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The Emergence ofAdvance Technologies andIndustrial Revolutions
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CAD systems, being produced following the third industrial revolution and the advancement of computer models in medical science, enable object modeling before design and analysis. To perform modeling, the object must be photographed with a 3D scanner or 3D imaging systems. Today, many intraoral and extraoral scanners are commercially available for 3D modeling, shaping, and imaging. In addition to 3D modeling, a software is needed to manipulate the 3D objects. In order for the photographed object to be manipulated by the software, it must be converted into an STL le format. In this format, regardless of its color, the object will have points in a three-dimensional space, providing the system with spatial object topographies. Thereafter, the STL formatted-le is rendered in the software to shape and assess it. In the eld of oral and maxillofacial surgery, CAD has also led to emergence of virtual surgical planning (VSP) and designing of surgical guides, splints, and implants. Virtual-based learning (VBL) is another CAD-based technology that is the new branch in dental education.
CAM system, which was created after the third and fourth industrial revolutions, is the result of combined use of software and computer-controlled machinery, with­out any manual intervention, aiming to provide a fully automated manufacturing process [13, 14]. CAM includes two subbranches: additive manufacturing (AM) and subtractive manufacturing (SM) [15]. AM is dened as quantiable layer-by­layer deposition of working materials to directly obtain CAD-based 3D objects [16,
17]. In this light, CAD/CAM benets fabrication of geometrically complex assem-
blies from a exible selection of materials [16, 18]. AM, also known as 3D printing, includes techniques such as binder jetting (inkjet printing), stereolithography (SLA)/digital light processing (DLP), fused deposition modeling (FDM), and selec­tive laser sintering (SLS)/selective laser melting (SLM) [15]. On the contrary, the controlled process of material removal and machining, drilling, and milling solid blocks is categorized as subtractive manufacturing technologies (SM).
Following the advancement of CAD/CAM systems, robotic surgeries were also evolved. Facilitated performing of these surgeries is among the many goals of inte­grating CAD/CAM technologies with medical sciences. Robotic surgery or naviga­tion surgery aims to employ a minimally invasive approach to access not-easily-accessible anatomical areas, for instance, posterior of the oral cavity, such as oropharynx, larynx, and hypopharynx, or even the skull base [19–21]. Combining VSP with robotic surgeries has been demonstrated to cut down on oper­ative durations and improve patient outcomes, rather than sole robotic surgery [20,
22]. In trans-oral robotic surgery (TORS), the robot is xated within the oral cavity
while surgeon views the surgical eld on the monitor. This method can benet edu­cational purpose through providing better visualization of the surgical environment for all students and residents.
Today, medicine has evolved from replacement therapies toward regenerative therapies. Therefore, tissue engineering products have gained attention of many researchers and clinicians. Contemporary tissue engineering-based approaches often employ a cocktail of stem cells, growth factors, scaffolds, and bioreactors, aiming to initiate and support regeneration aptitudes of host body [23]. The afore­mentioned technologies can be used to make these products.
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The eld of regenerative dentistry has made great strides in this eld using advanced technologies. Two of the most important applications of new technologies that are desired in this eld are bioprinting and bioreactors.
In order to produce engineered tissue, it is necessary to examine and bio-design the micro- and macro-environments of tissues. This is done with the purpose of imitation of physiological and mechanical tissue conditions, outside the body [24,
25]. Bioreactors are used to somewhat mimic the body’s physiological and mechan-
ical characteristics [24]. There are different types of systems for the bioreactor’s design, including (1) hydrodynamic shear stress, (2) direct mechanical stress, and (3) electromagnetic eld (EMF)-based bioreactors [24–26].
Bioprinting refers to additive manufacturing technologies in which the scaffold is fabricated from a blend of cells and biocompatible materials, the so-called bio­ink, in a layer-by-layer manner [27]. Categorization of the commonly used bioprint­ing technologies were extrusion-based methods, laser-based methods, and inkjet bioprinting [28].
All elds of applied modern technologies in the eld of oral and maxillofacial surgery are furtherly discussed in the following chapters.
The applications of CAD/CAM in the eld of oral and maxillofacial surgery are bone reconstruction surgeries, orthognathic surgeries, implant dentistry, and trans­oral robotic surgery (Fig.2) [8, 11, 29–34].
