3D-printed Surgical Templates Research Articles

Achieving automated and high-precision in situ analysis of the dimensional accuracy and dynamic deformation of 3D-printed surgical templates: an in vitro study

PurposeTo demonstrate the viability of a coordinate-measuring machine (CMM) for the geometric analysis of 3D printed surgical templates.MethodsThe template was designed and modified by adding 18 cylindrical landmarks for CMM test and then classified into five groups according to the slicing software and resins (opaque and transparent): Streamflow-O, Streamflow-T, Shapeware-T, Rayware-T and Polydevs-T (N = 3). Three standing times (0 w, 1 w, and 2 w) were included to observe possible deformation. All the measurements were performed automatically by the CMM through a preset program. The Euclidian distance (dxyz) was regarded as the representation of global dimension accuracy, and displacements in the x-, y-, and z-axes were also calculated.ResultsThe average dxyz values of Streamflow-O, Streamflow-T, Shapeware-T, Rayware-T and Polydev-T are 32.6 μm, 31.3 μm, 56.4 μm, 96.4 μm, and 55.3 μm, respectively. Deviations were mainly induced by the upward bending of the free end region (positive direction of the z-axis). Different resins did not have a significant influence on the dimensional accuracy. Moreover, deformation appeared to be negligible after 2 weeks of storage, and the z-axis displacements were only approximately 30 μm at week 1 and 10 μm at week 2.ConclusionsThe deviations of the DLP-printed template are induced mainly by z-axis displacements and are determined by the processing accuracy. After 2 weeks, the dimensional stabilities of these templates are reliable, which is encouraging for clinicians. Moreover, the CMM is preliminarily demonstrated to be a feasible tool for achieving automated geometric analysis of surgical templates.

Template based segmental mandibulectomy with nerve preservation and patient-specific PEEK plate reconstruction in a dog.

A 7-year-old French Bulldog presented with an acanthomatous ameloblastoma affecting approximately 30% of the right mandibular body. We utilized a patient-specific 3D-printed surgical template to perform lateral fenestration of the mandible and elevation of the inferior alveolar nerve (IAN), facilitating nerve preservation during subsequent segmental mandibulectomy. The resulting critical-sized bone defect was anatomically stabilized using a patient-specific polyetheretherketone (PEEK) bridging plate. The recovery process was uneventful, with maintained occlusion and orofacial sensitivity.Similar to cases in humans with ameloblastoma, preserving orofacial sensitivity through the preservation of the inferior alveolar nerve seems feasible in dogs. Consequently, potential negative consequences of permanent regional denervation, which are unavoidable in traditional mandibulectomy, can be avoided. Bridging the ostectomy with a PEEK plate, offering advantages such as radiolucency, absence of imaging artifacts, and a modulus of elasticity similar to bone, proved to be functional in this canine patient, with no signs of complications observed up to the latest follow-up at 6 months.

Use of surgical templates in the daily practice of the oral surgeon

BACKGROUND: Three-dimensional (3D) technology allows for the creation of individual surgical templates. This is a special construction, providing precise placement of dental implants in the jaw tissue. Templates are divided by the type of fixation into bone pins and screws and dental and gingival pins. The surgical template is made by 3D printing from a special resin. The technology allows the computer modeling to be transferred precisely to the patients jaw. The optimal angle for implant insertion and free overlapping of the template, which has holes for positioning and cooling the mucosa, is important to consider. The goals of template making are the correct positioning of the implant and the accuracy of placement, which affects the success of further prosthetics. The template is the link between surgery and prosthetics. Proper positioning of the implants increases the accuracy of the orthopedic prosthesis.
 AIM: The study was aimed to compare the standard implantation protocol and implant placement using a 3D-printed surgical template.
 METHODS: Comparative assessment of two groups of patients was conducted. Group 1 was implanted using a surgical template, whereas Group 2 was implanted according to the standard technique, without a template. In total, 35 patients with partial adentia and 10 patients with complete adentia were examined. The effectiveness of surgical templates during the placement of dental implants and the risks of complications were assessed.
 RESULTS: In Group 1, where surgical templates were used, a 40% decrease in the duration of surgery, a 90% reduction in the gingival incision area, and accurate positioning of the construct were observed. Postoperative complications such as pain, swelling, bleeding, and numbness developed less frequently by 70%. Group 2 was implanted according to the standard technique; however, the implant deviation from the planned position was observed in 35% of patients. The effectiveness of surgical templates lies in the accuracy of implant positioning and denture fabrication and reduction of complications.
 CONCLUSIONS: The use of surgical templates is indicated in complicated clinical cases, critical bone atrophy, and for avoiding damage to anatomically important areas. The planning of the surgical template is simultaneous with the placement of the implant and with consideration of the subsequent prosthetic construction, since the accuracy of positioning affects the accuracy of the prosthetic construction. The use of advanced technologies increases the effectiveness of dental implantation.

