Evaluation of direct and indirect additive manufacture of maxillofacial prostheses

Assessing the Dispersion Stability of Antimicrobial Fillers in Photosensitive Resin for Vat Polymerization 3D Printing

Polymers are widely used in healthcare due to their biocompatibility and mechanical properties; however, the use of polymers in medical products can promote biofilm formation, which can be a source of hospital-acquired infections. Due to this, there is a rising demand for inherently antimicrobial polymers for devices in contact with patients. 3D printing as a manufacturing technology has increased exponentially in recent years. Surgical guides, orthotics, and prosthetics, among other medical devices, created by vat polymerization have been used in hospitals to treat patients. Biocompatible resins are available for these applications, but there is a lack of antimicrobial resins, which would further improve the technology for clinical use. The focus of this study was to assess settling of candidate antimicrobial metal and metal oxide fillers in vat polymerization resin to determine which fillers were compatible with the resin. Dispersion stability was assessed by measuring settling over the maximum print duration of the medium priced desktop 3D printers to evaluate printability of 17 potentially antimicrobial resins. Eight materials displayed settling behavior during the test period: molybdenum oxide, zirconium oxide nanopowder, scandium oxide, zirconium oxide, titanium oxide, tungsten oxide, lanthanum oxide, and magnesium oxide. No settling was observed for manganese oxide, magnesium oxide nanopowder, titanium oxide nanopowder, copper oxide, silver oxide, zinc oxide nanopowder, zinc oxide, silver nanopowder, and gold nanopowder during the test period. This method could be applied to assess settling of other fillers introduced into 3D printing resins before actual printing.

Accuracy and resolution of conventional and additively manufactured silicone elastomers as applied in maxillofacial therapies

STATEMENT OF PROBLEM

Silicone elastomers are becoming more readily available for additive manufacturing, which may be advantageous for fabricating maxillofacial prostheses. However, the properties of three-dimensionally (3D) printed silicone as compared with conventionally processed silicone have not been well studied.

PURPOSE

The purpose of this in vitro study was to compare the dimensional accuracy and surface resolution of additively manufactured with conventional room-temperature vulcanized (RTV) silicones.

MATERIAL AND METHODS

A custom aluminum mold was used to generate hand-spatulated specimens (A103 and VerSilTal-50F, n=20). A computer-aided design and computer-aided manufacturing workflow was used to generate additively manufactured specimens (Sil30 and TrueSil, n=20). Digital surface scans of each specimen were recorded; a scan of the mold served as the control. Surface dimensions were measured with a digital metrology software program, while digital overlays were made using a 3D processing software program. The surface resolution of the specimens was assessed by analyzing 4 topographical landmarks (flat surfaces, raised lines, domes, and scribed lines) with a visual qualitative grading scale. The data were analyzed with 1-way analysis of variance, followed by a Student-Newman-Keuls post hoc test (α=.05).

RESULTS

The specimens demonstrated statistical differences in trueness and precision (P<.001). The TrueSil specimens showed the largest deviation in measurements of trueness and precision (up to -1.374%). The other specimens yielded percentage mean differences that were more consistently within the range of the American Dental Association International Organization for Standardization standard for elastomers. The manually fabricated specimens yielded more consistently ideal ratings for resolution than did the additively manufactured ones, with the Sil30 specimens receiving the most Charlie (not clinically acceptable) ratings.

CONCLUSIONS

Numerical differences between each specimen and the control were considered negligible for maxillofacial applications. Notable discrepancies related to the quality of resolution, wherein the benchtop-manufactured specimens consistently generated better results compared with additively manufactured ones. Other factors, such as resiliency, odor, and cost, posed limitations in justifying the use of silicones in a direct-to-print workflow.

Cost-effective 3D scanning and printing technologies for outer ear reconstruction: current status

Current 3D scanning and printing technologies offer not only state-of-the-art developments in the field of medical imaging and bio-engineering, but also cost and time effective solutions for surgical reconstruction procedures. Besides tissue engineering, where living cells are used, bio-compatible polymers or synthetic resin can be applied. The combination of 3D handheld scanning devices or volumetric imaging, (open-source) image processing packages, and 3D printers form a complete workflow chain that is capable of effective rapid prototyping of outer ear replicas. This paper reviews current possibilities and latest use cases for 3D-scanning, data processing and printing of outer ear replicas with a focus on low-cost solutions for rehabilitation engineering.

