A Digital Workflow For Modeling of Custom Dental I
A Digital Workflow For Modeling of Custom Dental I
A Digital Workflow For Modeling of Custom Dental I
https://doi.org/10.1186/s41205-019-0046-y
Abstract
Modern dental treatment with standard screw-type implants leave some cases unaddressed in patients with
extreme jaw bone resorption. Custom-made subperiosteal dental implant could be an alternative treatment
modality to sinus lift, nerve lateralization or zygomatic implant techniques. Subperiosteal dental implants were
utilized for many years to treat such patients. A combination of traditional subperiosteal implant designs with
current advancements in 3D imaging, design and printing allow to reduces treatment time and provides
abutments for prostheses in cases where other techniques do not provide satisfactory results. The data
manipulation and design software are important aspects in the manufacturing of custom implants. Programs that
are specialized for industrial or medical design typically cost tens of thousands of US dollars. In this work I establish
and test steps for design and production of a custom medical device (subperiosteal implant) from patient
computed tomography (CT) data. Work stages to be defined are: selection of necessary software, CT data
processing, 3D virtual model creation, modeling technique for custom implant and data file preparation for
printing. Patient CT data was successfully converted into a watertight STL (Standard Tessellation Language) model
of the maxilla. Error corrections and design were completed using freely available programs from Autodesk Inc.. The
implant was produced in Ti64 (a type 5 titanium alloy) using three-dimensional (3D) printing DMLS (direct metal
laser sintering) process. The avoidance of high cost software makes this treatment modality more accessible to
smaller clinics or mid-size production facilities and subsequently more available to patients.
Keywords: Subperiosteal implant, Custom dental implant, Advanced bone resorption, Medical device modeling,
Implant modeling, Modeling software
© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made.
Surovas 3D Printing in Medicine (2019) 5:1 Page 2 of 11
With the advent of computed tomography (CT) and The second approach avoids the second surgery by
freeform fabrication techniques (such as stereo-lithography using CT data obtained in advance and a refractory
and fused deposition modeling), new approaches for model for casting, duplicated from a 3D printed model.
patient treatment were introduced in medicine in general, This method assumes that the user has access to CT and
and in dentistry in particular. Rapid prototyping tech- 3D freeform manufacturing in plastics, but has no access
nology expanded the use of CT beyond diagnostics into to metal printing technology. The drawback of this
surgical planning and the making of patient-specific method is that more steps are involved than in the
tools and implants. It thus became possible to make conventional method. Consequently, it may not be as
anatomical models and patient-specific implants for precise (because of 3D printing and duplication steps).
different anatomic locations (such as skull parts, The third method gives us the shortest path to the
vertebrae, and hip joint replacement components) and final product—custom-made implants— because no
patient-specific instruments (e.g., surgical guides) [3–6]. extra 3D printing or model duplication steps are
Attempts to produce custom orthopedic prostheses based involved. Most of the manufacturing takes place in the
on CT imaging data have been reported since 1985. The digital environment. CT data are used to make a virtual
first documented case of an orthopedic device made using model, and the modeled implant is directly printed in
3D digital technology was a mandibular subperiosteal im- the material of choice.
plant made by James RA [7]. At that time, direct metal The fourth method appears to be unnecessary and
printing was not available; therefore, CT data were used redundant, but it has a place in practice, because the im-
to create anatomical models of patients’ mandibles, which plants manufactured by the digital method do not always
were then actualized as implants using traditional metal fit sufficiently well to be useful in practice. Once a
casting technology. surgeon encounters a poorly fitted implant made by the
After direc metal laser sintering (DMLS) technology third method, he/she must follow Method 4—take an
became available from EOS (Krailling, Germany) in 1995 impression and postpone implant placement until a
[6], it became possible to make three-dimensional ob- suitable implant has been made by the “hybrid” method.
jects in metal with virtually any complexity. This opened The use of this method might be necessary when a
up possibilities for completely digital manufacturing surgeon observes large discrepancies between the
processes—a route from patient anatomy virtualization implant and bone.
to digital design and direct printing in biologically com- This article will describe a digital approach for manu-
patible metal or alloy (such as steel, CoCr (cobalt-chro- facturing of subperiosteal dental implants, conducted
mium) alloy, Ti64 alloy, or pure titanium). Introduced with the following.
into the dental field, these techniques expanded the ways
in which custom subperiosteal implants could be made.
