Journal of
Clinical Medicine
Article
Sinus Lift and Implant Insertion on 3D-Printed Polymeric
Maxillary Models: Ex Vivo Training for In Vivo
Surgical Procedures
Diana Florina Nica 1 , Alin Gabriel Gabor 2 , Virgil-Florin Duma 3,4, *,† , Vlad George Tudericiu 5 , Anca Tudor 2
and Cosmin Sinescu 2,†






Citation: Nica, D.F.; Gabor, A.G.;
Duma, V.-F.; Tudericiu, V.G.; Tudor,
A.; Sinescu, C. Sinus Lift and Implant
Insertion on 3D-Printed Polymeric
Maxillary Models: Ex Vivo Training
for In Vivo Surgical Procedures. J.
Clin. Med. 2021, 10, 4718. https://
doi.org/10.3390/jcm10204718
Academic Editors: Samer Srouji and
Bruno Chrcanovic
Received: 21 August 2021
Accepted: 12 October 2021
Published: 14 October 2021
Publisher’s Note: MDPI stays neutral
with regard to jurisdictional claims in
published maps and institutional affil-
iations.
Copyright: © 2021 by the authors.
Licensee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms and
conditions of the Creative Commons
Attribution (CC BY) license (https://
creativecommons.org/licenses/by/
4.0/).
J. Clin. Med. 2021, 10, 4718. https://doi.org/10.3390/jcm10204718
1 School of Dental Medicine, “Victor Babes” University of Medicine and Pharmacy of Timisoara,
2A Eftimie Murgu Place, 300070 Timisoara, Romania; nica.diana@umft.ro
2 Research Center in Dental Medicine Using Conventional and Alternative Technologies, School of Dental
Medicine, “Victor Babes” University of Medicine and Pharmacy of Timisoara, 9 Revolutiei 1989 Ave.,
300070 Timisoara, Romania; gabor.alin30@gmail.com (A.G.G.); anca.ancutza@gmail.com (A.T.);
minosinescu@gmail.com (C.S.)
3 3OM Optomechatronics Group, Faculty of Engineering, “Aurel Vlaicu” University of Arad, 2 Elena Dragoi,
310177 Arad, Romania
4 Doctoral School, Polytechnic University of Timisoara, 1 Mihai Viteazu Ave., 300222 Timisoara, Romania
5 Dentavis Timisoara, 20B Popa Sapca Str., 300057 Timisoara, Romania; vladtudericiu@gmail.com
* Correspondence: duma.virgil@osamember.org; Tel.: +40-751-511451
† These two authors have equal contributions.
Abstract: Background and Objectives: The aim of this study is to demonstrate the increased efficiency
achieved by dental practitioners when carrying out an ex vivo training process on 3D-printed maxil-
laries before performing in vivo surgery. Materials and Methods: This developed ex vivo procedure
comprises the following phases: (i) scanning the area of interest for surgery; (ii) obtaining a 3D virtual
model of this area using Cone Beam Computed Tomography (CBCT); (iii) obtaining a 3D-printed
model (based on the virtual one), on which (iv) the dental practitioner simulates/rehearses ex vivo
(most of) the surgery protocol; (v) assess with a new CBCT the 3D model after simulation. The
technical steps of sinus augmentation and implant insertion could be performed on the corresponding
3D-printed hemi-maxillaries prior to the real in vivo surgery. Two study groups were considered,
with forty patients divided as follows: Group 1 comprises twenty patients on which the developed
simulation and rehearsal procedure was applied; Group 2 is a control one which comprises twenty
patients on which similar surgery was performed without this procedure (considered in order to com-
pare operative times without and with rehearsals). Results: Following the ex vivo training/rehearsal,
an optimal surgery protocol was developed for each considered case. The results of the surgery
on patients were compared with the results obtained after rehearsals on 3D-printed models. The
performed quantitative assessment proved that, using the proposed training procedure, the results of
the in vivo surgery are not significantly different (p = 0.089) with regard to the ex vivo simulation
for both the mezio-distal position of the implant and the distance from the ridge margin to sinus
window. On the contrary, the operative time of Group 1 was reduced significantly (p = 0.001), with
an average of 20% with regard to in vivo procedures performed without rehearsals (on the control
Group 2). Conclusions: The study demonstrated that the use of 3D-printed models can be benefi-
cial to dental surgeon practitioners, as well as to students who must be trained before performing
clinical treatments.
Keywords: dental implants; sinus lift; ex vivo training procedure; in vivo surgery procedure; 3D printing;
CAD/CAM techniques; maxillary models; Cone Beam Computed Tomography (CBCT); polymers
https://www.mdpi.com/journal/jcm
J. Clin. Med. 2021, 10, 4718 2 of 15

