Cranial Bone Grafts Research Articles

Anthropometric Outcomes following Fronto-Orbital Advancement for Metopic Synostosis

The authors' purpose is to present changes in anthropometric fronto-orbital dimensions after surgical correction of metopic synostosis. The authors retrospectively analyzed craniometric dimensions in older patients with metopic synostosis corrected by fronto-orbital advancement performed by the senior author (J.B.M.). Preoperative and postoperative linear measures (frontal breadth, cranial width, and intercanthal distance) were taken by direct anthropometry. Interdacryon distance and width of the bandeau were also recorded intraoperatively, before and after widening. Follow-up anthropometric values were compared to age- and sex-matched normative data and standard (z) scores were calculated. Sixteen patients met the inclusion criteria. Syndromic diagnosis was documented in five of 16 patients. Average age at the last postoperative evaluation was 8.9 ± 3.8 years (range, 4 to 16 years). Mean frontal width z-scores decreased postoperatively from 0.82 to -0.32 (p = 0.007), indicating diminished growth in this dimension. The last measured frontal width strongly correlated with the breadth of the bandeau after surgical correction but not with preoperative values. Postoperative mean cranial width diminished significantly to a more normal value. Mean intercanthal distance was normal preoperatively and remained so but was significantly greater in syndromic than in nonsyndromic cases. Frontal growth rate is diminished in the coronal plane after fronto-orbital advancement. The authors recommend primary techniques to overcorrect the width of the bandeau and frontal region, including zygomaticosphenoid osteotomies and interpositional cranial bone grafts to advance/widen the lateral orbital rim. Continued evaluation is required to assess whether overcorrection results in normal frontotemporal shape and breadth at skeletal maturity.

An Experimental Study of Particulate Bone Graft for Secondary Inlay Cranioplasty Over Scarred Dura.

Inlay cranioplasty in children is challenging because autologous bone is limited. Cranial particulate bone graft effectively closes defects when placed over normal dura. The purpose of this study was to determine if particulate bone graft will ossify when used for secondary cranioplasty over scarred dura. A 17 × 17-mm critical-sized defect was made in the parietal bone of 16 rabbits. Four animals had no implant (group 1). Twelve animals had the defect remade 16 weeks postoperatively, which was managed in 2 ways: group 2 (no implant; n = 6) and group 4 (particulate bone graft; n = 6). Particulate graft was obtained using a brace and bit from the frontal bone. Computed tomography was used to determine the area of ossification and thickness of the healed graft. Eight animals previously managed with particulate bone graft over normal dura were used as an additional control (group 3). Critical-sized defects filled with particulate bone graft over scarred dura (group 4) exhibited superior healing of the area (83.8%; range, 73.0%-90.6%) compared to control defects over normal dura (group 1: 62.9%; range, 56.5%-73.4%) or scarred dura (group 2: 56.9%; range, 40.0%-68.3%) (P = 0.0004). Particulate bone on scarred dura exhibited less ossified area (P = 0.002), and thinner bone (0.95 mm, range, 0.71-1.32 mm) compared to defects in which graft was placed over normal dura (group 3: area, 99.2%; range, 96.8%-100%; thickness, 1.9 mm, range; 1.1-3.1 mm) (P = 0.04). Particulate bone graft ossifies inlay cranial defects over scarred dura although inferior to placement over normal dura. Clinically, particulate bone graft may be used for secondary inlay cranioplasty.

Congenital Ocular Dystopia from Orbitofrontal Bone Dysplasia.

Several patients with ocular dystopia and craniofacial differences have been found to have orbital dysplasia and a frontal bone defect. This deformity is characteristically different from differential diagnoses of encephalocele, sphenoid dysplasia, craniofacial dysostoses, or atypical clefting. The authors retrospectively reviewed the craniofacial registries of two pediatric centers for patients presenting with ocular dystopia or orbitofrontal anomalies between 2000 and 2014. The features and treatment of these patients were analyzed. Four patients with congenital orbitofrontal bone dysplasia were identified, three with unilateral and one with bilateral frontal bone defects. Clinical signs of hypoglobus and vertical ocular dystopia of an average of 5.0 mm on the affected side were noted shortly after birth. The transversely oriented bony defect had an average surface area of 3.9 cm in unilateral cases and 10.7 cm in bilateral cases. Patients showed a characteristic orbital vertical elongation with an average orbital height-to-width ratio of 1.30-in excess of the average normal 1.14 by 14 percent-and inferior rim displacement. Cranial contour demonstrated frontal bossing and borderline dolichocephaly. Fronto-orbital reconstruction was performed in three patients, using cranial bone grafting to obliterate the orbital roof defect and elevate the orbital floor, which was successful in reducing ocular dystopia and preserving vision in each patient. One patient followed for 11 years postoperatively has a durable result with no surgical revision. Orbitofrontal bone dysplasia has not been previously reported, and includes a frontal bone defect and ocular dystopia. Single-stage fronto-orbital reconstruction appears to adequately correct it. Therapeutic, IV.