Accuracy of dental implant placement with 3D-printed surgical templates by using Implant Studio and MGUIDE. An observational study.

The purpose of the present study was to report early surgical template-related and postoperative complications of computer-guided implant placement and to evaluate its accuracy. Data were collected retrospectively from records of patients who had undergone computer-guided implant surgery between 2016 and 2018. Incidence of early surgical template-related and postoperative complications was recorded. Accuracy of implant placement was evaluated by comparing the data from postoperative CBCT records with that from the preoperative virtual implant planning by using appropriate image registration software. Depth, coronal, apical, and angular deviations were measured. A final number of 27 partially edentulous patients who received 52 implants with 31 static surgical templates were included in the study. All implants had been inserted in a fully guided manner using a flapless technique and following a one-stage approach. All implants were reported to have been successfully osseointegrated. Except for one template fracture, no other complication was recorded. The mean depth deviation was 0.57 ± 0.4 mm (95% CI 0.48 to 0.71 mm), the mean coronal deviation was 0.89 ± 0.7 mm (95% CI 0.73 to 1.07 mm), the mean apical deviation was 1.4 ± 1 mm (95% CI 1.16 to 1.71 mm), and the mean angular deviation was 2.74 ± 1.8 degrees (95% CI 2.29 to 3.26 degrees). The use of static surgical templates for fully guided implant placement demonstrated acceptable clinical performance. However, there are some factors affecting accuracy that should be considered during implant planning and surgery for further improvement of the technique. (Int J Comput Dent 2022;25(3):249-256; doi: 10.3290/j.ijcd.b2599735).

The accuracy of virtual surgical planning in segmental Le Fort I surgery: A comparison of planned and actual outcome

Segmental Le Fort I surgery is an effective technique to correct complicated dentomaxillofacial deformities. This retrospective study evaluated the accuracy of segmental Le Fort I surgery under the guidance of virtual surgical planning (VSP). A total of 129 patients who accepted segmental Le Fort I surgery were investigated in this study. VSP was transferred to segmental surgery with different pieces precisely with the aid of 3D-printed surgical templates and splints. The surgical result was evaluated by postoperative complications, color distance maps, and quantitative accuracy analysis. Outcomes showed that the VSP was successfully transferred to actual surgery with high accuracy. The overall mean linear difference was 1.28 mm, and the overall mean angular difference was 2.4°. Except for one case of root injury, there was no serious complication recorded. The results suggested that VSP was a reliable assistance for segmental Le Fort I surgery.

Computer-aided design-CAM-guided endodontic microsurgical localization and retrieval of two separated instruments from the periapical area of a mandibular second molar

Three-dimensional (3D) imaging devices used for the visualization of anatomic structures not only allow for a more accurate diagnosis but also facilitate precise planning of surgical treatments, such as in guided surgery for instrument retrieval using templates. The innovative template-based treatment methods could also play a crucial role in future modern surgical endodontic treatments, enabling exact preplanning and precision-guided surgical interventions, and resulting in greater accuracy and success rates. We present here a case of a patient with a periapical lesion below a right mandibular second molar, with a fractured file segment extruding beyond the apex in the distal canal, and another instrument half-way extruded from the mesial canal, with radiolucencies evident at the mesial and distal root apices. The patient was treated by employing a 3D-guided microsurgical approach. First, 3D optical scans were imported into a guided surgery program. Periapical lesions and extruded fractured instruments were marked within the software. The osteotomy size, apical resection level, and bevel angle were defined pretreatment. This case introduces a novel-guided microsurgical endodontic technique, incorporating recommended guidelines of modern surgical endodontic treatment with the aid of 3D-printed surgical templates, by which minimally invasive surgical treatment was ensured with preservation of tooth, bone, and surrounding anatomical structures.

