Int J CARS

DOI 10.1007/s11548-016-1415-2

ORIGINAL ARTICLE

Skull reconstruction after resection of bone tumors in a single

surgical time by the association of the techniques of rapid
prototyping and surgical navigation
M. V. M. Anchieta1,2 F. A. Salles1 B. D. Cassaro1 M. M. Quaresma1
B. F. O. Santos3

Received: 17 January 2016 / Accepted: 29 April 2016

CARS 2016

Abstract
Purpose Presentation of a new cranioplasty technique
employing a combination of two technologies: rapid prototyping and surgical navigation. This technique allows the
reconstruction of the skull cap after the resection of a bone
tumor in a single surgical time.
Methods The neurosurgeon plans the craniotomy previously on the EximiusMed software, compatible with the
Eximius Surgical Navigator, both from the company Artis
Tecnologia (Brazil). The navigator imports the planning and
guides the surgeon during the craniotomy. The simulation
of the bone fault allows the virtual reconstruction of the
skull cap and the production of a personalized modelling
mold using the MagicsMaterialise (Belgium)software.
The mold and a replica of the bone fault are made by rapid
prototyping by the company Artis Tecnologia (Brazil) and
shipped under sterile conditions to the surgical center. The
PMMA prosthesis is produced during the surgical act with
the help of a hand press.
Results The total time necessary for the planning and production of the modelling mold is four days. The precision
of the mold is submillimetric and accurately reproduces the
virtual reconstruction of the prosthesis. The production of
the prosthesis during surgery takes until twenty minutes
depending on the type of PMMA used. The modelling mold
avoids contraction and dissipates the heat generated by the
materials exothermic reaction in the polymerization phase.
The craniectomy is performed with precision over the draw-

M. V. M. Anchieta
anchieta9@gmail.com

Artis Tecnologia, Braslia, DF, Brazil

Master in Biomedical Engineering, UNB/DF, Braslia, Brazil

Resident in Neurosurgery of the School of Medicine,

UNIFESP, So Paulo, Brazil

ing made with the help of the Eximius Surgical Navigator,

according to the planned measurements. The replica of the
bone fault serves to evaluate the adaptation of the prosthesis
as a support for the perforations and the placement of screws
and fixation plates, as per the surgeons discretion.
Conclusions This technique allows the adequate oncologic
treatment associated with a satisfactory aesthetic result, with
precision, in a single surgical time, reducing time and costs.
Keywords Decompressive craniectomy Rapid prototyping Surgical navigation Cranioplasty Craniotomy
Reconstruction

Introduction
The presence of bone tumors in the skull can have aesthetic
and functional repercussions. The resection of the tumor
aims to eliminate the progression of the illness and to avoid
damage to the brain; one cannot, however, neglect the aesthetic commitment. The need for rapid surgical intervention
for decompressive craniectomy in traumatic pathologies can
limit planning time. Reestablishing the protective function of
the skull cap, as well as restoring the skulls aesthetic symmetry, is usually accomplished in a second surgical time. In
relation to tumors affecting the skull cap, surgery can be performed electively. When surgery is performed in two times,
the patient has an aesthetic disadvantage for a prolonged
period of time before being submitted to a new intervention, exclusively for the reconstruction of the skull cap. The
period between craniectomy and cranioplasty takes on average more than seven months and the complications from the
cranioplasty procedure can be different from the surgery for
tumor exeresis [1]. When the patient is submitted to two
surgical interventions, the costs and risks are high; in addi-

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tion to hospital costs, the patient is removed from his/her

social life and everyday activities. The use of the mold produced by rapid prototyping for modelling acrylic materials is
a high-precision and low-cost alternative for reconstructing
preexisting bone faults in comparison with the alternatives of
prefabricated prosthesis in PEEK or titanium. PMMA materials are low cost and widely used in skull reconstructions
[2]. These materials have a plastic phase and are easily modelled, but modelling directly over the skull can cause injuries
to brain tissues due to the generation of heat and the release
of free monomers. The CAD/CAM planning allows the perfect simulation of the skull reconstruction. When there is
no bone fault but just a bone tumor, it is necessary to carry
out the virtual planning of the craniotomy in order to simulate the bone fault and later its reconstruction. The virtually
planned millimetric reproduction of the craniotomy can be
performed on the patient by means of surgical navigation.
Image-guided surgical navigation or CGS (computer-guided
surgery), performed with the aid of optical systems, works
by way of a sterile vision camera that scans in real time
the DRF (dynamic reference frame) fixed to the patient and
its relation with previously calibrated surgical instruments.
The final precision of a surgical navigator depends on certain
factors, such as: type of scanning system, CT or MR quality,
DRF stability, patients register and instrument calibration
[3]. The surgical navigation system offers the professional
the possibility of assessing in real time the spatial location of
the anatomical structures during the surgical act [4]. When
anatomical marks are destroyed due to tumor invasion or
by removal of intraoperative bone tissues, the use of navigation allows a more radical resection associated with less
morbidity. Navigation confers safety and confidence to the
delineation of tumors and identification of the vital structures
hidden by the tumor [5]. In a single surgical time, it is possible to remove the bone tumor and manufacture the skull cap,
thus restoring functionality and aesthetics and reducing time
and cost.
The case used to illustrate the technique was diagnosed
as meningothelial meningioma [World Health Organization (WHO) grade I], and the surgery was carried out
at the Medicine School of the Federal University of Sao
Paulo-UNIFESP, Brazil. The female patient did not present
any cognitive compromise, and her complaint was purely
aesthetic. She was worried how she would look after
surgery.

