Application of a Customized Titanium Exoskeleton to Restore Form and Function in Comminuted Acute Facial Fractures

Introduction: Restoring premorbid form and function is the goal of craniofacial trauma surgery. Comminuted facial fractures are difficult to reconstruct due to bone loss and instability. Traditional fixation with plates and screws often fail due to resorption and secondary deformities. Titanium mesh is used in cranioplasty and orbital reconstruction, but its application in other facial regions is rare. This study presents a series of acute trauma patients treated with customized titanium mesh exoskeletons, molded intraoperatively using virtual planning models (VSP) to restore structure and function. Methods: This retrospective review (2022-2024) identified 23 patients with comminuted facial fractures treated with customized titanium exoskeletons. Craniofacial computed tomography (CT) Digital Imaging and Communications in Medicine data was used for virtual surgical planning (VSP) to achieve fracture reduction references, using mirror imaging of the uninjured contralateral side or a normal cohort image. Intraoperatively, the post-reduction models were used to shape standard titanium mesh to the patient’s craniofacial skeleton to generate a customized titanium exoskeleton that would bridge the area of comminuted fractures. Postoperative CT scans assessed anatomic reduction, and patient charts were reviewed for complications. Results: This technique was employed successfully in all patients with comminuted facial fractures. It was successful in several regions of the facial skeleton, including naso-orbital ethmoid (NOE), zygomaticomaxillary complex (ZMC), zygomatic arch, and mandible. This technique was more efficient and accurate in fracture reduction compared to standard plating methods. Postoperative CT scans demonstrated good anatomic reduction and VSP plan validity. Clinical assessment revealed excellent form and function long-term. One patient had partial intraoral exposure of mesh, which required limited removal. There were no known infectious, bleeding, or secondary deformity complications. Conclusion: This study presents the largest series of comminuted acute craniofacial fracture repairs using a customized titanium exoskeleton, demonstrating its effectiveness in stabilization, anatomical restoration, and secondary contour maintenance.