No funding was received for this work.

This study followed the Declaration of Helsinki on medical protocol and ethics and the Institutional Ethical Review Board approved the study.
1. Segmentation using a segmentation software
NOTE: The import process of the DICOM files requires the orientation of the axial, coronal and sagittal planes in the pop-up window to finish the setup.
<ol>
	<li>In the Bone Segmentation menu, choose the General feature. Use the marker &#34;-&#34; for unwanted segments and &#34;+&#34; for the segment of interest. Add markers on the 3D reconstructed model or on the different cross sections when scrolling and moving throughout the scan.</li>
	<li>Choose the Set button that demonstrates the segmentation. At this point, correct the markings and add new ones for better accuracy. Press Apply to create the new segment. Multiple segments can be created this way.</li>
	<li>After segmentation is complete, export the files as stl 3D files for 3D printing or planning of 3D reconstruction implants in 3D design CAD programs.</li>
</ol>
2. Designing reconstruction implants using 3D design software
<ol>
	<li>After preforming the bone segmentation using the segmentation software, import the stl files into the 3D design software (see Table of Materials).</li>
	<li>If further separation is needed (e.g., if one part is intended to be moved separately), do so here. In the Sculpt Clay menu, use the shave tool to separate the bone into two parts. In the Select/Move Clay menu, select the clay and mark the part to work on. Then, copy this part and create a new identical object in the object list in order to manipulate its position as observed in the next stage.</li>
	<li>Perform segment movement at this stage. Make sure that the axis of rotation is set on the part of the bone to stay in the same position. In the Select/Move Clay menu, select Reposition and set the rotation axis as planned.</li>
	<li>As the human skull is mostly symmetrical, use the healthy side for guidance to obtain the right positioning/replacement of the missing/mal-positioned segment. Use a mirroring technique to create a mirroring image of the normal side. In the Construct Clay menu, use the Mirror Clay option and set the plane at the center of the skull.</li>
	<li>Based on the mirrored half, perform segment rotation if needed and reconstruct the avulsed bony part using the Add Clay tool in the Construct Clay menu. This reconstruction is performed in order to build a patient specific reconstruction implant in the next stages, which will reconstruct the correct facial contour.</li>
	<li>After reconstructing the bony segment, create the patient specific reconstruction implant. In the Curves menu, use the Draw Curve option and create a continuous outer shape of the desired implant.</li>
	<li>At this stage, duplicate the bony segment as it will be needed to perform a Boolean function to separate the constructed implant. This is performed in the object list window by right clicking the segment and pressing the Duplicate option.</li>
	<li>Work in the new duplicated segment. In the Detail Clay menu, use the Emboss With Curve option to create the volume of the reconstruction implant. Pick the outer form of the sketched implant, and then place the circle-shaped cursor inside the sketched implant, on the surface of the bone. Note that the emboss will work outwards or on the inside of the bone, depending on the placement of the cursor. Then, choose the desired parameters - most importantly, the distance option that controls the thickness of the implant.</li>
	<li>Separate the implant from the bony segment. In the object list, choose the previously duplicated object from step 2.7, right-click and select Boolean &#8594; Remove From. Then choose the object containing the created implant.</li>
	<li>In case holes for screw fixation or for allowing angiogenesis are required, select Planes Category &#8594; Create Plane to create a parallel plane in which the holes for the plate are designed. Using manual manipulation, place the planes in maximum parallelism to the implant. In the Sketch menu, choose a circle and create circles in the desired size and position. A second larger circle can be created, which will serve as the countersink for the head of the intendent screw.</li>
	<li>In the Curves menu, use the Project Sketch option and choose the sketches designated to be transferred from the plane to the implant.</li>
	<li>To generate the countersink for the screws, In the Detail Clay menu, use the Emboss With Curve option. Pick the outer circles of the sketch, place the circle-shaped cursor inside the marked circular area on the surface and enter the distance that controls the depths of the countersink (e.g., 0.3 mm). To complete the process, press Apply and Lower to make sure that the emboss is performed in a subtraction manner and not an additive one.</li>
	<li>To complete the holes, in the SubD Surfaces menu, use the Wire Cut SubD option to create rods perpendicular to the implant based on the small circles created in step 2.10.</li>
	<li>To create the holes using the rods, use Boolean &#62; Remove From as in step 2.9. Choose one rod after the other, right click in the object list &#8594; Boolean &#8594; Remove From &#8594; Created Implant. 
	NOTE: Alternatively, the desired screws can be created/scanned and the Boolean function can be used to create the desired holes.</li>
	<li>To create a mesh in the implant (allowing for angiogenesis for instance), first generate a sketch (using the curve option) of the planned mesh as in step 2.6.
	<ol>
		<li>In the Detail Clay menu, use the Emboss with Wrapped Image option. Choose an image according to which the mesh will be created (there are several templates which come with the program). The white parts of the image will be subtracted in the mesh, and the black parts will be spared.</li>
		<li>Using manual control, adjust the direction and size of the design. Set the distance that represents the thickness of the holes generated and press Apply. The patient specific implant is ready for production.</li>
	</ol>
	</li>
</ol>