1. Introduction
In dental clinics, patients often have terminal edentulism that cannot be treated
using traditional prosthetic methods [1–3]. Also, sometimes they do not accept a mo-
bile/removable prosthesis. In such situations, to restore the essential functions of the
stomatognathic system, implant therapy must be used. Such a technique requires an
additional sinus lift surgery [4,5] as well as bone augmentation for the insertion of im-
plants [6–9]. Despite the drawback represented by the necessity for surgery, by following
such procedures, most patients can benefit from an optimal prosthetic restoration from
both a morphological and functional point of view.
To optimize the necessary in vivo procedures, extra support can be provided by three-
dimensional (3D) printing. The scope of using this technique is to be able to rehearse,
ex vivo, the surgical maneuvers before performing them on the patient. Therefore, the
expected rate of success in vivo may increase, as well as the precision and time-efficiency
of the intervention. In this respect, craniofacial surgery represents one of the top areas
where 3D printing technology has built up interest [10–12]. Thus, precise individual patient
models help practitioners in reconstruction in planning and morphological rehabilitation.
Also, they can serve as teaching and educational tools [13,14].
In general, 3D printing, also known as rapid prototyping, is a process of forming a solid
object of a required shape. It was first described and patented in 1986 by Charles Hull [15]
and in 1992 by Deckard et al. [16]. An additive manufacturing (AM) process, in which
successive layers of material are set in different shapes, is used. This process is distinct from
traditional (i.e., subtractive) machining techniques, which rely on eliminating materials
using methods such as cutting or drilling, starting from a semi-manufactured part. In
contrast, 3D printing starts from a digital model. Through AM, the desired object is created
layer by layer, until it reaches its final shape, using a range of possible methods [17–19].
Efforts to optimize related techniques, especially scanning [20–22], have been made to
increase parameters of the process such as precision, surface roughness, and size of objects
to be printed.
In the present work, maxilla models are obtained through 3D printing using Computer-
Aided Design/Computer-Aided Manufacturing (CAD/CAM). The design of the 3D-
printed models is based on the clinical data obtained from intraoral scanning, as well
as on paraclinical data retrieved from the patients using Cone Beam Computed Tomogra-
phy (CBCT). The obtained 3D-printed models are utilized for ex vivo training for implant
insertion and sinus lift simulations before performing the real, in vivo surgery in the
clinical area.
The first hypothesis of the study is to prove that using such implant simulations and
clinical procedure rehearsals provides a superior quality of prosthetic restorative treatments
on dental implants. To verify this hypothesis, a comparison must be made between the
clinical results obtained in the final in vivo procedure and those obtained when the ex vivo
training on models is performed.
The second hypothesis is that intervention time is reduced when such simulations are
performed, compared to the situation when they are not utilized. To verify this hypothesis,
a comparison must be made between the operative time necessary for the final in vivo
procedure when such simulations (and the corresponding ex vivo training on models) are
performed and the operative time necessary without this developed procedure.

2. Materials and Methods

Forty patients were included in this study. They were divided into two groups:
Group 1 comprised twenty patients selected for the developed clinical procedure,
which included simulations/rehearsals, as described in the following for one of these
clinical cases. Similar procedures were performed on each of these twenty patients.
Group 2 was a control group, consisting of other twenty treated patients on which
in vivo surgery was performed without the training developed in this work. This group
was considered in order to evaluate the second hypothesis of this study. As a necessary
J.
J. Clin.
Clin. Med. 2021, 10,
Med. 2021, 10, 4718
x FOR PEER REVIEW 33 of
of 15
16

type of surgery
remark, the cases specific to this
of Group 2 study was performed
were selected from a previously
larger group to of
developing
patients on thewhich
simu- 98
lation
the typeandofrehearsal procedure
surgery specific developed
to this study wasin this work. The
performed selection was
previously made by con-
to developing the 99
sidering
simulation an and
as good as possible
rehearsal matchdeveloped
procedure (in pairs ofinpatients)
this work.with theselection
The cases of Group
was made1 fromby 100
the point of view
considering an asof theirasclinical
good possible difficulty
match (in(please
pairssee in this respect
of patients) Section
with the cases3.2).
of Group 1 101
fromThis
the point
work of wasview of theirby
approved clinical difficulty of
the Committee (inMedical
this respect, please
Research of see Section Babes”
the “Victor 3.2). 102
This work
University was approved
of Medicine by the Committee
and Pharmacy of Medical
of Timisoara, Romania,Research of thethe
following “Victor Babes”
Ethical pro- 103
University
tocol of theofUniversity,
Medicine and
withPharmacy
the CECSofApproval
Timisoara,no.
Romania, following
09/02.03.2018, andthe Ethical
it was protocol
carried out 104
of the University
according with the
to guidelines CECS
of the Approval
Declaration no. 09/02.03.2018,
of Helsinki. An informed and it waswas
consent carried out
submit- 105
according
ted to all oftothe
guidelines of the Declaration
forty enrolled patients. of Helsinki. Informed consent was submitted to 106
all of the forty
2.1. Diagnosis enrolled patients. 107
As mentioned above, a clinical case selected from Group 1 is presented in the follow-
2.1. Diagnosis 108
ing, toAsdescribe
mentioned the above,
method, i.e., thecase
a clinical developed
selectedsimulation
from Groupand 1 isrehearsal
presentedprocedure.
in the following 109
This case
to describe the involved a 50-years-old
method, i.e., the developed male patient who
simulation presentedprocedure.
and rehearsal to the clinic with a 110
maxillary cantilever
This case involvedcemented prosthetic
a 50-year-old malerestauration.
patient whoThe patienttoaffirmed
presented the clinicthat theafunc-
with max- 111
tional role of this restauration has become completely inadequate, with
illary cantilever cemented prosthetic restoration. The patient affirmed that the functional no possibility of 112
mastication on the right side. The first step of the procedure included
role of this restoration became completely inadequate, with no possibility of masticationa clinical examination 113
(Figure 1), where
on the right side. Thethe missing
first stepmaxillary right first
of the procedure and second
included molars
a clinical was remarked.
examination (FigureThe 1), 114
first
where molar was extracted
the missing tworight
maxillary yearsfirst
ago,and
andsecond
the second
molars molar
weremore than ten
remarked. years
The first ago.
mo- 115
The intraoral
lar was examination
extracted two years showed
ago and a healthy
the secondgingival
molarand mucosal
over status.
ten years ago.For anintraoral
The accurate 116
diagnosis, a radiological evaluation was performed. The treatment
examination showed a healthy gingival and mucosal status. For an accurate diagnosis, options were ex-
a 117
plained, and the patient was also informed about the benefits and
radiological evaluation was performed. The treatment options were explained, and the risks of each treatment 118
option.
patient As washealso
wanted to avoid
informed a removable
about the benefits prosthesis
and risks dueof to its treatment
each inconvenience, theAs
option. treat-
he 119
ment
wanted option has been
to avoid an implant-supported
a removable prosthesis duecrown to its restauration.
inconvenience, the chosen treatment 120
option In was
this an
first step, a CBCT scan
implant-supported of the
crown maxilla was performed to evaluate the bone
restoration. 121
anatomy and confirm the absence of the maxillary sinus pathology (Figure 2). 122

