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Background: Establishing the cause of death when analysing burnt human remains is limiting due to thermal degradation. The heat generated by high combustion degrades the bone structure, definitively hiding the perimortem trauma in most cases, which is crucial for solving a court case. Case report: In November 2019, a completely burnt corpse was found inside a car set on fire near a location in Reggio Calabria, Italy. The corpse was subsequently subjected to an initial radiodiagnostic examination and an anthropological/medico-legal investigation, in order to confirm the biological profile of the unidentified subject, define the cause of death and assess the presence of perimortal lesions through macroscopic analysis of skull fragments subjected to fleshing. Conclusions: The soft tissue fleshing of the burnt skull fragments allowed the reconstruction of a partial calotte. Macroscopic analysis of the consolidated shell identified in the left fronto-parietal region a clear linear fracture, perimortal in nature, compatible with blunt trauma. Autopsy examination revealed the presence of carbonaceous residues within the larynx and especially the trachea, confirming ante-mortem combustion.The results of the autopsy examination and the anthropological analysis allowed us to state that the net linear fracture, perimortal in nature, caused the subject a complex encephalic trauma, resulting in loss of consciousness and subsequent death due to carbon monoxide inhalation. This result not only confirms the malicious hypothesis, but reveals a deliberate burning of the victim in order to conceal the evidence necessary to solve the forensic case.

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The frontal bone is the vital component of the human skull and forms a part of the anterior skull vault, base, and roof of the orbits. Frontal bone defects may arise secondary to various causes like trauma, congenital defects including craniofacial clefts, tumors in the frontal bone requiring surgical intervention, and infections, like osteomyelitis, that cause osteonecrosis of the frontal bone. Reconstruction of frontal bone has been explored in the literature, and various materials are available for rehabilitation, like auto/allografts, and alloplastic materials, including bone cement, titanium meshes, and patient-specific implant (PSI). All the available materials have their own advantages and disadvantages; hence, depending on the anatomy and physiology of the frontal bone and the involvement of the naso-orbito-ethmoidal (NOE) complex, patient selection and treatment plan become very crucial. This report presents a case of the frontal bone with a NOE defect, secondary to trauma, reconstructed using a PSI and costochondral graft.

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Background: The surgical approach for cranial reconstruction is influenced by the presence of pre-existing scar tissue. Scars that lie within the vicinity of cranial defect require modification. Purpose: The present study was conducted to analyse co-relation between craniectomy scar and cranioplasty incision. Materials and Methods: A retrospective evaluation of 70 patients who were divided into three groups based on location of cranioplasty incision line was done. In group I, incision was located parallel and outside the scar; group II, incision was located over the scar; and group III, mixed and criss-cross incision was present. The primary outcome variable of interest was to analyse co-relation between craniectomy and cranioplasty incisions. Results: There were 45 cases of group I, 15 cases of group II and 10 cases of group III. Thirty-three patients had defect on left side, 26 had on right side, and 10 had bifrontal defect. No significant association was noted between the site and cranioplasty incision (Chi2 = 9.155, p = 0.433 and likelihood ratio = 9.487, p = 0.394). Conclusion: Well-vascularized broad-based scalp flap that provides adequate exposure and located on healthy bone irrespective of pre-existing craniectomy scar forms the mainstay of successful cranial reconstruction.

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The aim of the present retrospective study was to confer the factors that are related to bone graft absorption and affect the outcomes of patients following cranioplasty (CPL). The present retrospective study includes cases of patients that underwent CPL between February, 2013 and December, 2022. All participants had a follow-up period of 1 to 10 years from the day of discharge from the hospital. In total, 116 (62.3%) of the 186 patients that underwent decompressive craniectomy (DC) were enrolled in the present study for CPL. A total of 109 (93.9%) patients were included in group A, and 7 (6.0%) patients were included in group B. On the whole, the results of the present study suggest that a CPL after 2.5-7.7 months of DC increases the possibility of bone absorption.