Objectives
With currently available technologies (as of 2018), it is
possible to make subperiosteal dental implants using any
1. Define a digital workflow from CT scan to printed
of the following four methods:
implant
2. Elucidate variables affecting the quality of the end
1. Conventional: bone impression and lost wax casting
product—i.e., the implant
metal
3. Determine the possibility of completing this task
2. Transitional: CT, 3D jaw model printing, lost wax
using freely available software
casting in metal
3. Digital: CT, modeling on virtual jaw model, printing
in metal using DMLS or similar technology Methods
4. Hybrid: bone impression, silicone impression or Data and software
stone model optical scanning, modeling of implant CT data were obtained from a patient scanned at the
on virtual jaw model, printing in metal using DMLS Radiology Department of the Hospital of Lithuanian
or similar technology University of Health Sciences. The patient was scanned
with a Toshiba Aquilion One multi-slice spiral tomo-
The first method is the known classic, long-established graph with preset protocol (0.25 mm step, 0.5 mm slice
approach that requires a second surgery for implant thickness, gantry angle, 0°.). Axial slices were exported
placement. During the first surgery, an impression is using FC30 convolution kernel. The data were anon-
taken with silicone material. Then, the implant is mod- ymized using DICOM Anonymizer by Sha He (2008)
eled on a refractory model, cast in metal, and finished [8]. The computer used was a PC with an Intel i5–3570
between surgeries—usually 2–3 weeks. The implant is 3.40 GHz CPU, 16 GB RAM, NVIDIA GeForce GT640
put into place in a second surgical procedure. 1 GB RAM video card, standard optical mouse, and
Surovas 3D Printing in Medicine (2019) 5:1 Page 3 of 11
running 64-bit Windows 10 operating system. The important step is correct choice of level thresholding for
programs used for digital work are listed in Table 1. the tissue of interest. The specific threshold at which the
program will build a surface is influenced by many
Workflow description factors: CT scanner and its software settings (convolu-
CT data-set review tion kernel), CT volume cropping, bone density of the
First the quality of the CT scan data was assessed. This actual patient, and most importantly, operator selection.
consisted of checking whether the ROI (region of Human decision for threshold selection is very import-
interest) was as required, if number and thickness of the ant and is the sum of anatomy knowledge and work
slices were sufficient, and if there were any scanning experience, which has no substitute.
artifacts of various nature. Following selection of the desired threshold for
The DICOM file header also had to be checked to de- volume label (or mask) (Fig. 3), the surface model of the
termine if the parameters used during scanning were selected anatomy is created (Fig. 4a).
correct. The parameters include the protocol used, This is usually a polygon mesh that can be saved as a
gantry angle, slice thickness, slice step, and convolution number of digital formats, such as .stl, .obj, .ply, and
kernel. If the gantry angle is set greater than 0.0° and the .vtk. In this case, .stl (STL) was used because of compati-
reconstructing software is unable to make the necessary bility with all currently used programs. The STL file for-
corrections, then shear distortions of the model may mat describes 3D objects as meshes made of stitched
occur [9]. The start and the end of a CT scan images triangles. Segmentation programs of all kinds, including
series often contains defective slices that have to be commercial software, are prone to errors while con-
discarded on dataset review (Fig. 1a). structing mesh models of anatomical structures. Created
If the data obtained from the CT contains errors mesh (i.e., virtual model of the jaw) often contains
(e.g., metal-induced scatter or movement artifacts), it non-manifold edges, holes, inverted triangles, and other
has to be determined if these errors affect the errors that hinder further processing steps. Human bone
anatomical region required for future modeling with its trabecular and cavernous structures is difficult
(Figs. 1b, 2a, b). for computers to convert to manifold (closed surface)
If so, then a decision has to be made whether to mesh structures, which is required by modeling
reacquire the CT scan or to take a bone impression software. This is very evident when a program tries to
instead. If CT artifacts do not affect the area of the recreate the trabecular bone structure (Figs. 4f and g).
