By: Ryan Pyrke and Anuja Goyal
Phineas Gage (1823-1860)
A 1 meter long tamping
iron which weighed 6
kilograms impaled
Phineas’ skull
 Miraculously survived.
 One of the most famous
and earliest recorded
survivors of a severe
skull fracture

2
Overview

Anatomy of the skull

Types of skull and maxillofacial trauma

Methods of treatment

Future research
3
Anatomy of the Skull
4
Types of Trauma

Basilar skull fracture

Penetrating skull fracture

Depressed and Compound skull fracture

Linear and Diastasis fractures
5
Basilar skull fracture
6
Penetrating skull fracture
7
Depressed skull fracture
8
Linear & Diastasis fractures
9
Methods Of Treatment
Autologous Reconstruction
 Allogenic Reconstruction
 Alloplastic Reconstruction

 Titanium Plates and Screws
 Titanium Mesh
 Ceramics (Glass)
 Calcium Orthophosphate
 Polymethyl-methacrylate (PMMA)
10
Autologous Reconstruction
Replacement bone from the patient is used
to mend a fracture
 Bone chips or dust
can be used to
mend small holes
 High degree of
biocompatibility
and long term
stability

11
Autologous Reconstruction (cont)

Complications can arise at the donor
sites of the patient

Not a suitable method for large skull
fractures
12
Allogenic Reconstruction
Bones from donors (living or cadaveric)
are used to mend a skull fracture
 Live donors share the same problems
as autologous reconstruction
 Short supply of materials
 Xenografts may be possible in the near
future that use bovine materials

13
Alloplastic Reconstruction
Synthetic substitutes are
used in place of live
materials
 Materials used to create
these implants include
titanium, ceramics,
calcium orthophosphate,
PMMA, and others
 Each have their own
individual benefits and
drawbacks

14
Titanium Plates and Screws
A very strong material.
Biocompatibility has
been proven over a long
period of time
 Most commonly used
material for the skull.
 Easy to implant and inert
within the body
 Alloys of titanium come
very close to matching
mechanical properties of
bone


15
Titanium Plate Example


Osteoplastic craniotomy
perfomed to alleviate
pressure on the brain
Can be performed to
provide access to brain
(i.e. to remove tumors)
16
Titanium Mesh

Allows for natural bone growth in the
gaps of the titanium mesh.
Over time
becomes very
strong and stable.
 Risk of infection
with larger scale
bone replacement.

17
Ceramics (Glass)
Very bio-compatible
 Post-operative imaging is unhindered
 Easy to break when fixing it to the skull
 TiO2/glass composites are used
 Fibrous tissue will not form around this
material
 Small implants can be connected by
chemical bonding

18
Calcium Orthophosphate





Very poor mechanical
properties
Biocompatible and nontoxic
Osteointegrates into
living tissue
Acts as an
osteoconductive scaffold
for new bone
Used as a coating to
promote bone growth
into porous implants
19
Calcium Orthophosphate
Used only as fillers, coating, or bone cement
and not practical for large-scale skull
reconstruction
 Protect against emission of toxins from a
coated material
 Increases the lifetime of an implant it
is integrated into

20
Polymethyl-methacrylate (PMMA)




PMMA is used most often for cranial
reconstruction
Powder Polymer and Liquid Monomer
combine to form cement that then hardens.
Heats up to 70°C
when mixed raising a
concern for
surrounding tissue
Performed free-hand
21
Future Applications

Biodegradable Plates

Ion Implantation

Biodegradable Adhesives
22
Biodegradable Plates

Plates and screws that will be
reabsorbed over time
 Biocompatible
 Adaptable
 Degrades at right amount of time
 Stable enough to allow bone to unify
 70/30
poly(L/DL-lactide) (PLDLA) is a
biodegradable material
23
Biodegradable Plates (continued)
24
Biodegradable Plates (continued)

Advantages:
 Plate and screws would not need to be
removed later on
 Since the material is reabsorbed it will not
affect long term development in children
25
Biodegradable Plates (continued)

Future Steps:
 Develop material for larger plate applications
 Investigate long-term effects of resorption
 Make material easier to work with
26
Ion Implantation

Process used to make materials more
bio-compatible

Prevents production/leakage of toxic byproducts

Ions are embedded on outer layer
27
Ion Implantation
28
Biodegradable Adhesives

An adhesive to hold bones together
while degrading over time

Development considerations
 Must bond to bone in a wet, bloody
environment
 Cannot be cytotoxic
 Strong enough to hold bone together
 Disappear gradually
29
Biodegradable Adhesives

Biomimicry: solving problems using
examples from nature
Proteinaceous Adhesive
produced by Sandcastle Worm
Developed biodegradable
adhesive
Used to assemble bits of
seashells underwater
Used to repair crainiofacial
fractures
Composed of opposite charged
proteins with Ca2+/Mg2+ ions
Created with oppositely charged
copolyelectrolytes
30
Biodegradable Adhesives

