11.5  Titanium: Mesh-Systems

11.5.1  Mesh-Systems

The excellent biocompatibility of titanium, the unique geometrical properties of titanium meshes and their easy handling make these mesh systems an ideal substitute for treating defects in nonload-bearing areas of the skull (Arx et al. 1995; Kessler and Hardt 1996; Kuttenberger and Hardt 2001).

• Dynamic mesh

(Hardt et al. 1992,1994; Reinert and Gellrich 1997; Kessler and Hardt 1996; Kuttenberger et al. 1999; Kuttenberger and Hardt 2001).

The dynamic mesh is available in three thicknesses: 0.1, 0.3, and 0.6 mm. Its preangled bars, which prevent kinking or wrinkling of the mesh, allow complex threedimensional contouring, which is especially applicable for orbital reconstruction.

Stable functional and aesthetic long-term results can be archieved in this anatomically complex region. The mesh may, therefore, be an alternative to bone or cartilage grafts (Fig. 11.23).

• Microdynamic mesh

(Hardt et al. 1992,1994; Kessler and Hardt 1996; Kuttenberger et al. 1999; Kuttenberger and Hardt 2001).

The laser-perforated microdynamic mesh consists of pure titanium (thickness of 0.1 mm) can be cut with scissors and is easily adapted and fixed with titanium microscrews.

11.5.2  Indications and Advantages

In general, the two microtitanium mesh systems are used in the following indications:

•Immediate reconstruction of bony defects

•Correction of extensive contour irregularities in combination with bone or cartilage grafts

•Reconstruction in areas predisposed to infection with or without autogenous transplants

•Contour reconstruction in aesthetically critical regions (supraorbital margin)

In specific cases of craniofacial reconstruction, these systems offer valuable, additional therapeutic options and have several advantages (Kuttenberger et al. 1999):

Advantages

•Immediate availability

•Universal applicability (orbital walls, cranial defects, comminuted fractures in fine-walled bone areas, wall defects of the maxillary sinus)

•No donor side morbidity

•Possible three-dimensional reconstruction of complex anatomical bone structures

•Combination with bone or cartilage grafts (Reinert and Gellrich 1991)

•No memory effect, no resetting

•Extremely low infection rate

•Combinationwithmicrovasculartransplants(Eufinger et al. 1999)

11.5.3  Defect Treatment Using

Titanium-Mesh

Bridging defects with titanium meshes to maintain contours provides aesthetically and functionally acceptable results (Figs. 11.24–11.28).

•Minor bony defects up to a size of 25 cm2 in comminuted fracture sites of nonload-bearing areas can easily be covered with the 0.3-mm mesh (Hardt et al. 1992; Kuttenberger and Hardt 2001).

•For major bone defects exceeding >25 cm2, reconstruction with calvarial bone is the treatment of choice (Mohr et al. 1994). Large defects covered by split calvarial grafts can be optimized by an additional coverage with titanium mesh to create an aesthetically acceptable contour, so that conspicuous bone loss due to resorption will not become obvious (Hardt et al. 1994). Contour irregularities in the contact zones between grafts can be avoided using microtitanium mesh strips (Reinert and Gellrich 1991; Hardt et al. 1994).

•In craniofacial reconstruction, contact with the paranasal sinuses cannot be avoided. If titanium meshes are in contact with the ethmoid or the frontal sinus, re-pneumatization of the sinus normally takes place and there are almost no mesh-related infections.

•Postoperative endoscopic controls by Deinsberger et al. (1998) showed complete epithelilization of

Fig.11.25  Severe maxillary-orbital and cranial defects after a submento-orbito-frontal gunshot injury. (a) Preoperative CT scan demonstrating severe comminution of the right nasal, ethmoidal, and orbital structures with extensive bone loss. (b) Reconstruction of the anterior sinus wall, supraorbital rim,

medial orbital wall and medial part of the orbital floor with dynamic titanium mesh (0.3 mm). (c) Postoperative CT scan demonstrating symmetrical reconstruction of the right orbital cavity. (d) Aesthetic result 1 year postoperatively with some inconspicuous scars

Fig.11.27  Reconstruction of the zygomatico-temporal area. After fixation of the zygomatic bone and zygomatic arch, a residual latero-temporal bone defect is covered with microtitanium

mesh (0.1 mm). The mobilized temporal muscle is attached to the mesh

Fig.11.28  Microvascular reconstruction after extensive bone and soft tissue loss. (a) Avulsion injury with partial loss of dura, frontal bone and skin caused by an axe blow. (b) Intraoperative view after craniotomy, refixation of the naso-frontal fragments and closure of the dural defect. (c) The remaining bony defect is

covered with a dynamic titanium mesh (0.3 mm). (d) The missing frontal soft tissues are reconstructed using a radial forearm flap. (e) Postoperative clinical and radiological results (1 week postoperatively)