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Comparative study of the circumferential and volumetric analysis between conventional casting and three-dimensional scanning methods for transtibial socket: A preliminary study

Mehmood W, Abd Razak NA, Lau MS, Chung TY, Gholizadeh H, Abu Osman NA

Proc Inst Mech Eng H, 2019 Feb;233(2):181-192.
PMID: 30518308 DOI: 10.1177/0954411918816124

Transtibial prosthetic sockets can be fabricated either by the conventional way, which involve using plaster of Paris bandages for casting. This will include modifications through hand, scanning and digital imaging of software. The aim of this study is to determine the circumferential profiles and conduct a volumetric analysis of a conventional socket that has fabrication using biosculptor technology. In doing this, a male transtibial amputee, age 28 years old with stable health condition was studied, where circumferential measurements were taken at intervals of 1 cm from the distal end of the residual limb to the medial tibial plateau level. Furthermore, the interior volume of both sockets and residuum were determined directly using water displacement method. A comparative value for the calculation of volume was also carried out using engineering mathematical equations. From these measurements, a total surface bearing transtibial sockets was fabricated to compare the changes of circumferential values of both sockets. The finding shows a percentage of the difference between the volume of the residual limb and conventional sockets to be 6.09%, whereas the biosculptor fabrication socket was 7.84% using the water displacement method. A comparison of circumferential profiles and volumetric analysis findings on the contrary showed that socket fabricated using the biosculptor technology is interchangeable with the conventional socket with more advantages, where biosculptor technology produces cheaper sockets and faster process with digital function in the procedure, unlike the conventional manual technique.
Effects of simple knee sleeves on pain and knee adduction moment in early unilateral knee osteoarthritis

Mohd Sharif NA, Usman J, Wan Safwani WKZ, Siew Li G, Abdul Karim S, Mohamed NA, et al.

Proc Inst Mech Eng H, 2019 Nov;233(11):1132-1140.
PMID: 31597554 DOI: 10.1177/0954411919874614

Knee sleeves are often prescribed to alleviate pain in people with early knee osteoarthritis. However, the biomechanics underlying their pain-relieving effect are still not well understood. This pre-post study aims at evaluating and comparing the effects of two different types of knee sleeves on knee adduction moment. Patients with clinically diagnosed knee osteoarthritis were recruited from the University of Malaya Medical Centre and were randomly assigned to two test groups using (1) a simple knee sleeve and (2) a simple sleeve with patella cutout. Knee adduction moment was collected using the Vicon motion capture system with two Kistler force plates. Pain, stiffness and physical functions were recorded using the Western Ontario and McMaster Universities Osteoarthritis Index. All measurements were taken before, immediately after and at the completion of 6 weeks of application (primary time point). In total, 17 participants with early unilateral knee osteoarthritis (47.7 (9.7) years) completed the study. Overall results show significant reduction in pain, early stance and late stance knee adduction moment and increased walking speed after 6 weeks of both knee sleeves application. This study results suggest that knee sleeves can reduce knee adduction moments in early unilateral knee osteoarthritis by 14.0% and 12.1% using the simple sleeve and the sleeve with patella cutout, respectively, and can potentially delay disease progression. In addition, knee sleeve with patella cutout does not provide additional benefits when compared to the simple knee sleeve.
Mechanical properties and biocompatibility of co-axially electrospun polyvinyl alcohol/maghemite

Ngadiman NH, Mohd Yusof N, Idris A, Kurniawan D

Proc Inst Mech Eng H, 2016 Aug;230(8):739-49.
PMID: 27194535 DOI: 10.1177/0954411916649632

Electrospinning is a simple and efficient process in producing nanofibers. To fabricate nanofibers made of a blend of two constituent materials, co-axial electrospinning method is an option. In this method, the constituent materials contained in separate barrels are simultaneously injected using two syringe nozzles arranged co-axially and the materials mix during the spraying process forming core and shell of the nanofibers. In this study, co-axial electrospinning method is used to fabricate nanofibers made of polyvinyl alcohol and maghemite (γ-Fe2O3). The concentration of polyvinyl alcohol and amount of maghemite nanoparticle loading were varied, at 5 and 10 w/v% and at 1-10 v/v%, respectively. The mechanical properties (strength and Young's modulus), porosity, and biocompatibility properties (contact angle and cell viability) of the electrospun mats were evaluated, with the same mats fabricated by regular single-nozzle electrospinning method as the control. The co-axial electrospinning method is able to fabricate the expected polyvinyl alcohol/maghemite nanofiber mats. It was noticed that the polyvinyl alcohol/maghemite electrospun mats have lower mechanical properties (i.e. strength and stiffness) and porosity, more hydrophilicity (i.e. lower contact angle), and similar cell viability compared to the mats fabricated by single-nozzle electrospinning method.
A review of evolution of electrospun tissue engineering scaffold: From two dimensions to three dimensions