It is a phase separated fluid

Will not cause volume change

Non-cytotoxic

Tested both in vitro and in vivo in a rat
31
Progression Of Surgical Methods

Implantation Of A Titanium Plate

Current Surgical Procedure

CAD Technology
32
Implantation Of A Titanium Plate

during initial surgery:
 first clean up wound
 template is made from soft malleable metal
 skull thickness is measured

preparation of plate:
 dental plaster cast made from impression
 titanium plate is formed by using a high pressure
hydraulic pump
 Many holes on the plate allow fluid to flow and
fibrous tissues to go through

Insertion of Plate:
 A second surgery is performed to insert the
plate
33
Current Surgical Procedure

Technology is used
to create custom
skull implants
34
CAD Technology
35
Ongoing Development

Various companies and
institutes are actively
researching maxillofacial and
skull implants
 Kelyniam is able to provide
custom skull implants 24 hours
after receiving CT scan data
 Research centered around the
use of PEEK, a growingly
popular new biomaterial
36
References
1.
2.
3.
4.
5.
6.
7.
8.
T. R. Rautray, R. Narayanan, and K. Kim. “Ion Implantation of Titanium Based
Biomaterials” Progress in Materials Science, vol. 56, pp. 1137-1177, 2011.
Deakin University Australia. “Phineas Gage’s Story.” Internet:
http://www.ijssst.info/info/IEEE-Citation-StyleGuide.pdf, 2010 [September 19, 2011].
Kelyniam. “ Kelyniam Announces Commercial shipping of Custom Skull Implants”
Internet: http://www.kelyniam.com/kelyniam-announces-commercial-shipping-ofcustom-skull-implants/, August 2, 2011 [September 18, 2011].
Heraeus. “Heraeus Medical” Internet: http://heraeus-medical.com/en/home_15.html,
2010 [September 20, 2011].
Synthes, “CMF – Craniofacial Reconstruction” Internet:
http://www.synthes.com/sites/NA/Products/Biomaterials/PorousPolyethyleneImplants/
Pages/home.aspx, 2010 [September 21, 2011].
Stryker, “Stryker Navigation system II” Internet: http://www.stryker.com/enus/Solutions/KneeReplacement/NavigationSystemII/index.htm, 2009 [September 20,
2011].
R. L. Drake, W. Vogl and A. W. M. Mitchell. “Head and Neck” in Gray’s Anatomy for
Students, B. Smith, Ed. Philadelphia: Elsevier, 2005, pp. 748-762.
S. Monkhouse. “Regional Anatomy” in Clinical Anatomy, 2nd ed.,T. Horne, Ed.
London: Elsevier, 2007, pp. 237-239.
37
References
9.
10.
11.
12.
13.
14.
15.
16.
17.
S. V. Dorozhkin. “Bioceramics of Calcium Orthophosphates” Biomaterials, vol. 31, pp.
1465-1485, Dec 2009.
B. R. Bell and C. S. Kindsfater. “The Use of Biodegradable Plates and Screws to
Stabilize Facial Fractures” Journal of Oral and Maxillofacial Surgeons, vol. 64, pp. 3139, 2006.
B. D. Winslow, H. Shao, R. J. Stewart, and P. A. Tresco. “Biocompatibility of
Adhesive Complex Coacervates modeled After the Sandcastle glue of
Phragmatopoma Californica for Craniofacial Reconstruction” Biomaterials, vol. 31, pp.
9373-9381, Oct 2010.
W. Wu, Y. Zhang, H. Li, and W. Wang. “Fabrication of Repairing Skull Bone Defects
Based on the Rapid Prototyping” Journal of Bioactive and Compatible Polymers, vol.
24. pp. 125-136, May 2009.
D.S. Gordon and G. A. S. Blair. “Titanium Cranioplasty” British Medical Journal, vol.
2, pp. 478-481, 1974.
U. Spetzger, V. Vougioukas, and J. Schipper. “Materials and Techniques for Osseous
Skull Reconstruction” Minimally Invasive Therapy, vol. 19, pp. 110-121, 2010.
U. Klammert, U. Gbureck, E. Vorndran, et al. “3D Powder Printed Calcium Phosphate
Implants for Reconstruction of Cranial and Maxillofacial Defects” Journal of CranioMaxillo-Facial surgery, vol. 38, pp.565-570, 2010.
M. geetha, A.K. Singh, R. Asokamani, and A.K. Gogia. “Ti based Biomaterials, the
ultimate choice for orthopaedic implants – A review” Progress in Materials Science,
vol. 54, pp. 397-425, 2009.
B Braun, “Partner for Surgery” Internet: http://www.bbraun.de/cps/rde/xchg/bbraunde/hs.xsl/aesculap-portal.html, 2009 [September 20, 2011].
38