3 D Vo l u m e R e n d e r i n g a n d 3D

P r inting ( A d d i t i ve
Manufacturing)
Rujuta A. Katkar, BDS, MDS, MSa,*, Robert M. Taft, DDS
b
,
Gerald T. Grant, DMD, MSc

KEYWORDS
 3D printing  3D volume rendering  Additive manufacturing  Rapid prototyping

KEY POINTS
 Three-dimensional (3D) volume rendering can be useful in volumetric assessment of bone
defects; however, this still needs to be visualized on a computer monitor.
 3D printing, additive manufacturing, and rapid prototyping techniques are being used in
surgical planning with satisfactory accuracy.
 Categories of additive manufacturing techniques are discussed based on manufacturing
process.
 3D printing applications in dentistry and maxillofacial prosthetics are discussed.
 Limitations include time and cost; accuracy depends on type of 3D printer, material, and
build thickness.

THREE-DIMENSIONAL VOLUME RENDERING

Volume rendering is a set of techniques used to display a 2-dimensional (D) projection

of a 3D discretely sampled data set. These volume-rendered images can be sectioned
in any plane and rotated in space, allowing 3D insight into the anatomy of craniofacial
bones. 3D-rendered images provide additional information for surgical planning and
teaching. Both multislice computed tomography and cone beam computed tomogra-
phy (CBCT) have been shown as reliable techniques in the volumetric assessment of
bone defects in alveolar and palatal regions.1 With these techniques, accurate assess-
ment of the size and extent of bone defects caused by oral clefts, for example, is
possible. This is important not only in the treatment planning but also to establish

Disclosure Statement: The authors have nothing to disclose.

a
Department of Comprehensive Dentistry, University of Texas Health San Antonio, School of
Dentistry, 7703 Floyd Curl Drive, San Antonio, TX 78229-3900, USA; b Department of Compre-
hensive Dentistry, University of Texas Health San Antonio, School of Dentistry, MC 7914, 7703
Floyd Curl Drive, San Antonio, TX 78229-3900, USA; c Oral Health and Rehabilitation, University
of Louisville School of Dentistry, 501 South Preston Street, Room 311, Louisville, KY 40202, USA
* Corresponding author.
E-mail address: katkarr@[Link]

Dent Clin N Am 62 (2018) 393–402

[Link] [Link]
0011-8532/18/ª 2018 Elsevier Inc. All rights reserved.
394 Katkar et al

the donor area and the volume of bone graft (Fig. 1). However, these volume-rendered
images are still limited to viewing on a computer monitor and provide only additional
visual cues. For a novice surgeon with limited experience with spatial perception,
accurately evaluating the anatomy from visual cues alone may be cognitively and
perceptually demanding. Consequently, 3D-rendered images may not provide a sig-
nificant advantage over traditional visualization methods.2

3D PRINTING OR ADDITIVE MANUFACTURING

3D printing, also known as additive manufacturing and rapid prototyping, was

first developed in late 1980s and was soon applied in medicine and surgery. The
application of digital technology with 3D volumetric imaging was first introduced to
the craniomaxillofacial region in 1983.3 In the 1990s, computer-aided design and
computer-aided manufacturing techniques began to be used in craniomaxillofacial
surgery. Many reports have demonstrated satisfactory accuracy of 3D-printed models
generated from DICOM (Digital Imaging and Communications in Medicine) images
and their use in surgical treatment planning.4–10
Additive manufacturing technologies have been categorized by the American Soci-
ety for Testing and Materials Standards body (ASTM Active Standard F2792, June
2012) according to manufacturing process (Fig. 2):
 Vat polymerization: Based on the exposure of a light source to a vat of a light-
sensitive resin in a layered fashion. Examples used in dentistry are stereolithography
or directed light projection. This type of printing requires a fair amount of post pro-
cessing to remove supports, remove unused material, and to complete the cure of
the material. These types of printers have become popular in dentistry (Figs. 3–5).
 Materials extrusion: Use of a filament that is extruded through a heated extruder
of a known diameter. This is the technology in most of the inexpensive desktop
printers used by hobbyists; however, it does have some application in dental and
medical use for models. This also has some necessary postprocessing.
 Material jetting: Use of a material that is jetted through multiple ports, the material
is then cured layer by layer. This permits use of different materials that allow for
color or different durometer (stiffness) within the same print. Supports are gener-
ally easily removed and the print is completed
 Binder jetting: A bed of powder, generally a gypsum material. A print head de-
livers color and a binder layer by layer. The powder supports the piece. The
completed part generally needs some type of postprocessing because the part
is rather fragile.

