|
 
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| REVIEW ARTICLE |
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| Year : 2023 | Volume
: 15
| Issue : 1 | Page : 72-79 |
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Contemporary era of Three-dimensional printing in pediatric dentistry: An overview
Shaik Rabiya Shaheen, E Sridevi, AJ Sai Sankar, VS S Krishna, M Sridhar, K Siva Sankar
Department of Pedodontics and Preventive Dentistry, Sibar Institute of Dental Sciences, Guntur, Andhra Pradesh, India
| Date of Submission | 22-Jul-2022 |
| Date of Decision | 10-Oct-2022 |
| Date of Acceptance | 10-Oct-2022 |
| Date of Web Publication | 30-Dec-2022 |
Correspondence Address:
A J Sai Sankar
Department of Pedodontics and Preventive Dentistry, Sibar Institute of Dental Sciences, Guntur, Andhra Pradesh
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jorr.jorr_35_22
The technique of three-dimensional (3D) printing is used for generating 3D objects using Computer-Aided Design software or 3D scanners. The employment of 3D printing in medical and dental fields is one among the foremost recent emerging trends since it has numerous advantages over traditional techniques in terms of patient-specific personalized care. The database was thoroughly searched using PubMed, Google Scholar, and Ebscohost with keywords such as 3D printing, additive manufacturing, study model, treatment planning, clinical approach, fluoride application, space maintainer, occlusal splints, endodontic procedures, rehabilitation, nasoalveolar molding, and so on. There were no restrictions made on the year of publication, but the articles published in English were evaluated. With the continual advancements within the technology, this paper is aimed toward reviewing the present literature on various applications together with its specific applications regarding pediatric dental practice.
Keywords: Additive manufacturing, endodontic procedures, fluoride application, nasoalveolar molding, occlusal splints, rehabilitation, space maintainer, study model, three-dimensional printing, treatment planning
How to cite this article:
Shaheen SR, Sridevi E, Sai Sankar A J, S Krishna V S, Sridhar M, Sankar K S. Contemporary era of Three-dimensional printing in pediatric dentistry: An overview. J Oral Res Rev 2023;15:72-9 |
How to cite this URL:
Shaheen SR, Sridevi E, Sai Sankar A J, S Krishna V S, Sridhar M, Sankar K S. Contemporary era of Three-dimensional printing in pediatric dentistry: An overview. J Oral Res Rev [serial online] 2023 [cited 2023 May 31];15:72-9. Available from: https://www.jorr.org/text.asp?2023/15/1/72/365917 |
| Introduction | |  |
Three-dimensional (3D) printing is a well-known, dynamically advancing technology that is being widely utilized in various sectors such as mechanical, civil, medical, and dental fields due to its imaging techniques through digitalization and automation of various work processes.[1] The goal of this technology was to provide the patients with the most accurate and least invasive therapy options possible.[2]
This technology is an additive technique in which an object is formed by creating one layer at a time and adding consecutive layers using specific tools that produce 3D models by utilizing Computer-Aided Design (CAD) technology. It also allows for the creation of complicated geometrical structures by using digital data and by utilizing a variety of materials in patients and other situations needing high accuracy and large-scale production.[3] The terms “generative process,” “rapid prototyping,” “desktop fabrication,” “layered manufacturing,” and “3D printing” are frequently used in conjunction with the term “additive process.”[4]
The history of additive manufacturing (AM) technology spans more than 40 years, which can be broken down into five or six distinct eras.[5] The inventor of the 3D printer, Charles Hull, secured its position in history with his patent application for Stereolithography (SLA) printing in 1986. The first attempts at 3D printing were made in the 1980s when Hideo Kodama developed the first CAD applications. Later in 1989, Scott Crump was granted a patent for a fused deposition modeling printer, and 3D Systems introduced the first commercial SLA printer in the world in 1988.[6] After that, a number of substitute procedures were created, as seen in [Figure 1].[5]
Rapid prototyping has many applications in human activity, such as engineering, research, the medical field, construction, architecture, automotive, aerospace, fossil reconstruction, and the computer industry.[7] Most objects in healthcare, such as medical devices, implants, tissue engineering scaffolds,[8] prosthetic replacements such as artificial ears, eyes, jaws, face, limbs, and so on, are manufactured using 3D printers due to their flexibility, durability, low friction, and accuracy.[9]
In the realm of dentistry, digitalization has enabled the development of dental and medical equipment, personalized treatment planning, smart molds, crown fabrication, space maintainers, orofacial prosthesis, regenerative therapies, orthodontic appliances, and other products. This technology also allows for the digital storage of patient data, thus reducing the need for physical storage.[10]
| Methodology | | |
To conduct this review, search terms such as 3D printing, rapid prototyping, AM study model, treatment planning, clinical approach, fluoride application, space maintainer, occlusal splints, endodontic procedures, rehabilitation, nasoalveolar molding (NAM), crowns, and so on were used to find peer-reviewed articles related to 3D printing and its applications in dentistry in databases such as PubMed, Ebscohost, and Google Scholar. The cross-referencing technique was repeated until no new articles were discovered. There were no restrictions on the year of publication, but only the publications available in English were considered.
