3D printing for perioperative planning has been around since the birth of STL. However, the medical community has gone through many milestones, and this “From Academia” blog highlights three recent publications demonstrating how the surgical communities are reinventing old surgical techniques using new 3D technologies, racing from 3D printed soft anatomical models, new 3D software tools, finite element analysis, to artificial intelligence and cloud computing. The first article is a review focusing on different applications of 3D printing in breast cancer management, ranging from visualization help to surgical guides that may be more superior to conventional guidance to post-surgical radiation treatment guidance. The second article is a research paper focusing on creating streamlined workflow leveraging improved, more automated segmentation processes (for soft tissues) and soft material 3D printing technologies to create better neurosurgical planning by creating 3D printed patient-specific brain tumour models. The final paper describes the use of affordable 3D printing technology to produce ready-to-use, sterilizable auricular carving and framework sizing templates to guide the perioperative sculpture of the cartilaginous framework during microtia reconstruction, considered one of the most challenging procedures in the field of reconstruction surgery.

“From Academia” features recent, relevant, close to commercialization academic publications. Subjects include but not limited to healthcare 3D printing, 3D bioprinting, and related emerging technologies.

Email: Rance Tino ( info@3dheals.com ) if you want to share relevant academic publications with us.

Applications of 3D printing in breast cancer management

Authored by Arpine Galstyan, Michael J. Bunker, Fluvio Lobo, Robert Sims, James Inziello, Jack Stubbs, Rita Mukthar & Tatiana Kelil. 3D printing in Medicine. February 9 2021

Clinical application of patient-specific 3D printing brain tumor model production system for neurosurgery

Authored by Yun-Sik Dho, Doohee Lee, Teahyun Ha, So Young Ji, Kyung Min Kim, Ho Kang, Min-Sung Kim, Jin Wook Kim, Won-Sang Cho, Yong Hwy Kim, Young Gyu Kim, Sang Joon Park & Chul-Kee Park. Nature Scientific Reports. March 26 2021

Multiscale sterilizable 3D printed auricular templates to guide cartilaginous framework sizing and sculpture during autologous microtia reconstruction

Authored by Bushra Alhazmi, Feras Alshomer, Bassam Alawirdhi. JPRAS open. March 19 2021

Related Articles:

Medical 3D Printing for Surgery: Anatomical Models and Surgical Guides

3D Printing and Bioprinting For Cancer Care – Guide

3D Bioprinting for Bone Regeneration

From Academia: 3D Printing for Neurosurgery Training, Vat Photopolymerization, soft robotic microsystem

From Academia: In Vivo & Robotic-assisted Minimally Invasive Bioprinting, 3DP for Liver Surgery

Smart Spine Surgery- From Planning to 3D Printed Templates

The Past and Present of 3D Printing in Maxillofacial Surgery

Other Expert Corner Blogs

Other From Academia Blogs

The post 3D Printing for Perioperative Planning of Breast Cancer, Brain Tumor, and Microtia appeared first on 3DHeals.

史俊，副主任医师/副教授/医学博士，上海交通大学医学院附属第九人民医院。 中华口腔医学会口腔颌面外科专科会员，中华口腔医学会口腔种植专科会员，上海市口腔医学会口腔颌面外科专业委员会青年委员，国际内固定协会（AO/ASIF）会员，国际内固定协会（AO/ASIF）亚太地区讲师1993年9月至2000年7月就读于于上海交通大学医学院（原上海第二医科大学），毕业后获口腔医学硕士学位。其后于上海交通大学医学院附属第九人民医院口腔颌面外科工作至今，主要从事口腔颌面部畸形的治疗的临床和科研工作。2003年9月至2006年6月，于上海交通大学医院原攻读口腔临床医学博士学位，师从中国工程院院士邱蔚六教授； 2008年赴德国Hannover大学进修。
史俊医师在口腔颌面部畸形的治疗和研究中具丰富工作经历，同时在应用医学图像分割、三维重建、口腔颌面外科手术导航等领域积累了丰富的研究经验。目前已发表第一作者论文11篇，参编著作3部。 主持上海市局级科研项目2项，国家教育部科研项目1项。
Shi Jun, Deputy Chief Physician/Associate Professor/Medical Doctor, Ninth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine. Member of the Oral and Maxillofacial Surgery Department of the Chinese Stomatological Association, member of the Oral Implantology Specialist of the Chinese Stomatological Association, Young Member of the Oral and Maxillofacial Surgery Committee of the Shanghai Stomatological Association, Member of the International Association of Internal Fixation (AO/ASIF), International Association of Internal Fixation ( AO/ASIF) Asia-Pacific lecturer studied at Shanghai Jiaotong University School of Medicine from September 1993 to July 2000 (formerly Shanghai Second Medical University) and obtained a master’s degree in stomatology after graduation. Later, he worked in the Department of Oral and Maxillofacial Surgery of the Ninth People’s Hospital affiliated to Shanghai Jiao Tong University School of Medicine. He is mainly engaged in the clinical and scientific research of the treatment of oral and maxillofacial deformities. From September 2003 to June 2006, he studied for a doctoral degree in oral clinical medicine at Shanghai Jiaotong University Hospital. He studied under Professor Qiu Weiliu of the Chinese Academy of Engineering. In 2008, he went to Hannover University in Germany for further study. Dr. Shi Jun has a wealth of work experience in the treatment and research of oral and maxillofacial deformities and has accumulated rich research experience in the fields of medical image segmentation, three-dimensional reconstruction, oral and maxillofacial surgery navigation. At present, 11 first author papers have been published and 3 books have been edited. He has presided over 2 Shanghai-level scientific research projects and 1 research project of the Ministry of Education.