Combined flaps based on the superficial temporal vascular system for reconstruction of facial defects

Facial defects are multicomponent deficiencies rather than simple soft-tissue defects. Based on different branches of the superficial temporal vascular system, various tissue components can be obtained to reconstruct facial defects individually. From January 2004 to December 2013, 31 patients underwent reconstruction of facial defects with composite flaps based on the superficial temporal vascular system. Twenty cases of nasal defects were repaired with skin and cartilage components, six cases of facial defects were treated with double island flaps of the skin and fascia, three patients underwent eyebrow and lower eyelid reconstruction with hairy and hairless flaps simultaneously, and two patients underwent soft-tissue repair with auricular combined flaps and cranial bone grafts. All flaps survived completely. Donor-site morbidity is minimal, closed primarily. Donor areas healed with acceptable cosmetic results. The final outcome was satisfactory. Combined flaps based on the superficial temporal vascular system are a useful and versatile option in facial soft-tissue reconstruction.

Computed tomography image guidance for more accurate repair of anterior table frontal sinus fractures.

Anterior table frontal sinus fractures accompanied by nasofrontal duct injury require surgical correction. Extracranial approaches for anterior table osteotomies have traditionally used plain radiograph templates or a "cut-as-you-go" technique. We compared these methods with a newer technique utilizing computed tomography (CT)-guided imaging. Data of patients with acute, traumatic anterior table frontal sinus fractures and nasofrontal duct injury between 2009 and 2013 were reviewed (n = 29). Treatment groups compared were as follows: (1) CT image guidance, (2) plain radiograph template, and (3) cut-as-you-go. Frontal sinus obliteration was performed in all cases. Demographics, operative times, length of stay, complications, and osteotomy accuracy were recorded. Similar demographics, concomitant injuries, operative times, and length of stay among groups were noted. No patients in the CT-guided group had perioperative complications including intraoperative injury of the dura, cerebrum, or orbital structures. In the plain radiograph template group, 25% of patients had inadvertent dural exposure, and 12.5% required take-back to the operating room for cranial bone graft donor site hematoma. In the cut-as-you-go group, 11% required hardware removal for exposure. There were no cases of cerebrospinal fluid leak, meningitis, or mucocele in any group (follow-up, 29.2 months). The CT image guidance group had the most accuracy of the osteotomies (95%) compared with plain radiograph template (85%) and the cut-as-you-go group (72.5%). A new technique using CT image guidance for traumatic frontal sinus fractures repair offers more accurate osteotomy and elevation of the anterior table without increased operative times or untoward sequelae.

Split cranial bone grafting in children younger than 3 years old: debunking a surgical myth.

In cranioplasty patients split cranial bone provides excellent structural support and fundamentally "replaces like with like." However, traditional teaching in craniofacial surgery is that cranial bone cannot be split before the age of 3 years because of the lack of diploic space. The authors have found this not to be the case and describe their experience with splitting cranial bone in children with craniosynostosis younger than 3 years. The authors completed a retrospective review of 418 cranioplasties performed between 1997 and 2013 by a single surgeon on patients younger than 3 years with syndromic and nonsyndromic craniosynostosis. Average patient age at the time of the procedure was 328 days. The youngest patient was 58 days old. Of the 418 cranial procedures performed in this study, cranial bone could be split and used as bone graft in every case. Although the presence of Lückenschädel prevented a complete split of the inner table from the outer table of the bone flap, split cranial bone grafting could still be performed, providing significant grafting material to foster reconstruction. No complications from split cranial harvest were observed. Contrary to popular belief and the misconception perpetuated by the Plastic Surgery In-Service Examination, the cranium of children younger than 3 years can indeed be safely and predictably split between the inner and outer cortex. This important finding provides the craniofacial surgeon with a valuable, expanded source of rigid bone for cranial vault remodeling in the pediatric patient population. Therapeutic, IV.

Cranial bone grafting for alveolar clefts: a 25-year review of outcomes.

