When a deadly, 7.8 magnitude earthquake struck Nepal in April of 2015, killing thousands of people, the 3D printing community jumped right in to offer assistance, from a 3D printable model (for a donation) of Nepal’s Boudhanath Stupa Buddhist temple from Pinshape and MiniWorld, to a call for desktop 3D printing solutions and design ideas to assist in earthquake relief, and important 3D printed medical supplies. Not only were homes devastated by the earthquake, but schools and surgical care systems were as well. Recently, a team of UK specialists went on a few aid and education missions to Nepal, in order to support and train local surgeons. The British Association of Oral and Maxillofacial Surgeons (BAOMS), along with its international education subcommittee the Norman Rowe International Education Foundation (NRIEF), was responsible for the missions.
Shakir Mustafa, consultant Oral and Maxillofacial Surgeon and NRIEF chair, said, “Our aim is to lay down the foundations for a future training programme through empowering local faculty to take charge of the education and training of future generations of Nepalese surgeons.”
Mustafa also treated several patients during the missions, and set up a five-year collaboration for training in orbital implant surgery, after he performed what is believe to be the first procedure of this kind in the country. After the first mission, the surgeons learned of 28-year-old mother Shashi Kala Rai, who’d been injured in a traffic accident and received an orbital wall and medial wall fracture. She’d already undergone a corrective bone graft surgery in India, but her left eye was lower and sunken-in, and had shrunk due to scarring. Rai’s left eye needed to be re-aligned and supported, and both left eyelids needed to have lateral revisions. Mustafa looked at copies of her CT scans, and determined that her original bone graft had been placed incorrectly, lying partially in the orbit and partially in the maxillary sinus.
He knew he could help Rai, and started to plan the operation when he returned to the UK, working with a group of 3D design and printing experts highly experienced in difficult facial reconstructive surgeries. Leading engineering and scientific technology company Renishaw plc supplied the metal 3D printing, and also donated funds and Rai’s implant, which it had helped create, due to the company’s skills in measurement in creating complex geometries.
Mustafa also collaborated with the Maxillofacial Prosthetics Laboratory at Morriston Hospital, located in Wales, to use CAD in designing the implant; a haptic arm was used to visualize and edit the implant plate in a 3D virtual environment. The plate would need to be big enough to cover the existing defects on the medial wall and orbital floor that were left by Rai’s first operation. To compensate for these defects, Mustafa took advantage of the flexible 3D printing technology process to make some changes to the clinical design, and made the venting holes bigger to help with drainage, reduced the plate’s extension up the medial wall to make surgical placement more predictable, and, to avoid the optic nerve, also reduced the extension at the back of the plate.
Mustafa and his team also added an exaggerated curvature to the plate in order to refashion the eye socket’s retrobulbar bulge, as Rai’s sunken eye appearance had been caused by orbital fat herniating into the maxillary sinus below at the time of her fracture. The PDR at the Cardiff Metropolitan Hospital 3D printed an anatomical model using SLA resin, so it could be sterilized and brought into the operating room for assistance during the difficult surgery. Renishaw’s additive manufacturing facility in Miskin, near Cardiff, created the proven titanium Ti MG1 implant on its AM250 machines. Due to how volatile the region still is after the earthquakes, a second implant was conventionally manufactured as a backup at Morriston Hospital.
The surgery was risky – due to the position of the optical nerve, any orbital implant procedures have the potential to ultimately cause double vision, or even blindness. There were additional risks to this particular procedure, since Rai’s scars from the first reconstruction were present. The fact that the surgery would be taking place in Nepal, where there are fewer than 50 oral and maxillofacial surgeons (as opposed to the over 1,000 in the UK), paved the way forward for such procedures and cooperations in the country.
In order to give Rai the necessary amount of recovery time so he could look at the results before he went back home, Mustafa got to work soon after he landed in Nepal. Because aftershocks and electrical power cuts occasionally happen in Nepal’s post-earthquake environment, he planned ahead and brought some of his own medical equipment, including a head lamp.
Mustafa said, “I am always ready to modify the operation to suit local conditions, but I will never compromise my standards and I always plan for perfection. That includes the implant which fitted perfectly.”
The operation took twice as long to complete as it would have in the UK, but it was ultimately a success, and believed to be not only Nepal’s first customized maxillofacial operation, but also the first 3D printed orbital implant surgery ever. Rai’s left eye has been placed back in the correct position, and she has no double vision, normal visual acuity, and good movement in both the eye and eyelid.
The surgery Mustafa completed, thanks to the use of 3D printing technology, has left a strong training legacy in Nepal, which ties back to the original BAOMS mission. As oral cancer is 20-30 times prevalent in Nepal than the UK, Mustafa and his fellow surgeons hope to start a medical teaching program, to teach local doctors and surgeons how to treat oncology and trauma patients.
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