(a) (b)
(a) Initial
Figure 1. (a) Initialclinical
clinicalassessment;
assessment;(b)(b)preoperative
preoperativeorthopantomogram
orthopantomogram (OPG)
(OPG) showing
showing anan insufficient
insufficient height
height forfor
an 123
maxillary right
implant insertion in the maxillary right first
first molar
molar edentulous
edentulous site.
site. 124

In this first step, a CBCT scan of the maxilla was performed to evaluate the bone 125
anatomy and confirm the absence of the maxillary sinus pathology (Figure 2).

2.2. Manufacturing of Hemi-Maxillary 3D Printed Model

An overview of this second step of the procedure is made in Figure 3. First, a digital
intraoral impression was performed using the digital intraoral scanning system Cerec
OMNICAM (Dentsply Sirona CEE Central, Bucharest, Romania). Thus, an initial 3D design
was obtained, as shown in the upper image in Figure 3a. Subsequently, the patient was
sent to the radiology center where a CBCT type scan was performed using CRANEX
3DX (Soredex, Tuusula, Finland). A radiographic CBCT scan allows getting an optimally
printed pattern due to its in-depth penetration of the tissues, as shown in the lower image
in Figure 3a.
 J. Clin.
J. Clin. Med. Med.
2021, 10,2021,
x FOR10,PEER
4718 REVIEW 4 of 16 4 of 15
5.02 mm

2.65 mm

(a) (b)
Figure 2. Cross sectional CBCT views corresponding to: (a) the 16 with a bone height of 5.02 mm; 126
(b) the 17 with a bone height of 2.65 mm and insufficient crestal width. 127
5.02 mm
2.2. Manufacturing of hemi-maxillary 3D printed model 128
An overview of this second step of the procedure is made in Figure 3. First, a digital 129
2.65 mm
intraoral impression was performed using the digital intraoral scanning system Cerec 130
OMNICAM (Dentsply Sirona CEE Central, Bucharest, Romania). Thus, an initial 3D de- 131
sign was obtained, as shown in the upper image in Figure 3a. Subsequently, the patient 132
(a)
was sent to the radiology center where a CBCT type scan was (b)performed using CRANEX 133

2.3DX
Figure Figure (Soredex,
Cross
2. sectionalTuusula,
CBCT views
Cross-sectional Finland).
CBCT views Radiographic
corresponding CBCT
to: (a) the
corresponding to: 16 scan
(a) with
the aallows
16 for getting
bone aheight
with bone of 5.02an
height mm;
of optimally
5.02 mm;
126 134
17printed
(b) the (b) with a pattern
bone due
height to
of its
2.65 in-depth
mm and penetration
insufficient of
crestalthe tissues,
width.
the 17 with a bone height of 2.65 mm and insufficient crestal width. as shown in the lower image
127 135
in Figure 3a. 136

CAD of2.2. Manufacturing of hemi-maxillary

hemi- CAM/3D Printing 3D printed modelFinal steps of 3D Printing 128
maxillaryAn overview of this second step of the procedure is made in Figure 3. First, a digital 129
intraoral impression was performed using the digital intraoral scanning system Cerec 130
OMNICAM (Dentsply Sirona CEE Central, Bucharest, Romania). Thus, an initial 3D de- 131
Form
sign was obtained, as shown in the upper image in Figure 3a. Subsequently, the patient 132
Wash
was sent to the radiology center where a CBCT type scan was performed using CRANEX 133
3DX (Soredex, Tuusula, Finland). Radiographic CBCT scan allows for getting an optimally 134
printed pattern due to its in-depth penetration of the tissues, as shown in the lower image
Initial 3D design
135
in Figure 3a. 136

