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- DOI 10.18231/j.ijce.2021.044
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- Citation
Three-dimensional printing in endodontics: A review of literature
- Author Details:
-
Jyoti Chauhan *
-
Ida de Noronha de Ataide
-
Marina Fernandes
Introduction
3D printing is an additive manufacturing process which involves incremental deposition of material. This is an improvement from subtractive manufacturing procedures like CAD/CAM where an object is cut from a block of material. [1], [2]
Limited option of materials and orientation requirements of CAD/CAM have led to their limited use in dentistry. [1], [2], [3] 3D printing proves to be useful in cases where subtractive manufacturing is inadequate.
In the field of dentistry, one of the following techniques can be used for 3-D printing: stereolithography apparatus (SLA), fused deposition modelling (FDM), MultiJet printing (MJP), PolyJet printing, ColorJet printing (CJP), digital light processing (DLP) and selective laser sintering (SLS), also known as selective laser melting (SLM). [3], [4]
SLA is most commonly used in dentistry. [4] Here, the exposure path of a UV laser is directed onto the surface of a vat of photosensitive resin. Subsequently curing starts from the bottom of the object, the layers bind together to form a solid mass. [1], [4] FDM printing has less precision than other methods. It involves deposition of layers of molten material from a filamentous nozzle and solidification within 0.1 second. [1], [3], [4] MultiJet printing and PolyJet printing take place by the spraying the polymer in very thin layers, each layer is cured after depositing onto a tray [1]. CJP involves selective dispersion of binder onto layers of powder. [4] In DLP printing, a vat of photosensitive resin is exposed to a two-dimensional image; the object is printed as the base is manipulated. The resin is cured from the bottom as the platform moves up. [1], [4] SLS and SLM printers use a computer directed laser and roller, where powdered material is dispensed in layers which are then melted or sintered. [1], [3], [4], [5], [6]
In the 1990s, Computed Tomography (CT) was used to 3D print surgical planning models. [7], [8], [9] When the FDA approved the first CBCT for dental use in 2000, it was found that in contrast to CT voxel, where axial height is determined by slice thickness, the CBCT voxel is cubic, allowing for higher resolution and hence more accurate measurements in multiple planes. [10], [1], [11] CBCT is therefore a more precise source of data for 3D printing, and has the added advantage of reducing radiation exposure, scan time as well as cost. [12], [11]
Review of Endodontic Applications
A literature search of PubMed and Scopus was done with the following terms: 3D printing, stereolithography, guided endodontic access, guided endodontic surgery, surgical guide, rapid prototyping, autotransplantation rapid prototyping. Articles were incuded if: (i) article described an application of 3D printing in endodontics, (ii) published in English. Fifty-seven articles met inclusion criteria and were utilized. Documented solutions to endodontic challenges include: guided endodontic access, applications in autotransplantation, pre-surgical planning, and for educational models.
Guided endodontic access
Pulp canal obliteration is insinuated in up to 75% of perforations during attempted location and negotiation of calcified canals.[13] In these cases, canals must be located in more apical portions of progressively narrowing roots. [14], [15], [16] The risk of perforation can be reduced by producing a true path of canal access and instrumentation.
In a case series, digital impressions and CBCT scans were recorded, these were merged to form an STL (stereolithography) file showing bony architecture for teeth in cases of pulp canal obliteration in maxillary incisors. Following this, access guides were printed and used to target burs to canal spaces without creating perforations. [17] Also, case reports narrating the use of 3D printed guides to access an obliterated maxillary incisor, [18] a mandibular molar, [19] type V dens evaginatus [20] and obliterated mandibular incisors [21] establish the practicality of this approach. In ex vivo investigations of accuracy, stent guided access preparations were assessed by superimposing a post access CBCT upon a pre-operative designed access. [22], [23], [24] The mean deviation of the access cavities were found to be lower than 0.7 mm. [22] Small deviations from the intended access (0.12- 0.34 mm at the tip of the bur) and a mean angular deviation of less than 2 degrees was reported. [23], [24] These examinations demonstrate that 3D printed access guides provide an coherent and safe method for both chemo-mechanical debridement and conservation of tooth structure.