Materials and methods

Craniotomy planning
3D computerized tomography (CT) images are used for the
patients evaluation and bone reconstruction. The images are

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acquired in Digital Imaging and Communications (DICOM)

format in 1 mm (or less) axial slices and must cover the
whole skull, as per the surgical navigation protocol. The
EximiusMed software from the company Artis Tecnologia
(Brazil) was used for evaluation and bone tumor segmentation (Fig. 1). This software for handling medical images is
compatible with the Windows platform and with the same
companys surgical navigation system. The EximiusMed
software has several tools, such as image merging and editing, and is given out for free to surgeons who are trained and
certified by the company. Craniotomy planning is carried
out by the neurosurgeon using the softwares image editor
3D slice tool. 3D slices can be viewed simultaneously in
2D multiplanar reconstructions to determine the adequate
tumor resection margin. This planning is sent via email by
the Artis Tecnologia; the company will be responsible for
subtracting the area outlined by the surgeon and virtually
produce the bone fault which is to be reproduced during
surgery.
Upon receiving the planning via email, both the craniotomy simulation and the reconstruction prosthesis are
made. Within 24 h after receiving the file for the planning,
the company sends the surgeon an email containing the virtual images of the skull cap and waits until they are assessed
and approved before starting producing the mold (Fig. 2).
After having received the surgeons approval, the mold will
be produced and shipped under sterile conditions within
4 days.
Mold production
The original CT image is used to make the process of mirroring in order to reestablish symmetry and aesthetics (Fig. 3a,
b). The planning performed by the surgeon on the EximiusMed software representing the bone fault is imported
(Fig. 3c), so as to be superimposed by mirroring on the
inverted image whereby the virtual cap is reproduced by way
of a Boolean process. When the fault compromises sides D
and E, a CT image is used from the databank of another
patient with similar craniometry. In this phase, functional
aspects such as thickness, resistance and adaptation are taken
into consideration. An overcontour is produced in order to
make the piece slightly larger than the opening, thus avoiding
the accidental penetration of the prosthesis into the brain.
The Magics software from the company Materialise (Belgium) is used to produce the modelling mold (Fig. 4). The
molds construction project is carried out in order to confer
mechanical resistance since the mold will be submitted to
pressure when modelling the PMMA. The molds precision
is such that the edges outlining the contour of the prosthesis
function as a knife cutting the excess of PMMA. An escape
area is projected in order to drain the excess material. The
prosthesis volume is calculated, and a 20 % safety margin is

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Fig. 1 EximiusMed editing and surgical planning software

Fig. 2 Images sent by email for surgeons evaluation and approval

Fig. 3 a CT presurgical image, b opposite side mirroring, c bone fault

added as a guideline for the quantity of material to be used

in the production of the prosthesis. This value is depicted in
high relief by prototyping, as well as the patients name. In
order to facilitate the understanding of the volume described
on the side of the mold, a ratio of square centimeters per
amount of PMMA powder is calculated, this being 1 cm3 for
1 g of polymer.
In order to produce the mold and the replica of the patients
bone fault, the company uses a 3D print technology 3D printer
from the company 3DSystems (USA). This piece of equip-

ment prints in high resolution layer by layer of 0.016 in.

thickness. The material used is a modified plaster that does
not get in contact with the PMMA. After being printed in
3D, the mold is submitted to surface treatment in order to
confer it resistance, whereas its interior receives a coat of
insulator. The mold parts and the fault replica are packed
individually in Tyvek-sealed blisters and submitted to sterilization by ethylene oxide so that no deformation or damage
can occur during transportation. The sterile set is shipped to
the hospital.

