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Classication ofCutting-Edge Additive Manufacturing Techniques
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H. S. H. Boroojeni et al.
Rapid Prototyping Models inOral
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andMaxillofacial Surgery: History, Definition, andIndications
SadraMohaghegh, SaharBaniameri, andArashKhojasteh
1 Introduction
In the age of virtual imaging, due to the emergence of recent advances in technology and digital solutions, diagnosis and treatment planning in the eld of maxillofacial surgery has changed and led to a change from a conventional two-dimensional (2D) technique to an advanced three-dimensional (3D) method, which is known as “rapid prototyping” [1, 2]. Rapid prototyping (RP) is one of the recent advances in modern surgery that creates a three-dimensional model with a layer-by-layer process of add­ing based on 3D computer-aided design (CAD) data. This technology is also referred to as “layer production,” “solid free form production,” or “3D printing” [3, 4]. This concept was rst introduced in the 1980s in engineering to build solid models of computed and day-to-day les [5]. Since then, exciting opportunities in various aspects of maxillofacial surgery, such as orthodontics, prosthetics, oral surgery, and implantology, have provided [6]. In maxillofacial surgery, RP models can be used for treatment planning and simulation.
Medical models or bio models represent three-dimensional medical imaging such as computed tomography (CT) scans, cone-beam computed tomography (CBCT), or magnetic resonance imaging (MRI) scans [7]. High-quality volumetric three-dimensional image data of the required anatomical structure can be obtained.
S. Mohaghegh · S. Baniameri Department of Oral and Maxillofacial Surgery, School of Dentistry, Shahid Beheshti University of Medical Sciences, Tehran, Iran
A. Khojasteh (*) Dental Research Center, Research Institute of Dental Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
© 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_5
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Digital Imaging and Communication in Medicine (DICOM) format les are created and converted to Standard Tessellation Language (STL) format les using computer­aided design (CAD) software. These les are then uploaded to a 3D printer, and a rapid prototype (RP) model is created, guided by the model’s quality assurance and dimensional accuracy [8, 9].
These models can be fabricated using various additive manufacturing methods, including material extrusion approaches such as fused deposition molding (FDM), vat polymerization (i.e., stereolithography), powder bed fusion (e.g., selective laser sintering and selective laser melting), and binder or material jetting (Fig.1) [10–12]. The features expected for each surgical indication specify the type of utilized mate­rial and fabrication method. Figure2 compared the advantages and disadvantages of different methods based on their possible application in oral and maxillofacial sur­gery [13].
RP models can enhance the surgical procedure’s precision, decrease the physi­cian’s stress, and comprehensively visualize the defects. Besides, using these mod­els in education can enhance the graduates’ practical knowledge, leading to high-quality health services [14, 15]. Setting aside the advantages of using RP mod­els, nowadays, VSP enables accurate analysis of the surgical site and the treatment plan. However, it must be considered that using VSP is more complicated than RP models in some instances. Therefore, virtual technologies do not entirely replace RP models [16].
abc
de
Fig. 1 Schematic drawing of additive manufacturing methods that can be used to fabricate rapid prototyping models [13]. (a) Powder bed fusion (b) Vat photopolymerization (c) Material extru­sion (d) Binder jetting (e) Material jetting
Rapid Prototyping Models in Oral and Maxillofacial Surgery: History, Denition…
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Fig. 2 Briey describe the pros and cons of using each method to fabricate rapid prototyping models for different oral and maxillofacial surgery procedures. Red color refers to an improper and green to the optimal situation. The yellow color means the intermediate status. ME material extru­sion, VATP vat polymerization, PBF powder bed fusion, BJ binder jetting, MJ material jetting [13]
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2 Treatment Planning
Treatment planning is the most common indication of RP models. Indeed, the importance of accuracy and result predictability in maxillofacial treatments makes surgeons analyze each step through printed models and evaluate the outcome. Using RP models can decrease the intervention time, reducing posttreatment complica­tions, such as excessive bleeding, morbidity, and infection [17, 18].
Application of RP models in OMFS can be categorized into two main domains: dental procedures, such as implant dentistry or sinus augmentation, and extraoral procedures, such as management of maxillomandibular defects [19], TMJ disorders [20], orbital wall reconstruction [21], and orthognathic surgery [13]. More speci­cally, RP models benet all four aspects of maxillofacial reconstruction. Figures3 and 4 show the application of models in the functional bone regeneration procedure to reconstruct the orbital wall and posterior mandible. Besides, these models can also be applied in bone contouring and in situ bone regeneration.
