Design and manufacturing of customized

surgical devices for mandibular rehabilitation

M. Fantini F. De Crescenzio L. Ciocca

Narayanan Kakkad
r0393594

Introduction

Malignant mandibular tumors

Mandibular continuity resection
Mandibular reconstruction
Primary surgery
Secondary surgery
Major concern:Stabilization of the resected stumps
Current solution:
Titanium bridging plates
Intra operative- Manual contouring and shaping
Time-consuming
Manually shaped pre-operatively
Limited shaping precision

So, Whats the way ahead???

Computed tomography
Computer aided design
Additive manufacturing (AM)
Direct metal laser sintering (DMLS)
Customized surgical devices
Virtual pre-planning

Focus of the paper: the design and manufacturing processes

omitting the strictly clinical procedures

Computer-aided mandibular reconstruction

process workflow

Data acquisition and 3D reconstruction

CT scan of the patients craniofacial skeleton(DICOM)

Amira 3.1.1: Thresholding of CT data
Rapidform XOS 2: Shellshell registration based on iterative closest points
algorithm

Primary surgery

Secondary surgery

Design of the surgical devices

CAD software used: Rhino 4.0

Cutting guide

Resection of the mandible

Guide the osteotomies
As decided in virtual pre-planning
Free space provided between the
guiding planes and the cortical
surface of the mandible
Maintains suitable distance from
the mandible
At least two holes for stable
fixation and to prevent rotation of
the resected stumps
Screws chosen by the surgeon
Reference elements designed by
thickening the outer surface of the
mandible

Cutting guide

Resection of the whole

mandibular ramus including
the condylar process.
Spread of the tumor
Simplified cutting guide
No retention bar

Repositioning guide

Secondary surgery
Dislocation induced in the
resected stumps by muscle
tension
The functions of various parts
are almost the same as for the
cutting guide

Bone plate

Designed by thickening the outer

surface of the mirrored healthy
contra-lateral side
Provide ideal mandibular profile
Aligned with the lower margin of the
mandibular ramus
Provide
a
functionally
and
aesthetically correct reconstruction
Reference notches
Extremities developed so as to be
referenced with respect to the first
guide

Mutual positioning

First approach
Complementary contact surfaces
Free space provided between the guiding planes of cutting guide and the cortical
surface of the mandible

Mutual positioning

Use the same reference holes on the mandible

Mandatory to increase the diameter of the screws
Diameter of the holes in the reconstructive bone plate is 1mm larger with respect to
the corresponding holes in the cutting guide

A comparison Between the two approaches

First approach
Rigid connection never missing
Assure a more precise relation
Second approach
More easy for final screwing
Preferred by the surgeons

Manufacturing of the surgical devices

EOSINT M270 machine

DMLS: fusing metal powder into a solid part and melting it locally using a
focused laser beam.
Material used to produce the cutting guide or the repositioning guide: multipurpose cobaltchromemolybdenum-based super-alloy
Material used to produce the bone plate with or without the condylar
prosthesis: prealloyed Ti6AIV4 alloy
Ti6AIV4 alloy advantages:excellent mechanical properties and corrosion
resistance combined with low specific weight and biocompatibility
Polishing: Reduces surface roughness
Sterilization

Manufacturing of the Mandible

3D dimension soluble support technology machine

Fused deposition modeling
Material used: Acrylonitrile Butadiene Styrene (ABS)
Filling options: solid and sparse(honeycomb structure)
Wash: agitation system with a hot soapy water bath

Discussion

Mandible accessed through a submandibular incision

Ti screws are used
Cutting guide or repositioning guide are surgically more invasive than the
customized bone plate
Surgeons feedback: Less time, increasing the self confidence, thanks to the reference
engaging arms
Cutting guide: Simplified resection step
Repositioning guide: native mandibular profile easily obtained
Customized bone plate: restores the original mandibular contour
Reconstruction operating time reduced
Time between pre-surgical planning and delivery of product should be as short as
possible to avoid variations in pre-operative clinical conditions
Further investigations required to test mechanical properties and the costs involved

Conclusion
The paper provides an insight into the fields of
Use of patient CT data to develop Customised surgical devices
Use of Additive manufacturing techniques for customisation
Surgical cutting and repositioning guides
The paper fails to provide info in the following areas:
The mechanical strength needed for the cutting guides to
withstand the forces
The mechanical strength needed for the bone plate
The costs involved

Thank you
Questions?????