| Three-Dimensional Printing Process | | |
The process of 3D printing ranges from digital designing to the production of an object by3D scanning of physical/digital model through 3D software and the fabrication of the framework by CAD software creates an STL/SLM document which will be exported to 3D printers as shown in [Figure 2].[10],[11] | Figure 2: Diagrammatic representation of 3D Printing process. 3D: Three-dimensional
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| Three-Dimensional Printing Techniques and Materials Used | | |
AM is available with a various technologies, as shown in [Table 1], which illustrates several materials and their uses in dentistry:[2],[8],[10] | Table 1: Techniques and materials used in three-dimensional printing[2],[8],[10]
Click here to view |
| Three-Dimensional Printing and its Applications in Pediatric Dentistry | | |
Pediatric dentistry is a subspecialty of dentistry that primarily works with children of a particular age group, and it is well-recognized that the dental treatment of a child patient frequently offers a problem to the clinician. Although 3D printers are employed in various fields of dentistry, there's relatively little research available on their usage in pediatric dentistry. The applications are divided into three subgroups that had not been done in the past as: educational/experimental, virtual treatment planning, and clinical use as illustrated in [Figure 3].[8] | Figure 3: 3D printing applications for educational, experimental, clinical and virtual treatment planning. 3D: Three-dimensional
Click here to view |
Educational approach
The utilization of 3D printing has the ability to drastically alter the learning pattern as well as educational standard protocols of dental students and practitioners performing various treatments such as endodontic, surgical, and oral hygiene procedures.[12] Conventionally, human-extracted teeth were used to train the dental trainees about the morphology of tooth and its identification,[13] but now with the advancements in the technology, it is possible to create virtual models which are interactive and also increase the spatial learning capacity.[14] In 2019, Marty et al.[15] produced 3D-printed models that approximated the presence of true pathology, as it can measure the size, extent, and depth of the deteriorated lesion, allowing the teacher to instruct and the student to carry out pulpotomy and fabricate a stainless steel crown.[15] Höhne et al. (2021),[16] used 3D-printed tooth with internal preparation for dental education in veneer preparation and found that it was a feasible and useful teaching concept in dental education.[16] These 3D models can also be used to replicate the gingival, periodontal defects with changing tissue properties which can help the clinician gain adequate proprioception and expertise before operating on the patient.[7]
The 3D printers allow the recreation of both hard and soft tissues in a single training jaw with magnified anatomical models, which could help trainees learn 3D spatial orientation and proper interaction between the physician and the patient.[17] Hanisch et al.,[18] attempted to develop patient-data-based training models for root tip resection (apicectomy) that can provide a feasible alternative to commercially available typodont models. In some circumstances, such as cleft lip and palate, all dental or medical students and surgical trainees may be unable to attend and participate in the cleft palate operation.[19] However, due to a paucity of cadaveric sources, traditional cleft Lip training today relies primarily on intraoperative teaching, in such situations 3D-printed models can give visual simulations, virtual-reality simulations, and training in cleft lip repair, which may help dental residents to improve surgical technique and skills before surgery.[20]
Virtual treatment planning
Accurate digital models of the patient's anatomy can be used as a base for virtual treatment planning of both preoperative and immediate postoperative endodontic procedures,[21] as well as preoperative surgical planning[22] and also has the ability to illustrate the modifications produced by braces in advance.[23] This might be aided by 3D printing technologies and 3D virtual planning software, both of which have proven to be effective in dentistry. Benefits include increased accuracy, reduced operating times, improved patient comfort, and the capacity to enable operator skill improvement.[23]
Clinical approach
The pediatric dentist performs a variety of treatment procedures, ranging from behavior management of the child and diagnosis of the cause to delivering optimal therapy such as endodontic treatments, interceptive and preventive orthodontic procedures, prosthetic procedures, and so on.
