Welsh Medical Team Combines Bone Grafts and 3D Printing for Patient-Specific Jaw Reconstruction

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[Image: Morriston Hospital]

Last year, researchers at the Morriston Hospital in Swansea, Wales introduced the ADEPT (Additive-manufacture for Design-led Efficient Patient Treatment) project, which was designed for patients suffering from diseases or significant damage to their facial structures and uses 3D printing technology to produce titanium implants. We initially heard about the project in terms of a 3D printed implant for a fractured eye socket, and now additive manufacturing has been put into play for a recent technique a surgical team at the hospital created to use 3D printing technology to reconstruct jaws affected by cancer.

While we’ve seen 3D printed patient-specific titanium jaw implants before, the hospital says that its technique is the first of its kind in the world – it combines traditional bone grafts with 3D printed titanium implants made specifically for individual patients.

Typically, surgeons use a piece of fibula from the patient’s leg to replace sections of jaw that have been lost or damaged, or had to be removed due to cancer. Unfortunately, an implant like this can compromise the shape of the patient’s jawline if it’s set too high; if it’s set too low, dental implants won’t work. The technique developed at Morriston designs a titanium implant that’s anatomically accurate, thanks to the patient’s CT scans, and is able to attach the fibula where it needs to be so the jawline can keep its aesthetic shape.

[Image via NHS Wales]

Often, the piece of bone being placed in the jaw needs to be trimmed during the operation so it fits; then, it’s held in place by a metal plate which the surgeon has to bend. This can take a long time, and a lot of skill is required to get it just right. So now, the team also creates millimeter-perfect cutting guides for the surgery, in order for the fibula bone to perfectly match the section of jaw that’s been removed.

“We used the CT image of the patient’s jaw on the other side and mirrored it, and the design of the implant and cutting guides is based on that shape. The titanium implant fits the patient’s jaw perfectly without the surgeon having to do any adjustment,” said Peter Llewelyn Evans, Maxillofacial Laboratory Services manager at Morriston Hospital. “Similarly, using cutting guides means the section of fibula exactly matches the section of jawbone removed.”

Debbie Hawkins pictured with consultant surgeon Madhav Kittur [Image: ABMU Healthboard]

By using the 3D printed cutting guides, the surgeon can also focus on connecting the fibula section to blood vessels in the neck, rather than adjusting the implant or bone.

The procedure was tried out for the first time on Swansea store worker, mother, and cancer patient Debbie Hawkins. She had developed a tumor in her lower jawbone, which had grown so much that it was threatening to break her jaw. The surgical team needed to remove and rebuild a section of her jawbone.

“When they told me what the procedure involved I was scared at first. I really didn’t know what to expect,” Hawkins said. “But what they have done, and the aftercare I have received, has been absolutely amazing.”

The team also used 3D printing technology to plan the surgery out ahead of time, so there wouldn’t be any surprises in the operating room.

“It has taken away the uncertainty. We know exactly what is going to happen before we go into theatre as everything is computer planned,” explained consultant surgeon Madhav Kittur. “This can save a lot of time – up to two hours. On average this operation takes eight to 10 hours, so when we take two hours out of that it is quite a sizable reduction. This is a big advance. It’s better aesthetically, the patient is under anaesthetic for less time, and recovery is better. Although we haven’t yet measured it, I would even say that the length of stay in hospital is also reduced.”

(L-R) Peter Llewelyn Evans, Mr Kittur, Debbie Hawkins, oral and maxillofacial nurse practitioner Julie Rees, and oral and maxillofacial department sister Karen Humphreys [Image: ABMU Healthboard]

A team of oral and maxillofacial surgeons at Morriston Hospital completed the surgery, including Kittur, Ketan Shah, and Simon Hodder; Evans and biomedical 3D technician Heather Goodrum assisted. The team recently published technical information about the procedure in the British Journal of Oral and Maxillofacial Surgery, and according to Kittur, five similar procedures have already been completed at the hospital, with a sixth being planned.

Hawkins only had to stay in the hospital for two weeks after her operation, and was back to work after three months of recovery. She says she’s “pleased” with her progress so far, though she hopes that she’ll soon be able to receive dental implants.

“Now and again I do have a few problems with my speech because I’m having to make certain jaw movements,” Hawkins said. “But I’m feeling much better. I get my odd days but otherwise I’m getting stronger all the time.”

This is just one of many examples of 3D printing technology helping to make surgeries easier, more accurate, and less time-consuming.

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