proposed implant, then one can proceed to the segmen- The situation mandates the use of specialized error
tation step. The image set also needs to be assessed for correcting programs such as Netfabb. Even then, the
motion artifacts, which can only be seen in the recon- program only corrects software errors introduced by
structed sagittal projection or 3D volume rendering. segmentation software, but not holes in the bone
anatomical structure. Fenestrations in the virtual bone
CT data import and virtual model production model may be part of the actual anatomy of the patient;
Slicer 3D software was used to create the 3D model of they also may be artifacts of thresholding. Anatomical
the jaw. Bone tissue segmentation was performed, as holes of models are to be corrected manually (holes
explained in the online Slicer 3D tutorial [10]. The most closed) or avoided during modeling (Figs. 4g and h).
Fig. 1 CT scan errors: a) incomplete image; b) x-ray scatter artifacts from metal objects in the patient tissues and cavities
Fig. 2 Modeling3D Slicer user interface, 4-up layout: a) b) d) red arrows point to x-ray scatter artifacts; a) yellow line emphasize angled patient
positioning during CT scan, to avoid artifacts in left maxillary region, important for modeling; a) c) d) ivory colour depicts thresholding label
which will be used for model generation
Surovas 3D Printing in Medicine (2019) 5:1 Page 5 of 11
Fig. 3 3D Slicer user interface, thresholding tool: thresholding level selected using slider or entering numerical value (depicted by red rectangle).
Bone label (standard from Slicer3D) is visualized by ivory colour in slice image (depicted by red arrows)
Fig. 4 Model preparation: a) newly generated bone tissue 3D model (mesh); b) model – fragments of vertebrae, hyoid bone and some noise
were removed; c) maxilla and mandible have put into occlusion; d) mandible trimmed down to size necessary for work; e) more noise removed
from mandible; f) maxilla presenting anatomical holes (apertures); g) “healing” anatomical holes in maxilla; h) “healed” maxilla, colour patches
represent former anatomical holes
Surovas 3D Printing in Medicine (2019) 5:1 Page 6 of 11
and concavities, especially near abutments. Pits and nar- or implants) and the relation to opposing dentition
row spaces are harbors for possible oral fluid micro- (antagonists).
organism contamination and proliferation. In addition, The modeling process of a custom dental implant
crevices impede tissue liquid circulation and thus hinder per se is the de novo creation process. This is in
regenerative processes. It is important to respect blood contrast to reconstructive surgery modeling, which
supply and not hinder periosteum to bone contact, such often uses contra-lateral mirroring to obtain correct
as with large metal areas. Overall, it is recommended to anatomical structures. Thus, new objects of intricate
use as little metal as possible to achieve masticatory shape must be created, which in turn must closely
force distribution goals. adapt to current anatomical structures. This task
requires suitable digital tools. Modeling for medical
applications is still a new and emerging field of digital
Prosthetic considerations design. There is a range of software built for the
One should plan dental function and aesthetic in dental prosthetic field and numerous programs for im-
advance, before designing the actual implant. First, plant planning and surgical guide creation. Although some
virtual models have to be put into centric relation by of these programs offer planing osteotomies and bone
means of existing dentition intercuspation or using grafting, the majority are predominantly limited to use of
x-ray markers in the removable dentures that are standard screw type implants from different manufac-
being used as scanning aides (Figs. 4b and c). Home turers. Consequently, they are not useful for modeling
work also includes examining diagnostic models and custom structures. Numerous software packages have
wax-ups that aid in planning abutments emergence been created for making fixed and removable dental pros-
profiles and their relation to planed prostheses. Using theses via CAD/CAM. It appeared that the most straight-
virtual teeth in the software during the process of forward route would be to use applications designed for
implant modeling also aids proper placement of modeling a partial removable dentures because of the
abutments (Figs. 5b and c). similarity of subperiosteal implants and the framework of
In addition, consider the lateral component of jaw partial removable denture. However, after testing several
movements—create anatomical and mechanical means software packages, this route proved to be unusable be-
of implant fixation. When creating fixed cementable cause the programs do not allow jaw model modification,
abutments, pay attention to parallelism of prospective are limited to preset structures, or require heavy
abutments with current partnering abutments (teeth customization to be useful.