Autotransplantation
The success of this procedure is dependent on viability of periodontal ligament (PDL) cells and appropriate adaptation of the transplanted tooth to the recipient site. [25], [26] Traditionally, the donor tooth is used as a template for preparation of the recipient site, which leads to multiple adjustments to the alveolar bone and hence an increased extra-oral time and increased risk of damage to the PDL. [25], [26], [27], [28] Therefore, attempts have been made to improve outcomes of autotransplantation. In two studies Computer Aided Rapid Prototyping (CARP) was used to print replicas of teeth and manipulation of the recipient bone sites was completed prior to extraction of the donor teeth. [29], [30] A number of case reports, clinical studies and in vitro studies provide evidence that preoperative CARP of transplant teeth decreases extra-oral time and improves outcomes. [31], [32], [33], [34], [35], [36], [37], [38], [39], [40], [41], [42], [43], [44], [45], [46], [47], [48], [49] In a case report, the autotransplantation of immature premolars in a maxillary incisor avulsion case using a completely digital workflow has been described. [28] Here CAD was used to select the appropriate donor teeth. Prototype teeth were modified to accommodate the dimensions of Hertwig’s epithelial root sheath and to minimize damage to the apical papilla. Osteotomy guides were created using the CAD software and this led to more accuracy and efficiency in the surgical procedure. In a case report, CAD was used to print surgical instruments customized for the transplanted tooth, achieving an apical deviation of less than 1mm from the planned final tooth position in a human mandible. [45] A systematic review has reported an overall success rate of 80-91% when rapid prototyping was used, leading to a reduction in extra-oral time to less than one minute in some cases. [26]
Surgical guides
In clinical scenarios it is difficult to gauge the right orientation, angulation and depth. Due to advancements in magnification, equipment and materials, endodontic microsurgery (EMS) has been accepted as a predictable procedure,[50], [51], [52] also targeted osteotomy and root end resection is a pre-requisite for EMS. Osteotomy diameter can be as small as 3 mm, which has been correlated with shorter healing time, decreased postoperative pain, and improved outcomes. [50], [53] Clinicians often find it difficult to carry out procedures in posterior molar area or if important anatomic structures are close to the root end. 3D printed stents can reduce the risk by avoiding invasion of neurovascular structures.
It has been reported that guides designed from CBCT produced more accurate osteotomies than the traditional free-hand technique in an in vitro model. [54] Case reports have described the use of a 3D printed guide for traditional root-end surgery, [55] as well as for designing a stent defining the upper and lower margins of the osteotomy, as well as the root resection site and angulation, resulting in increased clinical efficiency and precision, minimizing risk of sinus perforation. [56] Use of a 3D printed custom tissue retractor to enhance visualization and soft tissue handling during EMS on a maxillary incisor has also been described. [57]
|
Endodontic Application |
Teeth/ material studied |
Author/year |
Type of study |
3D printer |
|
Guided Endodontic Access |
Not stated |
Van der Meer WJ et al. 2016 [17] |
Case series |
Not stated |
|
Guided Endodontic Access |
Maxillary incisor |
Krastl G et al. 2016 [18] |
Case report |
PolyJet |
|
Guided Endodontic Access |
Mandibular molar |
Shi X et al. 2017 [19] |
Case report |
MJP |
|
Guided Endodontic Access |
Type V dens evaginatus |
Mena-Alvarez J et al. 2017 [20] |
Case report |
SLA |
|
Guided Endodontic Access |
Mandibular incisors |
Connert T et al. 2018 [21] |
Case report |
PolyJet |
|
Guided Endodontic Access |
48 extracted Teeth (undisclosed) |
Buchgreitz J et al. 2016 [22] |
Ex vivo study |
Not stated |
|
Guided Endodontic Access |
60 single Rooted human teeth |
Zehnder MS et al. 2016 [23] |
Ex vivo study |
PolyJet |
|
Guided Endodontic Access |
60 mandibular anterior teeth |
