Publications by authors named "Bilal Msallem"

14 Publications

  • Page 1 of 1

Biomechanical Evaluation of Patient-Specific Polymethylmethacrylate Cranial Implants for Virtual Surgical Planning: An In-Vitro Study.

Materials (Basel) 2022 Mar 7;15(5). Epub 2022 Mar 7.

Clinic of Oral and Cranio-Maxillofacial Surgery, University Hospital Basel, CH-4031 Basel, Switzerland.

Cranioplasty with freehand-molded polymethylmethacrylate implants is based on decades of experience and is still frequently used in clinical practice. However, data confirming the fracture toughness and standard biomechanical tests are rare. This study aimed to determine the amount of force that could be applied to virtually planned, template-molded, patient-specific implants ( = 10) with an implant thickness of 3 mm, used in the treatment of a temporoparietal skull defect (91.87 cm), until the implant cracks and finally breaks. Furthermore, the influence of the weight and porosity of the implant on its force resistance was investigated. The primary outcome showed that a high force was required to break the implant (mean and standard deviation 1484.6 ± 167.7 N), and this was very strongly correlated with implant weight (Pearson's correlation coefficient 0.97; < 0.001). Secondary outcomes were force application at the implant's first, second, and third crack. Only a moderate correlation could be found between fracture force and the volume of porosities (Pearson's correlation coefficient 0.59; = 0.073). The present study demonstrates that an implant thickness of 3 mm for a temporoparietal skull defect can withstand sufficient force to protect the brain. Greater implant weight and, thus, higher material content increases thickness, resulting in more resistance. Porosities that occur during the described workflow do not seem to reduce resistance. Therefore, precise knowledge of the fracture force of polymethylmethacrylate cranial implants provides insight into brain injury prevention and serves as a reference for the virtual design process.
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http://dx.doi.org/10.3390/ma15051970DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8911603PMC
March 2022

Functional and Cosmetic Outcome after Reconstruction of Isolated, Unilateral Orbital Floor Fractures (Blow-Out Fractures) with and without the Support of 3D-Printed Orbital Anatomical Models.

J Clin Med 2021 Aug 9;10(16). Epub 2021 Aug 9.

Department of Oral and Cranio-Maxillofacial Surgery, University Hospital Basel, CH-4031 Basel, Switzerland.

The present study aimed to analyze if a preformed "hybrid" patient-specific orbital mesh provides a more accurate reconstruction of the orbital floor and a better functional outcome than a standardized, intraoperatively adapted titanium implant. Thirty patients who had undergone surgical reconstruction for isolated, unilateral orbital floor fractures between May 2016 and November 2018 were included in this study. Of these patients, 13 were treated conventionally by intraoperative adjustment of a standardized titanium mesh based on assessing the fracture's shape and extent. For the other 17 patients, an individual three-dimensional (3D) anatomical model of the orbit was fabricated with an in-house 3D-printer. This model was used as a template to create a so-called "hybrid" patient-specific titanium implant by preforming the titanium mesh before surgery. The functional and cosmetic outcome in terms of diplopia, enophthalmos, ocular motility, and sensory disturbance trended better when "hybrid" patient-specific titanium meshes were used but with statistically non-significant differences. The 3D-printed anatomical models mirroring the unaffected orbit did not delay the surgery's timepoint. Nonetheless, it significantly reduced the surgery duration compared to the traditional method (58.9 (SD: 20.1) min versus 94.8 (SD: 33.0) min, -value = 0.003). This study shows that using 3D-printed anatomical models as a supporting tool allows precise and less time-consuming orbital reconstructions with clinical benefits.
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http://dx.doi.org/10.3390/jcm10163509DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8397200PMC
August 2021

Fibula Graft Cutting Devices: Are 3D-Printed Cutting Guides More Precise than a Universal, Reusable Osteotomy Jig?

J Clin Med 2020 Dec 20;9(12). Epub 2020 Dec 20.

Clinic of Oral and Cranio-Maxillofacial Surgery, University Hospital Basel, CH-4031 Basel, Switzerland.