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Fig. 4 Virtual preparation of the modelling mold

Fig. 5 a Surgical navigator, b outlining the osteotomy

Surgical navigator
The Eximius Surgical Navigator from the company Artis
Tecnologia (Brazil) imports the surgeons planning carried
out on the EximiusMed software. The craniotomy planning
can be visualized on the navigator in 3D and in axial, sagittal and coronal slices. This navigator model is portable and
can be used in different hospitals. The images for navigation are the same ones from the planning. In order to install
the navigation system, a Mayfield-type skull fastener is used
and must be stable during the whole procedure. Trepidation
of the craniotome can destabilize the fixation of the skull;
it is therefore recommended that the system be constantly
checked for precision during surgery. The patients register
is executed in five anatomical points around the skull: in the
ears tragus bilaterally, in the eyes outer telecanthus bilaterally and in the nasal filter. In the trans-operative period,
an additional point can be inserted in the bone to fine-tune
the precision of the register in the area of the tumor. Registers with up to 2 mm of error are considered satisfactory
for the execution of surgery. The surgeon uses the navigators probe to draw the planned craniotomy in the bone
(Fig. 5a). This marking can be made with methylene blue
(Fig. 5b), or with an electrical scalpel that burns the bone
superficially, in a way similar to a pyrograph. The scalpel

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can be calibrated in the navigation system and replace the

probe.
Prosthesis modelling
The mold is used in the surgical center by the surgeon himself/herself or by a duly trained assistant to model the PMMA
material. This type of material undergoes a small contraction during the polymerization phase, which could cause the
edges not to adapt properly, and the press avoids this contraction. The press is mounted on an auxiliary table, and the
material is handled according to the manufacturers instructions (Fig. 6a). When the PMMA is in its plastic phase, it is
inserted into the mold and pressed. A stainless steel hand
press is used to compress the material and keep it under
pressure until its complete polymerization (Fig. 6b). The
prosthesis production process starts after the patient has been
anaesthetized and is carried out in parallel with the opening of
the surgical bed. The prosthesis production time takes from
ten to twenty minutes, depending on the PMMA manufacturer. After polymerization, the material is taken out of the
mold, the excess being easily removed by hand. The prosthesis is washed abundantly with a saline solution and is
evaluated over the bone fault replica made by prototyping
(Fig. 6c). Perforations in the prosthesis and choice of fixa-

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Fig. 6 a Handling the PMMA, b manually pressing the material, c assessing the adaptation of the prosthesis over the bone fault replica

Fig. 7 a Craniotomy, b tumor removal, c evaluating the craniectomy using the bone fault replica, d fixating the prosthesis with titanium plates and
screws

tion material are at the discretion of the surgeon, who can use
the replica as a support to stabilize the prosthesis and execute
these procedures.
After the design has been defined, the craniotome is carefully used to perform the craniectomy (Fig. 7a) and remove
the tumor (Fig. 7b). The prototype bone fault replica can
help check the outline made with the aid of the navigator and assess the precision of the craniotomy (Fig. 7c).
Plates and screws in titanium are used for prosthesis fixation (Fig. 7d).
At some points the prosthesis may not stay perfectly
adapted due to the osteotomys difficulty of reproduction
in making tight turns with the osteotome. Another point of
difficult reproduction in the osteotomy is the lower inferior region of the temporal bone due to the difficulty of
access created by the temporal muscle. It is important to
evaluate the interface between the prosthesis and the bone
edge in order to check for the risk that the prosthesis might

migrate to the interior of the cranial cavity. The prosthesis

must overlay the cavity in order to avoid stress on the titanium fixation plates that must be used only to stabilize the
prosthesis in place and are not intended to avoid the migration of the prosthesis to the interior of the cranial cavity
(Fig. 8).
CT images are used to assess the adaptation of the prosthesis in the postsurgical period (Fig. 9a). Merging CT images
before and after surgery is used to assess the adequacy of the
technique (Fig. 9b).

Discussion
The reconstruction of the skull cap immediately after the
resection of a tumor is a difficult procedure [6]. This new
technique is fast, but it presents several phases and the precision of each of them is fundamental for the success of

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Fig. 8 Interface prosthesis and bone

Fig. 9 a Postsurgical CT, b merging presurgical and postsurgical CT

the technique. CT image acquisition must follow a protocol in order to meet the reconstruction planning of the
skull cap, as well as the surgical navigation. Image quality directly influences the results. The planning done on the
EximiusMed software is simple and fast. This planning can
be carried out anywhere and sent via email to the mold manufacturer, Artis Tecnologia (Brazil). Any doubts the surgeon
may have in relation to the softwares editing tools can be
resolved remotely. 3D printing quality by the rapid prototyping process will also influence the results. During prosthesis
production, each specific PMMA manufacturers instructions
must be taken into consideration in order to properly handle
the material. The PMMA must be inserted into the mold
during its plastic phase; if inserted before this phase, the
prosthesis may present bubbles and lose resistance. When
inserted into the mold after its plastic phase, the material will
become rubber-like and more resistant, becoming harder to
model. The press must perfectly join the mold edges to keep
prosthesis thickness as planned. If the material is not pressed