CAD of hemi- CAM/3D Printing Final steps of 3D Printing

maxillary

Form
3D printing system Form Cure
Form2 utilized to Wash
obtain the hemi-
maxillary models (c)
(a)3D design
Initial Final design (b)

Figure
Figure The
3. 3. steps
The ofof
steps the design
the and
design manufacturing
and manufacturing ofofa hemi-maxillary:
a hemi-maxillary:(a)(a) CAD-initial
CAD-initialand andfinal design;
final (b)(b)
design; CAM-3D
CAM-3D 137
printing,
printing,with a Form2
with a Form2 system
system(Formlabs
(FormlabsInc.,
Inc.,Somerville,
Somerville,MA,
MA,USA);
USA);(c)(c)final
finaltwo
twosteps
stepsofofthe
themanufacturing
manufacturingprocess,
process,i.e.,
i.e., 138
washing
washing and curing
and ofof
curing the obtained
the polymer-based
obtained polymer-based 3D-printed
3D-printedmodels.
models. 139
Form
The
Theobtained
obtained data were wereoverlaid totoreach
reachthetheoptimal
optimaldesign ofofthe
thefuture
future3D-printed
3D printingdata
system overlaid design Cure 3D-printed 140
model. With
model. With the help of
theutilized
help oftothis
this design, a polymeric model was obtained using the 3Dprinting
design, a polymeric model was obtained using the 3D printing 141
Form2
system Form2
system Form2 (Formlabs
(Formlabs Inc., Somerville, MA, USA). The initial 3D design of the maxillary
obtain the hemi- Inc., Somerville, MA, USA). The initial 3D design of the 142
ready for printing
maxillary ready for
maxillary
(upper image
printing
models
of Figure
(upper image3a) of
was further
Figure 3a)correlated
was further with the parameters
corelated with the 143
(a) Final design (b)
ofparameters
the printing system. The (c) process of the final 3D design (bottom of Figure 3a)
printing
of the printing system. The printing process of the final 3D design (bottom of 144
was carried
Figure 3a) out
waswith the following
carried out withsystem characteristics
the following systemand parameters (Figure
characteristics 3b): 3D
and parameters 145
printing can be carried out in slices, with thicknesses ranging from 0.01 to 0.10 mm137
Figure 3. The steps of the design and manufacturing of a hemi-maxillary: (a) CAD-initial and final design; (b) CAM-3D at
printing, with a Form2 system (Formlabs Inc., Somerville,
a temperature of 22 to MA, ◦ C and
25USA); (c) final two steps
a relative of the manufacturing
humidity of 60%. Theprocess, i.e.,
3D printing time138
of
washing and curing of the obtained polymer-based
each model was3D-printed
around 6 models.
h. After this process, the scaffold sites were washed and then 139
introduced for 30 min in an oven curing from the same 3D printing system (Figure 3c). The
The obtained
obtained partsdata were
were overlaid
finally to reach
processed to the optimal
remove smalldesign of the
excesses offuture
material.3D-printed 140
model. With theDigital
The help of3Dthis design,
Printer a polymeric
Form 2 in Figure model was obtained
3c, which using thelight-curing
uses laminated 3D printingresins 141
system(DigitalWax
Form2 (Formlabs
® DC-Series Inc.,Casting
Somerville,
Resin, MA,DWS,USA).Thiene, The initial
Italy), was3D design to
employed of obtain
the the142
maxillary ready for printing (upper image of Figure 3a) was further corelated
3D polymeric model of the hemi-maxilla for each considered case/patient. Figure 4 shows with the 143
parameters of the printing system. The printing process of the final 3D design
the 3D-printed polymeric-made hemi-maxilla model of this patient, in different views.144 (bottom of
Figure 3a) was carried out with the following system characteristics and parameters 145

J. Clin. Med. 2021, 10, 4718
time of each model was around 6 h. After this process, the scaffold sites were washed and 148
then introduced for 30 min in an oven curing from the same 3D printing system (Figure 149
3c). The obtained parts were finally processed to remove small excesses of material. 150
The Digital 3D Printer Form 2 in Figure 3c, which uses laminated light curing resins 151
(DigitalWax® DC-Series Casting Resin) was employed to obtain the 3D polymeric model 5 of 15 152
of the hemi-maxilla for each considered case/patient. Figure 4 shows the 3D-printed 153
polymeric-made hemi-maxilla model of this patient, in different views. 154

(a) (b) (c)

Figure
Figure 4. (a) 3D-printed model, 4. (a)
with (b)3D-printed
frontal andmodel, withview.
(c) lateral (b) frontal and (c) lateral view. 155

