1
Dentistry College, Mosul University, Mosul, Iraq
2
Department of Maxillofacial Surgery, AL-Jumhory Teaching Hospital, Mosul, Iraq
3
Department of Surgery, Mosul College of Medicine, Mosul University, Mosul, Iraq
Corresponding author details:
Israa Anwar Abd al-Hameed, BDS, MSc
Dentistry College
Mosul University
Mosul,Iraq
Copyright:
© 2019 Abd al-Hameed IA, et
al. This is an open-access article distributed
under the terms of the Creative Commons
Attribution 4.0 international License, which
permits unrestricted use, distribution, and
reproduction in any medium, provided the
original author and source are credited.
Cranioplasty is defined as the surgical repair of acquired defects or congenital deformities
of the cranium. It is performed mainly for anatomical reconstruction, brain protection, and
cosmetics, but evidence has shown that there is also improvement of brain physiology.
The aims of this paper are to describe a technique to fabricate polymethylmethacrylate
prostheses by hand during operation and at the same time describe the surgical outcomes
of this procedure. Between the years 2007 and 2011, 20 patients were complaining from
cranial bone defect due to many causes underwent cranioplasty operation in Mosul Medical
Center/IRAQ for reconstructed the defect using the polymethylmethacrylate that fabricated
by hand during the operation. The operations were done by the same maxillofacial surgeon
with different neurosurgeons. Age of patients extended from 14 years to 42 years with
mean 33.2 years. The main cause of cranial defect was trauma resulting from missiles
injuries that involved 14 patients and formed 70%. During the follow-up, all patients were
satisfied with the cosmetic result and no revision for cosmetic reasons was required. One
patient developed infection in one of stainless steel wire postoperatively that controlled
and resolved the problem by remove this wire only. Thus, the implanted material was well
tolerated in all cases. The majority of patients were males while the most common cause
of cranial defect was due to traumatic cranial injury by missiles injuries. Infection, being
the most feared complication of allograft implants, but there was a very low rate with the
technique described in this paper. This technique is quick and easy to perform, and provide
a cheap and safe way produces a strong implant very good cosmetic.
Cranioplasty; Cranial deformity; Cranium; Traumatic cranial injury
Cranioplasty is the surgical intervention to repair cranial acquired defects or congenital
deformities. The aim of cranioplasty is not only a cosmetic issue and reduce headaches due
to previous surgery or injury, also the repair of cranial defects improve brain physiology,
protect the brain and increases the social performances [1-5]. With emerging evidence for
the benefit of early decompressive craniectomy for ischemic stroke [6] diffuse traumatic
brain injury [7], and skull-infiltrating tumours [8] the cranioplastic surgery has widely
increased. The first goals are get good biocompatibility, defect closure with accurate
fitting of the plastic material to the bone borders and mainly a satisfying cosmetic result
is get [9]. Materials utilized for cranial reshaping include bone, auto/allografts, distinct
biomaterials, and even osteoinductive growth factors [10]. Polymethylmethacrylate
(PMMA), a conventional transparent thermoplastic is one of the most popular alloplastic
materials used in treatment of cranial defect during and after World War II [11,12]. PMMA
has advantage that it can be moulded during surgery into the shape of the cranial defect.
Performing a cranioplasty poses a challenge to neurosurgeons, plastic reconstructive
surgeons, and maxillofacial surgeons since the procedure often comprises very large skull
defects. The most postoperative complications may include haemorrhage, cerebrospinal
fluid (CSF) leaks and infections which due to foreign material implantation while the
seizures, and neurological deficits are less common. [13-15].
The aims of this study to describe a technique to fabricate PMMA prostheses by
hand during operation and at the same time describe the surgical outcomes of this
procedure.
Between the years 2007 and 2011, 20 patients were complaining from cranial bone
defect due to many causes underwent Cranioplasty operation in Mosul Medical Center/
IRAQ for cranial reshaping using the polymethylmethacrylate (Figure 1) that fabricated by hand during the surgery. All patients examined by CT scan
for the cranium before the operation (Figure 2). Under general
anaesthesia, the soft tissue of scalp is reopened and dissected
from the dura to explain the borders of bone defect and freed
from any adjacent tissue. The edges of cranial defect prepared
by using acrylic bur to bevelling them and bed formation for the
prosthesis to prevent slippage it inside the cranium (Figure 3).
The polymethylmethacrylate (PMMA) was prepared by mixing
the liquid with powder then waiting 3 minutes before reach the
material to dough stage for fabricated the prosthesis by the hands
on the site of defect (Figure 4), when the thermal reaction started
the splint should be removed away from the defect site to prevent
morbidity on brain, then we remove the excess and shaping the
prosthesis using acrylic bur, finally, fixation the prostheses using
stainless steel wire and closed the flap (Figures 5 & 6) and followup for 2 years was done.
Figure 1: Polymethylmethacrylate (PMMA)
Figure 2: CT scan for the cranial bone defect
Figure 3: Cranial bone defect and prepare the site for prosthesis
Figure 4: The prosthesis after fixation
Figure 5: The patient after surgery (posterior view)
Figure 6: The patient after surgery (anterior view)
Age of patients extended from 14 years to 42 years with mean
33.2 years, the male was17 patients that formed 85% while the
female was only three patients that found in 15% (Table 1). The
most cause of cranial defect was trauma resulting from missiles
injuries that involved 14 patients and formed 70% while cranial
defect due to tumour was involved four patients that presented in
20% and lastly the cranial decompression involved two patients and formed 10% (Table 2). During the follow-up, all patients were
satisfied with the cosmetic result. No revision for cosmetic reasons
was required. One patient developed an infection in one of stainless
steel wire postoperatively that controlled and resolved the problem
by removing this wire only. Thus, the perioperative morbidity was 5%.
We recorded that there is no deterioration in neurological status and
neuropathies (chronic pain after wound healing), postoperatively.
Patients showed well tolerated with prosthesis material in all cases.
Table 1: Sex incidence
Table 2: Causes of cranial defect
The majority of patients were males while the most common
cause of cranial defect was due to traumatic cranial injury by missiles
injuries. When time and cost are the goal, this procedure is a cheap
and safe way to treat cranial defect. Infection is the common cause of
complication in cases of allograft implants, but there was a very low
rate with the procedure that described in this paper. The benefits of
cranioplasty on neurologic function are also validated. This technique
has proven to be easy, safe and has excellent results.
This technique is quick and easy to perform, and provide a cheap
and safe way produces a strong implant with very good cosmetic
result.
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