Trueness and precision of skin surface reproduction in digital workflows for facial prosthesis fabrication

STATEMENT OF PROBLEM

How much skin surface details of facial prostheses can be transferred throughout the digital production chain has not been quantified.

PURPOSE

The purpose of this in vitro study was to quantify the amount of skin surface details transferred from the prosthesis virtual design through the prototype printing with various additive manufacturing (AM) methods to the definitive silicone prosthesis with an indirect mold-making approach.

MATERIAL AND METHODS

Twelve test blocks with embossed wrinkles of 0.05 to 0.8 mm and 12 test blocks with applied earlobe skin structures were printed with stereolithography (SLA), direct light processing (DLP), and PolyJet methods (n=4). DLP and SLA prototype specimens were duplicated in wax. All specimens were then transferred into medical-grade silicone. Rz values of the wrinkle test blocks and the root mean square error (RMSE) of the earlobe test blocks were evaluated by laser topography to determine the trueness and precision of each stage.

RESULTS

For the earlobe test blocks, the PolyJet method had superior trueness and precision of the final skin surface reproduction. The SLA method showed the poorest trueness, and the DLP method, the lowest precision. For the wrinkle test blocks, the PolyJet method had the best wrinkle profile reproduction level, followed by DLP and SLA.

CONCLUSIONS

The indirect mold-making approach of facial prostheses manufacturing may be associated with 7% of skin surface profile loss with SLA, up to 20% with DLP, and no detail loss with PolyJet.

Additive Manufacturing by Heating at a Patterned Photothermal Interface

Direct additive manufacturing (AM) of commercial silicones is an unmet need with high demand. We report a new technology, heating at a patterned photothermal interface (HAPPI), which achieves AM of commercial thermoset resins without any chemical modifications. HAPPI integrates desirable aspects of stereolithography with the thermally driven chemical modalities of commercial silicone formulations. In this way, HAPPI combines the geometric advantages of vat photopolymerization with the materials properties of, for example, injection molded silicones. We describe the realization of the new technology, HAPPI printing using a commercial Sylgard 184 polydimethylsiloxane resin, comparative analyses of material properties, and demonstration of HAPPI in targeted applications.

3D direct-write printing of water soluble micromoulds for high-resolution rapid prototyping

Direct-write printing has contributed tremendously to additive manufacturing; in particular extrusion based printing where it has extended the range of materials for 3D printing and thus enabled use across many more sectors. The printing inks for direct-write printing however, need careful synthesis and invariably undergo extensive preparation before being able to print. Hence, new ink synthesis efforts are required every time a new material is to be printed; this is particularly challenging for low storage modulus (G') materials like silicones, especially at higher resolutions (under 10 µm). Here we report the development of a precise (< 10 µm) 3D printable polymer, with which we 3D print micromoulds which are filled with standard silicones like polydimethylsiloxane (PDMS) and left to cure at room temperature. The proof of concept is demonstrated using a simple water soluble polymer as the mould material. The approach enables micrometre scale silicone structures to be prototyped with ease, away from the cleanroom.

Three-Dimensional Printing of Medical Devices Used Directly to Treat Patients: A Systematic Review

Until recently, three-dimensional (3D) printing/additive manufacturing has not been used extensively to create medical devices intended for actual clinical use, primarily on patient safety and regulatory grounds. However, in recent years there have been advances in materials, printers, and experience, leading to increased clinical use. The aim of this study was to perform a structured systematic review of 3D-printed medical devices used directly in patient treatment. A search of 13 databases was performed to identify studies of 3D-printed medical devices, detailing fabrication technology and materials employed, clinical application, and clinical outcome. One hundred and ten papers describing one hundred and forty medical devices were identified and analyzed. A considerable increase was identified in the use of 3D printing to produce medical devices directly for clinical use in the past 3 years. This is dominated by printing of patient-specific implants and surgical guides for use in orthopedics and orthopedic oncology, but there is a trend of increased use across other clinical specialties. The prevailing material/3D-printing technology used were titanium alloy/electron beam melting for implants, and polyamide/selective laser sintering or polylactic acid/fused deposition modeling for surgical guides and instruments. A detailed analysis across medical applications by technology and materials is provided, as well as a commentary regarding regulatory aspects. In general, there is growing familiarity with, and acceptance of, 3D printing in clinical use.