Cranial bone grafting for an alveolar cleft obtains membranous bone from a low-morbidity donor site. Although iliac crest bone is the favored donor site, there are no objective analyses of three-dimensional radiologic outcomes with cranial bone grafting and no studies evaluating complications and long-term outcomes in a large series of patients undergoing cranial bone grafting. A retrospective chart review was conducted on patients who underwent alveolar bone grafting from the cranium over a 25-year period performed by a single surgeon. Data collected included patient characteristics, complications, and clinical outcomes. Radiologic analysis of graft outcomes was determined using Amira volume-rendering software on the most recent 10 consecutive patients. The authors' study cohort included 308 patients, with an average age of 11.5 years. Complications involved harvesting the graft in 3.5 percent, the donor site in 1 percent, and the recipient site in 17.2 percent. Regrafting was required in 7.1 percent, with a clinical success rate of 92.9 percent. The average alveolar defect was 1.19 ml preoperatively and 0.19 ml postoperatively, with 85 percent fill of the cleft defect by radiologic analysis. Cranial bone grafting for the alveolar cleft is a low-morbidity operation and has success similar to that of iliac crest bone grafting. It should be considered more often as a viable option for the alveolar cleft patient. Therapeutic, IV.

Calvarial thickness and diploic space development in children with sagittal synostosis as assessed by computed tomography.

Following surgical management of craniosynostosis, residual calvarial defects may require reconstruction, frequently with the use of cranial bone grafts. Knowledge of optimal sites for harvest would be beneficial in such situations. The goal of this study is to compare calvarial thickness (CALV) and diploic thickness (DIPL) in children with corrected sagittal synostosis to normal controls (n = 47) using postoperative CT scans. We also compare the results from children who had undergone open (OPEN) (n = 26) and endoscopic (ENDO) (n = 26) surgery. On each skull, CALV and DIPL were measured at 44 points over 5 regions. Multiple regression analysis was used to compare CALV and DIPL controlling for gender and age. Children who had undergone previous craniosynostosis correction tended to have thinner CALV compared to controls in operated regions but thicker CALV in unoperated regions (P < 0.001). Adjusted mean CALV was thinner overall in ENDO compared to OPEN (P = 0.020). Children with corrected sagittal synostosis have thinner DIPL than controls (P = 0.002). No difference was found in DIPL comparing OPEN and ENDO (P = 0.977) approaches. Children who had undergone previous craniosynostosis correction tended to have thinner CALV when compared to controls in operated regions but thicker CALV in unoperated regions. ENDO calvaria were thinner than OPEN calvaria. Children with corrected sagittal synostosis have thinner DIPL than controls; no difference was found in DIPL comparing OPEN and ENDO approaches. Due to irregularities in bone development among children who had previously undergone calvarial reconstruction, individualized preoperative CT assessment is recommended in all patients undergoing secondary split calvarial bone grafting procedures.

From “Head to Heart

Sternal cleft is a rare anomaly and has been variously managed by using either autogenous tissue or synthetic materials for bony reconstruction. We report the reconstruction of sternal cleft in a 15-month-old child with a single-piece outer-table cranial bone graft that was harvested by splitting in situ. The reconstructed sternum was covered with bilateral pectoralis major advancement muscle flaps.

Reconstruction pré-implantaire du maxillaire atrophique

Extreme maxillary atrophy results from partial or total maxillary bone defect, affecting the alveolar and basal segments. The residual bone is only a few millimeters high and does not allow retention of dental prostheses (complete edentulation), or placing implants. Bone reconstruction with cranial bone grafts usually allows obtaining enough bone volume in a single step to place implants for prosthetic rehabilitation, 3 months later. Reconstruction begins by inserting bone grafts on the sinus floor. The pre-maxilla is then rebuilt with bone grafts placed on the nose floor then on the palate and vestibule. The premolar and molar sectors are rebuilt last with vestibular and palatine bone grafts assembled and stabilized by screws, or steel wire rings, and reinforced on their deep portion with diploe sheets. Extreme maxillary atrophy reconstruction with cranial bone grafts is a reliable technique with reproducible results and few complications (sinusitis, bone sequester). Nevertheless, it requires strong experience to adequately perform harvesting and reconstruction.

Does Mastoid Obliteration following Mastoidectomy Offer an Improvement in Quality of Life?