<ol>
	<li>Goodsaid, F., Frueh, F., Burczynski, M. E., Hock, F., Gralinski, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Personalized+Medicine.">Personalized Medicine.</a> Drug Discovery and Evaluation: Methods in Clinical Pharmacology. , (2019).</li><li>Hull, C. W. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Apparatus+for+production+of+three-dimensional+objects+by+stereolithography.">Apparatus for production of three-dimensional objects by stereolithography.</a> Google Patents. , (1986).</li><li>Petzold, R., Zeilhofer, H. F., Kalender, W. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Rapid+prototyping+technology+in+medicine--basics+and+applications.">Rapid prototyping technology in medicine--basics and applications.</a> Computerized Medical Imaging and Graphics. 23 (5), 277-284 (1999).</li><li>Schmauss, D., Gerber, N., Sodian, R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Three-dimensional+printing+of+models+for+surgical+planning+in+patients+with+primary+cardiac+tumors.">Three-dimensional printing of models for surgical planning in patients with primary cardiac tumors.</a> The Journal of Thoracic and Cardiovascular Surgery. 145 (5), 1407-1408 (2013).</li><li>Tam, M. D., Laycock, S. D., Bell, D., Chojnowski, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=3-D+printout+of+a+DICOM+file+to+aid+surgical+planning+in+a+6+year+old+patient+with+a+large+scapular+osteochondroma+complicating+congenital+diaphyseal+aclasia.">3-D printout of a DICOM file to aid surgical planning in a 6 year old patient with a large scapular osteochondroma complicating congenital diaphyseal aclasia.</a> Journal of Radiology Case Reports. 6 (1), 31 (2012).</li><li>Emodi, O., Shilo, D., Israel, Y., Rachmiel, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Three-dimensional+planning+and+printing+of+guides+and+templates+for+reconstruction+of+the+mandibular+ramus+and+condyle+using+autogenous+costochondral+grafts.">Three-dimensional planning and printing of guides and templates for reconstruction of the mandibular ramus and condyle using autogenous costochondral grafts.</a> British Journal of Oral and Maxillofacial Surgery. 55 (1), 102-104 (2017).</li><li>Leiser, Y., Shilo, D., Wolff, A., Rachmiel, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Functional+reconstruction+in+mandibular+avulsion+injuries.">Functional reconstruction in mandibular avulsion injuries.</a> Journal of Craniofacial Surgery. 27 (8), 2113-2116 (2016).</li><li>Mazzoni, S., Bianchi, A., Schiariti, G., Badiali, G., Marchetti, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Computer-aided+design+and+computer-aided+manufacturing+cutting+guides+and+customized+titanium+plates+are+useful+in+upper+maxilla+waferless+repositioning.">Computer-aided design and computer-aided manufacturing cutting guides and customized titanium plates are useful in upper maxilla waferless repositioning.</a> Journal of Oral and Maxillofacial Surgery. 73 (4), 701-707 (2015).</li><li>Rachmiel, A., Shilo, D., Blanc, O., Emodi, O. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Reconstruction+of+complex+mandibular+defects+using+integrated+dental+custom-made+titanium+implants.">Reconstruction of complex mandibular defects using integrated dental custom-made titanium implants.</a> British Journal of Oral and Maxillofacial Surgery. 55 (4), 425-427 (2017).</li><li>Xu, N., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Reconstruction+of+the+upper+cervical+spine+using+a+personalized+3D-printed+vertebral+body+in+an+adolescent+with+Ewing+sarcoma.">Reconstruction of the upper cervical spine using a personalized 3D-printed vertebral body in an adolescent with Ewing sarcoma.</a> Spine. 41 (1), E50-E54 (2016).</li></ol>

The authors have nothing to disclose.

