|Year : 2016 | Volume
| Issue : 2 | Page : 88-94
Case series of three-dimensional printing technology applied in complex craniofacial deformity surgery
Derick A Mendonca1, Vybhav Deraje1, Rajendra S Gujjalanavar1, Swaroop Gopal2
1 Department of Plastic Surgery, Sakra World Hospital, Bengaluru, Karnataka, India
2 Department of Neurosurgery, Institute of Neurosciences, Sakra World Hospital, Bengaluru, Karnataka, India
|Date of Web Publication||2-Aug-2016|
Department of Plastic Surgery, Sakra World Hospital, SY No 52/2 and 52/3, Devarabeesanahalli, Varthur Hobli, Opposite Intel, Outer Ring Road, Bengaluru - 560 103, Karnataka
Source of Support: None, Conflict of Interest: None
Introduction: Three-dimensional (3D) printing (additive manufacturing, rapid prototyping) is a technology that has attracted the attention of craniofacial surgeons to gain perfection in analysis, planning and execution of complex surgical challenges. Rapid prototyping technology was introduced to surgery via computer-aided design/computer-aided manufacturing, which enabled two-dimensional planning. The purpose of this article is to demonstrate the application of 3D printing (3DP) technology in craniofacial surgery, with a specific intention of addressing the planning of complex 3D deformities. Materials and Methods: This was a retrospective analysis of our surgical cases where we have used 3DP technology in 10 cases from 2014 to 2016 at a tertiary care hospital in India. 3D models were used in planning the correction of hypertelorism, craniosynostosis - open and endoscopic techniques, hemifacial microsomia, skull bone defects, and secondary orbital floor defects. The process of preparing a 3DP implant from a locally based company to suit the economic constraints of the patient has also been addressed in this article. Results: Each of the 10 patients are discussed, where this technology was used for planning, execution and training in craniofacial surgery. With the experience gained through these cases, the authors discuss the advantages of using 3DP technology in assessment of the true defect, accurate planning of the procedure, performance of model surgery, patient education, resident training, preparation of custom made implants, and more importantly providing all of these in an economical price using a locally based company for production of 3D models. Conclusion: 3DP models will revolutionize the way plastic and craniofacial surgeons think and plan surgical simulation. The authors recommend a wider application of such a technology to orthognathic surgery and any surgery that requires bony osteotomies with movement.
Keywords: Additive manufacturing, craniofacial surgery, maxillofacial surgery, model surgery, rapid prototyping, three-dimensional printing
|How to cite this article:|
Mendonca DA, Deraje V, Gujjalanavar RS, Gopal S. Case series of three-dimensional printing technology applied in complex craniofacial deformity surgery. J Cleft Lip Palate Craniofac Anomal 2016;3:88-94
|How to cite this URL:|
Mendonca DA, Deraje V, Gujjalanavar RS, Gopal S. Case series of three-dimensional printing technology applied in complex craniofacial deformity surgery. J Cleft Lip Palate Craniofac Anomal [serial online] 2016 [cited 2021 Oct 16];3:88-94. Available from: https://www.jclpca.org/text.asp?2016/3/2/88/187520
| Introduction|| |
Medical technological advances aim to improve patient's treatment outcome and empower the healthcare professional. Three-dimensional (3D) printing (additive manufacturing, rapid prototyping) is one such technology that has been widely embraced by the surgeon innovator with an intention to gain perfection in planning, execution, and analysis of complex surgical challenges. While 3D printing (3DP) technology has been around since 1980s, it was not until the early 2010s that 3DP became widely available commercially. Craniofacial surgeons have pioneered the use of this technology in the scientific arena. Rapid prototyping technology was introduced in the 1990s to medicine via computer-aided design (CAD), computer-aided manufacturing. The medical models or bio-models based on the 3DP technique represent 1:1 scale portions of the human anatomical region of interest obtained via 3D medical imaging.  Unlike rapid prototyping used for large-scale industrial products, 3DP in craniofacial surgery involves the individualized production of models, with every human body having distinct anatomy and pathology. Although 3DP has wide applications in many fields, in this article, we present our experience of using this technology in craniofacial surgery, with a specific intention of addressing the planning of complex deformities in 10 cases. With this early experience, we describe the process of producing a 3D model, its utility in managing cases and its role in training, simulation, and patient education.
| Materials and methods|| |
This was a retrospective analysis of our cases where we have used 3D models in 10 cases from 2014 to 2016 in a tertiary care hospital in India. 3D models were used during the correction of hypertelorism, craniosynostosis - open and endoscopic, hemifacial microsomia, skull bone defects, and orbital floor fractures. The age of the patients ranged from 5 months to 35 years of age. The time taken to produce the final 3D model from the time of receipt of computed tomography (CT) images ranged from 12 to 36 h. The cranioplasty molds took the least time, and the hypertelorism models took the longest time to produce, as more material was required. None of the patients had any major complication. One patient with hypertelorism had transient postoperative cerebrospinal fluid rhinorrhea which settled in 7 days time with conservative management.