Individual cutting guides for the reconstruction of lower jaw defects with fibular grafts are often used. However, the application of these osteotomy tools is costly and time intensive. The aim of this study was to compare the precision of osteotomies using a 3D-printed guide with those using a universal, reusable, and more cost-efficient Multi-Use Cutting Jig (MUC-Jig). In this non-blinded experimental study, 10 cranio-maxillofacial surgeons performed four graft removals each in a randomized order using the same osteotomy angle, both proximally (sagittal cut) and distally (coronal cut), of a graft (45°, 30°, 15°, or 0°), first with the MUC-Jig then with the 3D-printed cutting guide. The 40 fibula transplants (Tx) of each method (n = 80) were then analyzed concerning their Tx length and osteotomy angles and compared to the original planning data. Furthermore, the surgeons' subjective perception and the duration of the two procedures were analyzed. The mean relative length and mean relative angle deviation between the MUC-Jig (-0.08 ± 1.12 mm; -0.69° ± 3.15°) and the template (0.22 ± 0.90 mm; 0.36° ± 2.56°) group differed significantly ( = 0.002; = < 0.001), but the absolute deviations did not ( = 0.206; = 0.980). Consequently, clinically comparable osteotomy results can be achieved with both methods, but from an economic point of view the MUC-Jig is a more cost-efficient solution.
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http://dx.doi.org/10.3390/jcm9124119DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7766794PMC
December 2020

Facial Swelling in a Toddler Due to a Metastatic High-Risk Neuroblastoma.

J Dent Child (Chic) 2020 Sep;87(3):166-170

Dr. Augello is a senior consultant, Clinic of Oral and Cranio-Maxillofacial Surgery, University Hospital Basel, and Cantonal Hospital Aarau, Switzerland;, Email:

Neuroblastoma is a malignant embryonal tumor derived from the neural crest cells of the sympathetic nervous system. Curative therapy is challenging, especially because early-stage diagnosis in toddlers is difficult. Successful treatment of high-risk neuroblastoma is only achieved in approximately half of the cases and requires an immediate interdisciplinary approach. We present a 34-month-old toddler with swelling of the left side of the face of three days duration and a mandibular mass of unknown duration, which was diagnosed as a metastasis of a neuroblastoma. He also had metastases in the kidney, long bones and skull. Despite the poor prognosis in cases of disseminated skeletal involvement and N-myc amplification, the young patient remained free of recurrence during a follow-up period of 36 months after multidisciplinary treatment. The purpose of this case report is to increase awareness of the clinical features of neuroblastoma among pediatric dentists to support early-stage diagnosis and highlight interdisciplinary management.
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September 2020

Comparative Evaluation of Digitization of Diagnostic Dental Cast (Plaster) Models Using Different Scanning Technologies.

Dent J (Basel) 2020 Aug 2;8(3). Epub 2020 Aug 2.

Department of Oral and Cranio-Maxillofacial Surgery, University Hospital Basel, 4031 Basel, Switzerland.

Rapidly developing digital dental technologies have substantially simplified the documentation of plaster dental models. The large variety of available scanners with varying degrees of accuracy and cost, however, makes the purchase decision difficult. This study assessed the digitization accuracy of a cone-beam computed tomography (CBCT) and an intraoral scanner (IOS), as compared to a desktop optical scanner (OS). Ten plaster dental models were digitized three times (n = 30) with each scanner. The generated STL files were cross-compared, and the RMS values were calculated. Conclusions were drawn about the accuracy with respect to precision and trueness levels. The precision of the CBCT scanner was similar to the desktop OS reference, which both had a median deviation of 0.04 mm. The IOS had statistically significantly higher deviation compared to the reference OS, with a median deviation of 0.18 mm. The trueness values of the CBCT was also better than that of IOS-median differences of 0.14 and 0.17 mm, respectively. We conclude that the tested CBCT scanner is a highly accurate and user-friendly scanner for model digitization, and therefore a valuable alternative to the OS. The tested IOS was generally of lower accuracy, but it can still be used for plaster dental model digitization.
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http://dx.doi.org/10.3390/dj8030079DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7558308PMC
August 2020

In Vitro Mechanical and Biological Properties of 3D Printed Polymer Composite and β-Tricalcium Phosphate Scaffold on Human Dental Pulp Stem Cells.

Materials (Basel) 2020 Jul 8;13(14). Epub 2020 Jul 8.

Department of Oral and Cranio-Maxillofacial Surgery, University Hospital Basel, Spitalstrasse 21, 4031 Basel, Switzerland.