2.3. Ex
2.3. Ex vivo
Vivo simulation
Simulationofofsurgical
Surgicalprocedure
Procedure 156
In
In this
thisthird step
third of the
step of procedure, the dental
the procedure, the practitioner performed
dental practitioner on the polymeric
performed on the 157
3D-printed hemi-maxilla model the simulation of the sinus lift procedure
polymeric 3D-printed hemi-maxilla model the simulation of the sinus lift procedure by lateral ap-
by 158
proach, the insertion
lateral approach, theofinsertion
the ex-vivo implant,
of the as well
ex-vivo as theaslater
implant, welland
as crestal augmentation.
the later and crestal 159
Thus, the surgeon
augmentation. wasthe
Thus, able to observe
surgeon thetoexact
is able positioning
observe the exactof positioning
the bone formation, the
of the bone 160
thickness of the remaining bone, and the distance to the sinus membrane.
formation, the thickness of the remaining bone, and the distance to the sinus membrane. As a necessary 161
remark, the following operative phases described in the following section could not be
As a necessary remark, the following operative phases described in the following section 162
rehearsed on the 3D-printed model: incision, flap elevation, sinus membrane elevation,
could not be rehearsed on the 3D-printed model: incision, flap elevation, sinus membrane 163
flap repositioning, and suture.
elevation, flap repositioning. and suture. 164
2.4. Surgical procedure
Procedure 165
The real operation was performed between 2 to 5 days days (maximum)
(maximum) after after the
the rehearsal,
rehearsal, 166
depending on onthetheavailability
availabilityofofthe theoperation
operationory room roomand theand of the surgeon.
surgeon. Thecriterium
The essential essential 167
criterium
was to havehasthebeen
sameto have
healthy thesinus
samecondition
healthy sinus for the condition
patient. for the patient. 168
In this
this fourth
fourthstep of of
step thethe
procedure,
procedure,correlating
correlatingclinical information
clinical with with
information preclinical data,
preclinical 169
data,
as wellasaswell
with asthose
with obtained
those obtained on 3D-printed
on 3D-printed models, models, the medical
the medical doctor isdoctor
able towas able
pass to 170
to pass
the to theprocedure
surgical surgical procedure
for the sinus for lift
theandsinustheliftinsertion
and the of insertion of dental implants,
dental implants, as shown as in 171
shown
the in thein
example example
Figure 5infor Figure 5 for the considered
the considered patient. patient. 172
clinical stage
The first clinical stage iswasthethe sinus
sinus lift.lift.
For For
this this
case,case, a sinus
a sinus floorfloor augmentation
augmentation pro- 173
procedure via the lateral window approach with simultaneous
cedure via the lateral window approach with simultaneous implant placement implant placement for the 174
missing 16 and and aa sinus
sinus augmentation
augmentationfor foralatter implantation for 17 were planned.
latter implantation for 17 were planned. On On the 175
day of
day of the
thesurgery,
surgery,this thispatient
patientreceived
received 2 g2ofg amoxicillin
amoxicillinone onehour
hourbefore
beforethethe
procedure
procedure as 176
antibiotic
as prophylaxis:
antibiotic prophylaxis: 1 g one hourhour
1 g one before the procedure
before the procedureand theandrest
theofrest
the dose
of the12dose
h after
12 177
the firstafter
hours dose. theAsfirst
post-operative therapy, the patient
dose. As post-operative therapy,received 1 g three
the patient times 1 g
received a dayforper os
three 178
for 7 days [23]. Following the administration of local anesthesia
times a day per os for 7 days [23]. Following the administration of local anesthesia with with articaine, a crestal 179
incision was
articaine, performed,
a crestal incisionas well
wasas two vertical
performed, asreleasing
well as twoincisions on the
vertical distal aspect
releasing of the
incisions on 180
maxillary right second premolar and the mesial aspect of the
the distal aspect of the maxillary right second premolar and on the mesial aspect of edentulous crest of the third
the 181
molar, respectively.
edentulous crest of theThethird
incisions
molar,were made withThe
respectively. a 15C scalpelwere
incisions blade and with
made a full-thickness
a 15C scal- 182
mucoperiosteal
pel blade and a flap was reflected
full thickness with a lateralflap
mucoperiosteal sinus
waswall exposure
reflected with(Figure 5a).sinus wall
a lateral 183
A bony
exposure window
(Figure 5a). was then traced in the 16 and 17 regions using a piezo-surgical unit 184
(Figure 5b,c). The initial bone marking was done using tip SL1. This was followed by the
deepening of the mark using SL2. Using the SL3 tip, the Schneiderian membrane on the
windows edges was easily elevated (Figure 5d). Following the complete membrane eleva-
tion extending to the anterior and medial walls, the implant osteotomy was performed.
A C1 Implant 3.75 mm × 11.5 mm Standard Platform Conical Connection (MIS
Implants Technologies Ltd., Fair Lawn, NJ, USA) with simultaneous sinus lift procedure
was inserted on the 16 position (Figure 5e). A dedicated xenograft was compacted into the
sinus cavity (CompactBone® B., Dentegris GmbH, Monheim am Rhein, Germany). This
specific augmentative material was chosen because of its mineral composition, physical,
chemical, and biological properties, as well as because of its hydrophilic surface, with
J. Clin. Med. 2021, 10, 4718 6 of 15

a close resemblance to the characteristics of the human bone. Also, this material allows
J. Clin. Med. 2021, 10, x FOR PEER REVIEW 6 of 16
for fast revascularization because of its interconnecting pore system. Thus, it was able to
provide long-term stability of the augmented site with predictable results [24,25].