Ngadiman NHA, Noordin MY, Idris A, Kurniawan D

Proc Inst Mech Eng H, 2017 Jul;231(7):597-616.
PMID: 28347262 DOI: 10.1177/0954411917699021

The potential of electrospinning process to fabricate ultrafine fibers as building blocks for tissue engineering scaffolds is well recognized. The scaffold construct produced by electrospinning process depends on the quality of the fibers. In electrospinning, material selection and parameter setting are among many factors that contribute to the quality of the ultrafine fibers, which eventually determine the performance of the tissue engineering scaffolds. The major challenge of conventional electrospun scaffolds is the nature of electrospinning process which can only produce two-dimensional electrospun mats, hence limiting their applications. Researchers have started to focus on overcoming this limitation by combining electrospinning with other techniques to fabricate three-dimensional scaffold constructs. This article reviews various polymeric materials and their composites/blends that have been successfully electrospun for tissue engineering scaffolds, their mechanical properties, and the various parameters settings that influence the fiber morphology. This review also highlights the secondary processes to electrospinning that have been used to develop three-dimensional tissue engineering scaffolds as well as the steps undertaken to overcome electrospinning limitations.
Surface profile of laminated transfemoral socket fabricated with different types of reinforcement materials

Nik Zainuddin NAM, Abd Razak NA, Ab Karim MS

Proc Inst Mech Eng H, 2023 Jun;237(6):741-748.
PMID: 37131337 DOI: 10.1177/09544119231171787

Composite materials used in the prosthetic and orthotic fields have helped improve the fabrication of sockets. Laminated sockets proved to be stronger than conventional thermoplastic sockets. The internal surface of a laminated socket plays an important role in patient comfort and is influenced by the material used to fabricate the socket. This study analyzes the internal surface profile of five different materials, that is, Dacron felt, fiberglass, Perlon stockinette, polyester stockinette, and elastic stockinette. All sockets were fabricated using an acrylic resin mix with hardener powder at a ratio of 100:3. The internal surface of the sockets was tested using the Mitutoyo SurfTest SJ-210 series for 20 trials. The overall Ra values were 2.318, 2.380, 2.682, 2.722, and 3.750 µm for fiberglass, polyester, Perlon, elastic stockinette, and Dacron felt. Dacron felt yielded the lowest Ra value, thus, producing the smoothest internal surface but requiring high skill and the correct technique during the fabrication of a laminated socket. Fiberglass is considered the best material for the internal surface despite not producing the lowest value individually but overall is the lowest and most consistent, indicating that it is easy to use to laminate prosthetic sockets.
Machining of bone: Analysis of cutting force and surface roughness by turning process

Noordin MY, Jiawkok N, Ndaruhadi PY, Kurniawan D

Proc Inst Mech Eng H, 2015 Nov;229(11):761-8.
PMID: 26399875 DOI: 10.1177/0954411915606169

There are millions of orthopedic surgeries and dental implantation procedures performed every year globally. Most of them involve machining of bones and cartilage. However, theoretical and analytical study on bone machining is lagging behind its practice and implementation. This study views bone machining as a machining process with bovine bone as the workpiece material. Turning process which makes the basis of the actually used drilling process was experimented. The focus is on evaluating the effects of three machining parameters, that is, cutting speed, feed, and depth of cut, to machining responses, that is, cutting forces and surface roughness resulted by the turning process. Response surface methodology was used to quantify the relation between the machining parameters and the machining responses. The turning process was done at various cutting speeds (29-156 m/min), depths of cut (0.03 -0.37 mm), and feeds (0.023-0.11 mm/rev). Empirical models of the resulted cutting force and surface roughness as the functions of cutting speed, depth of cut, and feed were developed. Observation using the developed empirical models found that within the range of machining parameters evaluated, the most influential machining parameter to the cutting force is depth of cut, followed by feed and cutting speed. The lowest cutting force was obtained at the lowest cutting speed, lowest depth of cut, and highest feed setting. For surface roughness, feed is the most significant machining condition, followed by cutting speed, and with depth of cut showed no effect. The finest surface finish was obtained at the lowest cutting speed and feed setting.
Design of new generation femoral prostheses using functionally graded materials: a finite element analysis