3D printed biomaterials have been extensively investigated and developed in the field of bone regeneration related to clinical issues. However, specific applications of 3D printed biomaterials in different dental areas have seldom been reported. In this study, we aimed to and successfully fabricated 3D poly (lactic-co-glycolic acid)/β-tricalcium phosphate (3D-PLGA/TCP) and 3D β-tricalcium phosphate (3D-TCP) scaffolds using two relatively distinct 3D printing (3DP) technologies. Conjunctively, we compared and investigated mechanical and biological responses on human dental pulp stem cells (hDPSCs). Physicochemical properties of the scaffolds, including pore structure, chemical elements, and compression modulus, were characterized. hDPSCs were cultured on scaffolds for subsequent investigations of biocompatibility and osteoconductivity. Our findings indicate that 3D printed PLGA/TCP and β-tricalcium phosphate (β-TCP) scaffolds possessed a highly interconnected and porous structure. 3D-TCP scaffolds exhibited better compressive strength than 3D-PLGA/TCP scaffolds, while the 3D-PLGA/TCP scaffolds revealed a flexible mechanical performance. The introduction of 3D structure and β-TCP components increased the adhesion and proliferation of hDPSCs and promoted osteogenic differentiation. In conclusion, 3D-PLGA/TCP and 3D-TCP scaffolds, with the incorporation of hDPSCs as a personalized restoration approach, has a prospective potential to repair minor and critical bone defects in oral and maxillofacial surgery, respectively.
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http://dx.doi.org/10.3390/ma13143057DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7412522PMC
July 2020

Three-Dimensional Analysis of Isolated Orbital Floor Fractures Pre- and Post-Reconstruction with Standard Titanium Meshes and "Hybrid" Patient-Specific Implants.

J Clin Med 2020 May 22;9(5). Epub 2020 May 22.

Department of Oral and Cranio-Maxillofacial Surgery, University Hospital Basel, CH-4031 Basel, Switzerland.

The aim of this study was to compare the efficacy of the intraoperative bending of titanium mesh with the efficacy of pre-contoured "hybrid" patient-specific titanium mesh for the surgical repair of isolated orbital floor fractures. In-house 3D-printed anatomical models were used as bending guides. The main outcome measures were preoperative and postoperative orbital volume and surgery time. We performed a retrospective cohort study including 22 patients who had undergone surgery between May 2016 and November 2018. The first twelve patients underwent conventional reconstruction with intraoperative free-hand bending of an orbital floor mesh plate. The subsequent ten patients received pre-contoured plates based on 3D-printed orbital models that were produced by mirroring the non-fractured orbit of the patient using a medical imaging software. We compared the preoperative and postoperative absolute volume difference (unfractured orbit, fractured orbit), the fracture area, the fracture collapse, and the effective surgery time between the two groups. In comparison to the intraoperative bending of titanium mesh, the application of preformed plates based on a 3D-printed orbital model resulted in a non-significant absolute volume difference in the intervention group ( = 0.276) and statistically significant volume difference in the conventional group ( = 0.002). Further, there was a significant reduction of the surgery time (57.3 ± 23.4 min versus 99.8 ± 28.9 min, = 0.001). The results of this study suggest that the use of 3D-printed orbital models leads to a more accurate reconstruction and a time reduction during surgery.
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http://dx.doi.org/10.3390/jcm9051579DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7291031PMC
May 2020

Effects of Steam Sterilization on 3D Printed Biocompatible Resin Materials for Surgical Guides-An Accuracy Assessment Study.

J Clin Med 2020 May 17;9(5). Epub 2020 May 17.

Department of Oral and Cranio-Maxillofacial Surgery, University Hospital Basel, Spitalstrasse 21, 4031 Basel, Switzerland.

Computer-assisted surgery with three-dimensional (3D) printed surgical guides provides more accurate results than free-hand surgery. Steam sterilization could be one of the factors that affect the dimensions of surgical guide resin materials, leading to inaccuracies during surgeries. The purpose of this study was to evaluate the effects of steam sterilization on the dimensional accuracy of indication-specific hollow cube test bodies, manufactured in-house using Class IIa biocompatible resin materials (proprietary and third-party). To evaluate the pre- and post-sterilization dimensional accuracy, root mean square (RMS) values were calculated. The results indicate that, in all the groups, steam sterilization resulted in an overall linear expansion of the photopolymeric resin material, with an increase in outer dimensions and a decrease in inner dimensions. The effects on the dimensional accuracy of test bodies were not statistically significant in all the groups, except PolyJet Glossy ( > 0.05). The overall pre- and post-sterilization RMS values were below 100 and 200 µm, respectively. The highest accuracies were seen in proprietary resin materials, i.e., PolyJet Glossy and SLA-LT, in pre- and post-sterilization measurements, respectively. The dimensional accuracy of third-party resin materials, i.e., SLA-Luxa and SLA-NextDent, were within a comparable range as proprietary materials and can serve as an economical alternative.
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http://dx.doi.org/10.3390/jcm9051506DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7291001PMC
May 2020

Accuracy Assessment of Molded, Patient-Specific Polymethylmethacrylate Craniofacial Implants Compared to Their 3D Printed Originals.