Fig. 1. Volume-rendered image from a CBCT dataset showing an alveolar cleft defect.
 3D Printing 395

Fig. 2. Commercially available directed light projection printers are classified as vat poly-
merization types. These current laptop printers (NewPro 3D, Vancouver, Canada; Formlabs,
Somerville, MA) provide the flexibility of materials available.

 Powder bed fusion: Different powders, from metals, nylons, and other polymers
are fused with a laser or electron beam source. This technology requires a fair
amount of postprocessing and is used for printing cobalt chrome and titanium
frameworks for fixed and removable prosthetics in dentistry.
 Direct energy deposition: A powder flows directly under a source, such as a laser,
and the material is placed as needed. This is very useful in repair of a metal part.
 Sheet lamination: A sheet of material is stacked with a binder as the outline is cut
away with each layer. The resolution depends on the thickness of the sheet.
The fabrication of 3D-printed models (biomodels) for diagnosis, surgical training,
and planning seem to be the most common uses of additive technology, followed
by application for direct manufacture of implantable devices.11 In maxillofacial sur-
gery, printing a model based on scans of the area of interest allows for more thorough
preplanning of complex cases and the ability to test fit the fabricated parts before the
procedure (Fig. 6). This has been to shown to lead to an increase in fit accuracy of
fabricated prostheses and a reduction in operative time by 30 to 90 minutes.12 Further-
more, customized cranial reconstruction implant prostheses are required when treat-
ing large cranial defects. The use of custom titanium implants, fabricated using direct
metal laser sintering additive technology, for such defects has been demonstrated to
be much quicker to fabricate and place during surgery than conventional methods.
396 Katkar et al

Fig. 3. Stereolithography fabricated test coupons fabricated on a platform.

Fig. 4. Because 3D printers provide an active layer, usually with minimally cured material,
structures are used to support model parts that generally exceed 30 from upright positions.
 3D Printing 397

Fig. 5. Newer print strategies allow for stereolithography and directed light projection sour-
ces to use small vats and build within the vat and excess resin removed with each layer.

Fig. 6. A complex anatomic model.

398 Katkar et al

This is due to high accuracy and the ease in which various modifications are made to
suit each case at the design stage.13
Advances in preoperative virtual planning and patient-specific 3D printing seem to
provide additional predictability in complex surgical cases. A recent study reported
that the quality of preoperative planning for novice surgeons is improved with the
use of 3D-printed models when compared with 3D volume-rendered images in
pancreatic surgery.2 However, no such comparative study was found for the dental
and maxillofacial region in a literature search.
The major limitation of rapid prototyping lies in time and cost spent in generation of
3D objects (Fig. 7). Widespread use of rapid prototyping for surgical planning or indi-
vidual implant design does not seem to be justified because standard planning pro-
cedures or standard implants are sufficient. However, in complicated cases,
additional costs of rapid prototyping may be compensated by reduced operating
times and higher success rate of the surgical procedure.14
3D printing techniques are often presented as a timesaving tool for use in the oper-
ating room; however, this alleged advantage is often counterbalanced by the time
spent to prepare the model. According to a recent systematic review on advantages
and disadvantages of 3D printing in surgery, most of the reported studies were in
hospital-based maxillofacial (50.0%) and orthopedic (24.7%) operations. The main ad-
vantages reported were the possibilities for preoperative planning (48.7%), the accu-
racy of the process used (33.5%), and the time saved in the operating room (32.9%);
however, 21.5% of the studies stressed that the accuracy was not satisfactory. The

Fig. 7. Filament deposition modeling can be useful for medical models. It is inexpensive:
many of the printers can be purchased for less than $1000 and the filament is inexpensive.
However, the process is very slow and, owing to the nature of the preparation of the build,
it is best used when only the surface is of importance.
 3D Printing 399

time needed to prepare the object (19.6%) and the additional costs (19.0%) were also
seen as important limitations for routine use of 3D printing. Most of these studies were
case reports and case series with only 1 randomized controlled trial. The number of
advantages reported on 3D printing was twice that of reported disadvantages; how-
ever, this could be due to a publication bias with some investigators or journal editors
being reluctant to publish negative findings.15
To establish evidence-based guidelines, it will be essential to know in which types of
maxillofacial surgery and reconstruction. 3D printing is better than standard imaging
with or without volume rendering. This might have an impact on the reimbursement
for 3D-printed models.
Also, a 3D-printed skull model of the same individual can vary markedly depending
on the DICOM to STL (stereolithography) conversion software and the technical pa-
rameters used. In a recent study, a large variation was noted in size and anatomic ge-
ometries of the 3 physical skull models fabricated from an identical (or a single)
DICOM data set derived from a CBCT scan. Clinicians should be aware of this inac-
curacy in certain applications.16 Threshold-based segmentations can vary extensively
and are, therefore, likely to be a potential source of error in biomodeling. Even though
the approximate radiodensity ranges of typical tissues are known, a certain amount of
subjective consideration is required when choosing the threshold intensity value. This
problem is especially evident when the voxel intensity distribution over the image is
nonuniform, such as in CBCT imaging, and the image is not properly corrected.16

