Lab Tribune Middle East & Africa No. 5, 2024
Current and future regenerative possibilities: A review of 3D bioprinting applications / 3D-printed surgical guides to facilitate internal sinus lift
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DTMEA_No.5. Vol.15_LT.indd
PUBLISHED IN DUBAI
www.dental-tribune.me
Vol. 15, No. 5
Though it has had a slow start in dentistry, 3D bioprinting opens up a world of potential treatment options for dental patients. (Image: faahadkhan/Freepik)
Current and future regenerative
possibilities: A review of 3D bioprinting
applications
By Anisha Hall Hoppe,
Dental Tribune International
While the majority of dental clinicians are already familiar with the
capabilities of 3D printing for producing models, appliances, surgical
guides and more, the uses of bioprinting may be less familiar. A team
with the Datta Meghe Institute of
Higher Education and Research in
India has published a review of the
promising applications of bioprinting within dentistry, outlining the
power of being able to create human
tissue through cell deposition for enhanced reconstructive and regenerative treatment.
3D bioprinting is an advanced
technique that integrates additive
manufacturing with bioinks—composed of living cells and biomaterials—to create customised tissue
constructs. These constructs are crucial for regenerating damaged tissue
and restoring various maxillofacial
abnormalities. The authors explore
how this technology has gained increasing interest owing to its ability
to precisely control the deposition of
cells and materials, offering new
possibilities in dentistry and beyond.
Key components of 3D bioprinting include bioinks and scaffolds.
Bioinks mimic the extracellular environment, and scaffolds provide the
structural framework necessary for
cell growth and tissue formation. Because 3D bioprinting creates scaffolds with uniform cell dispersion,
the use of 3D-bioprinted materials
allows for customisation to the desired dimensions and configuration
of specific tissues. The process of 3D
bioprinting involves three major
stages: pre-printing, printing and
post-printing. Pre-printing includes
the design of the tissue model using
CAD software, the printing stage involves creating the construct using a
bioprinter and the post-printing
stage focuses on the maturation, implantation and testing of the bioprinted tissue.
The review covers various bioprinting techniques, including inkjet-based, extrusion-based and laser-assisted, each offering different
approaches to achieving precise tissue constructs. For instance, ink-
jet-based bioprinting uses ink droplets to localise cells accurately,
whereas extrusion-based bioprinting utilises a continuous flow of bioink for larger constructs. Laser-assisted bioprinting offers high cell viability by using non-contact methods to print moderately viscous
biological materials.
When it comes to dentistry,
some of the broader applications of
3D bioprinting include drug delivery
systems, root coverage, socket preservation and maxillofacial prosthodontics. However, the list of potential
applications is virtually endless, as
the technology also shows promise
in areas like periodontal repair and
dental pulp regeneration. Furthermore, the advent of 4D bioprinting
introduces smart scaffolds that can
respond to stimuli, potentially revolutionising tissue engineering.
Although progress in the application of 3D bioprinting, particularly
in dentistry, has been slow, the potential for personalising treatments
through architectural control and
material versatility offers great
promise for future developments. 3D
bioprinting may even surpass conventional fabrication methods.
The study, titled “Three-dimensional bioprinting as a tool for tissue
engineering: A review”, was published online on 11 September 2024
in Journal of Pharmacy and Bioallied
Sciences, ahead of inclusion in an
issue.
[2] =>
DTMEA_No.5. Vol.15_LT.indd
CLINICAL CASE
B2
Lab Tribune Middle East & Africa Edition | 5/2024
3D-printed surgical guides
to facilitate internal sinus lift
By Drs Andreas Keßler &
Stefanie Lindner, Germany
Introduction
The possibility of replacing a
tooth with a dental implant has considerably expanded the range of
therapies in patients who are missing
some or all of their natural teeth.
Nowadays, osseointegration of the
implant is highly pre dictable, and
the appropriate position of the implant is primarily determined by the
prosthetic requirements.1–4 The digitalisation of dentistry has fundamentally altered and revolutionised many
traditional workflows. Digital pro-
cess chains now make it possible to
merge CBCT scans with surface data
sets as well as to plan the optimal positioning of the implant virtually prior
to surgery. Surgical guides are usually employed to transfer the virtually planned position of the implant to the clinical situation intraoperatively.5 Alongside conventional
production by means of a subtractive process, the additive tech nique
for the production of surgical guides
is increasingly finding application.