Oshkour AA, Abu Osman NA, Yau YH, Tarlochan F, Abas WA

Proc Inst Mech Eng H, 2013 Jan;227(1):3-17.
PMID: 23516951

This study aimed to develop a three-dimensional finite element model of a functionally graded femoral prosthesis. The model consisted of a femoral prosthesis created from functionally graded materials (FGMs), cement, and femur. The hip prosthesis was composed of FGMs made of titanium alloy, chrome-cobalt, and hydroxyapatite at volume fraction gradient exponents of 0, 1, and 5, respectively. The stress was measured on the femoral prosthesis, cement, and femur. Stress on the neck of the femoral prosthesis was not sensitive to the properties of the constituent material. However, stress on the stem and cement decreased proportionally as the volume fraction gradient exponent of the FGM increased. Meanwhile, stress became uniform on the cement mantle layer. In addition, stress on the femur in the proximal part increased and a high surface area of the femoral part was involved in absorbing the stress. As such, the stress-shielding area decreased. The results obtained in this study are significant in the design and longevity of new prosthetic devices because FGMs offer the potential to achieve stress distribution that more closely resembles that of the natural bone in the femur.
A new prosthetic alignment device to read and record prosthesis alignment data

Pirouzi G, Abu Osman NA, Ali S, Davoodi Makinejad M

Proc Inst Mech Eng H, 2017 Dec;231(12):1127-1132.
PMID: 28985696 DOI: 10.1177/0954411917735082

Prosthetic alignment is an essential process to rehabilitate patients with amputations. This study presents, for the first time, an invented device to read and record prosthesis alignment data. The digital device consists of seven main parts: the trigger, internal shaft, shell, sensor adjustment button, digital display, sliding shell, and tip. The alignment data were read and recorded by the user or a computer to replicate prosthesis adjustment for future use or examine the sequence of changes in alignment and its effect on the posture of the patient. Alignment data were recorded at the anterior/posterior and medial/lateral positions for five patients. Results show the high level of confidence to record alignment data and replicate adjustments. Therefore, the device helps patients readjust their prosthesis by themselves, or prosthetists to perform adjustment for patients and analyze the effects of malalignment.
Downsizing and minimising medialisation of the acetabular component: Novel technique to preserve bone in THA

Raj JJ, Thompson M, Whitehouse SL, Jaiprakash A, Varughese I, Crawford RW

Proc Inst Mech Eng H, 2023 Mar;237(3):368-374.
PMID: 36734414 DOI: 10.1177/09544119231152351

Standard practice for acetabular component placement in total hip arthroplasty (THA) is to medialise the acetabular component. Bone preservation techniques during primary THA are beneficial for possible future revisions. The goal of this study is to examine the effect of downsizing and minimising medialisation of the acetabular component on bone resection volume. The volume of bone resected during acetabular preparation for different sizes of components was calculated and the volume of bone preserved by downsizing the cup was determined. Minimising medialisation of the acetabular component by 1-3 mm from the true floor was calculated. Absolute values and percentage of bone volume preserved when acetabular components are downsized or less medialised is presented. Downsizing the acetabular component by one size (2 mm) preserves between 2.6 cm3 (size 40 vs 42) and 8.4 cm3 (size 72 vs 74) of bone volume and consistently reduces resected bone volume by at least 35% (range 35.2%-37.5%). Similarly, reducing medialisation of a 56 mm acetabular cup (as an example of a commonly implanted component) by 3 mm reduces bone loss by 5.9 cm3- 44% less bone volume resection. Downsizing and minimising medialisation of the cup in THA substantially preserves bone which may benefit future revision surgeries. Surgeons could consider implanting the smallest acceptable acetabular shell to preserve bone without compromising on head size.
Stability of cervical spine after one-level corpectomy using different numbers of screws and plate systems