Fluoride application
Food or the constant flow of saliva may wash away topically applied fluoride, making it hard to maintain a sufficient fluoride concentration in the oral cavity over an extended period. Hence, to address the shortcomings of commercially available fluoride formulations, 3D printing technology may be used to generate customized fluoride formulation that prints a coverable thin film which can be adhered to the tooth surface for a slow-release fluoride delivery system for a long time [Figure 4]. However, further research should be conducted to improve its adhesive strength.[24] | Figure 4: Fluoride adhesive film made by 3D printer. 3D: Three-dimensional
Click here to view |
Preventive orthodontics
If a primary tooth extraction or loss is inevitable, the most secure way to retain arch space is to utilize an appliance known as “space maintainer,”[25] and those fabricated using CAD-computer-aided manufacturing (CAM) or 3D technology and current biomaterials are known as “Digital Space Maintainers.”[26] According to Pawar (2019)[27] and khanna (2021),[28] 3D printers can be used to fabricate space maintainers by digital scanning and designing resulted in increased appliance precision, reduced human errors such as inadequate band pinching, and the avoidance of fracture of the soldered loop by conventional procedure. The appliance is printed as a single unit, which reduces breakage and consequently appliance failure.[28]
According to Dhanotra and Bhatia,[26] 3D printers can also be used to fabricate other space maintainers such as the lingual arch and Nance button, which can overcome the disadvantages of traditional procedures such as tongue interferences due to the longer arm length of the lingual arch, which may interfere with permanent tooth eruption and soft-tissue lesions due to contact of the acrylic button with the palate. These digital space maintainers can also avoid the need of the impression in uncooperative children or those who are having a gag reflex.[26]
Corrective orthodontics
3D printing may be used to quickly and efficiently manufacture a range of appliances such as Hawley retainers, appliances for expansion of arch, retainers, brackets, occlusal splints, functional appliances, clear aligners, replica for orthognathic surgery or mock surgical models, and so on.[12]
Jindal et al.[29] concluded that 3D-printed clear aligners are more suitable for patient usage than thermoplastic-based aligners because of their accuracy. Nagib et al.,[30] reported that 3D printing technology along with the latest CAD software can be used to create orthodontic attachments for traction of impacted teeth such as chain accessories, brackets, lingual buttons, and even personalized metal attachments. In patients with a habit of bruxism and TMJ disorders, the 3D printers can be used for the fabrication of dental splint with its low cost, high efficiency, and high accuracy.[31]
Rehabilitation procedures
Nasoalveolar molding
In children with cleft, some pediatric dental surgeons propose using presurgical infant orthopedics which include NAM before surgery to take advantage of tissues with inherent growth potential, aid in arch alignment, improve lip repair, and improve the maxillary arch dimensions.[32] In such conditions, 3D printing can be used to design NAM appliances more efficiently than traditional methods as described by Abd El-Ghafour et al.[33] and Kasper et al.[32] It mainly begins with obtaining the patient's anatomical model with the cleft to support virtual treatment planning and fabrication of an appliance with a good fit. The NAM appliance created with 3D printers can automatically eliminate the artifacts associated with low-quality impressions using the software as well as reduces the possibility of aspiration and the accumulation of impression material in the cleft space.[32]
Prosthetic procedures
The open-faced stainless steel crown, celluloid strip crown, and zirconia crown are only a few options for tooth restoration because they are prefabricated and easily accessible, but the fit may differ among children. Due to this reason, custom-made crowns can be manufactured using 3D printers. The mechanical and physical qualities of 3D-printed crowns are typically suitable for intraoral usage, which has aroused interest in the restorative area. This results in greater possibilities when restoring primary teeth.[24]
Al-Halabi et al. (2020)[34] evaluated the fracture resistance force of three different Primary Molar Crowns and the results have shown that 3D-printed crowns and CAD\CAM fabricated crowns had a significantly higher fracture resistance force than direct celluloid composite crowns. In a randomized clinical trial, Al-Halabi et al. (2021)[35] evaluated the clinical outcomes of two types of esthetic crowns for pulp-treated primary molars and concluded that 3D-printed resin crowns have excellent marginal integrity and crowns retention with less cementing failure than the crowns manufactured by CAD/CAM system.[35]
Prosthetic rehabilitation
Patients with either syndromic or nonsyndromic abnormalities of the teeth such as anodontia or hypodontia can employ 3D printing to manufacture complete or partial dentures to restore normal shape, function, and aesthetics. Digitally produced dentures have gained popularity in the past few years because there are so many CAD/CAM applications that can provide digital try-in, which combines a facial scan with an intraoral scan and virtual tooth setup. Despite technological advancements, traditional dentures are still fabricated using lost wax technique.[36]