In implant treatment planning, one option is fabricating a master cast through acquired STL data and analyzing the surgical procedure on the 3D printed cast. Using additive manufacturing may reduce the possible distortions related to tradi­tional methods, demand much easier laboratory procedures, and decrease the costs [22].
Among different extraoral surgeries, RP models are most commonly used in patients with malignancies [16, 23]. In detail, RP models can be used in both recon­struction (Fig.3) and ablation phases. The application of free grafts is one of the treatment options for reconstructing mandibles with large defects. Using
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d
Fig. 3 shows the use of RP in the reconstruction of the orbital region. (a) Data extracted from CT scan. (b) Designing patient-specic implant. (c) Fabrication of the RP models illustrating the defects anatomy on the patient’s skull. (d) Patient-specic implant matching the defected area
patient- specic RP models, the grafted bone can be trimmed accurately ex vivo. This type of RP model is named “3D printed xation tray” [24]. Considering the importance of precision in this procedure, sintering-based methods are recom­mended for model fabrication.
In the case of using reconstruction plates, presurgical bending can be per­formed based on the fabricated RP, as shown in Fig.5. In the resection phase, the tumor’s borders can be colored on the models, enabling the surgeon to analyze the dimensions and location of the tumor. However, the more accurate approach is to fabricate hybrid prototyping models. In these types of RP models, the tumor part can be fabricated with different materials, and the vital structures around the
Rapid Prototyping Models in Oral and Maxillofacial Surgery: History, Denition…
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a b
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Fig. 4 shows the process of designing and manufacturing a patient-specic implant in the man­dible. (a) Designing patient-specic implants using CT scan data. (b) Printed model of patient mandible and the degradable implant. (c) Implants are placed in the defected area during surgery. (Figure courtesy of Dr. Arash Khojasteh)
tumor can be emphasized using different colors or materials. Hence, hybrid mod­els can better illustrate the relationship between tumor, intact bone, and sur­rounding tissue [25].
Photosensitive resins, polyamide, poly lactic acid (PLA), acrylonitrile butadiene styrene (ABS), and composite powders are the materials that can be used for fabri­cating treatment planning models [26]. Although there is no evidence regarding the optimal material and fabrication method, the following points have to be considered regarding each of the mentioned materials: photosensitive resin models are fabri­cated through sintering-based methods and inkjet printing [27]. However, more accurate models can be made through the latter method. ABS and PLA models are fabricated using extrusion-based printing methods, which have less accuracy than the abovementioned techniques. Binders can also be used to fabricate models made up of uncurable powders such as composites. Nevertheless, this method has less
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Fig. 5 Application of RP in presurgical plate bending. (a) Mandibular rapid prototype model fabricated by FDM. (b) Presurgical bending of reconstruction plate on the fabricated RP model. (Figure courtesy of Dr. Arash Khojasteh)
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accuracy than sintering-based and low-temperature extrusion methods. The fabrica­tion costs are the other important factor that must be considered. As Meglioli etal. [13] mentioned, inkjet printing imposes high costs while extrusion- and sintering­based methods have more acceptable results.
Different studies showed that the application of RP models can enhance the treat­ment procedure results [28]. However, it must be considered that there is limited comparative evidence in this eld.
3 Training andSimulation
Simulating the surgical procedure is the other indication of RP models. Considering the importance of operation time on the postsurgical complications, performing the simulation of the surgery before the actual treatment can enhance the post-operation results. Besides, models can be used to train surgeons for a specic procedure, since they are more accessible than cadaver and animal models. Therefore, RP models have been used for training temporal bone surgeries, implant treatments, and maxil­lary sinus augmentation [16, 29, 30]. CBCT can be helpful in evaluations, but with 3D printed models, physicians can observe the anatomy and simulate the procedure presurgical.
Moreover, 3D printed models can be helpful in designing aps [31–33]. Besides, in implant dentistry, due to esthetic expectations and poor bone quality, the anterior part of the maxilla has always been challenging for dental implants. Guided bone regeneration (GBR) is a complex procedure, but nowadays, with 3D models, sur­geons can be more familiar with the patient’s anatomy before surgery, leading to less operation time and less tissue manipulation [34–36].
Proper haptic feedback is the main factor that must be considered in simulating models. In detail, the composition of the models has to provide an elastic modulus, stiffness, and other mechanical properties as of the natural tissue [13]. Among the commonly used techniques, inkjet printing, usually performed with photosensitive resin, can provide models with proper feedback. Fabricating powders with binder
Rapid Prototyping Models in Oral and Maxillofacial Surgery: History, Denition…
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provide the same results. However, models with lower haptic feedback quality can be fabricated through other techniques (extrusion- and sintering-based). ADS, PLA, and photosensitive resins are used with these techniques [13].
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