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Cranial defects are broadly classified as either congenital or acquired. The prevalence of cranial injuries has notably increased, propelled by a heightened emphasis on aesthetics and the demand for skull reconstruction in contemporary society. Consequently, rehabilitation for these defects has also surged. Surgical correction or repair, known as cranioplasty, not only aims at aesthetic rehabilitation but also addresses psychological issues, improving social acceptance and overall performance. Amid evolving trends, the availability of advanced biomedical tools, technologies, and materials empowers surgeons and prosthodontists, leading to improved outcomes in aesthetics and functionality. One noteworthy technique highlighted in this case report involves using bone cement in conjunction with polymethyl methacrylate, adding novelty to the approach. The interdisciplinary management team, consisting of prosthodontists and neurosurgeons, played a pivotal role in improving neurological status and cosmetic outcomes for the patients.

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Very few clinical entities have undergone so many different treatment approaches over such a short period of time as craniosynostosis. Surgical treatments for this condition have ranged from simple linear craniectomies, accounting for the specific role of cranial sutures in assuring the normal growth of the skull, to more complex cranial vault reconstructions, based on the perceived role of the skull base in affecting the growth of the skull. While a great deal of evolution has occurred, there remains controversy regarding the ideal treatment including the best surgical technique, the optimal age for surgery, and the long-term morphological and neurodevelopmental outcomes. The evolution of the surgical management of craniosynostosis in the last 50 years has been affected by several factors. This includes the awareness of needing to operate on affected children during infancy to achieve the best results, the use of multistage operations, the availability of more sophisticated surgical tools, and improved perioperative care. In some forms of craniosynostosis, the operations can be carried out at a very young age with low morbidity, and with the postoperative use of a molding helmet, springs, or distractors, these operations prove to be as effective as traditional larger cranial reconstructions performed in older children. As a consequence, complex surgical operations have become progressively less utilized. A second relevant advance was the more recent advent of a molecular diagnosis, which allowed us to understand the pathogenesis of some associated malformations and neurodevelopmental issues that were observed in some children despite appropriate surgical treatment. Future research should focus on improving the analysis of longer-term outcomes and understanding the natural history of craniofacial conditions, including what issues persist despite optimal surgical correction. Progress in molecular investigations concerning the normal and pathological development of cranial sutures could be a further significant step in the management of craniosynostosis, possibly favoring a "medical" treatment in the near future. Artificial intelligence will likely have a role in establishing the diagnosis with less reliance on radiographic studies and in assisting with surgical planning. Overall, much progress has been made, but there remains much to do.

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A methodology has been developed in this work to design customized cranial implants from computed tomography (CT) scan images for symmetric as well as asymmetric defects. The two-dimensional CT scan images were converted into three-dimensional geometric models using software packages. Two cases of cranial cavities at different locations were considered for implant design using two different approaches. Case 1 is having a symmetric cranial cavity while Case 2 has an asymmetric frontal cranial cavity. The craniums with defects were 3D reconstructed. Customized cranial implants were made for the two cases. In Case 1, symmetry was used to design the cranial implant. Symmetry cannot be used in Case 2. In Case 2, the implant was designed by blending from the surface available adjacent to the missing portion of the cranium. 3D reconstructed bone models and customized implants were 3D printed in poly-lactic acid (PLA) using a fused deposition modeling process for form and fit evaluation. Finite element analysis was performed to compare the mechanical behavior of bone, and the two biomaterials - polyether ether ketone (PEEK), and Ti6Al4V. Static structural finite element analysis was performed to simulate the impact of falling off a bicycle with an impact on the cranial implants in the two cases. The load was modeled as a normal force acting on the surface of the implant. It was found that the stresses in the titanium alloy are comparable to those of PEEK for both the cases. However, the strains and deformation were found to be much smaller compared to those in PEEK. Therefore, the titanium alloy is the material of choice for both the cases among the materials under consideration. The designed implants are solid hence may face the challenge in bone ingrowth. In future studies, the implant can be made porous by incorporating a lattice structure to enhance osseointegration and promote bone ingrowth. Implants for both symmetric and asymmetric defect cases in cranium were successfully designed.