The most commonly used process in
dentistry is stereolithography along
with the technically related process
of digital light processing (DLP).6
2
In addition to the positioning of
the implants according to the prosthetic restoration, internal or external sinus lift can be planned in the
CAD software and transferred with
the aid of surgical guides. This can
improve the preoper ative briefing of
the patient, minimise the surgical risk
and achieve a predictable result. The
following case presents a corresponding workflow with a focus on
the planning and 3D printing of the
surgical guide.
Case presentation
A 56-year-old female patient
presented to our outpatient depart-
1
Fig. 1: Before treatment. Provisional bridge from tooth #13 to tooth #16.
3a
3b
Fig. 2: Merging of the DICOM volume data set with the STL surface data set. Figs. 3a & b: Alignment of the implants on the basis of the prosthetic restorations.
4
Fig. 4: Surgical guide aligned and furnished with supporting structures in the
software.
5
6
ment with a Kennedy Class II, missing
teeth #14 and 15, and requested closure of the gap. Her exist ing restoration was a provisional bridge from
tooth #13 to tooth #16 (Fig. 1). The
patient’s general medical his tory did
not reveal any abnormalities. The patient was informed of the available
treatment options, taking her general medical and dental history into
consideration.
In light of the patient’s request
for a fixed denture, the options
were a bridge from tooth #13 to
tooth #16 or implants in regions
#14 and 15 with subsequent crown
restoration of the implants and
tooth #16. Based on the integrity of
tooth #13, the patient opted for an
implant restoration. This was followed by comprehensive briefing
on the clinical procedure and the
taking of a CBCT scan and an impression of the situation.
Treatment planning
Preference should always be
given to a CBCT scan with a small
field of view (CS 9300, Carestream
Dental; 5×5×5 cm, 78kV, 6.3 mA,
20 seconds). This makes it possible
to reduce the patient’s exposure to
radiation and achieve a smaller
voxel size, which equates to a
higher level of detail. A cotton roll
is inserted in the buccal region for
better matching of the DICOM and
STL data sets via the soft tissue in
the CAD software. The STL data set
is obtained by means of an intraoral scanner or inlaboratory scanning of the plaster model.
The prosthetic restorations
were first designed in planning
software (Implant Studio, 3Shape).
The DICOM volume data set (from
the CBCT scan) was then merged
with the STL surface data set (from
► Page B3
7
Fig. 5: Surgical guide printed from V-Print SG. Fig. 6: Finished surgical guide after post-processing. Fig. 7: Surgical guide after the supporting structures had been detached, and the corresponding drilling sleeves
before their insertion.
[3] =>
DTMEA_No.5. Vol.15_LT.indd
CLINICAL CASE
B3
Lab Tribune Middle East & Africa Edition | 05/2024
◄ Page B2
the intraoral scan; Fig. 2), and the
implants were aligned on the basis of
the prosthetic restorations (Fig. 3).
The vertical dimension in region #14 was 10.5 mm and decreased distally from 5 to 7 mm in
region #15. Straumann Standard
Plus implants were planned for region #14 (3.3×10.0 mm) and region
#15 (4.3×8.0 mm). The use of implants of these lengths would require an internal sinus lift.
In order to allow guided preparation of the osteotomy to just before the maxillary sinus and the
Schneiderian membrane, implant
#15 was moved coronally in the
planning software and its length
shortened. The planning was completed with the creation of the surgical guide and the corresponding
drilling protocol.
the surgical guide is performed automatically based on the material to
be printed and the printer. In this
case, we used the transparent
3Dprinting material VPrint SG
(VOCO; Fig. 5) in combination with
the D20 II DLP printer (Rapid Shape).
Printing is followed by postprocessing, involving ultrasonic
cleaning in iso propanol and light
polymerising, to achieve the final
material characteristics of the surgical guide (Fig. 6). Once the supporting structures have been detached,
the corresponding drilling sleeves
can be inserted into the surgical
guide (Fig. 7). Sterilisation of surgical guides printed with VPrint SG is
possible and recommended. The
absolute dimensional stability of
the surgical guide with the drilling
8
9
10
11
Fig. 8: After the mid-crestal incision before raising the mucoperiosteal flap. Fig. 9: Fully guided preparation being performed
in accordance with the drilling protocol. Fig. 10: Insertion of bone substitute material. Fig. 11: Placement of the implants in
regions #14 and 15.
12
Fig. 12: Post-op radiograph showing the implants in regions #14 and 15.
13
14
Fig. 13: Resorbable membrane and bone substitute material prior to wound closure. Fig. 14: Screw-retained final restorations.