Objectives: 1) Recognize the impact mastoidectomy with obliteration has on quality of life (QOL). 2) Describe the QOL change with primary or secondary mastoid obliteration with autologous bone graft. 3) Review of the literature on mastoid obliteration. Methods: This retrospective observational study was conducted to determine if mastoid obliteration with autologous cranial bone graft following mastoidectomy improves QOL. Patients with cholesteatoma who had mastoidectomy with primary or secondary mastoid obliteration by a tertiary otologist were surveyed using the validated Glasgow Benefit Inventory (GBI), our primary outcome measure. Our secondary outcomes were recurrence rates. Results: Fifty-five patients were interviewed: 44 were primary obliterations, and 11 were secondary obliterations of an existing mastoid cavity. Overall GBI scores were improved, with average scores of 25. Average general subscale scores were 26, physical health scores were 22, and social health scores were 24. The primary obliteration group had average scores of 22, general subscale scores of 23, physical health scores of 21, and social health scores of 19. Those with secondary obliteration scored higher, with average scores of 37, general subscale scores of 40, physical health scores of 21, and social health scores of 42. Recurrence rates were comparable with the current literature. Conclusions: This study shows that mastoidectomy with obliteration using autologous cranial bone graft offers a significant QOL benefit. The GBI scores compare favorably with other otology procedures. Secondary obliterations after revision mastoidectomy scored much higher than primary obliterations. This is currently the only QOL study comparing these two patient groups.

Application of Cranial Bone Grafts for Reconstruction of Maxillofacial Deformities

This retrospective study evaluated outcomes with the use of calvarial bone grafts (CBGs) in maxillofacial reconstruction as well as donor and recipient site complications. The records of 50 consecutive patients from a private practice were reviewed; there were 34 women and 16 men, with an average age of 32.4 years (range 16 to 66 years). Among the 50 patients, CBGs were placed in 63 sites: the ramus (10), nasal dorsum (14), maxilla/alveolar ridge (12), glenoid fossa/temporal bone (14), mandibular body/symphysis (3), and orbitozygomatic complex (10). The longest follow-up averaged 22.4 months (range 12 to 48 months). An outer-table CBG harvest technique was utilized. All subjects were evaluated for infection, dehiscence, loss of graft, and any other complications. Three complications occurred (5%) at the recipient sites. Two grafts became infected requiring removal, and one nasal dorsal graft was mobile but remained in position. At 50 donor sites, 2 complications (4%) occurred, resulting in dural tears in two patients that were immediately repaired with no untoward consequence. In conclusion, CBGs are an effective bone source for maxillofacial reconstruction with low donor and recipient site complications.

Experimental Comparison of Cranial Particulate Bone Graft, rhBMP-2, and Split Cranial Bone Graft for Inlay Cranioplasty

Background : Particulate bone graft and recombinant human bone morphogenetic protein-2 (rhBMP-2) are options for inlay cranioplasty in children who have not developed a diploic space. The purpose of this study was to determine whether particulate bone graft or rhBMP-2 has superior efficacy for inlay cranioplasty and to compare these substances to split cranial bone. Methods : A 17 mm × 17 mm critical-sized defect was made in the parietal bones of 22 rabbits and managed in four ways: Group I (no implant; n=5), Group II (particulate bone graft; n=5), Group III (rhBMP-2; n=7), and Group IV (split cranial bone graft; n=5). Animals underwent microcomputed tomography and histologic analysis 16 weeks after cranioplasty. Results : Defects without an implant (Group I) demonstrated inferior ossification (41.4%; interquartile range [IQR], 28.9% to 42.5%) compared to those treated with particulate bone graft (Group II: 99.5%; IQR, 97.8% to 100%), rhBMP-2 (Group III: 99.6%; IQR, 99.5% to 100%), or split cranial bone (Group IV: 100%) (P < .0001). There was no difference between Groups II, III, and IV (P = .1). Defects treated with rhBMP-2 exhibited thinner bone (0.90 mm; IQR, 0.64 to 0.98) than particulate bone graft (1.95 mm; IQR, 1.09 to 2.83) or split cranial bone (1.72 mm; IQR, 1.54 to 1.88) (P = .006); particulate and split cranial bone grafted defects had a similar thicknesses (P = .6). Conclusions : Particulate bone graft, rhBMP-2, and split cranial bone close inlay calvarial defect areas equally, although the thickness of bone healed with rhBMP-2 is inferior. Clinically, particulate bone graft or split cranial bone graft may be superior to rhBMP-2 for inlay cranioplasty.