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BACKGROUND: Complex scalp wounds with cranial/dural involvement are challenging to reconstruct. Successful reconstruction can be achieved with cranial implants/hardware and free flap coverage. Wounds can breakdown and require revision procedures. We addressed reconstructive outcomes of different implants requiring free flaps. OBJECTIVE: To determine the factors associated with implant exposure. DESIGN: Multi-institutional retrospective review of 82 patients, 2000-2020, repaired with cranial implants and free flap coverage. RESULTS: Implant exposure occurred in 13/82 (16%) reconstructions. Flap atrophy or thinning leading to implant exposure occurred in 11/82 (13%) reconstructions, including partial flap atrophy OR 0.05 (95% CI 0.0-0.35) and total flap atrophy OR 0.34 (95% CI 0.02-19.66). Revision surgeries that occurred subsequent to flap reconstruction were also associated with implant exposure (OR 0.02 (95% CI 0.0-0.19)). Implant exposure was not associated with radiation therapy, patient health history, implant type, flap type, or postoperative complications. CONCLUSIONS: Implant exposure is associated with free flap atrophy, leading to inadequate implant coverage and the need for revision surgeries. Completing reconstruction with adequate soft tissue bulk and coverage and avoiding revision surgery may decrease the risk for implant exposure over time. LEVEL OF EVIDENCE: 4 Laryngoscope, 133:2954-2958, 2023.

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The occurrence of cranial injuries has increased dramatically, and due to greater awareness among the people concerned with aesthetics needing skull reconstruction, rehabilitation of these defects has also increased in our modern age. Rehabilitation of these deficiencies with prostheses not only works as a protective shell but also improves the patient's neurological state. These cranial deformities necessitate surgical correction or repair, known as cranioplasty. Its goal is not only to rehabilitate the imperfection aesthetically, but also to alleviate psychological issues and improve the patient's social acceptance and performance. New biomedical tools, technologies, and materials are available to surgeons and prosthodontists to improve aesthetics and functions. The purpose is to develop a novel method involving affordable 3D printing technology for creating individualized polymethylmethacrylate (PMMA) implants, aiming to democratize technology in prosthodontics.

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Background: Crouzon syndrome is a rare genetic disorder characterized by premature fusion of skull sutures during skull development, resulting in various craniofacial abnormalities and complex craniosynostosis is a condition in which more than one such sutures of the skull fuse prematurely. Case Description: Herein, we present a case of a 5-year-old male diagnosed with Crouzon-like syndrome and complex craniosynostosis involving multiple cranial sutures, including metopic, sagittal, coronal (right and left), and lambdoid sutures, and without any identifiable mutations on karyotyping. The patient underwent successful surgical intervention with a satisfactory outcome, highlighting the importance of early diagnosis and intervention to prevent or minimize associated neurological manifestations and craniofacial abnormalities. Conclusion: Our case report underscores the involvement of multiple cranial sutures in complex craniosynostosis and the absence of identifiable mutations or family history of similar craniofacial abnormalities, providing important insights into the diagnosis and management of this condition.