Dr. Shi Jun will be a speaker at the Shanghai event!

Jenny: 您第一次接触3D打印是什么时候？在什么情况下？那一刻的感受是什么？
When was the first time you touched 3D printing? under what conditions? What was the feeling at that moment?
Dr. Shi: 2003，一个复杂的面部外伤畸形病例，打印了一个纸质的头颅。立体影刷啊，很厉害的样子，跟传统的平面打印不一样哦。A new era begins. 但是，打印出来的stuff只能看看，临床的作用还不大。
Dr. Shi: In 2003, We 3D- printed a paper skull for a complex case of facial trauma. The three-dimensional structure is very impressive visually, and definitely not the same as traditional flat print. A new era begins. However, the 3d-printed models can only be used as a visual tool, the clinical role was not significant.
Jenny: 是什么因素促使您开始研究或从事3D打印（生物制造/生物打印）？
What prompted you to start research or engage in 3D printing (biological manufacturing/bioprinting)?

Dr. Shi: 博士课题开始于2004年初，做得是FEA。课题组的合作伙伴后来主要研发三维打印材料和工艺，并有了共同的科研小组。
Dr. Shi: I started my Ph.D. program in early 2004 and was done as FEA. The team’s partners later developed three-dimensional printed materials and processes, and a collaborative research team.
Jenny: 在从事3D打印（生物打印/生物制造）的过程中，谁对您的影响最大？是导师、病人、名人，还是其他人？您可以说出一个或多个。
Who is most affected by you in the process of 3D printing (biological printing / bio-manufacturing)? Is it a mentor, a patient, a celebrity, or someone else? You can say one or more.

Dr. Shi: 合作伙伴。姜闻博博士。
Dr. Shi:  Partners. Dr. Jiang Wenbo.
Jenny: 激励您从事3D打印的因素是什么？
What are the factors that motivate you to engage in 3D printing?

Dr. Shi: 发展越来越快，越来越能贴近临床应用，并获得良好的疗效。
Dr. Shi: The development of 3D printing technology is getting faster and faster, and there are more and more clinical applications with better clinical results.
Jenny: 您工作中最大的障碍是什么？如果您已经克服了这些障碍，您用的是什么方法？
What is the biggest obstacle in your work? If you have overcome these obstacles, what method do you use?

Dr. Shi: 无法合法合规的应用打印的医疗器械。貌似无法克服。
Dr. Shi:  A Lack of standardization and regulation to properly produce 3D-printed medical devices. We have not overcome that barrier. 
Jenny: 您认为“3D打印/生物打印”的最大挑战是什么？应对这些挑战的潜在解决方案是什么？
What do you think is the biggest challenge of “3D printing / bio-printing”? What are the potential solutions to these challenges?
Dr. Shi: 生物打印方面，理想的打印体系研发很重要。材料科学的快递进步和创新很重要。
Dr. Shi: In terms of bioprinting, the development of an ideal bioprinting process is very important. Faster material science innovation in this area is very important.
Jenny: 如果您有机会通过一个巨大的广告牌，向我们这个行业（如：医疗3D打印和生物制造）的数百万人，甚至数亿人宣传一个理念，您会在这个广告牌上写一条什么样的信息？
If you have the opportunity to promote a concept to millions of people in our industry (eg medical 3D printing and bio-manufacturing) through a huge billboard, what would you write on this billboard? Information?

