3D-printing techniques in a medical setting : a systematic literature review

Background: Three-dimensional (3D) printing has numerous applications and has gained much interest in the medical world. The constantly improving quality of 3D-printing applications has contributed to their increased use on patients. This paper summarizes the literature on surgical 3D-printing applications used on patients, with a focus on reported clinical and economic outcomes. Methods: Three major literature databases were screened for case series (more than three cases described in the same study) and trials of surgical applications of 3D printing in humans. Results: 227 surgical papers were analyzed and summarized using an evidence table. The papers described the use of 3D printing for surgical guides, anatomical models, and custom implants. 3D printing is used in multiple surgical domains, such as orthopedics, maxillofacial surgery, cranial surgery, and spinal surgery. In general, the advantages of 3D-printed parts are said to include reduced surgical time, improved medical outcome, and decreased radiation exposure. The costs of printing and additional scans generally increase the overall cost of the procedure. Conclusion: 3D printing is well integrated in surgical practice and research. Applications vary from anatomical models mainly intended for surgical planning to surgical guides and implants. Our research suggests that there are several advantages to 3D- printed applications, but that further research is needed to determine whether the increased intervention costs can be balanced with the observable advantages of this new technology. There is a need for a formal cost-effectiveness analysis

Synthetic skull bone defects for automatic patient-specific craniofacial implant design

Patient-specific craniofacial implants are used to repair skull bone defects after trauma or surgery. Currently, cranial implants are designed and produced by third-party suppliers, which is usually time-consuming and expensive. Recent advances in additive manufacturing made the in-hospital or in-operation-room fabrication of personalized implants feasible. However, the implants are still manufactured by external companies. To facilitate an optimized workflow, fast and automatic implant manufacturing is highly desirable. Data-driven approaches, such as deep learning, show currently great potential towards automatic implant design. However, a considerable amount of data is needed to train such algorithms, which is, especially in the medical domain, often a bottleneck. Therefore, we present CT-imaging data of the craniofacial complex from 24 patients, in which we injected various artificial cranial defects, resulting in 240 data pairs and 240 corresponding implants. Based on this work, automatic implant design and manufacturing processes can be trained. Additionally, the data of this work build a solid base for researchers to work on automatic cranial implant designs. Image Acquisition Matrix Size center dot Image Slice Thickness center dot craniofacial regionimaging technique center dot computed tomography Sample Characteristic - Organism Machine-accessible metadata file describing the reported data: https://doi.org/10.6084/m9.figshare.13265225This investigation was approved by the internal review board (IRB) of the Medical University of Graz, Austria (IRB: EK-30-340 ex 17/18). This work was supported by CAMed (COMET K-Project 871132), which is funded by the Austrian Federal Ministry of Transport, Innovation and Technology (BMVIT) and the Austrian Federal Ministry for Digital and Economic Affairs (BMDW) and the Styrian Business Promotion Agency (SFG). Furthermore, the Austrian Science Fund (FWF) KLI 678-B31: "enFaced: Virtual and Augmented Reality Training and Navigation Module for 3D-Printed Facial Defect Reconstructions" and the TU Graz LEAD Project "Mechanics, Modeling and Simulation of Aortic Dissection". Privatdozent Dr. Dr. Jan Egger was supported as Visiting Professor by the Overseas Visiting Scholars Program from the Shanghai Jiao Tong University (SJTU) in China. Finally, we thank Professor Hannes Deutschmann, MD, from the Department of Radiology - Division of Neuroradiology, Vascular and Interventional Neuroradiology of the Medical University of Graz, for having kindly provided us with the source CT datasets used in this work

Unveiling the prospects of point-of-care 3D printing of Polyetheretherketone (PEEK) patient-specific implants