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Skeletal remains analyzed by anthropologists, paleontologists and forensic scientists are usually found fragmented or incomplete. Accurate estimations of the original morphologies are a challenge for which several digital reconstruction methods have been proposed. In this study, the accuracy of reconstructing bones based on multiple linear regression (RM) was tested. A total of 150 digital models from complete zygomatics from recent past populations (European and African American) were studied using high-density geometric morphometrics. Some landmarks (i.e., 2, 3 and 6) were coded as missing to simulate incomplete zygomatics and the missing landmarks were estimated with RM. In the zygomatics, this simulated damage affects a few square centimeters or less. Finally, the predicted and original shape data were compared. The results indicate that the predicted landmark coordinates were significantly different from the original ones, although this difference was less than the difference between the original zygomatic and the mean zygomatic in the sample. The performance of the method was affected by the location and the number of missing landmarks, with decreasing accuracy with increasing damaged area. We conclude that RM can accurately estimate the original appearance of the zygomatics when the damage is small.

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The reconstruction of forehead and scalp defects is a difficult task. Common reconstructive methods are associated with multiple complications and may fail, requiring a difficult second surgery. We present the use of external tissue expansion as a method to achieve effective closure of a failed scalp and forehead reconstruction.

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Decompressive craniectomy is one of the most common neurosurgical procedures, usually performed after neuropathological disorders, such as traumatic brain injury (TBI), but also vascular accidents (strokes), erosive tumours, infections and other congenital abnormalities. This procedure is usually followed by the reconstruction of the cranial vault, which is also known as cranioplasty (CP). The gold-standard material for the reconstruction process is the autologous bone of the patient. However, this is not always a feasible option for all patients. Several heterologous materials have been created in the last decades to overcome such limitation. One of the most prominent materials that started to be used in CP is porous hydroxyapatite. PHA is a bioceramic material from the calcium phosphate family. It is already widely used in other medical specialties and only recently in neurosurgery. In this narrative review of the literature, we summarize the evidence on the use of PHA for cranial reconstruction, highlighting the clinical properties and limitations. We also explain how this material contributed to changing the concept of cranial reconstruction from reparative to regenerative surgery.

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INTRODUCTION: Cranial reconstruction (CR) is a neurosurgical procedure performed to restore the cranial vault after a decompressive craniectomy. There are contrasting reports from the literature about the complications related to the use of heterologous materials for CR in the pediatric population. In this study, the authors try to better define such a rate of adverse events for autologous and heterologous materials. MATERIALS AND METHODS: A systematic review of articles published up to December 2021 was performed. Studies were included if they reported the specific use of cranioplasty materials following craniectomy in patients younger than 18 years of age and had a minimum follow-up of at least 1 year. RESULTS: A total of 20 studies were selected. A total of 544 cases were included, of which 422 (77.6%) were with heterologous materials and 122 (22.4%) with autologous bone. The mean average age was 9.5 years. Polyetheretherketone and polymethylmethacrylate reported 29% and 33.3%, respectively, of complications, but only 3% and 5.6% of surgical revision. PHA reported a rate of 11.9%. Titanium reported 9.2% of complications and 4.1% of surgical revisions. Porous polyethylene had a complication rate of 36.4% and a revision rate of 0%. CONCLUSION: There is still no perfect material for CR. It seems that heterologous materials are superior to autologous bone for CR in children, and we may consider, whenever economic conditions will allow it, to use alloplastic material as first-line in small children.

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Background: Cranioplasty (CP) is a surgical intervention aiming to re-establish the integrity of skull defects. Autologous bone and different heterologous materials are used for this purpose, with various reported related complications, especially in children.This study aims to evaluate the rate of complication in a multicentric cohort of pediatric patients treated by porous hydroxyapatite (PHA) CP implantation and to assess the reliability of post-marketing clinical data collected by a manufacturing company. Methods: The authors proactively collected clinical data from 20 institutions in different European countries for patients under the age of 16 treated with a PHA implant. The data were obtained by conducting an on-site interview with physicians in charge of the patients (Post-Marketing Surveillance, PMS group). The endpoints were the incidence of adverse events and related implant removal. The clinical data were compared to the company-based register including all patients under the age of 16 who received the same implant from January 1, 2004 to December 31, 2020, and the collecting complications voluntarily reported by surgeons (Database, DB group). Results: The two groups were similar in terms of demographic characteristics and rate of complications. In the PMS group, a total of 11 (16.9%) complications were reported in the group of 65 patients that were proactively collected. Both fractures and infections were the most common complications with 4 cases each (6.2%). In the case of both infections and fractures, revision surgery was required for only one patient (1.5%). Three (4.5%) cases of displacements were reported, and in one (1.5%) case, a surgical revision was required, for a total of 3 (4.5%) cases requiring surgical revision. The average follow-up was 26.7 months. Conclusions: Different from a previous study on adult age, pediatric neurosurgeons are more prone to report even to the manufacturing company complications related to skull reconstruction in children. Therefore, these data can be compared with those of other clinical studies. The PHA CP in this series of 65 patients presents a complication rate collected on-site that is similar to other heterologous materials.