Safety and Efficacy of Recombinant Human Bone Morphogenetic Protein 2 on Cranial Defect Closure in the Pediatric Population

Traditional reconstructive options for cranial defects include autogenous bone graft, bone substitutes, and synthetic materials. The established standard for repairing cranial defects is autogenous bone. However, young children do not have abundant donor sites for bone harvest, which leads to challenges in closing calvarial defects. Synthetic materials are not ideal alternatives because they require subsequent retrieval and are prone to infection. Their long-term effects on growth of the skull are also not well studied. Bone morphogenetic protein 2 (BMP-2), are shown to positively affect closure of cranial defects in animal models. We present a study comparing the efficacy and safety of closure of cranial defect with bone graft augmented with recombinant human BMP-2 (rhBMP-2) and compared with a series of patients treated with bone graft alone. This study is a retrospective multicenter evaluation of 36 patients spanning 5 years. Twenty-one patients undergoing cranial defect closure augmented with rhBMP-2 were compared with 15 patients who underwent cranial defect closure using cranial bone shavings alone. We measured preoperative and postoperative defect size on volumetric computed tomographic scan reconstructions to compare defect sizes. The rhBMP-2 group had slightly increased proportional closure compared with the control group, 86% versus 76% (P < 0.018), respectively. Two patients in the rhBMP-2 group had postoperative fusion of a suture that was known to be patent at the time of cranial defect closure. No instances of brain edema, herniation, airway compromise, or other adverse effects directly attributable to rhBMP-2 were observed. Bone morphogenetic protein 2 may increase the amplitude and uptake of cranial bone grafts in cranial defect closure. This study shows that defect sizes of up to 16 cm can be reliably closed using this technique. Postoperative fusion of uninvolved sutures in 2 patients indicates that rhBMP-2 may have unreported adverse effects; consideration of this finding should be weighed against the benefit of improved closure of calvarial defects.

Cranial Bone Grafts in Forehead Reconstruction After Resection for Benign Tumors

Cranial bone graft was first used in forehead reconstruction by Muller and König as early as 1890. Because cranial bone graft is the ideal material for almost all facial and skull repairs, surgeons have subsequently used this technique to repair skull defects. In fact, membranous bone (calvaria) is superior to endochondral bone (ilium, rib) and maintains its volume to a significantly greater extent than endochondral bone.The authors, after reviewing the literature, report 3 cases of forehead benign tumors treated by resection and primary reconstruction using cranial bone grafts. The preoperative computed tomographic scanning should lead to appropriate diagnosis and treatment planning, which includes total excision and primary bone grafting of the defect to prevent soft-tissue contraction.

Computer-assisted midface reconstruction in Treacher Collins syndrome part 1: Skeletal reconstruction

IntroductionTreacher Collins syndrome (TCS) is a severe and complex craniofacial malformation affecting the facial skeleton and soft tissues. The palate as well as the external and middle ear are also affected, but his prognosis is mainly related to neonatal airway management. Methods of zygomatico-orbital reconstruction are numerous and currently use primarily autologous bone, lyophilized cartilage, alloplastic implants, or even free flaps. This work developed a reliable “customized” method of zygomatico-orbital bony reconstruction using a generic reference model tailored to each patient. MethodsFrom a standard computed tomography (CT) acquisition, we studied qualitatively and quantitatively the skeleton of four individuals with TCS whose age was between 6 and 20 years. In parallel, we studied 40 controls at the same age to obtain a morphometric database of reference. Surgical simulation was carried out using validated software used in craniofacial surgery. ResultsThe zygomatic hypoplasia was very important quantitatively and morphologically in all TCS individuals. Orbital involvement was mainly morphological, with volumes comparable to the controls of the same age. The control database was used to create three-dimensional computer models to be used in the manufacture of cutting guides for autologous cranial bone grafts or alloplastic implants perfectly adapted to each patient's morphology. Presurgical simulation was also used to fabricate custom positioning guides permitting a simple and reliable surgical procedure. ConclusionsThe use of a virtual database allowed us to design a reliable and reproducible skeletal reconstruction method for this rare and complex syndrome. The use of presurgical simulation tools seem essential in this type of craniofacial malformation to increase the reliability of these uncommon and complex surgical procedures, and to ensure stable results over time.