4D polycarbonates via stereolithography as scaffolds for soft tissue repair

3D printing has emerged as one of the most promising tools to overcome the processing and morphological limitations of traditional tissue engineering scaffold design. However, there is a need for improved minimally invasive, void-filling materials to provide mechanical support, biocompatibility, and surface erosion characteristics to ensure consistent tissue support during the healing process. Herein, soft, elastomeric aliphatic polycarbonate-based materials were designed to undergo photopolymerization into supportive soft tissue engineering scaffolds. The 4D nature of the printed scaffolds is manifested in their shape memory properties, which allows them to fill model soft tissue voids without deforming the surrounding material. In vivo, adipocyte lobules were found to infiltrate the surface-eroding scaffold within 2 months, and neovascularization was observed over the same time. Notably, reduced collagen capsule thickness indicates that these scaffolds are highly promising for adipose tissue engineering and repair.

Shape memory scaffolds are needed for minimally invasive tissue repair and void filling. Here the authors report on the development of 4D printed polycarbonate-based scaffolds with surface degradation properties which fill voids without deforming tissue and allow for tissue ingrowth with reduced immune response.

Are Nano TiO2 Inclusions Improving Biocompatibility of Photocurable Polydimethylsiloxane for Maxillofacial Prosthesis Manufacturing?

(1) Background: The development of a biocompatible material for direct additive manufacturing of maxillofacial extraoral prosthesis is still a challenging task. The aim of the present study was to obtain a photocurable PDMS, with nano TiO2 inclusions, for directly 3D printing of extraoral, maxillofacial prosthesis. The biocompatibility of the newly obtained nanocomposite was also investigated; (2) Methods: 2.5% (m/m) titania nanoparticles (TiO2) oxide anatase and a photoinitiator, benzophenone (BF) 4.5% were added to commercially available PDMS for maxillofacial soft prostheses manufacturing. The three different samples (PDMS, PDMS-BF and PDMS-BF-TiO2) were assessed by dielectric curing analysis (DEA) based on their viscosities and curing times. In vitro micronucleus test (MNvit) was performed for genotoxicity assessment and three concentrations of each compounds (2 mg/L, 4 mg/L and 8 mg/L) were tested in duplicate and compared to a control; (3) Results: The nanocomposite PDMS-BP-TiO2 was fully reticulated within a few minutes under UV radiation, according to the dielectric analysis. PDMS-BF-TiO2 nanocomposite showed the lowest degree of cyto- and genotoxicity; (4) Conclusions: In the limits of the present study, the proposed ex situ preparation of a PDMS-BP-TiO2 offers an easy, simple, and promising technique that could be successfully used for 3D printing medical applications.

Systematic Review of Clinical Applications of CAD/CAM Technology for Craniofacial Implants Placement and Manufacturing of Nasal Prostheses

The aim of this systematic review was to gather the clinical and laboratory applications of CAD/CAM technology for preoperative planning, designing of an attachment system, and manufacturing of nasal prostheses. According to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, an electronic search was carried out. Only human clinical studies involving digital planning for the rehabilitation of facial defects were included. A total of 21 studies were included with 23 patients, which were virtually planned through different planning software. The most common preoperative data for digital planning were CT scans in nine cases, CBCT in six cases, and laser scans in six cases. The reported planning softwares were Mimics in six cases, Geomagic Studio software in six cases, ZBrush in four cases, and Freeform plus software in four cases. Ten surgical templates were designed and printed to place 36 implants after digital planning, while post-operative assessment was done in two cases to check the accuracy of planned implants. Digital 3D planning software was reported for presurgical planning and craniofacial implants placement, fabrication of molds, designing of implants, designing of retentive attachments, and printing of silicone prostheses. Digital technology has been claimed to reduce the clinical and laboratory time; however, the equipment cost is still one of the limitations.

Comparison of artificial tooth position in dentures fabricated by heat curing and additive manufacturing

BACKGROUND

The purpose of this study was to compare the displacement of tooth arrangement in dentures fabricated by additive manufacturing (AM) and heat curing.

METHODS

Three-dimensional (3D) scanning was performed for edentulous jaw models. After the teeth were arranged, 3D scanning for the wax denture was performed. Heat-cured dentures were fabricated with heat-cure polymer resin. Based on data obtained by subtracting the model data from wax denture data, AM dentures were fabricated from ultraviolet-cured acrylic resin. Accuracy was verified by superimposing heat-cured and AM dentures on the tooth region data from the wax dentures and measuring displacement of the tooth arrangement.