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BACKGROUND: Giant disfiguring cranial tumors are exceptionally rare and develop over the course of many years, typically in patients who lack access to medical care. Here, we describe four patients who were flown to our center for treatment by a multidisciplinary surgical team, who had previously been turned down for treatment at multiple international centers in Africa, Europe, and the United States (US) due to complexity and financial concerns. The case series describes socioeconomic implications and the feasibility of offering such care to patients from outside the US. CASE DESCRIPTIONS: Four patients with giant skull disfiguring tumors were flown internationally and treated by a surgical team consisting of a complex cranial neurosurgeon, a craniofacial reconstructive plastic surgeon, and an oculoplastic surgeon. All patients underwent aggressive surgical therapy with the aim of complete tumor removal and simultaneous cranial reconstruction. A patient with osteogenic sarcoma underwent two additional resections in 3 years, with delayed reconstruction. They returned home but ultimately succumbed to the disease. A patient with ossifying fibroma required two follow-up procedures for cosmetic reconstruction and sought asylum in the US, where they remain today. Two additional patients, one with a giant plexiform neurofibroma and one with a cerebellopontine angle meningioma, achieved good results and returned to Africa 1 month and 3 weeks after surgery, respectively. CONCLUSION: Resection of giant disfiguring cranial tumors and reconstruction of the impacted region requires an experienced multidisciplinary team. These cases can be managed by transporting such patients from areas without access to medical care to specialized centers able to provide excellent care.

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BACKGROUND: Cranioplasty is a ubiquitous neurosurgical procedure consisting of reconstruction of a pre-existing calvarial defect. Many materials are available, including polymethylmethacrylate in hand-moulded (hPMMA) and prefabricated (pPMMA) form, hydroxyapatite (HA), polyetheretherketone (PEEK) and titanium (Ti). OBJECTIVE: To perform a network meta-analysis (NMA) to assess the relationship between materials and complications of cranioplasty. METHODS: PubMed/MEDLINE, Google Scholar, EMBASE, Scopus, and The Cochrane Library were searched from January 1, 1990 to February 14, 2021. Studies detailing rates of any of infections, implant exposure, or revision surgery were included. A frequentist NMA was performed for each complication. Risk ratios (RRs) with 95% CIs were calculated for each material pair. RESULTS: A total of 3620 abstracts were screened and 31 full papers were included. Surgical revision was reported in 18 studies and occurred in 316/2032 cases (14%; 95% CI 11-17). PEEK had the lowest risk of re-operation with a rate of 8/157 (5%; 95% CI 0-11) in 5 studies, superior to autografts (RR 0.20; 95% CI 0.07-0.57), hPMMA (RR 0.20; 95% CI 0.07-0.60), Ti (RR 0.39; 95% CI 0.17-0.92), and pPMMA (RR 0.14; 95% CI 0.04-0.51). Revision rate was 131/684 (19%; 95% CI 13-25; 10 studies) in autografts, 61/317 (18%; 95%CI 9-28; 7 studies) in hPMMA, 84/599 (13%; 95% CI 7-19; 11 studies) in Ti, 7/59 (9%; 95% CI 1-23; 3 studies) in pPMMA, and 25/216 (12%; 95% CI 4-24; 4 studies) in HA. Infection occurred in 463/4667 (8%; 95% CI 6-11) and implant exposure in 120/1651 (6%; 95% CI 4-9). CONCLUSION: PEEK appears to have the lowest risk of cranioplasty revision, but further research is required to determine the optimal material.

