed consent was obtained from the patient for the procedure and publication of this operative video.

Subcutaneous preservation versus cryopreservation of autologous bone grafts for cranioplasty: A systematic review and meta-analysis.

BACKGROUND: Cranioplasty corrects cranial bone defects using various bone substitutes or autologous bone flaps created during a previous craniectomy surgery. These autologous bone flaps can be preserved through subcutaneous preservation (SP) or cryopreservation (CP). AIM: We aim to compare outcomes and complications for both SP and CP techniques to enhance the current evidence about autologous bone flap preservation. METHODS: Five electronic databases were searched to collect all relevant studies. Records were screened for eligibility. Data were extracted from the included studies independently. We categorized surgical site infection (SSI) as either due to Traumatic brain injury (TBI) or not to reveal potential variations in SSI incidence. The double-arm meta-analysis utilized risk ratios (RR) and mean differences (MD) with corresponding confidence intervals (CI) to pool categorical and continuous outcomes, respectively. Proportions with their respective 95% CIs were pooled for single-arm meta-analyses to determine outcomes related to SP technique. RESULTS: Seventeen studies involving 1169 patients were analyzed. No significant difference in SSI rates was observed between SP and CP methods in patients with or without TBI. SP was linked to shorter hospital stays in two studies (194 patients). Single-arm analysis showed a 17% revision surgery rate across five studies (375 patients) and infection rates in 17 studies for SP. New bone formation occurred in 13.2% of patients, with 19.9% showing resorption. CONCLUSION: SP and CP methods showed similar SSI rates post-craniectomy in TBI and non-TBI patients. SP was associated with reduced hospitalization time, low infection rates, and a moderate need for revision surgery.

[Comparison of polymethyl methacrylate skull implant fixation by three types of titanium fasteners]. / Sravnenie sposobov fiksatsii implantov cherepa iz polimetilmetakrilata tremya vidami titanovykh krepezhei.

OBJECTIVE: To evaluate mechanical strength of three methods of polymethyl methacrylate skull implant fixation in two experimental models. MATERIAL AND METHODS: The first experiment was performed on a plastic model that was as close as possible to bone in structural characteristics. The second experiment was performed on a biological specimen (a ram's head). We assessed the quality of implant fixation to bone window edges by craniofixes, ties and microscrews and lateral intercortical screws. RESULTS: Craniofixes are feasible for small flat flaps, but not advisable for wide highly curved implants. They are also the most expensive method of fixation. Implant fixation by ties and microscrews is a universal method comparable in price to craniofix. Lateral intercortical fixation is effective both for small flat implants and wide implants with large curvature. However, this method is not always applicable. CONCLUSION: Combined fixation by lateral intercortical screws and ties allows for the most effective fixation while reducing the overall price of consumables.

Innovative Solutions for Patients Who Undergo Craniectomy: Protocol for a Scoping Review.

BACKGROUND: Decompressive craniectomy (DC) is a widely used procedure to alleviate high intracranial pressure. Multidisciplinary teams have designed and implemented external medical prototypes to improve patient life quality and avoid complications following DC in patients awaiting cranioplasty (CP), including 3D printing and plaster prototypes when available. OBJECTIVE: This scoping review aims to understand the extent and type of evidence about innovative external prototypes for patients who undergo DC while awaiting CP. METHODS: This scoping review will use the Joanna Briggs Institute methodology for scoping reviews. This scoping review will include noninvasive medical devices for adult patients who undergo DC while waiting for CP. The search strategy will be implemented in MEDLINE, Embase, Web of Science, Scielo, Scopus, and the World Health Organization (WHO) Global Health Index Medicus. Patent documents were also allocated in Espacenet, Google Patents, and the World Intellectual Property Organization (WIPO) database. RESULTS: This scoping review is not subject to ethical approval as there will be no involvement of patients. The dissemination plan includes publishing the review findings in a peer-reviewed journal and presenting results at conferences that engage the most pertinent stakeholders in innovation and neurosurgery. CONCLUSIONS: This scoping review will serve as a baseline to provide evidence for multidisciplinary teams currently designing these noninvasive innovations to reduce the risk of associated complications after DC, hoping that more cost-effective models can be implemented, especially in low- and middle-income countries. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/50647.

Customised pre-operative cranioplasty to achieve maximal surgical resection of tumours with osseous involvement-a case series.