RESULTS

In the maxillary dentures, the amount of tooth displacement for the heat-cured dentures and for the AM dentures ranged from -0.08 to +0.06 mm and from -0.25 to +0.06 mm respectively. A significant difference was observed between two dentures. In the mandibular dentures, the amount of tooth displacement for the heat-cured dentures and for the AM dentures ranged from -0.09 to +0.07 mm and from -0.03 to +0.07 mm respectively. No significant difference was observed between two dentures.

CONCLUSIONS

The artificial teeth of the maxillary dentures fabricated by AM showed a greater displacement compared to those by heat curing.

Digital Workflow in Maxillofacial Prosthodontics—An Update on Defect Data Acquisition, Editing and Design Using Open-Source and Commercial Available Software

Background: A maxillofacial prosthesis, an alternative to surgery for the rehabilitation of patients with facial disabilities (congenital or acquired due to malignant disease or trauma), are meant to replace parts of the face or missing areas of bone and soft tissue and restore oral functions such as swallowing, speech and chewing, with the main goal being to improve the quality of life of the patients. The conventional procedures for maxillofacial prosthesis manufacturing involve several complex steps, are very traumatic for the patient and rely on the skills of the maxillofacial team. Computer-aided design and computer-aided manufacturing have opened a new approach to the fabrication of maxillofacial prostheses. Our review aimed to perform an update on the digital design of a maxillofacial prosthesis, emphasizing the available methods of data acquisition for the extraoral, intraoral and complex defects in the maxillofacial region and assessing the software used for data processing and part design. Methods: A search in the PubMed and Scopus databases was done using the predefined MeSH terms. Results: Partially and complete digital workflows were successfully applied for extraoral and intraoral prosthesis manufacturing. Conclusions: To date, the software and interface used to process and design maxillofacial prostheses are expensive, not typical for this purpose and accessible only to very skilled dental professionals or to computer-aided design (CAD) engineers. As the demand for a digital approach to maxillofacial rehabilitation increases, more support from the software designer or manufacturer will be necessary to create user-friendly and accessible modules similar to those used in dental laboratories.

Past, Present, and Future of Soft-Tissue Prosthetics: Advanced Polymers and Advanced Manufacturing

Millions of people worldwide experience disfigurement due to cancers, congenital defects, or trauma, leading to significant psychological, social, and economic disadvantage. Prosthetics aim to reduce their suffering by restoring aesthetics and function using synthetic materials that mimic the characteristics of native tissue. In the 1900s, natural materials used for thousands of years in prosthetics were replaced by synthetic polymers bringing about significant improvements in fabrication and greater realism and utility. These traditional methods have now been disrupted by the advanced manufacturing revolution, radically changing the materials, methods, and nature of prosthetics. In this report, traditional synthetic polymers and advanced prosthetic materials and manufacturing techniques are discussed, including a focus on prosthetic material degradation. New manufacturing approaches and future technological developments are also discussed in the context of specific tissues requiring aesthetic restoration, such as ear, nose, face, eye, breast, and hand. As advanced manufacturing moves from research into clinical practice, prosthetics can begin new age to significantly improve the quality of life for those suffering tissue loss or disfigurement.

Design and development of model eye for retina laser by using additive manufacturing

Surgical skill of the surgeon can be improved by surgical simulation. Especially in ophthalmology, it is impossible to use real human/non-human primate eyes for ophthalmology surgery practice. However, surgical practice is most important for ophthalmologist. The retina laser surgery is one of the ophthalmology surgeries and it requires more surgical practice for surgeons to use the laser beam precisely to coagulate and fuse small areas of tissue. Dealing with the prospect of vision reduction or vision loss presents a peculiar problem and that can be highly stressful and frustrating for both doctors and patients. In this regard, training for indirect ophthalmoscopy and retinal photocoagulation is undergone using model eyes instead of real eyes. Properties and functioning of an existing model eye are huge and they differ from real human eye such as casings are completely rigid and focusing of retinal fundus is not completely covered. Therefore, this research concentrates to develop a model eye that assimilates close to the human eye by focussing on the maximum viewing area that is not done at the moment. Finally, the design and development of re-engineered model eye for retina laser is fabricated by additive manufacturing. Compared to existing plastic model eye, viewing area and viewing angle of the re-engineered model eye is increased by 16.66% and 6.14%, respectively. Due to design modifications and elimination of the insert, it can be reduced by 18.99% and 13.95% of height and weight of the top casing respectively. Developed re-engineered model eye will improve the surgical and diagnostic skill of the surgeon and increase their confidence and proficiency. It also augments the effective use of essential ophthalmic instruments. Additionally, it can reduce the surgical error and meet the existing demand of actual eyes for surgical practices.