Fig. 5 Model preparation continued: a) virtual jaw models in occlusion; b) virtual teeth added; c) prospective abutments have been placed in
places corresponding to future teeth; d) future abutments – sky blue abutments belong to subperiosteal implant and red one belongs to
planned screw type implant; e) a cut-off tool placed in the area of tooth 24 (FDI), where abutment was planned to bury deeper into the bone;
f) maxilla with cut-off and placed abutments
Surovas 3D Printing in Medicine (2019) 5:1 Page 7 of 11
Fig. 6 modeling principle: a) original model of the jaw; b) pre-made structures (loops and abutments) added on to virtual model; c) pre-made
structures and modelled (bulked) implant merged with original model; d) the 2nd copy of original model (yellow) recalled and matched with
model onto which implant was modelled (orange); e) implant – result of Boolean operation, subtraction of yellow model form orange model;
f) implant (resultant) model superimposed on the original jaw model. (Screenshots from Meshmixer program)
Fig. 7 modeling in Meshmixer program: a) pre-made structures (loops and abutments) added on to original jaw model; b) implant modeling
(bulking) by sculpt tool; c) pre-made structures and modelled (bulked) implant merged with original model; d) the 2nd copy of original model
(dark grey) recalled and matched with model onto which implant was modelled (light grey); e) implant – result of Boolean operation (with lots of
unwanted shells), f) implant (resultant) model superimposed on the original jaw model
Surovas 3D Printing in Medicine (2019) 5:1 Page 9 of 11
Fig. 8 Implant model cleaning and repair: a) and b) unwanted shells selected (orange) for deletion in Meshmixer program; c) implant cleaned
from unwanted snowflake like shells; d) implant model errors shown in Meshmixer program; e) implant model errors shown in NetFabb program;
f) repaired implant in Netfabb program
increasing comprehensiveness for error detection and the implant were checked for voids or pimples. These
correction(Table 2). were removed when encountered by abrasive instru-
The “default repair” script of the Netfabb program was ments. Implant fit was checked against a plastic jaw
used at all steps where it was necessary (Figs. 8d and e). model. In addition, implant outer surface was shaped
to the desired profile with tungsten carbide cutters
Printing and blasted with aluminum oxide 150 mkm at 5 bar
On completion of modeling, the implant design and jaw (Figs. 9d, e, f ). Complete preparation of the implant
model STL files (Figs. 9a, b, c) were sent to a printing for surgery includes more steps, which are metal
facility (Orthobaltic UAB, Lithuania). surface treatments (polishing, blasting, etching, etc.),
The jawbone model, created earlier, was printed in packaging and sterilization, but those are not in the
polyamide using an SLS printer ESO P 396, in 60 mkm scope of this article.
layers. The implant was produced using the EOS printer
EOSINT M 280 by DMLS process in Ti64 alloy Results
(100mkm layers), which is known to be biocompatible Patient CT data was successfully converted into a
and exhibits the required mechanical properties. The meshed surface (.stl) model of the maxilla using Slicer
implant was printed and then annealed in an argon en- 3D, an open source software program.
vironment. Supports were removed, and the implant was Error corrections and design were completed using
finished by a technician. The inner and outer surfaces of freely available Netfabb and Meshmixer programs from
Fig. 9 Final result: a) implant digital model superimposed on the jaw virtual model; b) and c) implant digital model in different projections;
d) implant with printing supports, immediately after production; e) implant with supports removed and mechanical grinding and polishing
completed; f) subperiosteal implant on the plastic model of maxilla
Autodesk Inc.. This article defines a workflow which According to authors knowledge (to the date 2019–04)
allows for fast and high quality digital modeling of there is only one medical device design software package
subperiosteal implants. The implant was produced in which CE certified. It is 3-matic Medical by Materialise.