Dual-Purpose 3D-Printed Surgical Template for Removal of Fractured Implant and New Implant Placement

Dental implants may fracture, and frequently excessive bone removal has to be performed in order to remove the apical fragment. In such instances, staged bone augmentation is indicated, creating more trauma, longer treatment time, and additional cost to the patient. Virtual surgical planning and guided surgery may increase the accuracy of the procedure and reduce treatment time. Through a case report, we show the use of digital planning and guided surgery to optimize implant removal, simultaneous implant placement, and bone augmentation.

Fast and Economical Protocol for In-House Virtual Planning and 3D-Printed Surgical Templates in Mandibular Reconstruction

In this work, a case series consisting of mandibular reconstruction with free fibula flap in ameloblastic carcinoma, pathological mandibular fracture and recontouring of mandibular angle hyperplasia that were treated successfully using fast and economical in-house virtual planning and 3D-printing protocol has been presented. Pre-operatively, the design of the reconstructed mandibular model and surgical templates were carried out, with the help of two types of free software. As the next step, all designed 3D hardware tools were printed using affordable fused deposition modeling desktop 3D printer. A 3D-printed reconstructed mandibular model was used for titanium plate bending. Our findings have illustrated that it necessitates an average of 5 h 29 min per case from virtual planning stage until the 3D printing of all 3D hardware tools is completed. The average cost for 3D-printed hardware tools and titanium plate per case is only $203.42.

Complete-arch fixed reconstruction by means of guided surgery and immediate loading: a retrospective clinical study on 12 patients with 1\u2009year of follow-up

BackgroundGuided implant surgery is considered as a safe and minimally invasive flapless procedure. However, flapless guided surgery, implant placement in post-extraction sockets and immediate loading of complete-arch fixed reconstructions without artificial gum are still not throughly evaluated. The aim of the present retrospective clinical study was to document the survival and success of complete-arch fixed reconstructions without artificial gum, obtained by means of guided surgery and immediate loading of implants placed also in fresh extraction sockets.MethodsA total of 12 patients (5 males and 7 females, with a mean age of 50.0 ± 13.8) were enrolled in this study. Implant planning was performed with a guided surgery system (RealGuide®, 3Diemme, Como, Italy), from which 3D-printed surgical templates were fabricated. All implants (Esthetic Line-EL®, C-Tech, Bologna, Italy) were placed through the guides and immediately loaded by means of a temporary fixed full-arch restoration without any artificial gum; the outcome measures were implant stability at placement, implant survival, complications, prosthetic success, soft-tissue stability, and patient satisfaction.ResultsOne hundred ten implants (65 of them post-extractive) were placed flapless through a guided surgery procedure and then immediately loaded by means of provisional fixed full arches. Successful implant stability at placement was achieved in all cases. After a provisionalization period of 6 months, 72 fixed prosthetic restorations were delivered. Only 2 implants failed to osseointegrate and had to be removed, in one patient, giving a 1-year implant survival rate of 98.2% (108/110 surviving implants); 8/12 prostheses did not undergo any failure or complication during the entire follow-up period. At the 1-year follow-up control, soft-tissue was stable in all patients and showed satesfactory aesthetic results.ConclusionsWithin the limits of this study, complete-arch fixed reconstruction by means of guided surgery and immediate loading of implants placed in fresh extraction sockets appears to be a reliable and successful procedure. Further long-term prospective studies on a larger sample of patients are needed to confirm these positive outcomes.

Virtual Surgical Planning Assisted Management for Cleft-Related Maxillary Hypoplasia.

Maxillary hypoplasia is a common developmental deformity affecting patients with cleft lip and palate. Various surgical techniques including conventional orthognathic surgery, total maxillary distraction osteogenesis, and anterior maxillary segmental distraction have been applied to address the deformity. With the evolution of 3D computed tomography imaging, the visualization of skeletal complexities in different perspectives is greatly enhanced and comprehensive surgical planning is achieved. Intraoperative efficiency is also improved with the fabrication of 3D-printed templates. The study aims to present different surgical techniques with virtual surgical planning (VSP) and 3D-printed surgical templates and the solution of representative cases. From January 2014 to January 2019, VSP was transferred to actual surgery or distraction precisely in 80 adult patients with cleft-related maxillary hypoplasia. The accuracy was analyzed and the relapse was also estimated and observed in 18 patients after 1-year follow-up. Based on our experience, VSP provides a more reliable and effective option to conventional model surgery. It facilitates the preoperative planning and accurately transfers the virtual plan to correct the cleft-related maxillary hypoplasia.