With the constant developing use of computers for virtual planning of surgical procedures, the combination with another developing technology, 3D printing, led to a whole new era of surgical treatment. Accuracy is the goal of these technologies and patient specific care, as the future goal, is presented in the form of surgical guides and patient specific reconstruction implants. We discuss surgical guides as part of a different future protocol. In the current protocol, we discuss the segmentation of DICOM images into 3D stl files that can be 3D printed as a model. We also discuss the 3D virtual planning of a patient specific implant. The use of diverse functions to help with the reconstruction of missing or displaced bony fragments are presented. Re-positioning of a segment and mirroring of the healthy side are such functions. Construction of the implant using the planned contour of the bone is detailed. Holes for fixation screws and designing a mesh or a cradle for bone graft placement and enabling for angiogenesis is shown. Always remember that the design is limited in size to the available soft tissue for closure. Allow for proper angiogenesis and use large holes/mesh when possible for this purpose. Patient specific implants do not undergo physical manipulation during surgery for compatibility to the remaining bone, as opposed to regular reconstruction plates (which weakens them). Thus, thinner plates can withstand much larger forces. Take into account that if the production process of the 3D printed titanium implant includes smoothing of the external aspect (for avoiding soft tissue irritation), it removes additional material (approximately 0.3 mm). When preparing implants with a cradle, it is crucial to avoid angles that interfere with proper placement of the implant onto the bone.
With that said, 3D planning and printing of patient specific implants is already used in clinical practice, showing positive results. The limitations of the method are the cost and the need for an engineer for the planning, which results in time consuming web meetings and discussions during the planning phase.
We found that in-house planning of the implant reduces costs dramatically and also allows for the use of local companies to print the implant. With the development of technology, the software interface becomes more user-friendly and allows for the surgeon to plan his own surgical procedures and patient specific implants. This entitles great advantages, the surgeon enters the operating room with the implant he developed following movements and reconstruction procedures he planned and thus he is aware of each step, and knows how to deal with unexpected developments during surgery. This protocol is intended for this exact purpose, allowing the surgeon to plan his own surgeries and create his own patient specific implants.

Personalized medicine is developing rapidly in many fields of medicine1. Oncologic personalized treatment is a subject of much discussion and thus is well known to the general population. 3D printing was first introduced by Charles Hull showing 3D printing of objects using stereolithography2. Since then, different technologies for 3D printing were developed. The method used is selected based on the purpose of the device.
The surgical field is rapidly embracing personalized medicine. Personalized treatment in the surgical field requires virtual planning using a computer-assisted design (CAD) software. The first stage always includes segmentation to create a 3D stl file. Computer assisted manufacturing (CAM) is referred as the manufacturing process of the 3D designed part. The first utilization of the technology was used in pre-operative model printing for surgical planning and mock surgery3,4,5. With the development of technology, virtual planning of the surgeries followed by the planning and manufacturing of surgical guides to assist in the surgery itself and patient specific reconstruction implants fitted perfectly on the bone of the patient became more popular6,7,8,9,10. The purpose of this protocol is to provide clinicians with the ability to create their own surgical guides and reconstruction patient specific implants. This method is more accurate than using stock plates because it fits perfectly and can be designed based on the characteristics of the specific defect. It also reduces the dependency on the surgeon&#39;s experience and reduces operation time.

<table><tbody><tr><td>D2P (DICOM to Print)</td><td>3D systems</td><td></td><td>Segmentation software to create 3D stl files</td></tr><tr><td>Geomagic Freeform</td><td>3D systems</td><td></td><td>Sculpted Engineering Design</td></tr></tbody></table>

3d planning and printing of patient specific implants for reconstruction of bony defects