Connert T et al. 2017 [24] |
Ex vivo study |
PolyJet |
|
Tooth autotransplantation |
Mandibular third molar |
Lee S-J et al. 2001 [29] |
Case series |
Not stated |
|
Tooth autotransplantation |
Third molars |
Lee S-J et al. 2012 [30] |
Case series |
Not stated |
|
Tooth autotransplantation |
Immature premolar |
Keightley A et al. 2010 [31] |
Case report |
CJP |
|
Tooth autotransplantation |
Right Mandibular Third molar |
Honda M et al. 2010 [32] |
Case report |
Not stated |
|
Tooth autotransplantation |
Maxillary left Second premolar |
Pang NS et al. 2010 [33] |
Case report |
Not stated |
|
Tooth autotransplantation |
Premolar and Third molar |
Shahbazian M et al. 2010 [34] |
Pre-clinical |
SLA |
|
Tooth autotransplantation |
Undisclosed |
Shahbazian M et al. 2012 [35] |
Case report |
SLA |
|
Tooth autotransplantation |
Mandibular Right third molar |
Park Y-S et al. 2012 [36] |
Case report |
Not stated |
|
Tooth autotransplantation |
Mandibular Second premolar |
Park Y-S et al. 2013 [37] |
Case Report |
Not stated |
|
Tooth autotransplantation |
Immature Third molars |
Jang J-H et al. 2013 [39] |
Case series |
Not stated |
|
Tooth autotransplantation |
Mesiodens |
Lee Y et al. 2014 [40] |
Case report |
Not stated |
|
Tooth autotransplantation |
Third molar |
Park J-M et al. 2014 [41] |
Case report |
PolyJet |
|
Tooth autotransplantation |
Maxillary left Central incisor |
Vandekar M et al. 2015 [42] |
Case report |
DLP |
|
Tooth autotransplantation |
Maxillary Right second premolar |
Van der Meer WJ et al. 2016 [43] |
Case report |
Not stated |
|
Tooth autotransplantation |
Mandibular premolars |
Khalil W et al. 2016 [44] |
In vitro study |
PolyJet |
|
Tooth autotransplantation |
Mandibular Left canine |
Anssari Moin D et al. 2016 [45] |
Ex vivo |
Not stated |
|
Tooth autotransplantation |
Mandibular Incisors, canines, premolars |
Anssari Moin D et al. 2017 [46] |
Ex vivo |
Not stated |
|
Tooth autotransplantation |
Maxillary Second premolar |
Cousley RRJ et al. 2017 [47] |
Case report |
CJP |
|
Tooth autotransplantation |
Maxillary Right canine |
Kim MS et al. 2017 [48] |
Case report |
Not stated |
|
Tooth autotransplantation |
Third molar |
Verweij JP et al.2017 [49] |
Systematic review |
Not stated |
|
Guided EMS |
All mandibular teeth |
Pinsky HM et al. 2007 [54] |
Pre-clinical |
Not stated |
|
Guided apicoectoectomy |
Mandibular Right premolar |
Liu Y et al. 2014 [55] |
Case report |
PolyJet |
|
Surgical guides |
Maxillary central incisor |
Strbac GD et al. 2016 [56] |
Case report |
PolyJet |
|
EMS soft tissue retraction |
Maxillary left central incisor |
Patel S et al. 2017 [57] |
Case report |
Not stated |
|
Simulation exercises |
Right Maxillary central incisor |
Kfir A et al. 2013 [58] |
Case report |
PolyJet |
|
Pre-treatment simulation |
Mandibular second molar and paramolar |
Kato H et al. 2015 [59] |
Case report |
FDM |
|
Research simulation |
Mandibular Molar replicas |
Marending M et al. 2016 [60] |
Pre-clinical |
Not stated |
|
Research simulation |
Replicas of teeth extracted for orthodontic, periodontic or prosthetic reasons |
Robberecht L et al. 2017 [61] |
Pre-clinical |
SLA |
|
Research simulation |
Replicas of mandibular molars |
Ordinola-Zapata R et al. 2014 [62] |
Pre-clinical |
MJP |
|
Research simulation |
Mandibular Second premolar |
Eken R et al. 2016 [63] |
Pre-clinical |
PolyJet |
|
Research simulation |
Resin models of maxillary central incisors |
Yahata Y et al. 2017 [64] |
Pre-clinical |
MJP |
|
Research simulation |
Replicas of mandibular molars |
Gok T et al. 2017 [65] |
Pre-clinical |
DLP |
|
Research simulation |
Sheets of Photopolymer material |
Mohmmed SA et al. 2017 [66] |
In vitro |
SLA |
Educational models and clinical simulation
Most dental educational institutes use extracted teeth, human cadavers, or commercially available resin teeth for preclinical exercises.[67], [68] Though extracted teeth can provide a clinical simulation close to reality, but it is difficult to find teeth with the required properties and disinfection, storage etc. can change the properties. Commercially available resin teeth are an alternative to the natural dentition but can be expensive.