Dr. Shi: Expand your touch via tech.
Jenny: 您职业生涯中曾遭遇的最大风险是什么？
What is the biggest risk you have encountered in your career?

Dr. Shi: 医患关系在遭遇医疗意外时的脆弱

Dr. Shi: The fragile relationship between doctors and patients in the event of a medical accident.
Jenny: 您的业余爱好是什么？在您的工作/3D打印之外，您对什么最有兴趣？
What is your hobby? What are you most interested in outside of your work/3D printing?
Dr. Shi: 业余爱好学习佛法；人工智能和机器人技术在整形领域中的开拓。
Dr. Shi: Learn Dharma; the development of artificial intelligence and robotics in the field of plastic surgery.
Jenny: 您的人生格言是什么？为什么?
What is your life motto? why?
Dr Shi: 色即是空，空即是色。不为什么。
Dr Shi: “Color is empty, empty is color. No reason.” (Buddhist philosophy)

The post Interview: Dr. Shi Jun (史俊), Oral and Maxillofacial Surgery, China appeared first on 3DHeals.

(What is your favorite quote? Why?)

“The mediocre teacher tells. The good teacher explains. The superior teacher demonstrates.  The great teacher inspires.” William Arthur Ward

As a doctor, we are all called to be teachers and mentors.  This serves as my beacon, in that I am here not just to impart knowledge and skills, but to model the professional behavior/approach of a physician.”

 

Ching Kit completed his undergraduate medical studies at the National University of Singapore and post-graduate training in Paediatrics and Pediatric Cardiology in Singapore. He subsequently did a fellowship in pediatric heart failure, mechanical circulatory support and heart transplantation at the Hospital for Sick Children, Toronto, Canada.  During his 2-year fellowship, he participated in a range of research projects resulting in numerous abstracts and publications. Upon returning to Singapore, he has started a pediatric advanced heart failure program (including mechanical circulatory support for children) in KK Women’s and Children’s Hospital and has successfully established a pediatric heart transplant and mechanical cardiac support programme in Singapore. His clinical areas of interest cover dilated cardiomyopathy, exercise echocardiography in cardiomyopathy and congenital heart disease, and fetal cardiovascular flow dynamics, while research areas of expertise and experience include 3D printing of heart models, exercise echocardiography, and fetal cardiology.

Dr. Chen Ching Kit will be our speaker at our first Singapore Event

Jenny: When was the first encounter you had with 3D printing? What was that experience like? What were you thinking at that moment?
Chen: This was back in 2012 when I was in Toronto, Canada.  I was shown a 3D printed heart model of double outlet right ventricle by a colleague at the Hospital for Sick Children. He showed me how it made a difference to the surgical planning of the patient.

Dr. Chen with a 3D-printed model of a heart. Congenital heart surgery is more challenging when it involves children as they are smaller in size. This is where having a heart printed in 3D form can be very useful. ST PHOTO: MARK CHEONG

I had not seen a 3D printed heart model prior to that, and I thought that it was really a neat thing to do. To my mind, the ability to present the complex anatomy with a 3D printed model would be a game-changer.
Jenny: What inspired you to start your journey in 3D printing ?
Chen: Back in 2014 when I was back in Singapore, we had a patient whom the attending cardiologists could not agree upon with respect to the morphologic diagnosis, and obviously the cardiac surgeons were confused.  There was a lot of debate during the discussion, and I thought that it would be useful to print the heart out and verify the anatomic diagnosis. And we did just that, and it proved very useful especially to the surgeons. Since then, I would offer to help print a heart model if the anatomy is complex, and if the surgeons are uncertain of the best surgical approach.  
Jenny: Who inspired you the most along this journey in 3D printing ? This can be a mentor, a patient, a celebrity, anyone basically. You can name more than one as well.
Chen: Dr. Shi-Joon Yoo from the Hospital for Sick Children.  He provided me with some advice and guidance when I started out on this journey.
Jenny: What motivates you the most for your work?
Chen: The satisfaction in making a difference in the lives of my patients, as well as innovating the way we provide care to our patients.
Jenny: What is/are the biggest obstacle(s) in your line of work? If you have conquered them, what were your solutions?
Chen: Time constraint. There is much to be done, but there isn’t always enough time. Still learning to juggle.
Jenny: What do you think is (are) the biggest challenge(s) in 3D Printing/bio-printing? What do you think the potential solution(s) is (are)?
Chen: In my opinion, the high cost involved in 3D printing is the greatest limitation. However, I believe that the cost will gradually improve in time with greater adoption of this technology.
Jenny: What advice would you give to a smart driven college student in the “real world”? What bad advice you heard should they ignore?
Chen: I would advise him to pursue his passion unreservedly, and to identify a good mentor who would be willing to walk the journey with him during his career.  
I don’t think that there is necessarily bad advice…. Just what would work and what wouldn’t and these vary from individual to individual.
Jenny: If you could have a giant billboard to promote a message to millions and even billions of people in our community (i.e. healthcare 3D printing and bio-fabrication), what message would that be?
Chen: At least from the perspective of a pediatric cardiologist, I would like the message to be something like… “3D printing… the next stage in the evolution of cardiovascular imaging.”
Jenny: What was/is the biggest risk you took in your career?
Chen: Changing career from a full-time clinician to a clinician-scientist.
Jenny: What do you enjoy in your spare time? What are you passionate about outside of your work/3d printing?
Chen: The only thing I do outside of work is Krav Maga.  And, I very much enjoy scuba diving! I do 1-2 dive trips each year.
Jenny: What does the word “3DHEALS” mean to you?  =)
Chen: Healing/impact patient care through 3D innovations.
 