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correctly, the prosthesis will turn thick, which can compromise its adaptation over the edge of the bone fault. Another
important phase is the quality of the Surgical Navigation
System and the patients register; in this phase it is important
to assess the precision or the register in known anatomical
points around the skull. One of the aspects capable of affecting the quality of adaptation is the type of drill used during
craniotomy, as well as the surgeons manual dexterity, since
craniotomy must be performed with utmost attention so as
not to deviate from the outline. The direction of the bone
edge cut leaving the cavity expulsive and allowing the prosthesis to overlay the bone confers greater resistance against
impacts and reduces the risks of the prosthesis migrating in
the skull cavity [7]. CAD/CAM technologies confer greater
precision to prefabricated prostheses in the reconstruction
of the skull cap [8]. Mold production by rapid prototyping
has submillimetric precision that will faithfully reproduce the
prosthesis negative. The use of a personalized prototype mold
for modelling prostheses in PMMA has some advantages.

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One of the advantages is complying with the specifications

of PMMA manufacturers that point out in the instructions
that the product is to be used only once and contraindicate
its resterilization. The material is handled inside the surgical center in a sterile environment and is not reprocessed. In
case of accident due to fall or contamination of the prosthesis
during surgery, another prosthesis can be made in minutes.
The PMMA-based material used is low cost, and it is recommended to have at ones disposal always twice the material
necessary for the production of the prosthesis. A characteristic of this type of material is its exothermal reaction,
which during the polymerization phase can reach upwards
of 100 C, and if applied directly over the skull can cause
brain damage [8]. Another characteristic is the contraction
that can vary depending on the amount of monomer used;
the greater the amount of monomer used, the greater the
contraction. These undesirable characteristics are eliminated
by using the mold; for heat is dissipated in the mold and,
together with pressure stabilization until complete polymerization, material contraction is avoided. The evaluation of
the adaptation result is performed over the bone fault replica
which serves as a basis for the surgeon who opts for making
perforations in the prosthesis and the placement of screws
and fixation plates. The navigation system allows planning
to be visualized over the CT image, and after the patients
register it becomes easier to locate the region where craniectomy will be performed [6]. The surgical navigator allows
the execution of a precise craniectomy and has been used for
performing minimally invasive surgeries [9]. Surgery simulation reduces surgical time since the safety margins have
already been established, as well as the spatial location of the
region where craniectomy will be performed.

Conclusion
It is possible to perform resections of bone tumors and the
reconstruction of the skull cap with precision in a single surgical time. Associating the technologies of rapid prototyping
and surgical navigation allows one to replicate the virtual
planning on the patient with great precision. PMMA is a lowcost alternative for cranioplasty. Using a personalized mold
for modelling the PMMA material and producing the reconstruction prosthesis during surgery reduces surgical time and
production costs. The possibility of interaction between the
surgeons planning and the navigation system is important in
locating the exact limits of the craniotomy. The reconstruction in a single surgical time does not mutilate the patient and
restores the skulls symmetry and aesthetics.

Dr. Bruno Fernandes de Oliveira Santos and Dr. Samuel Salu (Federal
University of Sao Paulo-UNIFESP).
Compliance with ethical standards
Conflict of interest The authors whose names are listed immediately
below certify that they have no affiliations with or involvement in any
organization or entity with any financial interest (such as honoraria;
educational grants; participation in speakers bureaus; membership,
employment, consultancies, stock ownership, or other equity interest;
and expert testimony or patent-licensing arrangements) or non-financial
interest (such as personal or professional relationships, affiliations,
knowledge or beliefs) in the subject matter or materials discussed in this
manuscript. Author names: Bruno Fernandes de Oliveira Santos. The
authors whose names are listed immediately below report the following
details of affiliation or involvement in an organization or entity with
a financial or non-financial interest in the subject matter or materials
discussed in this manuscript. Author names: Marcos Vinicius Marques Anchieta, Frederico Assis de Salles, Bruno Cassaro DalAva and
Marcelo Marques Quaresma. The authors above are developers of the
technics described in the manuscript and shareholders of the company
Artis Technologia, who made a donation of both the mold in rapid prototyping, as Eximius Surgical Navigator to the procedure. The surgery
which illustrates the case was conducted in a university hospital of Medicine School of the Federal University of Sao Paulo-UNIFESP, which is
public and free. There was no cost to the patient.

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Acknowledgments We thank the medical team that executed the

case which illustrates the new technique: Dr. talo Caprano Suriano,

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