Novel design for a customized, 3D-printed surgical template for thoracic spinal arthrodesis.

The integration of computer-aided design/computer-aided manufacturing (CAD/CAM) tools and medicine is rapidly developing for designing medical devices. A novel design for a 3D-printed patient-specific surgical template for thoracic pedicle screw insertion, using a procedure based on reverse engineering, is presented. The surgeon chooses the entry point on the vertebra. The optimal insertion direction and the size of the screws are defined via an algorithm on the basis of a patient-specific vertebra CAD model. The template features an innovative shape for a comfortable and univocal placement and a novel disengaging device. Three spinal fusions were performed to test the template. Excellent results were achieved in terms of the accuracy of the screw positioning, reduction in surgery duration, and number of X-rays. A novel design for a customized, 3D-printed surgical template for thoracic spinal arthrodesis was presented, and improvements in terms of precision, duration, and safety were achieved without changing the standard procedure.

Accuracy of a chairside fused deposition modeling 3D-printed single-tooth surgical template for implant placement: An in vitro comparison with a light cured template

PurposeTo compare the accuracy of a chairside fused deposition modeling (FDM) 3D-printed surgical template with that of a light-cured template for implant placement. Materials and methodsTwenty standard mandibular resin models with missing teeth 36 and 46 were selected. Surgical templates were fabricated using a chairside FDM 3D-printer (test group) or a light-curing 3D printer (control group) (n = 20/group). Forty implants were placed by a clinician blinded to group allocation. The angular, 3D, mesiodistal, buccolingual, and apicocoronal deviations at the implant base and tip between preoperative design and postoperative implant position were recorded. ResultsThe mean angular (test vs control groups: 3.22° ± 1.55° vs 2.74° ± 1.24°, p = 0.343) and 3D deviations at the implant base (test vs control groups: 0.41 ± 0.13 mm vs 0.35 ± 0.11 mm, p = 0.127) and tip (test vs control groups: 0.91 ± 0.34 mm vs 0.75 ± 0.28 mm, p = 0.150) were similar. The mesiodistal, buccolingual, and apicocoronal deviations at the implant base and tip also did not differ significantly between groups (p > 0.05). ConclusionsFor single tooth gap indications, implant placement with an FDM 3D-printed surgical template was as accurate as that with a light-cured template, and more efficient.

Computer-Aided Design and Three-Dimensional-Printed Surgical Templates for Second-Stage Mandibular Reconstruction.

It is extremely difficult in clinical practice to accurately reset the physiologic positions of the mandibular condyle and ramus because of ongoing bone remodeling, muscle stretching, occlusal disorders, and other factors; this makes it difficult to obtain a good shape for a reconstructed mandible, as well as a good condylar position. The present study aimed to investigate a standardized method for mandibular reconstruction in cases of obsolete mandibular defects, using a 3-dimensional (3D)-printed surgical template enhanced by computer-aided design. We collected computed tomography data preoperatively to computerize the physiologic positions of the mandibular condyle and ramus on the sagittal, axial, and coronal planes. Surgical simulation and 3D-printed template preparation were then conducted to assist in the implementation of actual surgery. Postoperative review was performed to assess the repositioning of the condyle, where patients were found to regain a satisfactory condyle position. Reconstruction error was ±0.56 mm, fulfilling the preoperative design. No complications and discomfort were reported. Overall, the combined use of computer-aided design and 3D-printed surgical templates can standardize mandibular reconstruction in cases of obsolete mandibular body defects.

One-Stage treatment for maxillofacial asymmetry with orthognathic and contouring surgery using virtual surgical planning and 3D-printed surgical templates

Asymmetry is one of the most common maxillofacial deformities. One-stage treatment for maxillofacial asymmetry with orthognathic and contouring surgery has been rarely reported. This retrospective study aims to investigate the feasibility of simultaneous orthognathic and facial bone contouring surgery with the help of virtual surgical planning and 3D-printed navigation templates for facial asymmetry. From January 2012 to December 2015, 51 patients diagnosed with maxillofacial asymmetry received treatment of combined orthognathic and contouring surgery under the guidance of virtual surgical planning and 3D-printed templates. Photographs and measurements were taken before and after operation to evaluate the effectiveness of the treatment. Photographs and cephalometric analysis showed the asymmetry was effectively corrected. All patients were satisfied with the aesthetic results. This study suggested the clinical feasibility of simultaneous orthognathic and contouring surgery for the treatment of maxillofacial asymmetry. Virtual surgical planning and 3D-printed surgical templates enable the surgeons to plan and carry out the procedure more predictably and achieve satisfactory outcomes.