The reconstruction procedure aims to reestablish the form and the function of the defectious areas. Donor site morbidity, limited donor tissue, incompatible features among recipient versus donor tissue, unpredictable resorption, and varying long­term results are the main disadvantages of the traditional reconstructive methods [35]. Therefore, CAD/CAM-based methods have gained an increased attention in terms of overcoming these drawbacks. In bone reconstruction, CAD/CAM can be used for virtual defect design, i.e., virtual surgical planning (VSP) [8, 36]. It can also be used for prototyping or creating a defect model, which involves thorough defect modeling and visualization preoperatively [37]. Of note, it can highly con­tribute to making patient-specic implants (PSI) [8, 38]. In orthognathic surgeries, CAD/CAM can be used for VSP [39, 40]. It is also used in fabrication of surgical
Reconstruction
Surgery
PSI VSP
Fig. 2 Flowchart of applications of CAD/CAM in oral and maxillofacial surgery (OMFS). PSI patient-specic implants, VSP patient-specic implants
Prototyping
CAD/CAM in OMFS
Orthognathic
Surgery
VSP Surgical Stent
Dental Implant
Surgery
Navigation Surgical Stent
Robotic Surgery
Soft Palate Surgery
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guides, mainly facilitating and benetting the surgical trajectory time-wise [11]. In the eld of dental implants, CAD/CAM is also used in surgical stents [41]. Navigational surgery is also one of their applications in implantology [42]. Finally, in robotic surgeries, trans-oral robotic (cleft palate) surgery (TORCS) is chiey implemented in soft tissue surgeries of the posterior portion of pharynx, such as the soft palate [43].
In OMFS reconstructions, entire condition and three-dimensional topography of tumor or defect can be evaluated and investigated on the computer monitor, preop­eratively [8, 36]. This allows a relaxed and laid-back approach to be achieved for thorough assessments. In prototyping, the defect model or tumor model may be consisted of a polymeric content, modeling the jaws. This furtherly contributes to comprehensive evaluations in terms of tumor/defect expansive specics, etc., to be performed not only preoperatively but also even prior to meeting the patient and viewing the two-dimensional radiographies. In prototyping or model design, mainly curable polymers with lower temperatures can be employed [44]. For example, FDM systems are very suitable for fabricating CAD models [44]. Therefore, CAD/ CAM in bone reconstruction and bone grafting can assist fabrication of patient­specic bone implants and preserving the protected healing space for in situ bone regeneration (Fig.3).
Bone contouring, functional bone replacement, and functional bone regeneration (FBR) can be achieved through application of bone implants [45–47].
Bone contouring refers to the usage of patient-specic products to restore the standard and anatomical contour of the bone. The individualized products are implanted in areas with nonspecic masticatory role and are not prone to undergo­ing jaw movement or functional or loadbearing incidents [48]. In bone contouring, there is mainly a need for prosthesis, meaning that the implanted substance will remain in place. In this eld, polymers such as polymethyl methacrylate (PMMA) are mainly used [49]. In this case, FDM printer can be used. High-density polyeth­ylenes (HDPE), such as polytetrauoroethylene (PTFE) or polyether ether ketone (PEEK), are employed for fabrication of bone contouring prostheses, and chin or cheek prostheses as well [50, 51]. Upon application of these materials, the selective laser sintering (SLS) method of AM is required [52].
On the other hand, aiming for functional bone replacement, implants must restore the functional behaviors of the resected tissue, including both mastication and jaw movement. In functional bone replacement, the resected region is replaced by a prosthesis that not only plays a functional role but can also generate and feasibly withstand the masticatory forces. While for functional bone replacement, the applied material has to tolerate the external forces and provide proper contour. Nowadays, the most commonly employed materials for fabrication of functional bone replace­ment prosthesis are titanium in the bones and tantalum in the spine area [53, 54]. In the past, stainless steels were used with this regard, but due to corrosive reactions and numerous postoperative complications, leading to screw loosening and macro­phage inammatory reactions, their application has minimized considerably [55,
56]. The use of titanium and tantalum in CAD/CAM is due to their high melting
point, making them usable with AM methods, such as selective laser melting (SLM).
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CAD/CAM in Reconstruction
FDM PMMA
SLS HDPE
SLS PTFE
SLS PEEK
FDM Gelatin
FDM Collagen
FDM Chitosan
FDM Fibrin
FDM GelMA
FDM PEG
Bone
Contouring
Patient Specific
Bone Implants
Functional
Replacement
Ti
SLM
Bone
Ta
SLMSSSLM
Natural
Synthetic
ECM Like
(Hydrogel)
Functional
Bone
Regeneration
Scaffoldprosthesisprosthesis
Mineral Like
Healing Space
Insitu Bone
Regeneration
TCP
HA
PDLLA
PCL
Composite
Protected
Ti
SLM
FDM Alginate
Fig. 3 Flowchart of applications of CAD/CAM in bone reconstruction surgery. PMMA poly- methyl methacrylate, HDPE high-density polyethylenes, PTFE polytetrauoroethylene, PEEK polyether ether ketone, GelMA gelatin and methacrylate, PEG polyethylene glycol, Ti titanium, Ta tantalum, SS stainless steel, ECM extracellular matrix, TCP tricalcium phosphate, HA hydroxyapa­tite, PDLLA poly (,-lactic acid), PCL polycaprolactone, FDM fused deposition modeling, SLS selective laser sintering, SLM selective laser melting
In functional bone regeneration, a three-dimensional scaffold is fabricated. The implanted scaffolds tend to induce bone formation, in order to replace the lost tissue and restore both function and form of the defected area using host body’s regenera­tive abilities. Tissue engineering scaffolds have been used to provide spatial support
The Emergence ofAdvance Technologies andIndustrial Revolutions
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to enable new bone formation in defected sites. In the other words, scaffolds should optimally imitate the native properties of extracellular matrix (ECM), both the min­eral and organic portions of the native bone tissue ECM [26]. Upon placement, the scaffold will undergo degradation and be replaced over a period of 6–18months with natural bone tissue of normal anatomical features [57]. In functional bone regeneration, materials that take the shape similar to bone at a lower temperature are needed. In order to imitate ECM, there are materials of natural and synthetic origin. Gelatin, collagen, chitosan, and brin are natural polymers or hydrogels used with the FDM method to reconstruct a bone-imitating scaffold [58, 59]. Organic scaf­folds that exist in synthetic form usually include a mixture of gelatin and methacry­late (GelMA), polyethylene glycol (PEG), and alginate, which are also mainly prepared by the FDM method [60, 61]. Bone-like mineral tissue is mainly com­posed of tricalcium phosphate (TCP), hydroxyapatite (HA), or composite of a poly­mer along with TCP or HA [62, 63].