Additive manufacturing (AM) or three-dimensional (3D) printing is rapidly gaining acceptance in the healthcare sector. With the availability of low-cost desktop 3D printers and inexpensive materials, in-hospital or point-of-care (POC) manufacturing has gained considerable attention in personalized medicine. Material extrusion-based [Fused Filament Fabrication (FFF)] 3D printing of low-temperature thermoplastic polymer is the most commonly used 3D printing technology in hospitals due to its ease of operability and availability of low-cost machines. However, this technology has been limited to the production of anatomical biomodels, surgical guides, and prosthetic aids and has not yet been adopted into the mainstream production of patient-specific or customized implants. Polyetheretherketone (PEEK), a high-performance thermoplastic polymer, has been used mainly in reconstructive surgeries as a reliable alternative to other alloplastic materials to fabricate customized implants. With advancements in AM systems, prospects for customized 3D printed surgical implants have emerged, increasing attention for POC manufacturing. A customized implant may be manufactured within few hours using 3D printing, allowing hospitals to become manufacturers. However, manufacturing customized implants in a hospital environment is challenging due to the number of actions necessary to design and fabricate the implants. The focus of this thesis relies on material extrusion-based 3D printing of PEEK patient-specific implants (PSIs). The ambitious challenge was to bridge the performance gap between 3D printing of PEEK PSIs for reconstructive surgery and the clinical applicability at the POC by taking advantage of recent developments in AM systems. The main reached milestones of this project include: (i) assessment of the fabrication feasibility of PEEK surgical implants using material extrusion-based 3D printing technology, (ii) incorporation of a digital clinical workflow for POC manufacturing, (iii) assessment of the clinical applicability of the POC manufactured patient-specific PEEK scaphoid prosthesis, (iv) visualization and quantification of the clinical reliability of the POC manufactured patient-specific PEEK cranial implants, and (v) assessment of the clinical performance of the POC manufactured porous patient-specific PEEK orbital implants. During this research work, under the first study, we could demonstrate the prospects of FFF 3D printing technology for POC PEEK implant manufacturing. It was established that FFF 3D printing of PEEK allows the construction of complex anatomical geometries which cannot be manufactured using other technologies. With a clinical digital workflow implementation at the POC, we could further illustrate a smoother integration and faster implant production (within two hours) potential for a complex-shaped, patented PEEK patient-specific scaphoid prosthesis. Our results revealed some key challenges during the FFF printing process, exploring the applicability of POC manufactured FFF 3D printed PEEK customized implants in craniofacial reconstructions. It was demonstrated that optimal heat distribution around the cranial implants and heat management during the printing process are essential parameters that affect crystallinity, and thus the quality of the FFF 3D printed PEEK cranial implants. At this stage of the investigation, it was observed that the root mean square (RMS) values for dimensional accuracy revealed higher deviations in large-sized cranial prostheses with “horizontal lines” characteristics. Further optimization of the 3D printer, a layer-by-layer increment in the airflow temperature was done, which improved the performance of the FFF PEEK printing process for large-sized cranial implants. We then evaluated the potential clinical reliability of the POC manufactured 3D printed PEEK PSIs for cranial reconstruction by quantitative assessment of geometric, morphological, and biomechanical characteristics. It was noticed that the 3D printed customized cranial implants had high dimensional accuracy and repeatability, displaying clinically acceptable morphologic similarity concerning fit and contours continuity. However, the tested cranial implants had variable peak load values with discrete fracture patterns from a biomechanical standpoint. The implants with the highest peak load had a strong bonding with uniform PEEK fusion and interlayer connectivity, while air gaps and infill fusion lines were observed in implants with the lowest strength. The results of this preclinical study were in line with the clinical applicability of cranial implants; however, the biomechanical attribute can be further improved. It was noticed that each patient-specific reconstructive implant required a different set of manufacturing parameters. This was ascertained by manufacturing a porous PEEK patient-specific orbital implant. We evaluated the FFF 3D printed PEEK orbital mesh customized implants with a metric considering the design variants, biomechanical, and morphological parameters. We then studied the performance of the implants as a function of varying thicknesses and porous design constructs through a finite element (FE) based computational model and a decision matrix based statistical approach. The maximum stress values achieved in our results predicted the high durability of the implants. In all the implant profile configurations, the maximum deformation values were under one-tenth of a millimeter (mm) domain. The circular patterned design variant implant revealed the best performance score. The study further demonstrated that compounding multi-design computational analysis with 3D printing can be beneficial for the optimal restoration of the orbital floor. In the framework of the current thesis, the potential clinical application of material extrusion-based 3D printing for PEEK customized implants at the POC was demonstrated. We implemented clinical experience and engineering principles to generate a technical roadmap from preoperative medical imaging datasets to virtual surgical planning, computer-aided design models of various reconstructive implant variants, to the fabrication of PEEK PSIs using FFF 3D printing technology. The integration of 3D printing PEEK implants at the POC entails numerous benefits, including a collaborative team approach, quicker turnaround time of customized implants, support in pre-surgical and intraoperative planning, improved patient outcomes, and decreased overall healthcare cost. We believe that FFF 3D printing of customized PEEK implants could become an integral part of the hospitals and holds potential for various reconstructive surgery applications