The post Interview: Dr. Chen Ching Kit, Pediatric Cardiac 3D Printing, Singapore appeared first on 3DHeals.

Dr ALALI, currently works in the plastic surgery department, Babtain center of the plastic and reconstructive surgery, Kuwait

Completed MSc in plastic and reconstructive surgery in University College London on 3D printing application in plastic surgery, Dr ALALI published a couple of papers on this subject and attended several conferences to promote 3D printing in healthcare.

Furthermore, Dr ALALI is a board member in an international society of digital medicine and editorial board member in the journal of digital medicine. He is currently a 3DHEALS community manager. 

 “I think our field is becoming more and more dynamic every day which is beneficial for our patients, we all want to deliver the best health care, the best is yet to come, I would love to see the bioprinting and organogenesis to be a tool that we no longer lose someone we love because of our limitations.”

 
Community: Kuwait 

3DHEALS members can get in touch with Dr. Ahmad ALALI here

Dr. Ahmad ALALI’s publications in healthcare 3D Printing:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4539849/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4859248/
https://www.ncbi.nlm.nih.gov/pubmed/28869160

Jenny: Tell us, what is one quote that represents you?
Ahmad: “Two things define you:
Your patience when you have nothing and your attitude when you have everything.”
Jenny: Tell us a little about yourself. (Where are you from originally? Where are you located? What are you working on?)
Ahmad: I was born and raised in Kuwait where I obtained my medical degree, I moved to London, did my MSc in Plastic and reconstructive surgery. I love research because it gives us answers to questions we have, and these answers aren’t limited to ourselves.
Jenny: What made you decide to become a 3DHEALS community manager?
Ahmad: I always love to share the experience and contribute to the society and the science, it is a great opportunity to advance, as it mentioned in quotes, success is never a one-man show.
Jenny: What do you think of innovations in healthcare 3D printing or bioprinting? What do you hope to see in the next five years? 10 years?
Ahmad: I think our field is becoming more and more dynamic every day which is beneficial for our patients, we all want to deliver the best health care, the best is yet to come, I would love to see the bioprinting and organogenesis to be a tool that we no longer lose someone we love because of our limitations.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4859248/
Jenny: If you have done 3D printing before, what have you made/designed? (Photos if available, preferably in healthcare application)
Ahmad: I designed a couple of things but the closest project to me is the real patient’s models of cleft lip and palate which were obtained from imaging data and transferred to models for education and training.
Jenny: Most of our community managers are entrepreneurial and adventurous, what risks/adventures have you taken that you’d like to share with us? Any hopes or regrets?
Ahmad: Life is about taking risks, while you always need to think deeply, I try never to regret because it leads to nowhere. I always look forward to the next big thing coming.
Jenny: What would you like to accomplish with this new 3DHEALS community in the future?
Ahmad: I would like to spread the knowledge and gather the interested people from around, also I love to bridge the gap between continents, thanks to technology that’s now easy achievable
Jenny: What do you think about the innovation environment (for health tech or for general technology) in your city? What can be done to improve it?
Ahmad: I think we have the resources but we don’t have the efforts of bringing the people together, brainstorm and share ideas
Jenny: What are you most proud of about your city?
Ahmad: The diversity, the support of science, and learning.
Jenny: What are you most proud of about the innovation community in your city?
Ahmad: The youth spirit of challenging themselves
Jenny: What do you think are the top priorities in healthcare innovations for your city/community?
Ahmad: I think it’s the same everywhere, we all aim to advance and achieve our goal of enhancing healthcare management.
Jenny: What do you hope to accomplish through your role as the 3DHEALS community manager?
Ahmad: I hope to bridge the gap, organize events, and make a group to share expertise and work together on promising projects which reflect on all of healthcare.
Jenny: What do you do for fun?
Ahmad: I travel, I love to explore places, It’s a great thing that the map is big enough to explore
Jenny: Anything else?
Ahmad: I’m honored and proud to be part of this great community, the best is yet to come 