Novel Procedure for Designing and 3D Printing a Customized Surgical Template for Arthrodesis Surgery on the Sacrum

In this article, the authors propose a novel procedure for designing a customized 3D-printed surgical template to guide surgeons in inserting screws into the sacral zone during arthrodesis surgeries. The template is characterized by two cylindrical guides defined by means of trajectories identified, based on standard procedure, via an appropriate Computer-Aided-Design (CAD)-based procedure. The procedure is based on the definition of the insertion direction by means of anatomical landmarks that enable the screws to take advantage of the maximum available bone path. After 3D printing, the template adheres perfectly to the bone surface, showing univocal positioning by exploiting the foramina of the sacrum, great maneuverability due to the presence of an ergonomic handle, as well as a break system for the two independent guides. These features make the product innovative. Thanks to its small size and the easy anchoring, the surgeon can simply position the template on the insertion area and directly insert the screws, without alterations to standard surgical procedures. This has the effect of reducing the overall duration of the surgery and the patient’s exposure to X-rays, and increasing both the safety of the intervention and the quality of the results.

Reconstruction of Mandibular Contour Using Individualized High-Density Porous Polyethylene (Medpor®) Implants Under the Guidance of Virtual Surgical Planning and 3D-Printed Surgical Templates.

The mandibular contour plays a significant role in the beautiful and youthful look but the reconstruction remains a challenging problem. The objective of this study was to evaluate the use of individualized high-density porous polyethylene (Medpor®) implants for comprehensive reconstruction of mandibular contour with the aid of computer-aided design/computer-aided manufacturing (CAD/CAM). From 2010 to 2014, 12 patients with mandibular contour deformities were enrolled in our retrospective study. Mandible models and individualized surgical templates were fabricated by three-dimensional (3D) printing and Medpor® implants were made according to the surgical templates. The Medpor® implants were used for both unilateral and bilateral mandibular contour deformities. In four cases, simultaneous mandibular orthognathic surgery was performed with unilateral mandibular contour reconstruction. Eleven patients had a reposeful postoperative recovery with no complication. Delayed infection was shown in one patient and the Medpor® implant was removed. All the 11 patients had the mandibular contour reconstructed satisfactorily. The technique and cases presented demonstrate the utility of Medpor® implants with CAD/CAM in comprehensive mandibular contour reconstruction. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Accelerating orthodontic tooth movement: A new, minimally-invasive corticotomy technique using a 3D-printed surgical template.

BackgroundA reduction in orthodontic treatment time can be attained using corticotomies. The aggressive nature of corticotomy due to the elevation of muco-periosteal flaps and to the duration of the surgery raised reluctance for its employ among patients and dental community. This study aims to provide detailed information on the design and manufacture of a 3D-printed CAD-CAM (computer-aided design and computer-aided manufacturing) surgical guide which can aid the clinician in achieving a minimally-invasive, flapless corticotomy.Material and MethodsAn impression of dental arches was created; the models were digitally-acquired using a 3D scanner and saved as STereoLithography ( STL ) files. The patient underwent cone beam computed tomography (CBCT): images of jaws and teeth were transformed into 3D models and saved as an STL file. An acrylic template with the design of a surgical guide was manufactured and scanned. The STLs of jaws, scanned casts, and acrylic templates were matched. 3D modeling software allowed the view of the 3D models from different perspectives and planes with perfect rendering. The 3D model of the acrylic template was transformed into a surgical guide with slots designed to guide, at first, a scalpel blade and then a piezoelectric cutting insert. The 3D STL model of the surgical guide was printed.ResultsThis procedure allowed the manufacturing of a 3D-printed CAD/CAM surgical guide, which overcomes the disadvantages of the corticotomy, removing the need for flap elevation. No discomfort, early surgical complications or unexpected events were observed.ConclusionsThe effectiveness of this minimally-invasive surgical technique can offer the clinician a valid alternative to other methods currently in use. Key words:Corticotomy, orthodontics, CAD/CAM, minimally invasive, surgical template, 3D printer.