We are in the midst of the 3D era in most aspects of life, and especially in medicine. The surgical discipline is one of the major players in the medical field using the constantly developing 3D planning and printing capabilities. Computer-assisted design (CAD) and computer assisted manufacturing (CAM) are used to describe the 3D planning and manufacturing of the product. The planning and manufacturing of 3D surgical guides and reconstruction implants is performed almost exclusively by engineers. As technology advances and software interfaces become more user-friendly, it raises a question regarding the possibility of transferring the planning and manufacturing to the clinician. The reasons for such a shift are clear: the surgeon has the idea of what he wants to design, and he also knows what is feasible and could be used in the operating room. It allows him to be prepared for any scenario/unexpected results during the operation and allows the surgeon to be creative and express his new ideas using the CAD software. The purpose of this method is to provide clinicians with the ability to create their own surgical guides and reconstruction implants. In this manuscript, a detailed protocol will provide a simple method for segmentation using segmentation software and implant planning using a 3D design software. Following the segmentation and stl file production using segmentation software, the clinician could create a simple patient specific reconstruction plate or a more complex plate with a cradle for bone graft positioning. Surgical guides can be created for accurate resection, hole preparation for proper reconstruction plate positioning or for bone graft harvesting and re-contouring. A case of lower jaw reconstruction following plate fracture and nonunion healing of a trauma sustained injury is detailed.

A 40 year old female patient with a broken, stock supplied, reconstruction fixation plate from a previous injury and a non-union fracture in the left body of her lower jaw presented to the department. Imaging shows the broken fixation plate and the mal-positioned left segment of the lower jaw (Figure 1). Using segmentation software, segmentation of the lower jaw was performed separating the broken fixation plate (Supplemental Figure 1 and Supplemental Figure 2). Using 3D design software, the left segment of the mandible was repositioned to the correct anatomical position (Supplemental Figure 3 and Supplemental Figure 4). Mirroring of the right healthy side was performed to allow for proper reconstruction of the missing bone (Supplemental Figure 5). The patient specific implant was designed, including holes for fixation screws (Supplemental Figures 6, 7, and 8). A mesh was designed to allow for additional bone graft placement according to the proper contour of the jaw, based on the healthy side, also enabling for superior angiogenesis through the holes in the mesh (Supplemental Figure 9).
The implant was sent for printing from titanium using selective laser sintering technology. Post-operative results can be observed in Figure 2. Notice the continuity of the lower jaw and the correct vertical position of the left lower jaw segment compared to the situation pre-operatively as observed in Figure 1. Also notice the symmetry in the bony contour that was reconstructed using the patient specific implant as the outer contour and an iliac crest bone graft for filling the voids.
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/60929/60929fig1.jpg" /> 
Figure 1: Pre-operation imaging of a 40 years old patient with a broken reconstruction plate and non-union fracture of the left lower jaw. (A) Panoramic image, notice the broken fixation plate and upper position of the left mandibular segment compared to the right. (B) On the left, a posterior-anterior cephalometric image and on the right a front view of a 3D reconstruction from the patient&#39;s computed tomography image. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/60929/60929fig1large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 2" class="xfigimg" src="/files/ftp_upload/60929/60929fig2.jpg" /> 
Figure 2: Post-operative imagining. (A) Panoramic image; notice the continuity of the lower jaw, compared to the upper position of the left mandibular segment observed in Figure 1. (B) On the left, a posterior-anterior cephalometric image can be observed. On the right, a front view of the 3D reconstruction from a computed tomography image can be observed. Notice the continuity of the bone following repositioning of the left segment and filling the voids with an iliac crest bone graft. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/60929/60929fig2large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Supplemental Figure 1" src="/files/ftp_upload/60929/60929suppfig1.jpg" /> 
Supplemental Figure 1: Segmentation software. A view of the workspace and the bone segmentation process. On the left is the 3D reconstruction of the computed tomography image. On the right are the different views which allow for browsing through the different sections. The yellow circles are the &#34;-&#34; markers for removal of the marked piece and the orange ones are the &#34;+&#34; markers for the region of interest. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/60929/60929suppfig1large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Supplemental Figure 2" src="/files/ftp_upload/60929/60929suppfig2.jpg" /> 
Supplemental Figure 2: Segmentation process. Following the segmentation of the lower jaw. The previous broken reconstruction plate was removed from the region of interest. This segment is exported as a 3D stl file. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/60929/60929suppfig2large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Supplemental Figure 3" src="/files/ftp_upload/60929/60929suppfig3.jpg" /> 
Supplemental Figure 3: 3D design software. The 3D stl files were exported from a segmentation software and imported into 3D design software. (A) The workspace. (B) The imported 3D facial bones. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/60929/60929suppfig3large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Supplemental Figure 4" src="/files/ftp_upload/60929/60929suppfig4.jpg" /> 
Supplemental Figure 4: Further segmentation and repositioning. (A) Segmentation of the lower jaw into two different pieces. (B) The smaller part of the lower jaw was repositioned to its correct anatomical position. The hinge of the movement was set to the left mandibular condyle. Both the pre and post movement setups can be observed. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/60929/60929suppfig4large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Supplemental Figure 5" src="/files/ftp_upload/60929/60929suppfig5.jpg" /> 
Supplemental Figure 5: Mirroring function of the healthy side. (A) Defining the mid sagittal plane for the mirroring. (B) Merging the mirrored part (which allows for proper reconstruction of the lower border of the jaw) with the remaining segment in the patient and filling voids. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/60929/60929suppfig5large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Supplemental Figure 6" src="/files/ftp_upload/60929/60929suppfig6.jpg" /> 
Supplemental Figure 6: Creating the patient specific implant. (A) Creating the outer shape of the implant using the curve function. (B) Creating the thickness of the plate. This is created on the reconstructed mandible following the mirroring technique. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/60929/60929suppfig6large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Supplemental Figure 7" src="/files/ftp_upload/60929/60929suppfig7.jpg" /> 
Supplemental Figure 7: Separation of the plate and planning holes. (A) Following the separation of the patient specific implant using the Boolean function. (B) Creating holes for the screws and countersink using a perpendicular plane. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/60929/60929suppfig7large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Supplemental Figure 8" src="/files/ftp_upload/60929/60929suppfig8.jpg" /> 
Supplemental Figure 8: Holes and countersink preparation. (A) Following countersink preparation using the emboss function. (B) On the left, the rods created for hole preparation can be observed. On the right is the implant with holes following subtraction of the rods from the implant using the Boolean function. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/60929/60929suppfig8large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Supplemental Figure 9" src="/files/ftp_upload/60929/60929suppfig9.jpg" /> 
Supplemental Figure 9: Preparing a mesh. (A) Mesh preparation using the Emboss with Wrapped Image function. (B) Left and bottom views of the final patient specific implant on the existing lower jaw following repositioning. Note the implant will guide the surgeon for the correct repositioning during surgery. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/60929/60929suppfig9large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>