As mentioned above, another category of CAD/CAM application in bone recon­struction surgery is in situ bone regeneration through preserving a protected healing space. In this method, there is a need to preserve a protected healing space, so that the body can generate bone in that space. To make this guided or protected healing space in the CAD-CAM method, the material of the membrane is usually titanium, and the method of choice, SLM [64, 65].
All elds of applied modern technologies and application of CAD/CAM in the eld of oral and maxillofacial surgery are furtherly discussed in the following chapters.
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H. Nokhbatolfoghahaei and A. Khojasteh
CBCT andMRI Data Acquisition
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asaBasis forComputer-Assisted Maxillofacial Treatments
MitraGhazizadeh Ahsaie
1 Introduction
The invention of advanced imaging such as computed tomography (CT) and mag­netic resonance imaging (MRI) has revolutionized the medical and dental treat­ments. The oral and maxillofacial region has a complex anatomy due to the presence of various critical organs, such as the nerves, vessels, teeth, eye, and brain. Serving as the third eye, three-dimensional imaging modalities provide accurate details on hard and soft tissue, anatomic land marks, variations, abnormalities, and patholo­gies of the maxillofacial region [1].
Since the development of the rst medical CT scanners in 1960s, various genera­tions have been introduced, each producing higher impact in the diagnosis and treat­ment plans. The fundamental principles of CT, whether applied to multidetector computed tomography (MDCT) or CBCT, are the same: a collimated x-ray source and detector, mounted in a xed or rotating gantry, turn around the patient’ head [2]. During this rotation, the X-ray beam is attenuated, the remnant photons are captured by the detector, and further reconstruction algorithms mathematically and spatially process this attenuated data into a 3D map (Fig.1).
The initial CTs, also known as the rst-generation CT scanners, used a pencil­shaped X-ray beam and a single-array detector, with a translate rotate function, and required a 5-min scan time. Subsequently, the CT scanner design evolved through four generations, decreasing scan time to 1–2s. In the late 1990s, MDCT or mul­tislice CT (MSCT) was introduced, having 64–640 detector rows; this technology has now become the most widely used CT scanner design. This technology has considerably reduced scan times, which is an important factor in reducing motion artifacts especially in pediatric, trauma, or elderly patients [3].
M. Ghazizadeh Ahsaie (*) Department of Oral and Maxillofacial Radiology, School of Dentistry, Shahid Beheshti University of Medical Sciences, Tehran, Iran e-mail: mitraghazizadeh@sbmu.ac.ir
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 A. Khojasteh et al. (eds.), Emerging Technologies in Oral and Maxillofacial Surgery, https://doi.org/10.1007/978-981-19-8602-4_2
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X-ray
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Fig. 1 Cone beam imaging geometry. A divergent cone beam X-ray is projected from the tube head and is directed to the detector. The machine continues evolving around the object for the entire 360° or along a reduced or partial trajectory
M. Ghazizadeh Ahsaie
In 1980s, CBCT was originally developed in angiography, and in the early 2000s, this modality was introduced in dental and maxillofacial 3D imaging. While CBCT is used for many purposes including routine oral and maxillofacial surgical treat­ments, like extraction of the mandibular third molars and removal of impacted teeth and placement of dental implants, with expanding availability of a third-party appli­cation software capable of importing data in Digital Imaging and Communications in Medicine (DICOM) format, the role of maxillofacial CBCT has now expanded in a broad range of 3D printing procedures of models and surgical guides for jaw or facial reconstruction.
In the 1980s, MRI was developed and entered practical clinical diagnosis. In this noninvasive technique, the patient is placed in a large magnet. Radiofrequency (RF) pulse is directed to the tissue, and the volumetric data is produced based on a map of the distribution of hydrogen and local tissue properties that inuence the strength of the magnetic resonance signal. To accurately assess maxillofacial soft tissues, MRI can provide three-dimensional views and even provide soft tissue prosthesis using additive manufacturing techniques [4].
CBCT and MRI data acquisition as a basis for computer-assisted maxillofacial treatments is further discussed in this chapter, focusing on their operating principles and clinical applications.
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