An advanced prosthetic manufacturing framework for economic personalised ear prostheses

Craniofacial prostheses are commonly used to restore aesthetics for those suffering from malformed, damaged, or missing tissue. Traditional fabrication is costly, uncomfortable for the patient, and laborious; involving several hours of hand-crafting by a prosthetist, with the results highly dependent on their skill level. In this paper, we present an advanced manufacturing framework employing three-dimensional scanning, computer-aided design, and computer-aided manufacturing to efficiently fabricate patient-specific ear prostheses. Three-dimensional scans were taken of ears of six participants using a structured light scanner. These were processed using software to model the prostheses and 3-part negative moulds, which were fabricated on a low-cost desktop 3D printer, and cast with silicone to produce ear prostheses. The average cost was approximately $3 for consumables and $116 for 2 h of labour. An injection method with smoothed 3D printed ABS moulds was also developed at a cost of approximately $155 for consumables and labour. This contrasts with traditional hand-crafted prostheses which range from $2,000 to $7,000 and take around 14 to 15 h of labour. This advanced manufacturing framework provides potential for non-invasive, low cost, and high-accuracy alternative to current techniques, is easily translatable to other prostheses, and has potential for further cost reduction.

3D printing tissue-mimicking materials for realistic transseptal puncture models

Applications of additive manufacturing (commonly referred to as 3D printing) in direct fabrication of models for pre-surgical planning, functional testing, and medical training are on the rise. However, one current limitation to the accuracy of models for cardiovascular procedural training is a lack of printable materials that accurately mimic human tissue. Most of the available elastomeric materials lack mechanical properties representative of human tissues. To address the gap, the authors explore the multi-material capability of material jetting additive manufacturing to combine non-curing and photo-curing inks to achieve material properties that more closely replicate human tissues. The authors explore the impact of relative material concentration on tissue-relevant properties from puncture and tensile testing under submerged conditions. Further, the authors demonstrate the ability to mimic the mechanical properties of the fossa ovalis, which proves beneficial for accurately simulating transseptal punctures. A fossa ovalis mimic was printed and assembled within a full patient-specific heart model for validation, where it exhibited accuracy in both mechanical properties and geometry. The explored material combination provides the opportunity to fabricate future medical models that are more realistic and better suited for pre-surgical planning and medical student training. This will ultimately guide safer, more efficient practices.

The use of 3D printing technology in the creation of patient-specific facial prostheses

BACKGROUND

Personalised medicine aims to optimise patient outcomes by tailoring treatments and interventions to the individual. While this approach can offer a number of benefits, it can be accompanied by significant overheads in terms of resources. Prostheses exist in order to restore and replicate the normal functions and appearance of the body but if these are not individually tailored to the patient's needs then a true restoration cannot be fully achieved. Traditionally a labour intensive process, the fabrication of craniofacial prostheses, involves taking a plaster cast of the area to be treated, hand carving wax models of the restoration and multiple meetings with the patient to alter this wax restoration before making a final prosthesis in silicone.

AIMS

Utilising the patient's pre-existing computed tomography (CT) images and 3D printing technology, a patient-specific prosthesis can be created with improved efficiency and accuracy.

METHODS

This study demonstrates methods used to create a patient-specific orbital prosthesis using CT images. These images were manipulated in a way which allowed for the intact orbit to be mirrored and used to develop a 3D printed model which acted as the starting point to create a silicone prosthesis.

RESULTS

The benefits of using this method include reduced manufacturing time, decreased outpatient appointments, improved personalised outcomes and a repeatable process allowing multiple prostheses to be made.

CONCLUSIONS

3D printing is a valuable tool which can provide significant savings in time and improve patient outcomes by offering a tailored approach to each individual's treatment.