Three-Dimensional Printing in Dentistry

The basic premise of digital workflow in dentistry is based around 3 elements. First is
data acquisition, such as in various scanning technologies. This is followed by manip-
ulation and processing of data, created using a computer-aided design software.
Finally, the processed data are used for manufacturing of structures in the desired ma-
terial through computer-aided manufacturing.17 In the manufacturing step, 3D printing
(additive manufacturing) is becoming a fast growing alternative for certain
manufacturing previously performed by subtractive manufacturing.
3D printing technology is being used in various dental applications, primarily in
implant dentistry for making surgical guides. In implantology, the use of surgical
guides has been strongly recommended to facilitate better planning and reduce the
risk of operative complications.18 The accuracy of surgical guides produced using
stereolithography has been shown to be fairly accurate, with an angular deviation of
2 and linear deviation of 1.1 mm at the hex and 2 mm at the apex.19 The fabrication
of custom implant screws has also been researched. The SLS additive process can
create implants with complex geometry and a porous surface. This has been shown
to increase osseointegration and has been successfully tested in patients.20,21
The type of 3D printer, material used for printing, and build thickness are known to
influence the accuracy of printed models. Fleming and colleagues22 reviewed studies
that compared conventional and digital dental models. They found varying reported
results but minimal differences, and seemed to advocate the differences as clinically
acceptable. However, data distortion during data conversion and manipulation to
convert the digital surface information to the stereolithography file format, and the
subsequent model shrinkage during building and postcuring from the rapid prototyp-
ing technique, may further influence the accuracy of the reconstructed models.23 One
recent study compared reconstructed rapid prototyping models produced by 3D
printing and conventional stone models for different degrees of dental crowding. Sta-
tistically significant differences were found for all planes in all categories of crowding,
except for crown height in the moderate crowding group and arch dimensions in the
400 Katkar et al

Fig. 8. Capture of patient defect from a digital camera system. An STL file can be fabricated
for design and fabrication of the ear either from the contralateral side or from a library.

mild and moderate crowding groups. It was concluded that the rapid prototyping
models were not clinically comparable with conventional stone models regardless
of the degree of crowding.23
Additive manufacturing is being used and investigated for several intraoral prostho-
dontic applications, including printing stone models from intraoral scans, making
custom impression trays, and direct fabrication of dental prostheses.24,25
The use of additive manufacturing is also being investigated in bone graft applica-
tions with customizable scaffold material, allowing for control of overall hardness and
rate of dissolution.26
In maxillofacial prosthetics, the combination of scanning technology, design soft-
ware, and 3D printers allow for a much more comfortable digital impression technique
and prosthesis fabrication. Extraoral prosthesis fabrication has proven to be useful in
pediatric restorations. With minimal capture times, use of digital design, and printing
molds a prosthesis can be fabricated with very little interaction with the patient.27
 3D Printing 401

Fig. 9. 3D-printed mold for an ear.

These technologies provide access to fabrication of extraoral prosthesis in cases in

which there is minimum support to provide the expertise for the traditional sculpting
and mold fabrication. Digital images can be downloaded to a commercial vender
and design can be done remotely through virtual meetings (Figs. 8 and 9).