Watch this Scientific Journal Video about 3D Planning and Printing of Patient Specific Implants for Reconstruction of Bony Defects at JoVE.com

3D Planning and Printing of Patient Specific Implants for Reconstruction of Bony Defects

This protocol describes the use of 3D planning and printing for reconstruction of bony defects. We use segmentation tools to create 3D models followed by 3D design software to create patient specific implants for reconstruction purposes concomitant to ablative surgery or as a second stage.

We are in the midst of the 3D era in most aspects of life, and especially in medicine. The surgical discipline is one of the major players in the medical ...

3d-planning-printing-patient-specific-implants-for-reconstruction

Nanyang Technological University

Research

JoVE Journal

Medicine

6.4K Views.  Rambam Medical Care Center. Dit protocol maakt de virtuele behandeling van patiënten met benige defecten en het creëren van nieuwe chirurgische gids en fixatieplaten mogelijk. Met behulp van dit protocol kunnen implantaten virtueel worden gemaakt en ontworpen op basis van wat haalbaar is voor gebruik in de operatiekamer met superieure nauwkeurigheid en kortere werkingsduur. Patiëntspecifieke implantaten die met ons protocol zijn gepland, zijn gebaseerd op nauwkeurige 3D-beeldvorming, wat resulteert in perfect passend...

Video: 3D Planning and Printing of Patient Specific Implants for Reconstruction of Bony Defects

Application of 3D Printing in the Construction of Burr Hole Ring for Deep Brain Stimulation Implants

3D printing has been widely applied in the medical field since the 1980s, especially in surgery, such as preoperative simulation, anatomical learning and surgical training. This raises the possibility of using 3D printing to construct a neurosurgical implant. Our previous works took the construction of the burr hole ring as an example, described the process of using softwares like computer aided design (CAD), Pro/Engineer (Pro/E) and 3D printer to construct physical products. That is, a total of three steps are required, the drawing of 2D-image, the construction of 3D-image of burr hole ring, and using a 3D printer to print the physical model of burr hole ring. This protocol shows that the burr hole ring made of carbon fiber can be rapidly and accurately molded by 3D printing. It indicated that both CAD and Pro/E softwares can be used to construct the burr hole ring via integrating with the clinical imaging data and further applied 3D printing to make the individual consumables.