PURPOSE: Surgical resection with bony margins would be the treatment of choice for tumours with osseous involvement such as meningiomas and metastasis. By developing and designing pre-operative customised 3D modelled implants, the patient can undergo resection of meningioma and repair of bone defect in the same operation. We present a generalisable method for designing pre-operative cranioplasty in patients to repair the bone defect after the resection of tumours. MATERIALS AND METHODS: We included six patients who presented with a tumour that was associated with overlying bone involvement. They underwent placement of customised cranioplasty in the same setting. A customised implant using a pre-operative imaging was designed with a 2-cm margin to allow for any intra-operative requirements for extending the craniectomy. RESULTS: Six patients were evaluated in this case series. Four patients had meningiomas, 1 patient had metastatic breast cancer on final histology, and 1 patient was found to have an intra-osseous arteriovenous malformation. Craniectomy based on margins provided by a cutting guide was fashioned. After tumour removal and haemostasis, the cranioplasty was then placed. All patients recovered well post-operatively with satisfactory cosmetic results. No wound infection was reported in our series. CONCLUSION: Our series demonstrate the feasibility of utilising pre-designed cranioplasty for meningiomas and other tumours with osseous involvement. Following strict infection protocols, minimal intra-operative handling/modification of the implant, and close follow-up has resulted in good cosmetic outcomes with no implant-related infections.

Titanium mesh cranioplasty for cosmetically disfiguring cranio-facial tumours in a resource limited setting.

Background: The aesthetic reconstruction of disfiguring cranio-facial defects after tumour excision can be quite challenging to the neurosurgeon with limited resources. The choice of cranioplasty implant, intraoperative technicalities and the patients' postoperative appearance are critical considerations in management. There are a number of synthetic materials available for cranioplasty, however, the customised implants are not readily available in our practice setup. They are also mostly constructed and contoured after the bony defect has been created or require sophisticated software construction pre-operatively. Methods: Eight patients with cranio-facial tumour pathologies who presented to our neurosurgical service, and had titanium mesh cranioplasty for the correction of cosmetically disfiguring cranio-facial tumours. Results: There were 6 females, and 2 male patients respectively, with an age range between 28 and 74years. The histological diagnoses were meningioma, frontal squamous cell carcinoma, fibrous dysplasia, frontal mucocoele, cemeto-ossifying fibroma, osteoma, and naso-ethmoidal squamous cell carcinoma. The patient with naso-ethmoidal squamous cell carcinoma had post-operative subgaleal empyema which was amenable to incision and drainage procedure. The patient with a frontal cemento-ossifyng fibroma had a transient immediate post-operative mechanical ptosis, which resolved completely in 3months. All of the total eight patients (100%) had satisfactory cosmetic outlook at a minimum follow up period of 1month post-operatively (Numeric Rating Scale of at least 7/10). One of the patients required a revision surgery on account of implant displacement. Conclusion: Cranioplasty is a common reconstructive neurosurgical procedure. It is important to the neurosurgeon for its neuro-protective function, and in the restoration of intra-cranial CSF dynamics. However, the cosmetic outlook appears to be more important to patients in the absence of pain and/or neurological deficits. Titanium mesh reconstruction is commonly used globally, and is becoming the preferred choice in low resource settings.

Perioperative risk factors for major complications after bone replacement in decompressive craniectomy.

INTRODUCTION: Bone flap replacement after a decompressive craniectomy is a low complexity procedure, but with complications that can negatively impact the patient's outcome. A better knowledge of the risk factors for these complications could reduce their incidence. PATIENTS AND METHODS: A retrospective review of a series of 50 patients who underwent bone replacement after decompressive craniectomy at a tertiary center over a 10-year period was performed. Those clinical variables related to complications after replacement were recorded and their risk factors were analyzed. RESULTS: A total of 18 patients (36%) presented complications after bone flap replacement, of which 10 (55.5%) required a new surgery for their treatment. Most of the replacements (95%) were performed in the first 90 days after the craniectomy, with a tendency to present more complications compared to the subsequent period (37.8% vs 20%, p > 0.05). The most frequent complication was subdural hygroma, which appeared later than infection, the second most frequent complication. The need for ventricular drainage or tracheostomy and the mean time on mechanical ventilation, ICU admission, or waiting until bone replacement were greater in patients who presented post-replacement complications. Previous infections outside the nervous system or the surgical wound was the only risk factor for post-bone flap replacement complications (p = 0.031). CONCLUSIONS: Postoperative complications were recorded in more than a third of the patients who underwent cranial bone flap replacement, and at least half of them required a new surgery. A specific protocol aimed at controlling previous infections could reduce the risk of complications and help establish the optimal time for cranial bone flap replacement.

Consensus-based recommendations for diagnosis and surgical management of cranioplasty and post-traumatic hydrocephalus from a European panel.