(a) (b) (c)

(d) (e) (f)

Figure5.5.(a)
Figure (a)Flap
Flapdesign;
design;(b)
(b)the
thebony
bonywindow;
window;(c)(c)the
thebony
bonywindow,
window,almost
almostcompleted
completedsaving
savingthe
theblood
bloodvessels;
vessels;(d)
(d)the
the 185
Schneiderianmembrane
Schneiderian membrane was
was elevated;
elevated; (e) inserted implant in
in the
the 16 th position with simultaneous sinus augmentation; (f)
16th position with simultaneous sinus augmentation; 186
sinus
(f) liftlift
sinus procedure
procedure1717
and
andlateral crest
lateral crestaugmentation.
augmentation. 187

A the
At bony window
level of 17, was then
a sinus traced in
elevation the 16 and
procedure 17 aregions
with using a lateral
simultaneous piezo-surgical unit
and vertical 188
(Figures 5b and
augmentation c). The
of the crestinitial bone marking
was performed (Figurewas5f).
done
Theusing tip SL1.
augmented This
area waswas followed
completely 189
covered with a collagen
by the deepening of themembrane
mark using SL2. Using® the
(BoneProtect Membrane,
SL3 tip, Dentegris GmbH, membrane
the Schneiderian Monheim 190
am
on Rhein, Germany).
the windows edges was easily elevated (Figure 5d). Following the complete membrane 191
The incisions
elevation extending were closed
to the with interrupted
anterior and medial sutures
walls, the 4-0 implant
polyesterosteotomy
(Resorba Medical
was per- 192
GmbH,
formed.Nürnberg, Germany). 193
A C1 Implant 3.75 mm x 11.5 mm Standard Platform Conical Connection (MIS Im- 194
2.5. Assessment
plants Technologiesof the Surgical
Ltd., FairProcedure
Lawn, NJ, USA) with simultaneous sinus lift procedure was 195
A CBCT was performed
inserted on the 16 position (Figure the day5e).
after
A the surgeryxenograft
dedicated in the fifthwasstep of the procedure.
compacted into the 196
Thus,
sinus each
cavitypatient was followed
(CompactBone ® up two weeks
B., Dentegris GmbH, after the surgery
Monheim am to checkGermany).
Rhein, if the healing
This 197
was uneventful.
specific Also, material
augmentative no complications
was chosen occurred
becauseinofthe six-month
its mineral period during
composition, the
physical, 198
osteointegration of implants.
chemical, and biological properties, as well as because of its hydrophilic surface, with a 199
closeFor the considered
resemblance to thecase, this CBCT of
characteristics assessment
the humanisbone.presented
Also,in thematerial
this cross-sections
allows in
for 200
Figure 6. Measurements were then performed, as presented in the following
a fast revascularization because of its interconnecting pore system. Thus, it is able to pro- section. 201
videAll the phases
a long-term aboveof
stability were performed, site
the augmented for with
each predictable
patient in the study,
results by the same
[24,25]. 202
surgeon. All the CBCT examinations were performed by the same radiologist.
At the level of 17, a sinus elevation procedure with simultaneous laterally and a ver- 203
tical augmentation of the crest were performed (Figure 5f). The augmented area was com- 204
pletely covered with a collagen membrane (BoneProtect® Membrane, Dentegris GmbH, 205
Monheim am Rhein, Germany). 206
The incisions were closed with interrupted sutures 4-0 polyester (Resorba Medical 207
GmbH, Nürnberg, Germany). 208
2.5. Assessment of the surgical procedure 209
A CBCT was performed the day after the surgery in the fifth step of the procedure. Thus, 210
each patient was followed up two weeks after the surgery to check if the healing has been 211
uneventful. Also, no complications occurred in the six months period during the osteoin- 212
tegration of implants. 213
For the considered case, this CBCT assessment is presented in the cross-sections in 214
Figure 6. Measurements were then performed, as presented in the following section. 215
All the phases above have been performed, for each patient in the study, by the same 216
surgeon. All the CBCT examinations were performed by the same radiologist. 217
J. Clin. Med. 2021, 10, x FOR PEER REVIEW 7 of 16

J. Clin. Med.
J. Clin. 2021,
Med. 10,10,
2021, x FOR
4718PEER REVIEW 7 of7 of
16 15

(a) (b)
Figure 6. (a) Postoperative control of the patient using 3D imaging; (b) the augmented 17 site (cross-sections). 218
(a) (b)
3. Results 219
Figure 6.Figure
(a) Postoperative control of
6. (a) Postoperative the patient
control of theusing 3Dusing
patient imaging; (b) the augmented
3D imaging; 17 site (cross-sections).
(b) the augmented 17 site (cross-sections). 218
3.1. Positioning assessments 220