Advancements in Soft-Tissue Prosthetics Part A: The Art of Imitating Life

Physical disfigurement due to congenital defects, trauma, or cancer causes considerable distress and physical impairment for millions of people worldwide; impacting their economic, psychological and social wellbeing. Since 3000 B.C., prosthetic devices have been used to address these issues by restoring both aesthetics and utility to those with disfigurement. Internationally, academic and industry researchers are constantly developing new materials and manufacturing techniques to provide higher quality and lower cost prostheses to those people who need them. New advanced technologies including 3D imaging, modeling, and printing are revolutionizing the way prostheses are now made. These new approaches are disrupting the traditional and manual art form of prosthetic production which are laborious and costly and are being replaced by more precise and quantitative processes which enable the rapid, low cost production of patient-specific prostheses. In this two part review, we provide a comprehensive report of past, present and emerging soft-tissue prosthetic materials and manufacturing techniques. In this review, part A, we examine, historically, the ideal properts of a polymeric material when applied in soft-tissue prosthetics. We also detail new research approaches to target specific tissues which commonly require aesthetic restoration (e.g. ear, nose and eyes) and discuss both traditional and advanced fabrication methods, from hand-crafted impression based approaches to advanced manufactured prosthetics. We discuss the chemistry and related details of most significant synthetic polymers used in soft-tissue prosthetics in Part B. As advanced manufacturing transitions from research into practice, the five millennia history of prosthetics enters a new age of economic, personalized, advanced soft tissue prosthetics and with this comes significantly improved quality of life for the people affected by tissue loss.

Characterization of a composite polylactic acid-hydroxyapatite 3D-printing filament for bone-regeneration

Autologous cancellous-bone grafts are the current gold standard for therapeutic interventions in which bone-regeneration is desired. The main limitations of these implants are the need for a secondary surgical site, creating a wound on the patient, the limited availability of harvest-safe bone, and the lack of structural integrity of the grafts. Synthetic, resorbable, bone-regeneration materials could pose a viable treatment alternative, that could be implemented through 3D-printing. We present here the development of a polylactic acid-hydroxyapatite (PLA-HAp) composite that can be processed through a commercial-grade 3D-printer. We have shown that this material could be a viable option for the development of therapeutic implants for bone regeneration. Biocompatibility in vitro was demonstrated through cell viability studies using the osteoblastic MG63 cell-line, and we have also provided evidence that the presence of HAp in the polymer matrix enhances cell attachment and osteogenicity of the material. We have also provided guidelines for the optimal PLA-HAp ratio for this application, as well as further characterisation of the mechanical and thermal properties of the composite. This study encompasses the base for further research on the possibilities and safety of 3D-printable, polymer-based, resorbable composites for bone regeneration.

A systematic review of the computerized tools and digital techniques applied to fabricate nasal, auricular, orbital and ocular prostheses for facial defect rehabilitation

A systematic review was conducted in early 2019 to evaluate the articles published that dealt with digital workflow, CAD, rapid prototyping and digital image processing in the rehabilitation by maxillofacial prosthetics. The objective of the review was to primarily identify the recorded cases of orofacial rehabilitation made by maxillofacial prosthetics using computer assisted 3D printing. Secondary objectives were to analyze the methods of data acquisition recorded with challenges and limitations documented with various software in the workflow. Articles were searched from Scopus, PubMed and Google Scholar based on the predetermined eligibility criteria. Thirty-nine selected papers from 1992 to 2019 were then read and categorized according to type of prosthesis described in the papers. For nasal prostheses, Common Methods of data acquisition mentioned were computed tomography, photogrammetry and laser scanners. After image processing, computer aided design (CAD) was used to design and merge the prosthesis to the peripheral healthy tissue. Designing and printing the mold was more preferred. Moisture and muscle movement affected the overall fit especially for prostheses directly designed and printed. For auricular prostheses, laser scanning was most preferred. For unilateral defects, CAD was used to mirror the healthy tissue over to the defect side. Authors emphasized on the need of digital library for prostheses selection, especially for bilateral defects. Printing the mold and conventionally creating the prosthesis was most preferred due to issues of proper fit and color matching. Orbital prostheses follow a similar workflow as auricular prosthesis. 3D photogrammetry and laser scans were more preferred and directly printing the prosthesis was favored in various instance. However, ocular prostheses fabrication was recorded to be a challenge due to difficulties in appropriate volume reconstruction and inability to mirror healthy globe. Only successful cases of digitally designed and printed iris were noted.