J Clin Med 2020 Mar 19;9(3). Epub 2020 Mar 19.

Department of Oral and Cranio-Maxillofacial Surgery, University Hospital Basel, CH-4031 Basel, Switzerland.

The use of patient-specific implants (PSIs) in craniofacial surgery is often limited due to a lack of expertise and/or production costs. Therefore, a simple and cost-efficient template-based fabrication workflow has been developed to overcome these disadvantages. The aim of this study is to assess the accuracy of PSIs made from their original templates. For a representative cranial defect (CRD) and a temporo-orbital defect (TOD), ten PSIs were made from polymethylmethacrylate (PMMA) using computer-aided design (CAD) and three-dimensional (3D) printing technology. These customized implants were measured and compared with their original 3D printed templates. The implants for the CRD revealed a root mean square (RMS) value ranging from 1.128 to 0.469 mm with a median RMS (Q1 to Q3) of 0.574 (0.528 to 0.701) mm. Those for the TOD revealed an RMS value ranging from 1.079 to 0.630 mm with a median RMS (Q1 to Q3) of 0.843 (0.635 to 0.943) mm. This study demonstrates that a highly precise duplication of PSIs can be achieved using this template-molding workflow. Thus, virtually planned implants can be accurately transferred into haptic PSIs. This workflow appears to offer a sophisticated solution for craniofacial reconstruction and continues to prove itself in daily clinical practice.
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http://dx.doi.org/10.3390/jcm9030832DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7141183PMC
March 2020

Evaluation of the Dimensional Accuracy of 3D-Printed Anatomical Mandibular Models Using FFF, SLA, SLS, MJ, and BJ Printing Technology.

J Clin Med 2020 Mar 17;9(3). Epub 2020 Mar 17.

Clinic of Oral and Cranio-Maxillofacial Surgery, University Hospital Basel, CH-4031 Basel, Switzerland.

With the rapid progression of additive manufacturing and the emergence of new 3D printing technologies, accuracy assessment is mostly being performed on isosymmetric test bodies. However, the accuracy of anatomic models can vary. The dimensional accuracy of root mean square values in terms of trueness and precision of 50 mandible replicas, printed with five common printing technologies, were evaluated. The highest trueness was found for the selective laser sintering printer (0.11 ± 0.016 mm), followed by a binder jetting printer (0.14 ± 0.02 mm), and a fused filament fabrication printer (0.16 ± 0.009 mm). However, highest precision was identified for the fused filament fabrication printer (0.05 ± 0.005 mm) whereas other printers had marginally lower values. Despite the statistically significance ( < 0.001), these differences can be considered clinically insignificant. These findings demonstrate that all 3D printing technologies create models with satisfactory dimensional accuracy for surgical use. Since satisfactory results in terms of accuracy can be reached with most technologies, the choice should be more strongly based on the printing materials, the intended use, and the overall budget. The simplest printing technology (fused filament fabrication) always scored high and thus is a reliable choice for most purposes.
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http://dx.doi.org/10.3390/jcm9030817DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7141211PMC
March 2020

Strawberry gingivitis: Challenges in the diagnosis of granulomatosis with polyangiitis on gingival specimens.

Oral Surg Oral Med Oral Pathol Oral Radiol 2019 Dec 2;128(6):e202-e207. Epub 2019 Aug 2.

Clinic of Oral and Cranio-Maxillofacial Surgery, University Hospital Basel, Basel, Switzerland; Medical Additive Manufacturing Research Group, Department of Biomedical Engineering, University of Basel, Allschwil, Switzerland.

Strawberry gingivitis is a rare oral manifestation of granulomatosis with polyangiitis (GPA, formerly known as Wegener's granulomatosis). It manifests as a red-purple hyperplastic gingivitis that frequently goes unrecognized as a disease-specific symptom, especially if it is the primary and only manifestation of the disease. GPA is a systemic necrotizing granulomatous vasculitis that takes a fatal course without treatment. Oral health care providers, who are among the first to examine the oral cavity, should be familiar with its typical appearance, clinical course, diagnostic parameters, and management. This article highlights the challenges to early-stage diagnosis of initial multiple gingival enlargements because histologic biopsies are often nonspecific and histology alone may not be sufficient to make a correct diagnosis of GPA from gingival specimens. Because strawberry gingivitis may be the first manifestation of GPA, awareness of it should be increased so that it can be diagnosed by its unique clinical appearance and additional related diagnostic parameters even if the histologic gingival findings are nonspecific.
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http://dx.doi.org/10.1016/j.oooo.2019.07.015DOI Listing
December 2019

Three-dimensional Assessment of the Breast: Validation of a Novel, Simple and Inexpensive Scanning Process.