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Interview: Richard Doerer, Detroit, Michigan, Director of Technology, BioModel3D

3DHEALS Newsletter, December 24th, 2018

The post Interview: Dr. Ahmad ALALI, 3D Printing in Plastic Surgery appeared first on 3DHeals.

Dr Paul S D’Urso is an Australian Neurosurgeon and the Founder & Executive Chairman of the Anatomics group of companies in Melbourne, Australia. His unique experience in research, clinical practice, teaching, commercialization and medico-legal opinion has made him an internationally recognized Australian neurosurgeon, scientist, and innovator. Dr. D’Urso invented the technology of BioModelling with groundbreaking Ph.D. research and founded Anatomics, one of the world’s most innovative medical software & device companies in 1995. Dr. D’Urso was a fellow at the Cambridge University Neurosurgery unit and a clerk at Harvard Medical School. He has published and presented over 130 scientific papers, holds multiple international patents and has won over 30 prestigious research prizes. Dr. D’Urso will be our speaker for upcoming Melbourne event. 
Jenny: When was the first encounter you had with 3D printing? What was that experience like? What were you thinking at that moment?
Paul: My first experience of 3D printing was when I encountered Australia’s first 3D printer in 1991. It was a 3D Systems SLA 250. This was the first commercially released 3D printer. The term ‘3D printing’ didn’t exist at the time. We called it a stereolithography machine. It sat in its own special room behind a big window and was a marvel at the time. I could immediately see the potential of the technology in medicine and became committed to doing research to see if we could print body parts from CT scan data.

Sternum Design

Jenny: What inspired you to start your journey/company/career/research in 3D printing (bio-fabrication/bio-printing)?
Paul: The thought of being able to see and touch people’s internal anatomy before surgery inspired me to commence a Ph.D. to make the process possible. At that time this was only an idea but I wanted to make it a reality.
Jenny: Who inspired you the most along this journey in 3D printing (bio-printing/bio-fabrication)? This can be a mentor, a patient, a celebrity, anyone basically. You can name more than one as well.
Paul: My mentors were Prof Leigh Atkinson (neurosurgeon), Dr. Michael Lanigan (plastic surgeon), Prof David Effeney (vascular surgeon). They all encouraged me that my research was valuable and had a real impact on the surgery that they performed.
Jenny: What motivates you the most for your work?
Paul: Taking ideas and making them a reality so as to improve the way that surgery is performed.
Jenny: What is/are the biggest obstacle(s) in your line of work? If you have conquered them, what were your solutions?
Paul: There have been so many obstacles. Initially, it was the lack of computing power and software and the lack of data compatibility. Subsequently, professional jealousy and resistance by colleagues to adopt new techniques. Most recently regulatory and insurance bureaucracy.
Jenny: What do you think is (are) the biggest challenge(s) in 3D Printing/bio-printing? What do you think the potential solution(s) is (are)?
Paul: To achieve the full potential of 3D printing regulators around the world will need to recognize that it is the ‘process’ of mass customization that requires regulation and not the end ‘device’. 3D printing allows prosthetic devices to have infinite specifications to best suit individual patients. Once the regulators create a ‘process orientated’ regulatory system government and insurers will recognize the enormous benefits that 3D printing technology can deliver. Surgeons need to understand that if they plan a procedure in advance 3D printing can allow a patient-specific solution to be manufactured. Planning will improve surgical workflow and patient outcomes and lead to greater satisfaction for all people involved.

Sternum Design

Jenny: If you are granted three wishes by a higher being, what would they be?
Paul:

• The FDA creates a ‘process orientated’ regulatory pathway for prosthetic implants.
• That hospitals recognize the enormous benefit that patient-specific solutions can deliver.
• That surgeon comes to understand that planning will improve efficiency and outcomes.