Process of three-dimensional printing
Medical additive manufacturing is defined as the manufacture of dimensionally accurate physical models of human anatomy derived from medical image data using a variety of additive manufacturing technologies.  3DP, in concept, is as simple as printing a text document through a printer. The only difference is that it requires a custom made 3DP and the ink is replaced by various synthetic materials. The whole process of 3DP a craniofacial model has been simplified into a lucid flowchart [Figure 1]. The critical step in fabricating a good 3D model is to first get a high quality 1-2 mm slice CT image of Digital Imaging and Communications in Medicine format of the target organ. 3D reconstruction of this image is done using medical computer-aided design software program. The CAD file is electronically translated to stereolithographic (SLA) file format and sent to the 3DP. ,, Rapid prototyping follows using layer-by-layer SLA accumulation. The rapid prototype model is then fabricated on plaster by jetting of the materials.  The materials used are photopolymer, acrylonitrile butadiene styrene, thermoplastic, plastic powder, metal powder, ceramic powder, titanium alloys, eutectic metals, paper, foil, etc. The type of materials used depends on the type of 3DP technology required. Technology that uses a liquid base includes stereolithography and polyjet printing. Printers that use a powder base include selective laser sintering, 3DP, direct metal laser sintering and electron beam melting. A solid base is used by fused deposition modeling and laminated object manufacturing.  The main limitations to 3DP are model assembly time and cost. Production of 3D surgical models requires outsourcing to third-party medical modeling manufacturers, which results in costs as high as $4000 and manufacturer-to-office assembly times ranging from 2 to 3 weeks. , We have used 3D models created by an Indian startup company (Osteo3d, Bengaluru, India), who produce it at 1/5 th of the cost, as compared to developed countries. The other merit is that the time taken from receipt of CT data to production and availability of 3D models can be less than 12 hours, as the model is locally printed and delivered. The time taken to start the process of 3DP is short, as the CT data can be uploaded online through cloud-based software, designed by the company.
|Figure 1: Flow chart depicting the process of three-dimensional printing|
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| Results|| |
Case 1: Hypertelorism
A 17-year-old girl presented with severe hypertelorism and tessier no "0" cleft with cleft lip. She had no diplopia or malocclusion. She was also diagnosed to have clinical depression due to the facial deformity resulting in social recluse. [Figure 2]a shows hypertelorism, vertical dystopia with an intercanthal distance (ICD) of 6.5 cm. 3D model of the skull was prepared and the surgical plan included box osteotomies and vertical dystopia correction. The 3D model enabled comprehensive analysis of the true defect and exact mapping of the proposed movements of osteotomized segments. A model surgery was also carried out where marking was made over the model and cuts performed using a simple electric saw. The model surgery was replicated on the patient during the surgery leading to excellent results postoperatively as shown in [Figure 3]d. A nasal reconstruction was carried out in the second stage. The patient had no diplopia postoperatively and the postoperative ICD was 3.5 cm. She had an excellent surgical outcome and eventually good psycho-social adjustment [Figure 2]a-d and [Figure 3]a-d.
|Figure 2: (a) Preoperative picture showing hypertelorism and vertical dystopia, (b) three-dimensional model showing hypertelorism, (c) model surgery with osteotomy cuts, (d) model surgery showing medial advancement of box osteotomized segments|
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|Figure 3: (a) Intraoperative picture showing osteotomy cuts, (b) intraoperative picture showing medial advancement and fixing of box osteotomized segments with plates, (c) postoperative computed tomography scan showing good correction, (d) postoperative clinical picture|
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Case 2: Hypertelorism
A 24-year-old man presented with Tessier "0" cleft and hypertelorism with an ICD of 7 cm. He also had a history of anosmia. The occlusion was normal, and the CT scan showed severe midline ethmoidal hyperplasia with no evidence of any encephaloceles. Based on the information provided by the 3D model, it was decided that the patient would require only transverse movements of the orbits medially and bone grafts over the defects laterally. Box osteotomies were carried out as per plan and the postoperative result in [Figure 4]e shows a reduction of ICD to 4 cm. Excess skin was banked using a Kawamoto stitch in the midline for subsequent use in nasal reconstruction. Postoperative period was uneventful, and the patient is now being considered for the next stage of surgery [Figure 4]a-e.