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Reconstruction of cranial defects is an arduous task for craniomaxillofacial surgeons. Additive manufacturing (AM) or three-dimensional (3D) printing of titanium patient-specific implants (PSIs) made its way into cranioplasty, improving the clinical outcomes in complex surgical procedures. There has been a significant interest within the medical community in redesigning implants based on natural analogies. This paper proposes a workflow to create a biomimetic patient-specific cranial prosthesis with an interconnected strut macrostructure mimicking bone trabeculae. The method implements an interactive generative design approach based on the Voronoi diagram or tessellations. Furthermore, the quasi-self-supporting fabrication feasibility of the biomimetic, lightweight titanium cranial prosthesis design is assessed using Selective Laser Melting (SLM) technology.

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The repair of large cranial defects with bone is a major clinical challenge that necessitates novel materials and engineering solutions. Three-dimensionally (3D) printed bioceramic (BioCer) implants consisting of additively manufactured titanium frames enveloped with CaP BioCer or titanium control implants with similar designs were implanted in the ovine skull and at s.c. sites and retrieved after 12 and 3 mo, respectively. Samples were collected for morphological, ultrastructural, and compositional analyses using histology, electron microscopy, and Raman spectroscopy. Here, we show that BioCer implants provide osteoinductive and microarchitectural cues that promote in situ bone regeneration at locations distant from existing host bone, whereas bone regeneration with inert titanium implants was confined to ingrowth from the defect boundaries. The BioCer implant promoted bone regeneration at nonosseous sites, and bone bonding to the implant was demonstrated at the ultrastructural level. BioCer transformed to carbonated apatite in vivo, and the regenerated bone displayed a molecular composition indistinguishable from that of native bone. Proof-of-principle that this approach may represent a shift from mere reconstruction to in situ regeneration was provided by a retrieved human specimen, showing that the BioCer was transformed into well-vascularized osteonal bone, with a morphology, ultrastructure, and composition similar to those of native human skull bone.

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BACKGROUND: Scalp arteriovenous malformations, also known as cirsoid aneurysms, are complex collections of directly communicating arteries and veins. As a cirsoid aneurysm grows, it can recruit a blood supply from multiple intracranial and extracranial vessels and involve both scalp and facial tissue. Depending on their size and complexity, a variety of strategies can be used to treat them. CASE DESCRIPTION: We have presented the case of a giant cirsoid aneurysm treated with endovascular embolization, resection, and reconstruction using multiple expanded scalp and facial flaps. A 15-year-old boy had presented with a pulsatile left temporal scalp mass that had slowly grown to involve most of his left scalp and extend into the ipsilateral face. At his next presentation, at 19 years old, he had recently developed episodic lateral visual field loss, photophobia, headaches, and vertigo. Catheter angiography demonstrated an extensive arteriovenous malformation supplied primarily by the left superficial temporal, posterior auricular, and occipital arteries, as well as by the ophthalmic artery, The angiogram also showed a dural arteriovenous fistula. Initially, tissue expanders were placed in the vertex, occipital, and left lower facial regions. The patient then underwent endovascular embolization, followed by resection and reconstruction of the tissue defect using multiple expanded scalp and facial flaps. The patient recovered well without neurological deficits and had complete resolution of his symptoms. Our surgical collaboration resulted in overall preservation of his hairline and facial symmetry. CONCLUSION: Large cirsoid aneurysms can require multidisciplinary treatment combining embolization, resection, and plastic surgical techniques to close the tissue defects.

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