Using Computer-Aided Design/Computer-Aided Manufacturing for Autogenous, Split Calvarial Bone Graft-based Cranioplasty: Optimizing Reconstruction of Large, Complex Skull Defects

Abstract

Background: While autologous split calvarial bone is an ideal graft material in cranioplasty, selection of a donor site can be challenging and limited in the reconstruction of complicated cranial defects. Computer-aided design and manufacturing (CAD/CAM) may improve donor-site harvest and contouring and mitigate operative complications in split calvarial bone graft-based cranioplasty for complex patients, but has not previously been studied in this unique setting. Methods: In this study, a retrospective review of patients who presented to the institution and underwent split-calvarial bone graft-based cranioplasty using CAD/CAM to optimize reconstruction of full-thickness cranial defects ≥30 cm2 was performed. Patient demographics, complications from past operations, intraoperative variables, and immediate and long-term postoperative outcomes were recorded. The CAD/CAM predicted and actual postoperative graft measurements were compared. Results: Five patients were identified who fulfilled inclusion criteria. Mean age at operation was 43 years and mean size of cranial defect was 69 cm2. Mean operative time was 443 minutes and mean estimated blood loss was 450 mL. There were no dural tears, sagittal sinus bleeds, or other intraoperative complications. There were no immediate postoperative complications requiring extended hospital stay or reoperation. The postoperative graft surface areas were on average within 2.1% of the planned graft and this difference was not statistically significant (P = 0.28). All patients expressed satisfaction with cranial contour postoperatively. Conclusion: Based on the early experience, the use of CAD/CAM enhances calvarial graft selection and improves contour accuracy in the reconstruction of complex skull defects with minimal complications.

Conformity of the Virtual Surgical Plan to the Actual Result Comparing Five Craniofacial Procedure Types

“…However, autologous cranioplasty has been studied, and has demonstrated reasonable conformity when comparing the surface area of the planned graft with the actual graft. 44 This study demonstrated that permanent custom-printed cranial implants resulted in the highest virtual surgical plan conformity. Lessconforming cases were characterized as having more variables left to intraoperative decisionmaking (i.e., adjusting final position of the maxillomandibular complex in orthognathic surgery to optimize dental show), involving a large volume of skeletal manipulation with nonrigid fixation (i.e., cranial vault remodeling), or undergoing postoperative manipulation (i.e., mandibular distraction).…”

A Novel Titanium Cranioplasty Technique of Marking the Coronal and Squamosoparietal Sutures in Three-Dimensional Titanium Mesh as Anatomical Positioning Markers to Increase the Surgical Accuracy and Reduce Postoperative Complications

“…However, there are no marks on the titanium mesh to accurately match the skull. One of the recent studies indicated that the use of computer-aided design or computer-aided manufacturing for CP improves contour accuracy in the reconstruction of complex skull defects with minimal complications ( 26 ). In our study, surgical accuracy <95.8% was the only independent predictor of overall postoperative complications.…”

Decision-Making in Adult Cranial Vault Reconstruction

“…23 Computer-aided design and manufacturing technology has also been used to design patient-specific osteotomy guides for harvest of split cranial bone graft to ensure optimal reconstruction. 24 Under all circumstances, split cranial bone grafts must be rigidly fixed and precisely shaped to maximize bone-to-bone contact between graft and bone at the recipient site.…”