Tel Alessandro, Tuniz Francesco, Fabbro Sara, Sembronio Salvatore, Costa Fabio, Robiony Massimo
Resident, Maxillofacial Surgery Department, Academic Hospital of Udine, Department of Medicine, University of Udine, Udine, Italy.
Consultant, Neurosurgery Department, Academic Hospital of Udine, Department of Medicine, University of Udine, Udine, Italy.
J Oral Maxillofac Surg. 2020 Dec;78(12):2297.e1-2297.e16. doi: 10.1016/j.joms.2020.08.007. Epub 2020 Aug 12.
Restoring the ideal geometry of the skull vault can be a challenging task. This is especially true for complex cases when cranial reconstruction is associated with concomitant cranial resection in a one-stage procedure. Oftentimes, cranioplasty designing and production are delegated to external companies, with a significant increase in time and cost to fabricate an alloplastic implant. This case series collects and critically examines previous experiences in the field of in-house cranial reconstruction providing an updated protocol to establish a novel standard for cranial reconstruction with a substantial reduction of costs.
A virtual craniotomy was digitally designed by the surgeon and transferred in the operating room using navigation and a surgical guide. Cranial reconstruction was planned using interpolation functions, recreating the ideal shape of the skull vault. Molds were designed, and 3D printed to intra-operatively shape polymethyl methacrylate (PMMA) according to the pre-operative plan. For validating the accuracy of reconstruction, as well as the restoration of the appropriate skull thickness, software-encoded color maps and root-mean-square error (RMSE), were calculated.
All surgeries were uneventful. No adverse reactions to PMMA were observed. Accuracy of the procedure was validated, showing a submillimetric deviation from the original planning and a plate thickness value similar to the adjoining bone. All steps of design and production were performed by the surgical team, and costs were seven to ten times less than the past.
We discussed and improved previous reports in the field of computer-guided in-house cranioplasty, particularly when complex one-stage resective and reconstructive procedures are planned. The use of three-dimensional analyses provides a validation of the accuracy of the resulting cranial reconstruction. The authors hope that the results might inspire other colleagues to consider computer-guided in-house cranioplasty, giving surgeons the mastery of each planning phase with a substantial decrease in costs.
恢复颅骨穹窿的理想几何形状可能是一项具有挑战性的任务。对于复杂病例而言尤其如此，即在一期手术中颅骨重建与同期颅骨切除术相关联时。通常，颅骨成形术的设计和制作委托给外部公司，制作异体植入物的时间和成本会大幅增加。本病例系列收集并批判性地审视了内部颅骨重建领域的既往经验，提供了一种更新的方案，以建立一种成本大幅降低的颅骨重建新标准。
由外科医生进行数字化虚拟颅骨切开设计，并使用导航和手术导板在手术室中进行转换。使用插值函数规划颅骨重建，重新创建颅骨穹窿的理想形状。设计模具，并进行3D打印，以便在术中根据术前计划对聚甲基丙烯酸甲酯（PMMA）进行塑形。为验证重建的准确性以及适当颅骨厚度的恢复情况，计算了软件编码的彩色地图和均方根误差（RMSE）。
所有手术均顺利进行。未观察到对PMMA的不良反应。该手术的准确性得到验证，显示与原始计划的偏差小于毫米，且钢板厚度值与相邻骨骼相似。设计和制作的所有步骤均由手术团队完成，成本比过去降低了七至十倍。
我们讨论并改进了计算机辅助内部颅骨成形术领域的既往报告，特别是在计划进行复杂的一期切除和重建手术时。三维分析的应用验证了颅骨重建结果的准确性。作者希望这些结果能激励其他同事考虑计算机辅助内部颅骨成形术，使外科医生能够掌握每个规划阶段，同时大幅降低成本。
