Cranial Plating: Indications for Skull Reconstruction with Metal Implants

Titanium cranial plates (and mesh) are standard for neurosurgical and craniofacial reconstruction. Indications span trauma, oncology, congenital, and degenerative conditions.

Primary Indications

1. Traumatic Skull Defects

• Depressed/comminuted fractures with dural penetration
• Bone loss from penetrating injury or comminution
• Post-decompressive craniectomy (cranioplasty) — typically 3-6 months post-injury
• Compound fractures with contamination risk

2. Tumor Resection Reconstruction

• Primary bone tumors (osteosarcoma, chondrosarcoma, fibrous dysplasia)
• Metastatic calvarial lesions with structural compromise
• Meningioma en bloc resection with bone involvement
• Skull base reconstruction after endoscopic/endonasal approaches

3. Congenital & Developmental

• Craniosynostosis (syndromic/non-syndromic) — vault remodeling + plating
• Encephalocele/meningocele repair
• Craniofacial syndromes (Crouzon, Apert, Pfeiffer) — staged reconstruction
• Craniofacial clefts (Tessier classification)

4. Infection & Inflammatory Sequelae

• Post-meningitic/osteomyelitic bone loss
• Necrotizing fasciitis debridement defects
• Paget's disease with structural failure

Implant Materials & Selection

Surgical Principles

• Rigid fixation (screws) — micromotion prevents osseointegration
• Pericranial flap coverage when possible — reduces exposure/infection
• Antibiotic prophylaxis (cefazolin ± vancomycin)
• Post-op CT for position verification

Complications

• Infection/exposure (5-15%) — may require removal
• Hardware failure (screw loosening, plate fracture)
• CSF leak, hematoma, seizure
• Aesthetic asymmetry, palpable hardware

Multidisciplinary planning (neurosurgery, plastics, oculoplastics, ENT) optimizes functional and aesthetic outcomes for complex defects.

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Material	Indications	Advantages	Limitations
Titanium mesh/plate	Most defects	Biocompatible, MRI-safe, moldable, strong	Thermal conductivity, palpable, cost
PEEK (polyetheretherketone)	Custom implants	Radiolucent, elastic modulus ~bone, MRI-safe	Cost, requires prefabrication
PMMA (bone cement)	Small defects, intraoperative	Inexpensive, moldable, antibiotic-eluting	Exothermic, non-degradable, infection risk
Autologous bone	Children, infected fields	Osteogenic, no foreign body	Donor morbidity, resorption, limited volume
Bioactive (hydroxyapatite, Bioglass)	Specific indications	Osteoconductive	Brittle, limited load-bearing