|Figure 4: (a) Preoperative picture of a case of severe hypertelorism and bifid nose, (b) computed tomography scan showing ethmoidal hyperplasia and hypertelorism, (c) markings of box osteotomies on three-dimensional model-frontal view, (d) intraoperative picture of box osteotomy, medial advancement and fixation, (e) postoperative result with banking of excess skin using a K stitch|
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Case 3: Revision craniosynostosis
A 2-year-old male child presented with multisutural craniosynostosis with a history of worsening cranial deformity in spite of corrective surgery at 1 year of age at a different center. Other than the turribrachycephalic skull, the child also had greatly raised intracranial pressure with papilledema and copper beaten appearance of skull. Because of the complex nature of the deformity and the extra burden of the second surgery, a 3D model was prepared for meticulous planning of osteotomies and the movements of the bone segments. Thorough preoperative planning enabled faster surgery, decreased anesthesia time in a compromised patient and better outcomes as evident in [Figure 5]a-e.
|Figure 5: (a) A case of multisutural craniosynostosis with turribrachycephaly, (b) preoperative computed tomography scan showing turribrachycephaly, (c) three-dimensional model with markings for total cranial vault remodeling - frontal view, (d) three-dimensional model-profile view, (e) postoperative result|
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Case 4: Isolated early metopic craniosynostosis
A 5-month-old female infant presented with isolated metopic craniosynostosis leading to early trigonocephaly. Alarmed by the deformity, the parents demanded early intervention. Endoscopic craniosynostosis release was offered, but that required postoperative orthotic helmet therapy. After the endoscopic release of metopic suture, a 3DP helmet was produced for cranial molding postoperatively. The helmet therapy is to be used for 12 months, and the postoperative picture [Figure 6]e shows good recovery and excellent correction of hypotelorism and trigonocephaly. The helmets need to be adjusted during the molding period to allow for skull shape changes [Figure 6]a-e.
|Figure 6: (a) A case of early metopic craniosynostosis, (b) computed tomography scan showing fused metopic suture in a 5-month-old baby, (c) markings for endoscopic craniosynostosis release, (d) postoperative three-dimensional printed helmet therapy for cranial molding, (e) excellent postoperative result after endoscopic craniosynostosis release and three-dimensional printed helmet therapy|
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Case 5: Hemifacial microsomia
A middle-aged female, who had hemifacial microsomia, presented with mandible asymmetry and occlusal cant, but was not ready for a complete maxilla-mandibular orthognathic surgery. She demanded only chin correction for which a genioplasty was planned. A 3D model was prepared and osteotomy cuts and advancement was marked, executed and shown to the patient preoperatively. After the patient was reassured, actual surgery was performed in line with the preoperative plan. [Figure 7]d shows excellent results and more importantly, a satisfied patient [Figure 7]a-d.
|Figure 7: (a) A case of hemifacial microsomia showing chin asymmetry, (b) three-dimensional model with markings for genioplasty, (c) model surgery demonstrated to patient, (d) postoperative result showing excellent symmetry|
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Case 6: Secondary contour deformity postfrontal bone fracture
A young male adult presented with a history of multiple pan facial fractures due to a road traffic accident 1 year back. He had frontal none fracture, naso orbito ethmoidal fracture, and bilateral maxilla fracture with severe communition bone loss and soft tissue injuries. The primary fracture fixation was done in another hospital which got secondarily infected. Debridement of necrotic bone was done. He now presented to us with a contour deformity for bone and soft tissue correction. A 3D model was produced which demonstrated the true extent of the defect and the previous metal work. Surgical correction was planned which involved removal of previous implants and onlay hydroxylapatite cranioplasty with a titanium mesh base. Although many materials can be used for 3DP, few materials can be permanently inserted into the human body. Thus far, titanium is the ideal realistic material for human body use. Therefore, 3D titanium-based implants could be implanted, but cost concerns may limit extensive use. Immediate postoperative result [Figure 8]d shows excellent contour of the forehead. The 3D model averted any intraoperative surprises and prepared the surgeon to perform a well-orchestrated surgery [Figure 8]a-d.
|Figure 8: (a) A case of secondary frontal bone contour defect postmultiple facial fractures and bony loss, (b) computed tomography picture showing the frontal bone defect, (c) three-dimensional model depicting the true extent of defect, (d) immediate improvement in forehead contour after using hydroxyapatite implant with a titanium mesh base|
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Case 7: Orbital floor defect
[Figure 9]a and b shows pre- and postoperative CT scans of a young adult patient who had secondary enophthalmos due to an orbital blowout fracture. The orbital floor reconstruction was carried out using a patient-specific customized 3DP titanium implant. Using the contralateral orbital anatomy, ideal ipsilateral orbital structures can be simulated on computer software and can be manufactured using 3DP technology. Based on this 3D model, orbital wall reconstruction can be successfully performed. The postoperative picture [Figure 9]b shows perfect restoration of orbital floor anatomy [Figure 9]a and b.