Production of the surgical
guide
Importing the STL surgical
guide data set into the corresponding nesting software makes
it possible to align the surgical
guide and furnish it with supporting structures (Fig. 4). The slicing of
sleeves inserted is guaranteed
without restriction.
Implantation
After local anaesthesia, a midcrestal incision was per formed and
a mucoperiosteal flap was raised
(Fig. 8). The flap design should be
chosen such that the flap will not
affect the positioning of the surgical guide. The osseous situation
corresponded to the CBCT findings
of a buccally atrophied alveolar
ridge. After pilot drilling, the fully
guided preparation was performed
in accordance with the drilling protocol (Fig. 9). The vertical drilling up
to just before the maxillary sinus
was controlled by the surgical
guide. The cortical bone of the
sinus floor could then be selectively fractured using osteotomes
and the Schneiderian membrane
lifted to 11 mm, and subse quently
bone substitute material was inserted (BioOss, Geistlich; Fig. 10).
After placement of the implants
(Figs. 11 & 12), the buccal atrophy
in regions #14 and 15 was reconstructed with bone substitute material and covered with a resorbable membrane (BioGide, Geistlich;
Fig. 13). Salivaproof wound closure
was performed using ePTFE suture
material.
The provisional bridge was
modified at the base to create
space in case of swelling and inserted with methacrylate based
temporary luting material (Bifix
Temp, VOCO). The screwretained
final restorations were fabricated
from a multilayered monolithic zirconia (DD cubeX2 ML, Dental
Direkt; Fig. 14).
Discussion
Placement of an implant in a
suboptimal position can have effects on the osseointegration,
cleanability and function of the implant. In addition to aesthetic compro mises in the prosthetic restoration, an inadequate implant position may be associated with functional issues and an increased risk
of periimplantitis.7,8
In order to achieve a prosthetically and biologically adequate implant position, surgical guides are
used nowadays to transfer digital
planning to reality. The ma terials
used for the printing of surgical
guides are usually methacrylatebased and differ in their properties,
such as the modulus of elasticity.
The precision of guided implant
surgery is usually defined as the
discrepancy between the planned
and actual postoperative clinical
position of the implant. Equally
good results in trans fer precision
have been obtained in studies with
milled and printed guides in edentulous spaces such as in the presented case.9,10 Sterilisation at
135°C for 5 minutes had no significant effect on the material used.9
However, the surgical guide material and printer used did have a significant effect.9 In in vivo studies,
deviations have been evaluated
with implants placed with surgical
guides and been found to be significantly below the deviations
using freehand procedures.11 In addition to positioning, surgical
guides facilitate the procedure for
the surgeon, as demonstrated in
this case. Corresponding planning
allows guiding of the drill up to just
before the maxillary sinus, allowing
more efficient fracturing of the cortical bone of the maxillary sinus
floor with an osteotome and lifting
of the Schneiderian membrane.
This shortens the overall duration of the surgery, making it more
acceptable and pleasant for the patient.
Editorial note: This article was first
published in 3D printing international
magazine of dental printing technology, Vol. 4, Issue 1/2024.
Please scan the QR code for the
list of references.
Dr Andreas
Keßler is a
distinguished
dentist and
academic based in Munich in Germany. He completed his dentistry studies at LMU Munich in 2013, followed
by a doctorate in 2014. Since then,
he has been a research associate
at LMU’s department of restorative
dentistry and periodontics. In 2021,
he attained a postdoctoral about
qualification in additive manufacturing and thereby became authorised
to lecture at LMU, earning the title of
Privatdozent. He was appointed senior physician in 2022 and completed
an MSc in prosthetics in the same
year. Dr Keßler’s career reflects a
dedication to advancing both clinical
practice and dental research. He may
be contacted at andreas.kessler@
med.uni-muenchen.de.
Dr Stefanie
Lindner is a
dentist and
researcher. She graduated from LMU
Munich in Germany in 2016 and thereafter pursued practical experience
as a dental intern in private practice
in 2017. Since 2018, Dr Lindner has
been a dedicated research associate
at LMU’s department of restorative
dentistry and periodontics. In 2019,
she earned her doctorate, and in
2022, she completed an MSc in
prosthetics, showcasing her commitment to advancing dentistry through
research and practice. She can be
contacted at stefanie.lindner@med.
uni-muenchen.de.
[4] =>
DTMEA_No.5. Vol.15_LT.indd
SAVE / THE / DATE
14-15
Nov 2025
Face-to-Face // Dubai // UAE
www.cappmea.com // +97143476747
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