Here, we present a protocol to demonstrate 3D printing in the construction of deep brain stimulation implants.

3D printing has been widely applied in the medical field since the 1980s, especially in surgery, such as preoperative simulation, anatomical learning and ...

Behavior

Novel Process for 3D Printing Decellularized Matrices

3D bioprinting aims to create custom scaffolds that are biologically active and accommodate the desired size and geometry. A thermoplastic backbone can provide mechanical stability similar to native tissue while biologic agents offer compositional cues to progenitor cells, leading to their migration, proliferation, and differentiation to reconstitute the original tissues/organs1,2. Unfortunately, many 3D printing compatible, bioresorbable polymers (such as polylactic acid, PLA) are printed at temperatures of 210 &#176;C or higher - temperatures that are detrimental to biologics. On the other hand, polycaprolactone (PCL), a different type of polyester, is a bioresorbable, 3D printable material that has a gentler printing temperature of 65 &#176;C. Therefore, it was hypothesized that decellularized extracellular matrix (DM) contained within a thermally protective PLA barrier could be printed within PCL filament and remain in its functional conformation. In this work, osteochondral repair was the application for which the hypothesis was tested. As such, porcine cartilage was decellularized and encapsulated in polylactic acid (PLA) microspheres which were then extruded with polycaprolactone (PCL) into filament to produce 3D constructs via fused deposition modeling. The constructs with or without the microspheres (PLA-DM/PCL and PCL(-), respectively) were evaluated for differences in surface features.

This protocol describes the production of polycaprolactone (PCL) filament with embedded polylactic acid (PLA) microspheres which contain decellularized matrices (DM) for 3D printing of structural tissue engineering constructs.

3D bioprinting aims to create custom scaffolds that are biologically active and accommodate the desired size and geometry. A thermoplastic backbone can ...

Bioengineering

Voxel Printing Anatomy: Design and Fabrication of Realistic, Presurgical Planning Models through Bitmap Printing

Most applications of 3-dimensional (3D) printing for presurgical planning have been limited to bony structures and simple morphological descriptions of complex organs due to the fundamental limitations in accuracy, quality, and efficiency of the current modeling paradigm. This has largely ignored the soft tissue critical to most surgical specialties where the interior of an object matters and anatomical boundaries transition gradually. Therefore, the needs of the biomedical industry to replicate human tissue, which displays multiple scales of organization and varying material distributions, necessitate new forms of representation. 
Presented here is a novel technique to create 3D models directly from medical images, which are superior in spatial and contrast resolution to current 3D modeling methods and contain previously unachievable spatial fidelity and soft tissue differentiation. Also presented are empirical measurements of novel, additively manufactured composites that span the gamut of material stiffnesses seen in soft biological tissues from MRI and CT. These unique volumetric design and printing methods allow for deterministic and continuous adjustment of material stiffness and color. This capability enables an entirely new application of additive manufacturing to presurgical planning: mechanical realism. As a natural complement to existing models that provide appearance matching, these new models also allow medical professionals to "feel" the spatially varying material properties of a tissue simulant-a critical addition to a field in which tactile sensation plays a key role.

This method demonstrates a voxel-based 3D printing workflow, which prints directly from medical images with exact spatial fidelity and spatial/contrast resolution. This enables the precise, graduated control of material distributions through morphologically complex, graduated materials correlated to radiodensity without loss or alteration of data.

Most applications of 3-dimensional (3D) printing for presurgical planning have been limited to bony structures and simple morphological descriptions of ...

Designing CAD/CAM Surgical Guides for Maxillary Reconstruction Using an In-house Approach

Computer-aided design/computer-assisted manufacturing (CAD/CAM) is now being evaluated as a preparative technique for maxillofacial surgery. Because this technique is expensive and available in only limited areas of the world, we developed a novel CAD/CAM surgical guide using an in-house approach. By using the CAD software, the maxillary resection area and cutting planes and the fibular cutting planes and angles are determined. Once the resection area is decided, the necessary faces are extracted using a Boolean modifier. These superficial faces are united to fit the surface of the bones and thickened to stabilize the solids. Not only the cutting guides for the fibula and maxilla but also the location arrangement of the transferred bone segments is defined by thickening the superficial faces. The CAD design is recorded as .stl files and three-dimensionally (3-D) printed as actual surgical guides. To check the accuracy of the guides, model surgery using 3-D-printed facial and fibular models is performed. These methods may be used to assist surgeons where commercial guides are not available.