Autotransplantation of tooth/autogenous tooth transplantation
Patients with permanent loss of tooth or agenesis have substantial therapeutic challenges and most of them are related to the developmental stages of tooth. Despite the fact that implant insertion is not a realistic option and should be avoided unless dentoalveolar growth is complete,[37] in such situations tooth autotransplantation (TAT) provide an effective biological method for the replacement of tooth in young patients following traumatic dental injuries, developmental anomalies, specific orthodontic problems, or agenesis. The TAT offers various advantages, including the potential to promote periodontal healing and to aid in the preservation of the alveolar ridge.[38] In dentistry, 3D technology, such as Objet30 Prime® Printer, PolyJet is beneficial for autogenous tooth transplantation, which permits the creation of a new recipient socket with the aid of a surgical replica of the tooth to be transplanted, thus reducing handling and extraoral time.[39] Sato et al. (2021)[40] published a case report in 2020 documenting the treatment of fused maxillary right lateral incisor in a 10-year-old patient using 3D printing technique and endodontic invasion where 3D-printed guides were employed for hemisection of fused tooth and autotransplantation.[40]
Surgical reconstruction
Rapid prototyping is a unique technique that is now being employed for trauma surgery, tumors/pathology-induced anomalies (maxillary or mandibular resection), difficult temporomandibular joint repair, and the treatment of problematic facial asymmetry.[37] In craniofacial surgeries, 3D imaging and computer-assisted surgical planning may improve the surgical outcome in craniofacial surgeries.[41] In 2017, Dupret-Bories et al.[42] constructed mandibular template using 3D software for replacing the body of mandible in patient with osteosarcoma.
3D-printing techniques that can precisely replicate complicated craniofacial geometries are well-suited for addressing individual needs and for patient-specific therapies that fit a specific defect site to accomplish both esthetic cosmesis and functional replacement by enabling efficient template planning, resulting in less consumption with superior quality of preconformed screw plates.[42]
The second-most common facial bone fractures in children are the mandible fractures which account for 52% with involvement of two or more sites. Due to various unique characteristics of children patients, including growth and development of tooth germs, psychological status, and unstable deciduous teeth, surgical therapy for pediatric patients may differ from that of adults in maxillofacial fracture surgery. Du et al.,[43] employed a 3D printer in a pediatric patient with multiple mandibular fractures which helps to design the placement of titanium plates and prevent injury to the tooth germs.
Advantages
- Patient treatment becomes fast, smooth, and with greater accuracy
- Possible to create complicated geometric shapes and interconnecting elements that do not need to be assembled
- Wastage of the materials reduced
- Reduced patient appointments, treatment stages and improved education of patient through visualization
- Can create individual products in small quantities at a reasonable cost and with quick delivery.[6],[7],[44]
Disadvantages
- Cost and availability of the material
- Finishing the final product takes time and requires expertise
- The final quality is likely to be a major drawback to 3D printing because each consecutive layer is deposited on top of the last in traditional 3D printing methods, an inherent vulnerability is physically built into the design
- Extra treatment may be required to achieve maximum strength depending on the type of material used
- Ceramics are the most widely utilized materials in dentistry; however due to high porosity caused during fabrication, they are unable to be 3D printed. However, further studies and newer techniques will be able to overcome these drawbacks.[9],[44]
Limitations
- Initial setup is quite high
- 3D printing involves the use of both digital file capture equipment and CAD software. Its application may also be hampered by a scarcity of well-trained operators
- There may be regulatory issues because all medical devices must meet the requirements set by the US Food and Drug Administration
- Lot of medical-legal issues around 3D printing which needs extensive research
- Time may vary because various printers use different materials to print the model.[4],[45]
| Conclusion | | |
3D printing is modernizing digital dentistry by enhancing diagnostic, therapeutic, and educational opportunities for patients, as well as offering a minimalistic approach and better treatment. It also provides efficiency, scalability, accessibility, accuracy, and less time consuming by minimizing the need for manual modeling in dental labs. However, as there are still many issues that need to be addressed, such as printing materials, casting technique, Auto-mated software technology, bio-stability, validation, compatibility, and so on. The benefits of 3D printing outweigh the drawbacks. The 3D printing has the potential to transform the pediatric dentistry and there is considerable room for further research. As a result, additional research and development can be planned in the future.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1]
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