Radiological Society of North America (RSNA) 3D printing Special Interest Group (SIG): Guidelines for medical 3D printing and appropriateness for clinical scenarios

Este número da revista Cadernos de Estudos Sociais estava em organização quando fomos colhidos pela morte do sociólogo Ernesto Laclau. Seu falecimento em 13 de abril de 2014 surpreendeu a todos, e particularmente ao editor Joanildo Burity, que foi seu orientando de doutorado na University of Essex, Inglaterra, e que recentemente o trouxe à Fundação Joaquim Nabuco para uma palestra, permitindo que muitos pudessem dialogar com um dos grandes intelectuais latinoamericanos contemporâneos. Assim, buscamos fazer uma homenagem ao sociólogo argentino publicando uma entrevista inédita concedida durante a sua passagem pelo Recife, em 2013, encerrando essa revista com uma sessão especial sobre a sua trajetória

Anatomical and functional custom made restoration techniques with Direct Metal Laser Forming technology: systematic workflow and CAD-CAM

Introduction Bone defects are usually repaired by the body’s healing process itself. If severe fracture, tumor or infection occur on large bones, it poses a serious challenge to the regeneration ability of the bones. One of the latest advancement in medical science is the rapid prototyping technologies. Therefore, the aim of the present study was the developing and testing of a reliable workflow to fabricate custom-made grafts in the field craniofacial surgery. Material and Methods In this study 14 patients with different cranio-facial bone defects were enrolled. Two evaluation methods were associated to test the results of the workflow. Surveys were given to patients undergone surgery and their surgeons to have a subjective analysis of the workflow. For each patient the produced prosthesis was superimposed on the original prosthesis design, the displacement between was evaluated. Results Significant level of discomfort at 4 weeks after surgery compared to 2 days after surgery, aesthetic improvement significant improved 1 year after surgery compared to 4 weeks after surgery. Aesthetic improvement 1 year after surgery and aesthetic improvement according to expectations showed correlation, aesthetic improvement 1 year after surgery and aesthetic improvement according to expectations showed correlation. The mean distance of the printed model was significant smaller than the virtual model, with a mean difference of -0.075 mm. Conclusion According to the results of the present study custom made bone graft made with laser sintering technique represents a valid alternative to traditional bone grafts with high clinical accuracy and the advantage to avoid morbidity of the donor site or of the patient due to animal grafting

Histological Processing of CAD/CAM Titanium Scaffold after Long-Term Failure in Cranioplasty

Cranioplasty is a frequently performed procedure after craniectomy and includes several techniques with different materials. Due to high overall complication rates, alloplastic implants are removed in many cases. Lack of implant material osseointegration is often assumed as a reason for failure, but no study has proven this in cranioplasty. This study histologically evaluates the osteointegration of a computer-aided design and computer-aided manufacturing (CAD/CAM) titanium scaffold with an open mesh structure used for cranioplasty. A CAD/CAM titanium scaffold was removed due to late soft tissue complications 7.6 years after cranioplasty. The histological analyses involved the preparation of non-decalcified slices from the scaffold's inner and outer sides as well as a light-microscopic evaluation, including the quantification of the bone that had formed over the years. Within the scaffold pores, vital connective tissue with both blood vessels and nerves was found. Exclusive bone formation only occurred at the edges of the implant, covering 0.21% of the skin-facing outer surface area. The inner scaffold surface, facing towards the brain, did not show any mineralization at all. Although conventional alloplastic materials for cranioplasty reduce surgery time and provide good esthetic results while mechanically protecting the underlying structures, a lack of adequate stimuli could explain the limited bone formation found. CAD/CAM porous titanium scaffolds alone insufficiently osseointegrate in such large bone defects of the skull. Future research should investigate alternative routes that enable long-term osteointegration in order to reduce complication rates after cranioplasty. Opportunities could be found in mechano-biologically optimized scaffolds, material modifications, surface coatings, or other routes to sustain bone formation