Methods for designing a computer-aided design/computer-aided manufacturing (CAD/CAM) surgical guide are shown. Cutting planes are separated, united, and thickened to easily visualize the necessary bone transfer. These designs can be three-dimensional printed and checked for accuracy.

Computer-aided design/computer-assisted manufacturing (CAD/CAM) is now being evaluated as a preparative technique for maxillofacial surgery. Because this ...

Three-Dimensional Printing of a Complex Aortic Anomaly

Complex congenital aortic anomalies include diverse types of malformations that may be clinically asymptomatic or present with respiratory or esophageal symptoms. These anomalies may be associated with other congenital heart diseases. It is hard to identify the accurate anatomic vessel location from two-dimensional imaging data, such as computed tomography. As an additive manufacturing method, three-dimensional (3-D) printing can covert the acquired imaging data into 3-D physical models. This protocol describes the procedure for modeling the volumetric DICOM imaging into 3-D data and printing it as an anatomically realistic 3-D model. Using this model, surgeons can identify the vessel location of complex aortic anomalies, which is helpful for pre-operative planning and intra-operative guidance.

Here, we present a protocol to use three dimensional printed models for pre-operative planning and intra-operative reorganization of complicated vascular locations when handling a congenital aortic anomaly.

Complex congenital aortic anomalies include diverse types of malformations that may be clinically asymptomatic or present with respiratory or esophageal ...

Combining Augmented Reality and 3D Printing to Display Patient Models on a Smartphone

Augmented reality (AR) has great potential in education, training, and surgical guidance in the medical field. Its combination with three-dimensional (3D) printing (3DP) opens new possibilities in clinical applications. Although these technologies have grown exponentially in recent years, their adoption by physicians is still limited, since they require extensive knowledge of engineering and software development. Therefore, the purpose of this protocol is to describe a step-by-step methodology enabling inexperienced users to create a smartphone app, which combines AR and 3DP for the visualization of anatomical 3D models of patients with a 3D-printed reference marker. The protocol describes how to create 3D virtual models of a patient&rsquo;s anatomy derived from 3D medical images. It then explains how to perform positioning of the 3D models with respect to marker references. Also provided are instructions for how to 3D print the required tools and models. Finally, steps to deploy the app are provided. The protocol is based on free and multi-platform software and can be applied to any medical imaging modality or patient. An alternative approach is described to provide automatic registration between a 3D-printed model created from a patient&rsquo;s anatomy and the projected holograms. As an example, a clinical case of a patient suffering from distal leg sarcoma is provided to illustrate the methodology. It is expected that this protocol will accelerate the adoption of AR and 3DP technologies by medical professionals.

Presented here is a method to design an augmented reality smartphone application for the visualization of anatomical three-dimensional models of patients using a 3D-printed reference marker.

Augmented reality (AR) has great potential in education, training, and surgical guidance in the medical field. Its combination with three-dimensional (3D) ...

Treatment of Facial Deformities using 3D Planning and Printing of Patient-Specific Implants

Technological advancements in surgical planning and patient-specific implants are constantly evolving. One can either adopt the technology to achieve better results, even in the less experienced hand, or continue without it. As technology develops and becomes more user-friendly, we believe it is time to allow the surgeon the option to plan his/her operations and create his/her own patient-specific surgical guides and fixation plates allowing him full control over the process. We present here a protocol for 3D planning of the operation followed by 3D planning and printing of surgical guides and patient-specific fixation implants. During this process we use two commercial computer-assisted design (CAD) software. We also use a fused deposition&#160;modeling printer for the surgical guides and a selective laser sintering printer for the titanium patient-specific fixation implants. The process includes computed tomography (CT) imaging acquisition, 3D segmentation of the skull and facial bones from the CT, 3D planning of the operations, 3D planning of patient-specific fixation implant according to the final position of the bones, 3D planning of surgical guides for performing an accurate osteotomy and preparing the bone for the fixation plates, and 3D printing of the surgical guides and the patient-specific fixation plates. The advantages of the method include full control over the surgery, planned osteotomies and fixation plates, significant reduction in price, reduction in operation duration, superior performance and highly accurate results. Limitations include the need to master the CAD programs.