Rosli R, Abdul Kadir MR, Kamarul T

Proc Inst Mech Eng H, 2014 Apr;228(4):342-9.
PMID: 24622982 DOI: 10.1177/0954411914527074

Anterior corpectomy and reconstruction using a plate with locking screws are standard procedures for the treatment of cervical spondylotic myelopathy. Although adding more screws to the construct will normally result in improved fixation stability, several issues need to be considered. Past reports have suggested that increasing the number of screws can result in the increase in spinal rigidity, decreased spine mobility, loss of bone and, possibly, screw loosening. In order to overcome this, options to have constrained, semi-constrained or hybrid screw and plate systems were later introduced. The purpose of this study is to compare the stability achieved by four and two screws using different plate systems after one-level corpectomy with placement of cage. A three-dimensional finite-element model of an intact C1-C7 segment was developed from computer tomography data sets, including the cortical bone, soft tissue and simulated corpectomy fusion at C4-C5. A spinal cage and an anterior cervical plate with different numbers of screws and plate systems were constructed to a fit one-level corpectomy of C5. Moment load of 1.0 N m was applied to the superior surface of C1, with C7 was fixed in all degrees of freedom. The kinematic stability of a two-screw plate was found to be statistically equivalent to a four-screw plate for one-level corpectomy. Thus, it can be a better option of fusion and infers comparable stability after one-level anterior cervical corpectomy, instead of a four-screw plate.
A case study on interface pressure pattern of two garment orthoses on a child with cerebral palsy

Shaari IH, Abu Osman NA, Shasmin HN

Proc Inst Mech Eng H, 2020 Aug;234(8):884-894.
PMID: 32459140 DOI: 10.1177/0954411920923541

Many studies have shown that medical compression products produce different levels of interface pressure during the usage of the products. However, limited studies have explored the pattern of interface pressure exerted by orthotic garments. This case study aimed to investigate the pattern of interface pressure exerted by two types of orthotic garments on a child with cerebral palsy. A 13-year-old child diagnosed with ataxic spastic diplegia cerebral palsy has difficulty to perform sit-to-stand motion even with a walking frame due to his truncal ataxia. A TheraTogsTM orthosis and a Dynamic Lycra® Fabric Orthosis (DLFO) were prepared for the child. The child's sit-to-stand ability without and with the usage of orthoses was recorded using five sit-to-stand tests. The garments' interface pressure was measured using F-scan (9811E) and F-scan 6.5.1 version software. The pressure was recorded when the child was in sitting position and performing sit-to-stand-to-sit motion. Overall, the child completed the five sit-to-stand test duration within 2.53 ± 0.04 s and 2.51 ± 0.09 s with the usage of TheraTogsTM orthosis and DLFO, respectively. Higher pressure was exerted by Dynamic Lycra Fabric Orthosis (axillary = 122 mmHg) in contrast to TheraTogsTM orthosis (77 mmHg) when the child was in a sitting position. Lower pressure was exerted by DLFO (7 mmHg), over xiphoid level and for TheraTogsTM orthosis is 1.2 mmHg over axillary level when the child was performing sit-to-stand motion. The largest range of pressure was exerted by TheraTogsTM orthosis with a minimum pressure of 5 mmHg and a maximum pressure of 155 mmHg during sit-to-stand motion. Overall, the DLFO exerted higher mean interface pressure on the child in comparison to TheraTogsTM orthosis when the child's body was in a sitting position wearing both upper garment and pants. Both TheraTogsTM orthosis and DLFO presented a different range of interface pressure over different body segments and activities.
Evaluation of the carotid artery stenosis based on minimization of mechanical energy loss of the blood flow

Sia SF, Zhao X, Li R, Zhang Y, Chong W, He L, et al.

Proc Inst Mech Eng H, 2016 Nov;230(11):1051-1058.
PMID: 28095764 DOI: 10.1177/0954411916671752