REFERENCES

1. Albuquerque MA, Gaia BF, Cavalcanti MGP. Comparison between multislice

and cone-beam computerized tomography in the volumetric assessment of cleft
palate. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011;112:249–57.
2. Zheng Y, Yu D, Zhao J, et al. 3D printout models vs. 3D-rendered images: which
is better for preoperative planning? J Surg Educ 2016;73:518–23.
3. Hemmy D, David D, Herman G. Three-dimensional reconstruction of craniofacial
deformity using computed tomography. Neurosurgery 1983;13:534–41.
4. D’Urso PS, Barker TM, Earwaker WJ, et al. Stereolithographic biomodelling in
cranio-maxillofacial surgery: a prospective trial. J Craniomaxillofac Surg 1999;
27:30–7.
5. Zhou L, Shang H, He L, et al. Accurate reconstruction of discontinuous mandible
using a reverse Engineering/Computer-aided Design/Rapid prototyping tech-
nique: a preliminary clinical study. J Oral Maxillofac Surg 2010;68:2115–21.
6. Zimmerer RM, Ellis E III, Aniceto GS, et al. A prospective multicenter study
to compare the precision of posttraumatic internal orbital reconstruction with
standard preformed and individualized orbital implants. J Craniomaxillofac
Surg 2016;44:1485–97.
7. Arora A, Datarkar AN, Borle RM, et al. Custom-made implant for maxillofacial de-
fects using rapid prototype models. J Oral Maxillofac Surg 2013;71:e104–10.
8. Taft RM, Kondor S, Grant GT. Accuracy of rapid prototype models for head and
neck reconstruction. J Prosthet Dent 2011;106:399–408.
9. Nizam A, Gopal R, Naing L, et al. Dimensional accuracy of the skull models
produced by rapid prototyping technology using stereolithography apparatus.
Arch Orofac Sci 2006;1:60–1, 66.
402 Katkar et al

10. Salmi M, Paloheimo KS, Tuomi J, et al. Accuracy of medical models made by ad-
ditive manufacturing (rapid manufacturing). J Craniomaxillofac Surg 2013;41:
603–9.
11. Lantada AD, Morgado PL. Rapid prototyping for biomedical engineering: current
capabilities and challenges. Annu Rev Biomed Eng 2012;14:73–96.
12. Wilde F, Plail M, Riese C, et al. Mandible reconstruction with patient-specific pre-
bent reconstruction plates: comparison of a transfer key method to the standard
method–results of an in vitro study. Int J Comput Assist Radiol Surg 2012;7:
57–63.
13. Jardini AL, Larosa MA, Filho RM, et al. Cranial reconstruction: 3D biomodel and
custom-built implant created using additive manufacturing. J Craniomaxillofac
Surg 2014;42:1877–84.
14. Rengier F, Mehndiratta A, von Tengg-Kobligk H, et al. 3D printing based on imag-
ing data: Review of medical applications. Int J Comput Assist Radiol Surg 2010;5:
335–41.
15. Martelli N, Serrano C, van den Brink H, et al. Advantages and disadvantages of 3-
dimensional printing in surgery: a systematic review. Surgery 2016;159:1485–500.
16. Huotilainen E, Jaanimets R, Valásek J, et al. Inaccuracies in additive manufac-
tured medical skull models caused by the DICOM to STL conversion process.
J Craniomaxillofac Surg 2014;42:e259–65.
17. van Noort R. The future of dental devices is digital. Dental Mater 2012;28:3–12.
18. Lal K, White GS, Morea DN, et al. Use of stereolithographic templates for surgical
and prosthodontic implant planning and placement. Part I. the concept.
J Prosthodont 2006;15:51–8.
19. Turbush SK, Turkyilmaz I. Accuracy of three different types of stereolithographic
surgical guide in implant placement: an in vitro study. J Prosthet Dent 2012;108:
181–8.
20. Figliuzzi M, Mangano F, Mangano C. A novel root analogue dental implant using
CT scan and CAD/CAM: selective laser melting technology. Int J Oral Maxillofac
Surg 2012;41:858–62.
21. Mangano FG, De Franco M, Caprioglio A, et al. Immediate, non-submerged, root-
analogue direct laser metal sintering (DLMS) implants: a 1-year prospective
study on 15 patients. Lasers Med Sci 2014;29:1321–8.
22. Fleming P, Marinho V, Johal A. Orthodontic measurements on digital study
models compared with plaster models: a systematic review. Orthod Craniofac
Res 2011;14:1–16.
23. Wan Hassan WN, Yusoff Y, Mardi NA. Comparison of reconstructed rapid proto-
typing models produced by 3-dimensional printing and conventional stone
models with different degrees of crowding. Am J Orthod Dentofacial Orthop
2017;151:209–18.
24. Barazanchi A, Li KC, Al-Amleh B, et al. Additive technology: update on current
materials and applications in dentistry. J Prosthodont 2017;26(2):156–63.
25. Chen H, Zhao T, Wang Y, et al. Computer aided design and 3-dimensional
printing for the production of custom trays of maxillary edentulous jaws based
on 3-dimensional scan of primary impression. Beijing Da Xue Xue Bao Yi Xue
Ban 2016;48:900–4.
26. Habibovic P, Gbureck U, Doillon CJ, et al. Osteoconduction and osteoinduction of
low-temperature 3D printed bioceramic implants. Biomaterials 2008;29:944–53.
27. Grant GT, Aita-Holmes C, Liacouras P, et al. Digital capture, design and
manufacturing of an facial prosthesis: clinical report on pediatric patient.
J Prosthet Dent 2015;114(1):138–41.