Jenny: What advice would you give to a smart driven college student in the “real world”? What bad advice you heard should they ignore?
Paul: Don’t give up on realizing your dream. Become resilient despite constant setbacks. Understand that the majority of people see the glass as being half empty and want to understand how they can personally benefit. Be very patient as bureaucratic inertia is extremely difficult to overcome.
Jenny: If you could have a giant billboard to promote a message to millions and even billions of people in our community (i.e. healthcare 3D printing and bio-fabrication), what message would that be?
Paul: Personalized healthcare benefits all people!
Jenny: What were/was the best investment you made in 3D printing/bio-printing/bio-fabrication?
Paul: $50000 to buy Australia’s first 3D printer. Anatomics is still using it!
Jenny: What were/was the worst investment you made in 3D printing/bio-printing/bio-fabrication?
Paul: Software development that lead to nothing.
Jenny: What was/is the biggest risk you took in your career?
Paul: So many risks as a Neurosurgeon and founder of Anatomics! The biggest was commencing my Ph.D. to develop BioModelling technology in 1992 before I knew if it was even possible to 3D print from CT data.
Jenny: What do you enjoy in your spare time? What are you passionate about outside of your work/3d printing?
Paul: Riding my bicycle and drinking red wine.
Jenny: What is your favorite quote? Why?
Paul: A fool with a tool is still a fool.
Jenny: What does the word “3DHEALS” mean to you? =)
Paul: Inspiration from San Francisco to turn people on to BioModelling technology.

The post Interview: Dr. Paul D'Urso, Australian Neurosurgeon and the Founder & Executive Chairman of the Anatomics appeared first on 3DHeals.

Want to write a piece for 3DHEALS Expert Corner? Email us: info@3dheals.com

(THIS IS A RE-POST OF DR. OTERO’S LINKEDIN POST.)
Dear colleagues and friends,
I have spent almost a year doing a clinical fellowship with Prof. Maurice Mommaerts at the European Face Centre in Brussels, a referral for hemifacial microsomia and surgery. I have noticed that patients are increasingly aware of facial asymmetries, although many of them are not related to malocclusions. I would love to hear how these patients are treated in other clinics.
I will describe the treatment options we currently use for unilateral or bilateral jaw angle deficiency, which detailed in an interesting paper by Büttner and Mommaerts (2015). The causes of facial asymmetries will not be discussed here. Let us assume there is no malignancy or progressive disease underlying the asymmetry.
A well-defined jawline is a sign of strength, youth, health, and sexual attractiveness. The jawline is less attractive when one or more of the following are present: overlying saggy skin, excess fat deposits, masseteric hypertrophy, or inadequate bone structure. The ideal proportions have varied over time and between cultures. In the contemporary Western world, the most attractive jawline angle in the profile view is considered to be 130° (±2°) for men and 126° (±2°) for women. It should have a gentle but well-defined slope that starts at the height of the nasal ala at 65–75° degrees from the Frankfort horizontal plane (Mommaerts, 2016). In the frontal view, the male jaw width should be similar or slightly less than the distance between the left and right, with the vertical position of the angle at the level of the lip commissure. For women, the intergonial width is generally smaller, aiming for an oval shape, but this depends on the patient’s wishes and sociodemographic factors. Scientific data about this are limited.