BACKGROUND: Internal carotid artery stenosis requires an accurate risk assessment for the prevention of stroke. Although the internal carotid artery area stenosis ratio at the common carotid artery bifurcation can be used as one of the diagnostic methods of internal carotid artery stenosis, the accuracy of results would still depend on the measurement techniques. The purpose of this study is to propose a novel method to estimate the effect of internal carotid artery stenosis on the blood flow based on the concept of minimization of energy loss.
METHODS: Eight internal carotid arteries from different medical centers were diagnosed as stenosed internal carotid arteries, as plaques were found at different locations on the vessel. A computational fluid dynamics solver was developed based on an open-source code (OpenFOAM) to test the flow ratio and energy loss of those stenosed internal carotid arteries. For comparison, a healthy internal carotid artery and an idealized internal carotid artery model have also been tested and compared with stenosed internal carotid artery in terms of flow ratio and energy loss.
RESULTS: We found that at a given common carotid artery bifurcation, there must be a certain flow distribution in the internal carotid artery and external carotid artery, for which the total energy loss at the bifurcation is at a minimum; for a given common carotid artery flow rate, an irregular shaped plaque at the bifurcation constantly resulted in a large value of minimization of energy loss. Thus, minimization of energy loss can be used as an indicator for the estimation of internal carotid artery stenosis.
Thermomechanical investigations of PEKK-HAp-CS composites

Singh R, Singh G, Singh J, Kumar R, Rahman MM, Ramakrishna S

Proc Inst Mech Eng H, 2019 Nov;233(11):1196-1203.
PMID: 31545132 DOI: 10.1177/0954411919877979

In this experimental study, a composite of poly-ether-ketone-ketone by reinforcement of hydroxyapatite and chitosan has been prepared for possible applications as orthopaedic scaffolds. Initially, different weight percentages of hydroxyapatite and chitosan were reinforced in the poly-ether-ketone-ketone matrix and tested for melt flow index in order to check the flowability of different compositions/proportions. Suitable compositions revealed by the melt flow index test were then taken forward for the extrusion of filament required for fused deposition modelling. For thermomechanical investigations, Taguchi-based design of experiments has been used with input variables in the extrusion process as follows: temperature, load applied and different composition/proportions. The specimens in the form of feedstock filament produced by the extrusion process were made to undergo tensile testing. The specimens were also inspected by differential scanning calorimetry and photomicrographs. Finally, the specimen showing the best performance from the thermomechanical viewpoint has been selected to extrude the filament for the fused deposition modelling process.
Investigation of EMG parameter for transtibial prosthetic user with flexion and extension of the knee and normal walking gait: A preliminary study

Sobh KNM, Abd Razak NA, Abu Osman NA

Proc Inst Mech Eng H, 2021 Apr;235(4):419-427.
PMID: 33517847 DOI: 10.1177/0954411920985753

Electromyography signal has been used widely as input for prosthetic's leg movements. C-Leg, for example, is among the prosthetics devices that use electromyography as the main input. The main challenge facing the industrial party is the position of the electromyography sensor as it is fixed inside the socket. The study aims to investigate the best positional parameter of electromyography for transtibial prosthetic users for the device to be effective in multiple movement activities and compare with normal human muscle's activities. DELSYS Trigno wireless electromyography instrument was used in this study to achieve this aim. Ten non-amputee subjects and two transtibial amputees were involved in this study. The surface electromyography signals were recorded from two anterior and posterior below the knee muscles and above the knee muscles, respectively: tibial anterior and gastrocnemius lateral head as well as rectus femoris and biceps femoris during two activities (flexion and extension of knee joint and gait cycle for normal walking). The result during flexion and extension activities for gastrocnemius lateral head and biceps femoris muscles was found to be more useful for the control subjects, while the tibial anterior and also gastrocnemius lateral head are more active for amputee subjects. Also, during normal walking activity for biceps femoris and gastrocnemius lateral head, it was more useful for the control subjects, while for transtibial amputee subject-1, the rectus femoris was the highest signal of the average normal walking activity (0.0001 V) compared to biceps femoris (0.00007 V), as for transtibial amputee subject-2, the biceps femoris was the highest signals of the average normal walking activity (0.0001 V) compared to rectus femoris (0.00004 V). So, it is difficult to rely entirely on the static positioning of the electromyography sensor within the socket as there is a possibility of the sensor to contact with inactive muscle, which will be a gap in the control, leading to a decrease in the functional efficiency of the powered prostheses.
Mechanobiological modelling of tendons: Review and future opportunities

Thompson MS, Bajuri MN, Khayyeri H, Isaksson H

Proc Inst Mech Eng H, 2017 May;231(5):369-377.
PMID: 28427319 DOI: 10.1177/0954411917692010