Introduction: Planning cranioplasty (CPL) in patients with suspected or proven post-traumatic hydrocephalus (PTH) poses a significant management challenge due to a lack of clear guidance. Research question: This project aims to create a European document to improve adherence and adapt to local protocols based on available resources and national health systems. Methods: After a thorough non-systematic review, a steering committee (SC) formed a European expert panel (EP) for a two-round questionnaire using the Delphi method. The questionnaire employed a 9-point Likert scale to assess the appropriateness of statements inherent to two sections: "Diagnostic criteria for PTH" and "Surgical strategies for PTH and cranial reconstruction." Results: The panel reached a consensus on 29 statements. In the "Diagnostic criteria for PTH" section, five statements were deemed "appropriate" (consensus 74.2-90.3 %), two were labeled "inappropriate," and seven were marked as "uncertain."In the "Surgical strategies for PTH and cranial reconstruction" section, four statements were considered "appropriate" (consensus 74.2-90.4 %), six were "inappropriate," and five were "uncertain." Discussion and conclusion: Planning a cranioplasty alongside hydrocephalus remains a significant challenge in neurosurgery. Our consensus conference suggests that, in patients with cranial decompression and suspected hydrocephalus, the most suitable diagnostic approach involves a combination of evolving clinical conditions and neuroradiological imaging. The recommended management sequence prioritizes cranial reconstruction, with the option of a ventriculoperitoneal shunt when needed, preferably with a programmable valve. We strongly recommend to adopt local protocols based on expert consensus, such as this, to guide patient care.

Calvarial hemangiomas: Series of 6 cases and review of literature.

Calvarial haemangiomas are benign, vascular tumours of the skull involving parietal and frontal bones. Mostly these lesions remain asymptomatic, and present with cosmetic deformity, headache, uncommon neurological symptoms and reported as case reports and case series. The radiological appearance can range from sessile growing intradiploically to globular and the lesions may extend outwards or inwards after eroding the outer and inner tables of the skull. "Sunburst appearance" and "Wagon-wheel sign" are classical radiological findings but the lesions may present simply as a lytic expansile or even sclerotic calvarial mass. Because of varied clinical presentation and atypical radiological characteristics, the final diagnosis can be clinched by histology only. In selected cases where these lesions are not cosmetically acceptable, en bloc resection with tumour free margins followed by cranioplasty is the treatment of choice. Most reports of calvarial haemangiomas in literature are in the form of case reports.

Functional outcome after late cranioplasty after decompressive craniectomy: a single-center retrospective study.

OBJECTIVE: The best time for cranioplasty (CP) after decompressive craniectomy (DC) is controversial, and there are no authoritative guidelines yet. Both complications as well as outcome may depend on the timing of CP. The aim of this single-center study was to evaluate the impact of late CP on procedural safety as well as on patient outcome. METHODS: All patients receiving CP at a tertiary university medical center between 01/2015 and 12/2022 were included retrospectively. Patients' conditions were assessed according to the modified Rankin Scale (mRS) prior to CP and 6 months after. Baseline characteristics, indication for DC, time from DC to CP, and postoperative complications according to the Landriel Ibañez Classification were analyzed. RESULTS: CP was performed in 271 patients who previously underwent DC due to traumatic brain injury (25.5%), ischemic stroke (29.5%), aneurysmal subarachnoid hemorrhage (26.9%), or intracerebral hemorrhage (18.1%). The median interval between DC and CP was 143 days (interquartile range 112-184 days). Receiver operating characteristic analysis revealed a cut-off of 149 days, where CP performed within 149 days after DC led to an improvement on mRS after CP (p = 0.001). In multivariate analysis, additional rehabilitation after and better mRS before CP were independently associated with improvement of outcome. The rate of complications was similar between early and late CP (24.8% and 25.4%, respectively, p = 0.562). CONCLUSIONS: Late cranioplasty is a safe procedure. The outcome was improved when additional rehabilitation was performed after cranioplasty and was not associated with the timing of cranioplasty.

Revolutionizing Neurosurgery: The Cutting-Edge Era of Digitally Fabricated Cranial Stents.

Cranial defects are broadly classified as either congenital or acquired. The prevalence of cranial injuries has notably increased, propelled by a heightened emphasis on aesthetics and the demand for skull reconstruction in contemporary society. Consequently, rehabilitation for these defects has also surged. Surgical correction or repair, known as cranioplasty, not only aims at aesthetic rehabilitation but also addresses psychological issues, improving social acceptance and overall performance. Amid evolving trends, the availability of advanced biomedical tools, technologies, and materials empowers surgeons and prosthodontists, leading to improved outcomes in aesthetics and functionality. One noteworthy technique highlighted in this case report involves using bone cement in conjunction with polymethyl methacrylate, adding novelty to the approach. The interdisciplinary management team, consisting of prosthodontists and neurosurgeons, played a pivotal role in improving neurological status and cosmetic outcomes for the patients.