Single-Donor Allogeneic Platelet Fibrin Glue and Osteoconductive Scaffold in Orbital Floor Fracture Reconstruction

Commonly used materials for orbital floor fracture reconstruction include autologous cranial bone graft and titanium mesh. We have evaluated here a biomaterial combining biphasic calcium phosphate (hydroxyapatite [HA]/β-tricalcium phosphate [TCP]) osteoconductive scaffold with single-donor allogeneic platelet fibrin glue. The study was conducted on 10 consecutive patients with a follow-up of up to 4 years. Platelet fibrin glue was prepared by mixing equal volumes of single-donor platelet-rich plasma and cryoprecipitate with HA/β-TCP followed by activation with human thrombin prepared by plasma activation. Postoperative evaluations included serial photographs, repeated physical examination, and 3-dimensional computed tomography scan performed 2 years after surgery. The fibrin-rich platelet biomaterial was easy to mold and to apply on the surgical site allowing the surgeon to sculpt accurately the bone defect, providing mechanical stability while avoiding spillage of the scaffold. No infection of the orbit or extrusion of HA/β-TCP was observed. Ocular motility was normal, and no diplopia or enophthalmos of the injured orbit was noted. Coronal computed tomography scans of the reconstructed orbits revealed good restoration of the orbital floor defect in all 10 patients. The use of single-donor platelet fibrin glue combined with an osteoconductive scaffold offers a valuable alternative to autologous cranial bone graft or titanium mesh in the reconstruction of orbital floor bone defect.

Mastoidectomy and mastoid obliteration with autologous bone graft: A quality of life study

BackgroundA mastoid cavity resulting from a canal wall down mastoidectomy can result in major morbidity for patients due to chronic otorrhea and infection, difficulty with hearing aids and vertigo with temperature changes. Mastoid obliteration with reconstruction of the bony external ear canal recreates the normal anatomy to avoid such morbidity. Few have the studied the quality of life benefit that this procedure confers.MethodsThis retrospective observational study was conducted to determine if mastoid obliteration with autologous cranial bone graft following mastoidectomy improves quality of life (QOL). Patients with cholesteatoma who had mastoidectomy with primary or secondary mastoid obliteration by a tertiary otologist were surveyed using the validated Glasgow Benefit Inventory (GBI), our primary outcome measure.ResultsFifty-eight patients were interviewed. Forty-six were primary obliteration after canal wall down mastoidectomy of a primary cholesteatoma. Twelve were secondary obliteration of an existing canal wall down mastoid cavity. Overall GBI scores were improved, with average scores of 22. Average general subscale scores were 23, physical health scores were 25, and social health scores were 22. The primary obliteration group had average scores of 19, general subscale scores of 20, physical health scores of 21, and social health scores of 22. Those with secondary obliteration scored higher, with average scores of 31, general subscale scores of 34, physical health scores of 39, and social health scores of 25.ConclusionThis study shows that mastoidectomy with obliteration using autologous cranial bone graft offers a significant QOL benefit. The GBI scores compare favourably with other otorhinolaryngology procedures. Secondary obliterations after revision mastoidectomy scored much higher than primary obliterations. This is currently the only QOL study comparing these two patient groups.

Importance of patient-specific intraoperative guides in complex maxillofacial reconstruction

BackgroundConventional maxillofacial reconstruction often leads to suboptimal results due to inaccurate planning or surgical difficulties in adjusting a free flap and osteosynthesis plates into a three-dimensional defect. ObjectivesTo justify the importance of patient-specific intraoperative guides in complex maxillofacial reconstruction. Clinical exampleA 40-year old patient underwent a left hemimaxillectomy for an adenoid cystic carcinoma of the palate. Six years later, massive recurrence required radical resection of the left orbit and reconstruction with cranial bone grafts and a free latissimus dorsi flap. Postoperative radiotherapy resulted in local osteoradionecrosis. Surgical revision and restoration of the maxillary defect with a prefabricated fibula flap was performed. The authors provide ample information on the application of computer-aided design and manufacturing (CAD-CAM) and rapid prototyping at each reconstructive step. DiscussionStereolithographic models enable simulation of the resective and reconstructive phases, prebending of reconstruction plates and fabrication of surgical guides. ConclusionsOptimal restitution of complex maxillofacial defects requires meticulous planning of the surgical and prosthetic phases and effective transfer of the plan to the operating room through patient specific guides. CAD-CAM technology and stereolithographic models represent an effective strategy to achieve this. Improved patient outcomes and intraoperative efficiency certainly offset the inherent increase in costs.

Advanced Cranial Reconstruction Utilizing Intracranial Free Flaps and Cranial Bone Grafts

Advanced Cranial Reconstruction Utilizing Intracranial Free Flaps and Cranial Bone Grafts