A new methodology for design and manufacturing of a customized silicone partial foot prosthesis using indirect additive manufacturing

The production of customized prostheses for the foot and ankle still relies on slow and laborious steps of the traditional plaster molding fabrication techniques. Additive manufacturing techniques where three-dimensional objects can be constructed directly based on the object's computer-aided-design data in a layerwise manner has opened the door to new opportunities for manufacturing of novel and personalized medical devices. The purpose of the present study was to develop a new methodology for design and manufacturing of a customized silicone partial foot prosthesis via an indirect additive manufacturing process. Furthermore, the biomechanics of gait of a subject with partial foot amputation wearing the custom silicone foot prosthesis manufactured by the indirect additive manufacturing was characterized, in comparison with a matched healthy participant. This study has confirmed the possibility of producing silicone partial foot prosthesis by indirect additive manufacturing procedure. The amputated subject reported total comfort using the custom prosthesis during walking, as well as cosmetic advantages. The prosthesis restored the foot geometry and normalized many of gait characteristics. The findings presented here contribute to introduce a proper understanding of biomechanics of walking after wearing silicone partial foot prosthesis and are useful for prosthetists and rehabilitation therapists when treating patients after partial foot amputation.

Simplifying the digital workflow of facial prostheses manufacturing using a three-dimensional (3D) database: setup, development, and aspects of virtual data validation for reproduction

PURPOSE

To set up the digital database (DDB) of various anatomical parts, skin details and retention elements in order to simplify the digital workflow of facial prostheses manufacturing; and to quantify the reproduction of skin wrinkles on the prostheses prototypes with stereolithography (SLA) and direct light processing (DLP) methods.

METHODS

Two structured light scanners were used to obtain the nasal and auricle forms of 50 probands. Furthermore, the ala nasi and scapha areas were captured with the digital single lens reflex camera and saved in jpeg format. The four magnetic retention elements were remodeled in computer aided design (CAD) software. The 14 test blocks with embossed wrinkles of 0.05-0.8mm were printed with SLA and DLP methods and afterwards analyzed by means of profilometry and confocal microscopy.

RESULTS

The introduced DDB allows for production of customized facial prosthesis and makes it possible to consider the integration of concrete retention elements on the CAD stage, which makes the prosthesis modelling more predictable and efficient. The obtained skin structures can be applied onto the prosthesis surface for customization. The reproduction of wrinkles from 0.1 to 0.8mm in depth may be associated with the loss of 4.5%-11% of its profile with SLA or DLP respectively. Besides, the reproduction of 0.05mm wrinkles may be met with up to 40% profile increasement.

CONCLUSIONS

The utilization of DDB may simplify the digital workflow of facial prostheses manufacturing. The transfer of digitally applied skin wrinkles till the prostheses' prototypes may be associated with deviations from 11 to 40%.

Feasibility of designing, manufacturing and delivering 3D printed ankle-foot orthoses: a systematic review

BACKGROUND

Ankle-foot orthoses (AFO) are prescribed to manage difficulty walking due to foot drop, bony foot deformities and poor balance. Traditional AFOs are handmade using thermoplastic vacuum forming which provides limited design options, is labour-intensive and associated with long wait times. 3D printing has the potential to transform AFO production and health service delivery. The aim of this systematic review was to determine the feasibility of designing, manufacturing and delivering customised 3D printed AFOs by evaluating the biomechanical outcomes, mechanical properties and fit of 3D printed compared to traditionally manufactured AFOs.

METHOD

Electronic databases were searched from January 1985 to June 2018 according to terms related to 3D printing and AFOs. Studies of any design from healthy or pathological populations of any age were eligible for inclusion. Studies must have investigated the effect of customised 3D printed AFOs using any 3D printing technique on outcomes related to walking ability, biomechanical function, mechanical properties, patient comfort, pain and disability. Any other orthotic type or AFOs without a 3D printed calf and foot section were excluded. The quality of evidence was assessed using the GRADE process.

RESULTS

Eleven studies met the eligibility criteria evaluating 3D printed AFOs in healthy adults, and adults and children with unilateral foot drop from a variety of conditions. 3D printing was used to replicate traditional AFOs and develop novel designs to optimise the stiffness properties or reduce the weight and improve the ease of use of the AFO. 3D printed custom AFOs were found to be comparable to traditional custom AFOs and prefabricated AFOs in terms of temporal-spatial parameters. The mechanical stiffness and energy dissipation of 3D printed AFOs were found to be similar to prefabricated carbon-fibre AFOs. However, the sample sizes were small (n = 1 to 8) and study quality was generally low.