|Figure 9: (a) Computed tomography image of patient with orbital floor fracture and enophthalmos, (b) custom made, patient specific three-dimensional printed titanium implant used showing excellent reconstruction of the orbital floor|
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Case 8-10: Cranioplasty
Three patients who had undergone craniotomy for intracranial tumors presented with loss of bone graft post-radiography. These cranial defects were treated with custom-made hydroxylapatite implants using a 3DP mold. [Figure 10] a-c show preparation of such implants using the patient-specific 3DP mold. There is an inner and an outer mold. Hydroxyapatite is placed in between the two molds in the sandwich technique and time is allowed for setting. Once the setting is done, the implant prepared fits perfectly to the cranial defect [Figure 10]a-c.
|Figure 10: (a-c) Preparation of hydroxyapatite implant using three-dimensional printed patient specific molds for cranioplasty|
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| Discussion|| |
3DP in craniofacial plastic surgery was probably first used for skull bone reconstruction. In 1994, Mankovich et al.  first applied 3D technology for skull reconstruction. Choi and Kim  reviewed 35 articles on 3DP in craniofacial surgery and also presented their experience in 800 cases where this technology was used. Engel et al.  have presented a single case of hypertelorism where 3DP model was used for planning and simulation and concluded that this approach allowed reducing time of surgery, accurately planning the location of the osteotomies and precontouring the osteosynthesis material. With 3DP, a precise and cost-effective prefabricated model ascertained from computed tomographic data can be used to create precontoured plates and help to plan for potential bone graft harvest geometry before surgery.  Virtual surgical planning using "in office" 3DP is feasible and allows for a more cost-effective and less time-consuming method for creating surgical models and guides.  We have applied this technology in 10 cases in the past 3 years for a variety of craniofacial deformities such as hypertelorism, craniosynostosis, hemifacial microsomia, cranial bone defects, and orbital floor defects. 3D skull models, 3DP patient specific titanium implants and 3DP helmets for cranial molding have been the tools that helped in reconstructing such defects. With the experience gained through these cases, the authors put forth a list of advantages gained by using 3DP technology:
- Assessment of true extent of the defect: A 3DP model can be the clinician's extra eye for examining a defect. Modern 3DP models allow for a precise high definition of the contours. The model provides comprehensive anatomical details of the target region and helps the surgeon to accurately record the true extent of a defect, thus avoiding any surgical surprises
- Accurate planning of the procedure: Having got a thorough knowledge of the defect, the 3D model can help the surgeon in planning the operative procedures such as osteotomy cuts, bone segment advancement, need for bone grafts, precontouring of implants, and planning incisions. Preoperative marking of the proposed cuts and movements will give the surgeon a visual reinforcement of the surgical planning
- Performance of model surgery: The osteotomy cuts can actually be performed on the 3D models before the surgical procedure to be more comfortable with the anatomy, the defect, possible hurdles and to predict the final result. It prepares the surgeon for the actual encounter, decreases the operative time, decreases anesthesia time. The steps of the surgery can be accurately predicted and the surgical team is more prepared for the subsequent steps. Precontoured implants can be used further decreasing the operative time. The surgeon is more relaxed and stress free and the whole team works like a well-oiled unit
- Patient education: A well-informed patient is a safe patient. The steps of the surgery can be demonstrated to the patient and the patient can gain a fair idea about the expected results of the surgery
- Training: There is a definite paradigm shift of surgical training from apprenticeship toward simulation. Residents and fellows cannot be better trained than with a 3D model of the pathology and model surgery. Simulation osteotomy cuts such as fronto-orbital advancement, Lefort I, II and III, genioplasty, fracture fixation, maxilla reconstruction, and cranioplasty can be performed by the residents to gain "hands on" training in craniofacial plastic surgery. 3DP models will be an integral part of simulation surgery training protocols in the future
- Preparation of custom made patient specific implants made up of titanium and hydroxyapatite can help in more harmonious restoration of anatomy in complex contour defects
- Production of custom made 3DP helmets for cranial vault molding postoperatively after endoscopic craniosynostosis surgery
- Having a company based locally that produces 3D models can greatly cut down on the cost of complex procedures. These models can be supplied to neighboring developing countries at a reasonable cost. This has major implications for health care delivery in the health-care systems of developing countries.
In spite of the several advantages listed above, very few craniofacial centers utilize this technology. The authors observe that the main limiting factor is the nonavailability of a local company that provides 3DP technology services. If the 3D models have to be prepared in a different city and then transported, it can cause delay and inconvenience to the patients who are economically restrained.
| Conclusion|| |
3DP technology has empowered the armamentarium of the craniofacial surgeon in tackling complex craniofacial deformity correction. 3DP models will revolutionize the way surgeons think and plan surgical simulation. We recommend a wider application of such a technology in orthognathic surgery and any surgery, which requires bony osteotomies with movement.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
The authors would like to thank Mr. Deepak Raj (Founder, Osteo3d, Bengaluru, Karnataka, India) for advice in planning and production of 3D models for our cases.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]
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