3. 3. Results
Following the described procedure, a comparison was made between the mezio-dis-
Results 221
219
tal3.1. Positioning
positions
3.1. Positioning Assessments
ofassessments
the implant on the maxillary arch on the CBCT of the model and on the 222
220
patient´s postoperative
Following the CBCT, procedure,
described as shown incomparison
the panoramic viewsbetween
in Figure
the7.mezio-dis-
Also, the 223
Following the described procedure, a acomparison wasmade
was made between the mezio-distal 221
distances
positions from theimplant
of the top of the
on maxillary ridge
the maxillary to the
arch lowest
on the CBCT cutofonthe
themodel
maxillary sinus
and the buc-
patient’s 224
tal positions of the implant on the maxillary arch on the CBCT of the model and on the 222
calpostoperative
wall were measured
CBCT, ason the cross-section
shown in Figure
in the panoramic views8.in Figure 7. Also, the distances from 225
patient´s postoperative CBCT, as shown in the panoramic views in Figure 7. Also, the 223
theTable
top of1 the
provides the results
maxillary ridge to ofthe
thelowest
measurements performed
cut on the maxillaryon the CBCT
sinus buccal made on
wall were 226
distances from the top of the maxillary ridge to the lowest cut on the maxillary sinus buc- 224
the 3D-printed model after the implant
measured on the cross-section in Figure 8. insertion versus the CBCT made on the patients 227
cal wall were measured on the cross-section in Figure 8. 225
after the final (i.e., real clinical procedure of) implant insertion. 228
Table 1 provides the results of the measurements performed on the CBCT made on 226
the 3D-printed model after the implant insertion versus the CBCT made on the patients 227
after the final
4.64 mm(i.e., real clinical procedure of) implant insertion. 228

5.08 mm
4.64 mm
5.08 mm

(a) (b)
Figure
Figure Measurement
7. 7. Measurementofofthethemezio-distal
mezio-distalposition
positionof
of the
the implant (i.e.,
(i.e., distance
distancefrom
fromthe
theanterior
anteriortooth
toothtotothe
themiddle
middleofof
the 229
the implant
implant (D1))
(D1)) onon
(a)(a) the
the training
training CBCT
CBCT
(a) model
model (D1-3D)
(D1-3D) and
and onon (b)
(b) thethe postoperative
postoperative CBCT
CBCT
(b) (D1-P) - panoramic
(D1-P)—panoramic view.
view. 230

Figure 7. Measurement of the mezio-distal

Table 1 position
provides ofthe
the results
implantof(i.e.,
thedistance from the anterior
measurements performedtoothon
to the
the middle of
CBCT made on 229
the implant (D1)) on (a) the training CBCT model (D1-3D) and on (b) the postoperative CBCT (D1-P) - panoramic view.
the 3D-printed model after the implant insertion versus the CBCT made on the patients 230
after the final (i.e., real clinical procedure of) implant insertion.
The statistical processing of these results was performed using SPSSv17, calculating
the mean and the standard deviations (SD). Descriptive statistics were performed for the
numerical variables and comparisons between these series of pair values (i.e., D1-3D and
D1-P) were done with the non-parametric Wilcoxon Signed Ranks test (Table 2). The results
were considered significant for a value of p < 0.05 (Table 3). As it may be concluded from
these data, the difference between the distances from the anterior tooth to the middle of
the implant in the two considered situations is statistically insignificant (Wilcoxon Signed
Ranks Test, p = 0.089).
 J. Clin. Med. 2021, 10, 4718 8 of 15

Table 1. Measurements performed on CBCT images: 3D-printed models (rehearsed procedures) versus patients (postoperative).

Patient CBCT Measurements on 3D-Printed Models (mm) CBCT Measurements on Postoperative Patients (mm)
Distance from the
Distance from the Ridge Distance from the Anterior Distance from the
Anterior Tooth to the
Margin to the Sinus Tooth to the Middle of the Ridge Margin to the
Middle of the Implant
Window (D2-3D) Implant (D1-P) Sinus Window (D2-P)
(D1-3D)
1 4.23 4.47 4.25 4.72
2 3.91 5.10 4.01 4.87
3 4.43 4.87 4.47 4.64
4 3.86 4.58 3.92 4.98
5 4.67 5.75 4.51 5.68
6 4.64 4.35 4.78 4.73
7 3.80 4.29 3.82 4.48
8 3.86 5.67 3.91 5.39
9 3.90 4.92 4.17 5.19
10 3.92 5.17 4.03 4.83
11 4.45 4.77 4.27 4.91
12 4.29 4.57 4.37 4.31
13 3.95 4.86 3.94 5.07
14 4.17 5.14 4.26 4.92
15 3.83 5.12 4.15 5.37
16 3.89 4.93 4.06 5.19
17 4.57 4.62 4.41 4.95
18 4.49 4.71 4.45 4.58
19 2021, 10, x FOR PEER
J. Clin. Med. 4.54
REVIEW 5.12 4.52 5.34 8 of 16
20 4.48 4.72 4.51 4.60