Ti64 allow using 3D printing DMLS process. Other as- Though, its cost is prohibitive to small companies.
pects of subperiosteal implant use, such as implant sur-
face treatment, surgical and prosthetic steps are out the Conclusions
scope of current article. Clinical results using 3D printed Custom dental implants have their niche in modern
subperiosteal implants will be reported in future dental practice, serving patents with advanced maxillary
publications. or mandibular bone resorption. This type of medical de-
Legal background. Patient-specific (custom-made) vice can be designed using freely available or inexpensive
implants are not required to be CE certified. According software tools from CT scans and produced by current
to Medical Device Directive (MDD) 93/42/EEC, “cus- 3D manufacturing technology to the required precision
tom-made medical device - Any device specifically made and fit. Numerous factors have to be taken into account
in accordance with a duly qualified medical practitioner’s by medical device designers as implant modeling quality
written prescription which gives, under his responsibility, is affected by the following:
specific design characteristics and is intended for the sole
use of a particular patient”. Patient-specific (custom-- 1 CT scan data quality
made) implants must comply with the relevant essential 2 Segmentation software algorithms and settings
requirements established in MDD as applicable to ensure 3 modeling software output quality
their safety. 4 Error repair software algorithms
Our implants are registered in the State Health Care
Accreditation Agency under the Ministry of Health of Development of specialized software for this application
the Republic of Lithuania as medical devices that fully would be advantageous for dental specialists, producers,
comply MDD and Lithuanian Medical Norm MN 4:2009 and patients.
“Medical Devices Safety Technical Regulation”.
The software used for modeling of custom medical de- Abbreviations
CAD/CAM: computer assisted design/computer assisted manufacturing;
vices is also considered medical device. Computer pro- CoCr: cobalt and chromium alloy; CT: computed tomography, computer
grams which process data derived from patients usually tomography; DICOM: Digital Imaging and Communications in Medicine
considered to be Class IIb medical device. In European (DICOM) is a standard for storing and transmitting medical images;
DMLS: direct metal laser sintering; FDI: The FDI Dental Numbering System for
Union they are required to be CE certified. Neither of Adult Teeth; SLS: selective laser sintering; STL: surface tessellation language; a
programs used in this publication are CE certified. file format; Ti64: titanium, aluminum 6%, vanadium 4% alloy
Surovas 3D Printing in Medicine (2019) 5:1 Page 11 of 11
Acknowledgments
Ignas Gudas and Domantas Ozerenskis from Orthobaltic UAB for DMLS
printing implants and models.
Funding
This work has received no funding.
Authors’ contributions
Authors is sole contributor to writing. Other contributors are listed in
Acknowledgments section. The author read and approved the final
manuscript.
Competing interests
Author design, produce and use custom dental implants in his daily practice
(if this to be considered to be competing interest).
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
References
1. Yun MH. Changes in regenerative capacity through lifespan. Int J Mol Sci.
Oct. 2015;23(10):25392–432. https://doi.org/10.3390/ijms161025392.
2. Carl E. Misch (1993) contemporary implant dentistry: Mosby.
3. Moss JP, Linney AD, Arridge SR. A computer system for the interactive
planning and prediction of maxillofacial surgery. Am J Orthod Dentofacial
Orthop Dec. 1988;94(6):469–75.
4. Robertson DD, Walker PS, Granholm JW, Nelson PC, Weiss PJ, Fishman
EKMD. Design of custom hip stem prostheses using three-dimensional CT
modeling. J Comput Assist Tomogr. 1987;11(5):804–9.
5. Murphy SB, Kijewski PK, Simon SR, Chandler HP, Griffin PP, Reilly DT, et al.
Computer-aided simulation, analysis, and design in orthopedic surgery.
Orthop Clin North Am. 1986;17:637–49.
6. Shellabear M, Nyrhilä O. DMLS – development history and state of the art.
Lane 2004; 2004. p. 1–12.
7. James RA. Complete mandibular subperiosteal implant fabricated from
model generated from computer tomography data. Implantologist 01/0,
vol. 3; 1985. p. 35–7.
8. Sha He (2008) DICOM Anonymizer. Available via : https://sourceforge.net/
projects/dicomanonymizer . Last accessed 11 Apr 2019.
9. Winder J, Bibb R. Medical rapid prototyping technologies: state of the art
and current limitations for application in oral and maxillofacial surgery.
J Oral Maxillofac Surg. 2005;63:1006–15.
10. Nabgha Farhat Ms.(2014)Tutorial: Preparing Data for 3D Printing Using 3D
Slicer. Available from: https://youtu.be/MKLWzD0PiIc, Published on Jan 8,
2014 by user 3D Slicer, tutorial prepared by Nabgha Farhat, Brigham and
Women's Hospital, accessed on 2018.04.25.