In Vivo 2019 May-Jun;33(3):839-842

Medical Additive Manufacturing Research Group, Department of Biomedical Engineering, University of Basel, Allschwil, Switzerland

Background/aim: Methods to assess three-dimensionally the breast surface are increasingly used in plastic and reconstructive surgery. The aim of this study was to validate the use of the Structure Sensor 3D scanner (Occipital, Inc., Boulder, CO, USA) connected to an iPad Pro (Apple, Inc., Cupertino, CA, USA) as a novel, inexpensive and handheld three-dimensional scanning process.

Materials And Methods: Surface images of a medical human female anatomy torso model of rigid plastic were repeatedly acquired with Structure Sensor 3D scanner and compared with those obtained using two clinically established 3D imaging systems. Digital measurements of vector and surface breast distances were analyzed using Mimics® Innovation Suite 20 medical imaging software (Materialise, Leuven, Belgium).

Results: The analysis of variance (ANOVA) revealed no statistically significant difference among measurements obtained using different scanning processes for all the variables examined (p>0.05).

Conclusion: The study demonstrates analogous practicability and reliability for surface image acquisition using the newly introduced Structure Sensor 3D scanner and other clinically established scanners.
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http://dx.doi.org/10.21873/invivo.11548DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6559897PMC
August 2019

Patient-Specific Surgical Implants Made of 3D Printed PEEK: Material, Technology, and Scope of Surgical Application.

Biomed Res Int 2018 19;2018:4520636. Epub 2018 Mar 19.

Medical Additive Manufacturing Research Group, Department of Biomedical Engineering, University of Basel, Basel, Switzerland.

Additive manufacturing (AM) is rapidly gaining acceptance in the healthcare sector. Three-dimensional (3D) virtual surgical planning, fabrication of anatomical models, and patient-specific implants (PSI) are well-established processes in the surgical fields. Polyetheretherketone (PEEK) has been used, mainly in the reconstructive surgeries as a reliable alternative to other alloplastic materials for the fabrication of PSI. Recently, it has become possible to fabricate PEEK PSI with Fused Filament Fabrication (FFF) technology. 3D printing of PEEK using FFF allows construction of almost any complex design geometry, which cannot be manufactured using other technologies. In this study, we fabricated various PEEK PSI by FFF 3D printer in an effort to check the feasibility of manufacturing PEEK with 3D printing. Based on these preliminary results, PEEK can be successfully used as an appropriate biomaterial to reconstruct the surgical defects in a "biomimetic" design.
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http://dx.doi.org/10.1155/2018/4520636DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5884234PMC
September 2018

Craniofacial Reconstruction by a Cost-Efficient Template-Based Process Using 3D Printing.

Plast Reconstr Surg Glob Open 2017 Nov 17;5(11):e1582. Epub 2017 Nov 17.

Clinic for Oral and Cranio-Maxillofacial Surgery, University Hospital of Basel, Basel, Switzerland; Medical Additive Manufacturing Research Group, Hightech Research Center, Department of Biomedical Engineering, University of Basel, Allschwil, Switzerland and Department of Hand Surgery, Kantonsspital Baselland, Liestal, Switzerland.

Craniofacial defects often result in aesthetic and functional deficits, which affect the patient's psyche and wellbeing. Patient-specific implants remain the optimal solution, but their use is limited or impractical due to their high costs. This article describes a fast and cost-efficient workflow of in-house manufactured patient-specific implants for craniofacial reconstruction and cranioplasty. As a proof of concept, we present a case of reconstruction of a craniofacial defect with involvement of the supraorbital rim. The following hybrid manufacturing process combines additive manufacturing with silicone molding and an intraoperative, manual fabrication process. A computer-aided design template is 3D printed from thermoplastics by a fused deposition modeling 3D printer and then silicone molded manually. After sterilization of the patient-specific mold, it is used intraoperatively to produce an implant from polymethylmethacrylate. Due to the combination of these 2 straightforward processes, the procedure can be kept very simple, and no advanced equipment is needed, resulting in minimal financial expenses. The whole fabrication of the mold is performed within approximately 2 hours depending on the template's size and volume. This reliable technique is easy to adopt and suitable for every health facility, especially those with limited financial resources in less privileged countries, enabling many more patients to profit from patient-specific treatment.
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http://dx.doi.org/10.1097/GOX.0000000000001582DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5732683PMC
November 2017
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