As technology develops and becomes more user-friendly, planning of operations and patient-specific surgical guides and fixation plates should be performed by the surgeon. We present a protocol for 3D planning of orthognathic skeletal movements and 3D planning and printing of patient-specific fixation plates and surgical guides.

Technological advancements in surgical planning and patient-specific implants are constantly evolving. One can either adopt the technology to achieve ...

Digital Hybrid Model Preparation for Virtual Planning of Reconstructive Dentoalveolar Surgical Procedures

Virtual, hybrid three-dimensional (3D) model acquisition is presented in this article, utilizing the sequence of radiographic image segmentation, spatial registration, and free-form surface modeling. Firstly cone-beam computed tomography datasets were reconstructed with a semi-automatic segmentation method. Alveolar bone and teeth are separated into different segments, allowing 3D morphology, and localization of periodontal intrabony defects to be assessed. The severity, extent, and morphology of acute and chronic alveolar ridge defects are validated concerning adjacent teeth. On virtual complex tissue models, positions of dental implants can be planned in 3D. Utilizing spatial registration of IOS and CBCT data and subsequent free-form surface modeling, realistic 3D hybrid models can be acquired, visualizing alveolar bone, teeth, and soft tissues. With the superimposition of IOS and CBCT soft tissue, thickness above the edentulous ridge can be assessed about the underlying bone dimensions; therefore, flap design and surgical flap management can be determined, and occasional complications may be avoided.

A workflow for creating three-dimensional (3D) virtual hybrid models has been designed based on cone-beam computed tomography dataset and intraoral optical scans utilizing radiographic image segmentation methods and free-form surface modeling. Digital models are used for the virtual planning of reconstructive dentoalveolar surgical procedures.

Virtual, hybrid three-dimensional (3D) model acquisition is presented in this article, utilizing the sequence of radiographic image segmentation, spatial ...

The Use of Mixed Reality in Custom-Made Revision Hip Arthroplasty: A First Case Report

The technology of 3D printing and visualization of anatomical structures is rapidly growing in various fields of medicine. A custom-made implant and mixed reality were used to perform complex revision hip arthroplasty in January 2019. The use of mixed reality allowed for a very good visualization of the structures and resulted in precise implant fixation. According to the authors' knowledge, this is the first described case report of the combined use of these two innovations. The diagnosis preceding the qualification for the procedure was the loosening of the left hip's acetabular component. Mixed reality headset and holograms prepared by engineers were used during the surgery. The operation was successful, and it was followed by early verticalization and patient rehabilitation. The team sees opportunities for technology development in joint arthroplasty, trauma, and orthopedic oncology.

A complex revision hip arthroplasty was performed using a custom-made implant and mixed reality technology. According to the authors&#39; knowledge, this is the first report of such procedure described in the literature.

The technology of 3D printing and visualization of anatomical structures is rapidly growing in various fields of medicine. A custom-made implant and mixed ...

A Pilot Study Showing Application of Palatal Bone Harvesting Under Dynamic Navigation Guidance in Oral Implantology

In cases of insufficient bone volume in the implant area, bone augmentation surgery is often required to ensure an adequate amount of bone around the implant. In autologous bone grafting procedures, some patients face insufficient bone volume at conventional intraoral bone harvesting sites. Due to the high difficulty associated with completing palatal osteotomies freehand, fewer palatal lateral osteotomies have been reported, and palatal bone blocks are not routinely used in bone augmentation procedures. With the development of digitally guided implant technology, palatal bone harvesting has become feasible. In this paper, we will present a method of obtaining a circumferential bone block of the palate for implant surgical application through dynamic navigation guidance. A total of three patients had undergone this procedure to obtain circumferential palatal bone blocks and completed bone augmentation surgery. The bone augmentation results in the implanted area have been favorable, and there has been some bone recovery at the harvesting site. This is a safe and effective way to obtain intraoral bone blocks.

The protocol introduces a novel surgical method for palatal ring bone block harvesting using dynamic navigation guidance, addressing the challenge of insufficient bone volume in typical intraoral grafting areas and offering a viable solution for effective bone augmentation in implant dentistry.

In cases of insufficient bone volume in the implant area, bone augmentation surgery is often required to ensure an adequate amount of bone around the ...

3D Planning and Printing of Patient Specific Implants for Reconstruction of Bony Defects

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