When jaw definition is lacking, we have the following options:
1-   For a transverse deficiency, hydroxyapatite and calcium carbonate are mixed with fibrin sealant and inserted through a standard sagittal split osteotomy incision as an implant for minor cases.
2-   When performing a bilateral sagittal split in orthognathic surgery, the condylar segment is rotated clockwise which vertically lengthens and accentuates the jaw angle. If a step is noticed between the two segments at the lower border of the ramus, calcium-phosphate cement works well covering the gap provided the osteotomy is left undisturbed long enough for it to set.
3-   For more significant jaw angle deficiencies we use a three-dimensional (3D) custom-made titanium implant. After verifying the facial asymmetry by computed tomography (CT), the DICOM images are segmented through ProPlan CMF® software, and then they are exported in STL format. The software allows this conversion if you do not use any of its additional features (e.g., performing osteotomies for orthognathic surgery).
The STL file is imported to Geomagic Freeform®, a relatively user-friendly software for processing 3D objects, which allows clay-like thanks to the haptic mouse. We establish a sagittal half and mirror it to the side that is likely to need treatment. There is an option for Boolean subtractions to precisely determine the volume needed to restore facial harmony. In cases where there is no optimal side, the angles are planned as explained above.
The file is sent to the company that makes the custom-made titanium implants. You will receive a 3D PDF to verify your design. After your approval, you will receive the titanium implant along with a 3D-printed plastic mandible so that you can test the fit. If the implant is too long, you receive a two-piece implant with matching notches (like puzzle pieces) that snap to its original shape. Please see the video above (reproduced with permission by ).
The incision is placed approximately 15 mm lateral to the oblique line of the mandible, starting at a midpoint of the occlusal plane up to the second premolar. Standard subperiosteal dissection is performed to completely expose the mandible angle. It is important to have a visual reference (e.g., the cusp of a molar) and fix the implant with two or three monocortical screws placed in an accessible area. We then use a quick cone beam CT to confirm that the implant is in the correct position. The wound is closed in layers, with Vicryl 4-0 sutures, followed by 3-0 sutures in a watertight manner. For successful healing, the incisions must be closed without tension.
This department has placed custom-made 3D-printed titanium facial implants in 24 patients (to correct asymmetries of the zygoma, frontal bone, orbital floor, and jaw) in the last 3 years. Two of these implants needed to be removed. In both cases, we believe the reason for failure was that the implants were too large: one has been replaced with a smaller implant, and the other one will soon be replaced in the same way.
Previous studies report a high rate of success with facial implants composed of alloplastic materials, such as polyetheretherketone (PEEK) or . Another option bone grafts, but they have disadvantages such as donor site morbidity and unpredictable resorption. Titanium appears to be a good material for bioactivity and osteointegration. increase in tension over the jaw angle produces a facelift effect highly appreciated by most patients.

Please share your approach to treating these patients!

Author

Dr. Joel Joshi Otero is an Oral and Maxillofacial surgeon trained in Seville, Spain. He later worked for three years as a Specialist in Hamad Medical Corporation (biggest governmental hospital in Qatar). Afterwards, he got accepted for further training and sub-specialized in Facial Cosmetic Surgery with Professor Maurice Mommaerts in the European Face Centre in Brussels, Belgium. This one-year fellowship is granted by the European Association of Oral and Cranio Maxillo-Facial Surgery.

References

Büttner, M and Maurice Y Mommaerts: Contemporary aesthetic management strategies for deficient jaw angles. news 2, 1–3 (2015).

Mommaerts, Maurice: The ideal male jaw angle — An Internet survey. Journal of Cranio-Maxillofacial Surgery 44, 381–391 (2016).

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Hui Jenny Chen, MD and Michelle Gabriel, MS, MBA
(This blog is adapted from our A Roadmap from Idea to Implementation: 3D Printing for Pre-Surgical Application: Operational Management for 3D Printing in Surgery)

Depending on existing infrastructure, creating an in-house center can be very expensive and require hard-to-find expertise. Often, it is not a viable initial option for smaller medical centers. Except for imaging acquisition, outsourcing is an option along each of the remaining six steps of the 3D printing workflow. Outsourcing these steps allows the medical center to bypass the initial cost/risk and associated operational challenges of creating an in-house service. Currently, several established companies like 3D System(NC, USA) and Materialise (Belgium) provide such services beyond their core businesses, including services on DICOM conversion, segmentation, and printing all-in-one services. The cost of these services can often amount to thousands of dollars. Although the absolute dollar value appears high for such services, in high-risk, rare, and complex surgical cases, the relative cost of adding a 3D printing step is actually tolerable to most healthcare providers.

However, on the other end of the spectrum a larger academic center may be prepared to heavily invest in creating a centralized 3D printing center. The Mayo Clinic was one of the first medical centers to demonstrate its investment (51) It has made significant strides in exploring the innovative use of the technology, creating quality standards, and generating global influence in this field. Almost all the surgical departments, from pediatrics, neurosurgery, to orthopedics, are now routinely using their 3D printing service. The widespread acceptance of the technology within the Mayo Clinic has significantly increased the case volume and helped to justify the cost. It is now one of a few go-to institutions for educating clinicians and 3D printing industries about medical 3D printing, which acts as additional revenue stream.

Providers should consider the following questions when making the decision on creating an in-house 3D printing service versus using outside vendors:

What is the existing infrastructure that could be used for 3D printing?

