Application-specific selection of biomaterials for pediatric craniofacial reconstruction: Developing a rational approach to guide clinical use

BACKGROUND: Biomaterials provide an invaluable alternative to autogenous bone graft for pediatric craniofacial reconstruction. However, there is no uniform agreement on the choice of biomaterial for different reconstructive needs. METHODS: Patients who had reconstruction of the craniofacial skeleton with alloplastic materials from 1994 to 2006 by a single surgeon were reviewed. Biomaterials used consisted of three classes: cement pastes, biomaterials designed to be replaced by bone, and prefabricated polymers. The study included 25 patients with a mean age of 5.5 years and a mean follow-up of 3.3 years. RESULTS: Cement pastes used for onlay augmentation to the cranial skeleton in eight patients consisted of hydroxyapatite (n = 5) and calcium phosphate (n = 3). One patient had a postoperative infection that resolved with partial implant removal and antibiotics. Biomaterials designed to be replaced by bone consisted of bioactive glass (n = 3) and demineralized bone (n = 8), which were used for inlay reconstruction of full-thickness calvarial defects in 11 patients. Computed tomographic scanning showed adequate bone mineralization in nine patients; two of the three patients with calvarial defects greater than 5 cm in diameter demonstrated variable mineralization. Prefabricated porous polyethylene was used in six patients for either onlay malar augmentation (n = 3) or inlay calvarial reconstruction (n = 3). One patient had a peri-implant infection that resolved with aspiration, irrigation, and intravenous antibiotics. CONCLUSIONS: The authors developed an algorithm to guide use of biomaterials in craniofacial reconstruction based on whether (1) growth of the underlying craniofacial skeleton is nearly complete (>90 percent); (2) onlay or inlay reconstruction is to be performed; and (3) the reconstruction is performed in a load-bearing or non-load-bearing area.