Tendons are adapted to carry large, repeated loads and are clinically important for the maintenance of musculoskeletal health in an increasing, actively ageing population, as well as in elite athletes. Tendons are known to adapt to mechanical loading. Also, their healing and disease processes are highly sensitive to mechanical load. Computational modelling approaches developed to capture this mechanobiological adaptation in tendons and other tissues have successfully addressed many important scientific and clinical issues. The aim of this review is to identify techniques and approaches that could be further developed to address tendon-related problems. Biomechanical models are identified that capture the multi-level aspects of tendon mechanics. Continuum whole tendon models, both phenomenological and microstructurally motivated, are important to estimate forces during locomotion activities. Fibril-level microstructural models are documented that can use these estimated forces to detail local mechanical parameters relevant to cell mechanotransduction. Cell-level models able to predict the response to such parameters are also described. A selection of updatable mechanobiological models is presented. These use mechanical signals, often continuum tissue level, along with rules for tissue change and have been applied successfully in many tissues to predict in vivo and in vitro outcomes. Signals may include scalars derived from the stress or strain tensors, or in poroelasticity also fluid velocity, while adaptation may be represented by changes to elastic modulus, permeability, fibril density or orientation. So far, only simple analytical approaches have been applied to tendon mechanobiology. With the development of sophisticated computational mechanobiological models in parallel with reporting more quantitative data from in vivo or clinical mechanobiological studies, for example, appropriate imaging, biochemical and histological data, this field offers huge potential for future development towards clinical applications.
Bacterial adherence and biofilm formation on medical implants: a review

Veerachamy S, Yarlagadda T, Manivasagam G, Yarlagadda PK

Proc Inst Mech Eng H, 2014 Oct;228(10):1083-99.
PMID: 25406229 DOI: 10.1177/0954411914556137

Biofilms are a complex group of microbial cells that adhere to the exopolysaccharide matrix present on the surface of medical devices. Biofilm-associated infections in the medical devices pose a serious problem to the public health and adversely affect the function of the device. Medical implants used in oral and orthopedic surgery are fabricated using alloys such as stainless steel and titanium. The biological behavior, such as osseointegration and its antibacterial activity, essentially depends on both the chemical composition and the morphology of the surface of the device. Surface treatment of medical implants by various physical and chemical techniques are attempted in order to improve their surface properties so as to facilitate bio-integration and prevent bacterial adhesion. The potential source of infection of the surrounding tissue and antimicrobial strategies are from bacteria adherent to or in a biofilm on the implant which should prevent both biofilm formation and tissue colonization. This article provides an overview of bacterial biofilm formation and methods adopted for the inhibition of bacterial adhesion on medical implants.
Three-dimensional analysis of reconstructed skulls using three different open-source software versus commercial software

Yap Abdullah J, Manaf Abdullah A, Zaim S, Hadi H, Husein A, Ahmad Rajion Z, et al.

Proc Inst Mech Eng H, 2024 Jan;238(1):55-62.
PMID: 37990963 DOI: 10.1177/09544119231212034

This study aimed to compare the 3D skull models reconstructed from computed tomography (CT) images using three different open-source software with a commercial software as a reference. The commercial Mimics v17.0 software was used to reconstruct the 3D skull models from 58 subjects. Next, two open-source software, MITK Workbench 2016.11, 3D Slicer 4.8.1 and InVesalius 3.1 were used to reconstruct the 3D skull models from the same subjects. All four software went through similar steps in 3D reconstruction process. The 3D skull models from the commercial and open-source software were exported in standard tessellation language (STL) format into CloudCompare v2.8 software and superimposed for geometric analyses. Hausdorff distance (HD) analysis demonstrated the average points distance of Mimics versus MITK was 0.25 mm. Meanwhile, for Mimics versus 3D Slicer and Mimics versus InVesalius, there was almost no differences between the two superimposed 3D skull models with average points distance of 0.01 mm. Based on Dice similarity coefficient (DSC) analysis, the similarity between Mimics versus MITK, Mimics versus 3D Slicer and Mimics versus InVesalius were 94.1, 98.8 and 98.3%, respectively. In conclusion, this study confirmed that the alternative open-source software, MITK, 3D Slicer and InVesalius gave comparable results in 3D reconstruction of skull models compared to the commercial gold standard Mimics software. This open-source software could possibly be used for pre-operative planning in cranio-maxillofacial cases and for patient management in the hospitals or institutions with limited budget.

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