Existing personnel and software may be available to be part of the new service. For example, several larger hospital systems including Cedar Sinai and the Kaiser Permanente groups have existing funding for innovative projects such as simulation programs that include 3D printing services. Medical centers with comprehensive imaging services are often equipped with high-quality imaging hardware that can generate high-resolution medical images required for 3D printing. Some newer scanners (e.g. GE) are already equipped with existing 3D printing protocols from various popular prosthetics or device companies. Additionally, many imaging and medical centers have purchased licenses for popular 3D visualization software packages such as Vitrea (Vital, USA), which contains many similar post-processing functionalities to other 3D printing specific software. Some of the larger companies like GE and Siemens, are already adding 3D printing functionality into their newest software. Highly-trained technicians who are already familiar with post-acquisition imaging processing already have many of the skills required for 3D printing. The learning curve for these centers will be significantly less steep than a center without experienced personnel in 3D visualization software.

What is the turn around time required for the applications?

Turn around time is a critical factor to consider as many surgical cases are urgent and need to occur in a timely fashion. The medical center needs to identify the slowest point among the production steps and investigate if the most time-consuming step can be performed faster if outsourced. Good and effective communication between the requesting clinicians and the 3D printing team is the most important step to quickly conceptualize the best 3D printing strategy. Because many surgical cases require more timely response, a few major academic hospitals, like Boston Children’s Hospitaland the Mayo Clinic, have officially incorporated 3D printing for surgical planning as part of their Electronic Healthcare Records (EHR). Ineffective initial communication with either in-house or outsourced 3D printing services will prove costly in time and money. The next most time-consuming and labor-intensive step is segmentation and image post-processing. If in-house bioengineering and/or 3D software expertise are already available, then it is much easier to keep this step in-house, since communicating to a multidisciplinary clinical team can be more effective when the engineering step is completed in-house.

On the other hand, some outsource vendors have experienced design/engineering teams who can offer faster printing and shipping/transportation strategies. They may more quickly scale and modify production to shorten turn around time and meet the demand.

What is the equipment needed to achieve the end point?

Software and hardware requirements will highly depend on the goals of the 3D printing center. For example, the resolution and material requirements for creating a pre-surgical educational model for the patients or medical students will be much less than a pre-surgical model intended for a pediatric cardiothoracic surgeon to simulate the intra-operative environment for complex congenital heart disease. Flexible materials which cost significantly more than typically used resins may be needed for pre-surgical models for complex vascular surgery. The size of the model required will also help determine what hardware is needed. For example, a pediatric heart model is small enough to fit inside the popular desktop SLA printer Form 2 (FormLabs , USA) but an actual sized adult pelvis will not fit.

How much does the clinical team want to be involved in the printing process?

In general, when extensive multidisciplinary communication among different clinical and engineering teams is needed, an in-house 3D printing service is intuitively more efficient and convenient for rapid prototyping and correction of errors and defects in the model. The cost and time of re-designing and reproducing a model will increase significantly with outsourcing.

Again, the steps where clinical team involvement can occur are variable depending on individual cases. For example, in complex maxillofacial cases where the surgeons often want to see a variety of surgical strategies, it may make sense to keep the design/segmentation steps in-house and outsource the final printing with an outside vendor. Models intended for educating patients (patients’ families) and students/residents usually do not require extensive in-house multidisciplinary discussion and can be outsourced easily.

What to look for when selecting for an outsource vendor for pre-surgical 3D printing:

Given the promise of the healthcare market, more and more 3D printing companies are now interested in providing services to healthcare providers. Because of isolation from the healthcare facility, it is important for outsource vendors to understand and respect the sensitive nature of the medical record. It is imperative to prepare a HIPAA compliant data transfer process. Currently, some hospitals use LifeImage (MA, USA) as a way to transfer images. For complex cases, the ability to effectively communicate with the radiologist and treating clinicians requires the vendor to have certain healthcare familiarity or clinical experience. Even with experienced vendors, occasional unsatisfactory products may still be produced and it is important that the vendors can provide adequate customer service to either effectively rectify the mistakes or design backup plans in case of such failure. For example, making multiple versions of the prints with different design or structural emphasis is one such strategy.

Table V summarizes the pros and cons for in-house and outsourced solutions. Many facilities will start with a combination of in-house and outsource services. Depending on the clinical needs, medical centers now have many choices in combining the two services to achieve optimal results. There is also a new growing trend of collaborative works between specialized 3D printing companies with large healthcare systems. (53)

Table V. In House vs. Outsourcing: Pros and Cons

https://3dheals.com/idea-to-implementation-talent-allocation-in-3d-printing-for-pre-surgical-applications/

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