CONCLUSION

The biomechanical effects and mechanical properties of 3D printed AFOs were comparable to traditionally manufactured AFOs. Developing novel AFO designs using 3D printing has many potential benefits including stiffness and weight optimisation to improve biomechanical function and comfort.

Data related to the experimental design for powder bed binder jetting additive manufacturing of silicone

The data included in this article provides additional supporting information on our recent publication (Liravi et al., 2018 [1]) on a novel hybrid additive manufacturing (AM) method for fabrication of three-dimensional (3D) structures from silicone powder. A design of experiments (DoE) study has been carried out to optimize the geometrical fidelity of AM-made parts. This manuscript includes the details of a multi-level factorial DOE and the response optimization results. The variation in the temperature of powder-bed when exposed to heat is plotted as well. Furthermore, the effect of blending ratio of two parts of silicone binder on its curing speed was investigated by conducting DSC tests on a silicone binder with 100:2 precursor to curing agent ratio. The hardness of parts fabricated with non-optimum printing conditions are included and compared.

Direct 3D printing of silicone facial prostheses: A preliminary experience in digital workflow

Direct silicone printing may be applied to the fabrication of maxillofacial prostheses, although its clinical feasibility is unknown. The present clinical report shows an early application of a directly printed silicone prosthesis for the rehabilitation of a nasal defect. Two extraoral scanning systems were used to capture the face and the defect. The virtual construction of the nasal prosthesis was performed with free-form software. Two prostheses were printed in silicone and post-processed by manual sealing and coloring. The clinical outcome was acceptable for an interim prosthesis; however, the marginal adaptation and color match were not satisfactory without further individualization.

Development of a 3D printable maxillofacial silicone: Part I. Optimization of polydimethylsiloxane chains and cross-linker concentration

STATEMENT OF PROBLEM

Conventionally, maxillofacial prostheses are fabricated by hand carving the missing anatomic defect in wax and creating a mold into which pigmented silicone elastomer is placed. Digital technologies such as computer numerical control (CNC) milling and 3-dimensional (3D) printing have been used to prepare molds directly or indirectly into which a biocompatible pigmented silicone elastomer is placed.

PURPOSE

The purpose of this in vitro study was to develop a silicone elastomer by varying composition that could eventually be 3D printed directly without a mold to create facial/body prostheses.

MATERIAL AND METHODS

The silicone was composed of polydimethylsiloxane (PDMS), filler, catalyst, and cross-linker. Four types of base silicone polymers were prepared with different PDMS molecular weight combinations with long, medium, and short chain length PDMS. The effect of the cross-linker (2.5% to 12.5%) content in these bases was assessed for the effect upon the mechanical properties of the elastomer. Ten readings were made for each formulation, and differences in the means were evaluated with a 2-way ANOVA (α=.05).

RESULTS

Variations in silicone composition resulted in hardness from 6.8 to 28.5 durometer, tensile strength from 0.720 to 3.524 kNm^-1 and tear strength from 0.954 to 8.484 MPa. Significant differences were observed among all formulations (P<.05). These formulations have mechanical properties comparable with the commercial silicones currently used for the fabrication of facial prostheses. The formulation with 5% cross-linker content and high content of long-chain PDMS chains with optimum mechanical properties was chosen for further development.

CONCLUSIONS

The optimum combination of mechanical properties implies the use of one of these formulations for further evaluation in a 3D printer capable of actively mixing and extruding 2-component, room temperature vulcanization silicone.

Fabrication of low cost soft tissue prostheses with the desktop 3D printer

Soft tissue prostheses such as artificial ear, eye and nose are widely used in the maxillofacial rehabilitation. In this report we demonstrate how to fabricate soft prostheses mold with a low cost desktop 3D printer. The fabrication method used is referred to as Scanning Printing Polishing Casting (SPPC). Firstly the anatomy is scanned with a 3D scanner, then a tissue casting mold is designed on computer and printed with a desktop 3D printer. Subsequently, a chemical polishing method is used to polish the casting mold by removing the staircase effect and acquiring a smooth surface. Finally, the last step is to cast medical grade silicone into the mold. After the silicone is cured, the fine soft prostheses can be removed from the mold. Utilizing the SPPC method, soft prostheses with smooth surface and complicated structure can be fabricated at a low cost. Accordingly, the total cost of fabricating ear prosthesis is about $30, which is much lower than the current soft prostheses fabrication methods.