Tooth prototypes can be used for simulation exercises and have multiple benefits over extracted teeth. [58], [69], [59], [60], [61]. Earlier CT slices and starch were used to reconstruct exigent clinical cases such as extracanal invasive resorption[70] and a molar with three distal roots.[71] In a case report clear tooth replica was used to simulate ideal access, instrumentation and obturation preoperatively in a complex type 3 dens invaginatus scenario, before treating the clinical case.[58] In an evaluation of dental student file preferences, commercially available 3D printed molar replicas (RepliDens, Zurich, Switzerland) were used to avoid variance in initial canal configuration [60]. A porous, radiopaque hydroxyapatite-based matrix with hardness similar to dentin to print ceramic models for endodontic lab exercises has been developed. [61]
3D printing can be used to manufacture a large number of identical prototypes and hence can be utilized in pre-clinical research. Variables like the shaping ability[62] and stress values[63] of different rotary file systems, centering ability of access preparations[64] and different obturation techniques for C-shaped canals[65] have been investigated with uniformly controlled canal configurations. Growth of Enterococcus faecalis biofilms on SLA materials comparable to dentin has been demonstrated and subsequently this was applied in vitro model to evaluate irrigation techniques.[66]
Conclusion
The literature on use of Three-dimensional printing in Endodontics is limited to case reports and pre-clinical studies. Also, acquiring technical expertise within endodontic practices is an obstacle to its widespread use. Hence, consideration should be given to include 3D printing within the curriculum. More studies need to be done at a larger scale with long term follow ups which will help endodontists in making informed decisions regarding the use of this technique in clinical practice.
Conflict of Interest
The author declares no potential conflicts of interest with respect to research, authorship, and/or publication of this article.
Source of Funding
None.
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How to Cite This Article
Vancouver
Chauhan J, Ataide IDND, Fernandes M. Three-dimensional printing in endodontics: A review of literature [Internet]. IP Indian J Conserv Endod. 2021 [cited 2025 Sep 11];6(4):198-204. Available from: https://doi.org/10.18231/j.ijce.2021.044
APA
Chauhan, J., Ataide, I. D. N. D., Fernandes, M. (2021). Three-dimensional printing in endodontics: A review of literature. IP Indian J Conserv Endod, 6(4), 198-204. https://doi.org/10.18231/j.ijce.2021.044
MLA
Chauhan, Jyoti, Ataide, Ida de Noronha de, Fernandes, Marina. "Three-dimensional printing in endodontics: A review of literature." IP Indian J Conserv Endod, vol. 6, no. 4, 2021, pp. 198-204. https://doi.org/10.18231/j.ijce.2021.044
Chicago
Chauhan, J., Ataide, I. D. N. D., Fernandes, M.. "Three-dimensional printing in endodontics: A review of literature." IP Indian J Conserv Endod 6, no. 4 (2021): 198-204. https://doi.org/10.18231/j.ijce.2021.044