4.35 mm
4.73 mm

(a) (b)
Figure
Figure8.8.Measurement
Measurementofofthe thedistance
distancebetween
betweenthe thetop
topofofthe
theridge
ridgeand
andthe
thelowest
lowestaccess
accesscut
cutatatthe
thebuccal
buccalwall
wallofofthe
the 231
maxillary
maxillarysinus
sinus(for
(forpatient
patientnumber
number6 6ininTable
Table1)1)onon(a)
(a)the
thetraining
trainingCBCT
CBCTmodel
model(D2-3D)
(D2-3D)andandon on(b)(b)the
thepostoperative
postoperative 232
CBCT
CBCT(D2-P)
(D2-P)cross-section.
cross-section. 233

Table 1. Measurements performedTable 2. Descriptive

on CBCT statistics models
images: 3D-printed regarding the distance
(rehearsed from theversus
procedures) anterior tooth (postoperative).
patients to the middle of the 234
implant following rehearsal procedures on 3D-printed models (D1-3D) compared to the distance
Patient CBCT measurements on the
from 3D-printed models
anterior tooth (mm)
to the CBCT
middle of the measurements
implant on postoperative
following implant procedurespatients (mm)
on patients (D1-P).
Distance from the anterior Distance N
Distance from the ridge Distance
Mean (mm) SDfrom the anterior
(mm) Distance Maximum
Minimum (mm) from the ridge
(mm)
tooth to the middle of theD1-3D
margin to the
20 sinus window
4.194 tooth to the middle of the 3.80margin to the sinus4.67
0.316 window
implant (D1-3D) D1-P 20
(D2-3D) 4.241 0.260(D1-P)
implant 3.82 (D2-P) 4.78
1 4.23 4.47 4.25 4.72
2 3.91 5.10 4.01 4.87
3 4.43 4.87 4.47 4.64
J. Clin. Med. 2021, 10, 4718 9 of 15

Table 3. Ranks regarding the D1-3D distances compared with the D1-P distances (the Wilcoxon
Signed Ranks test results).

N Mean Rank (mm) Sum of Ranks (mm)

Negative Ranks 6a 9.92 59.50
D1-P versus Positive Ranks 14 b 10.75 150.50
D1-3D Ties 0c - -
Total 20 - -
Remarks: a D1-P < D1-3D; b D1-P > D1-3D; c D1-P = D1-3D.

Similar statistical processing was performed using SPSSv17 for the distance from
the ridge margin to sinus window, in a comparative look between the data obtained
when rehearsing on 3D-printed models (D2-3D) and when performing implant procedures
on patients (D2-P). Descriptive statistics were performed for the numerical variables.
Comparisons between these series of pair values were done with the non-parametric
Wilcoxon Signed Ranks test (Table 4). The results were considered significant for a value of
p < 0.05 (Table 5). The difference between these distances was also statistically insignificant
(Wilcoxon Signed Ranks Test, p = 0.350).

Table 4. Descriptive statistics regarding the distance from the ridge margin to the sinus window
for rehearsals on 3D-printed models (D2-3D) and the distance from the ridge margin to the sinus
window for implant procedures on patients (D2-P).

Distance N Mean (mm) SD (mm) Minimum (mm) Maximum (mm)

D2-3D 20 4.887 0.385 4.29 5.75
D2-P 20 4.936 0.347 4.31 5.68

Table 5. Ranks regarding the D2-3D distances compared to the D2-P distances (the Wilcoxon Signed
Ranks test results).

N Mean Rank Sum of Ranks

Negative Ranks 9a 8.89 80.00
D2-P versus Positive Ranks 11 b 11.82 130.00
D2-3D Ties 0c - -
Total 20 - -
Remarks: a D2-P < D2-3D; b D2-P > D2-3D; c D2-P = D2-3D.

3.2. Operative Time

Another important aspect of a surgical procedure, essential from the patient’s point of
view, is the operative time. We registered the corresponding operative time intervals T for
the procedures described above for the patients in Group 1 (i.e., with performed rehearsals
on 3D-printed models) and compared them to the time intervals T0 necessary for the same
surgery procedures for the patients in Group 2 (i.e., for the twenty clinical cases that did
not benefit from a simulation/rehearsal prior to the surgery). The comparison between
these time intervals for each of the twenty patients considered in the control Group 1 and
in the study Group 2 was made in Table 6.
The twenty clinical cases of the control Group 2 (numbered 10 to 200 in Table 6) were
selected to be an as good as possible match (from the point of view of the clinical difficulty)
with the twenty cases selected for the study Group 1. This relative match of the cases
presented in parallel in Table 6 for Groups 1 and 2 is an inherent limitation of the present
work, as one cannot use the same clinical cases for both analyzes. Instead, cases with
similar levels of difficulty from a clinical point of view must be selected for an as rigorous
as possible comparison.
J. Clin. Med. 2021, 10, 4718 10 of 15

Table 6. Operative time intervals of implant procedures without (T0 ) versus with 3D-model-based simulations/rehearsals (T).

Patient of (Control) Operative time Without Patient of Study Operative Time with Performed
Group 2 3D-Model-Based Rehearsal T0 (min) Group 1 Simulation/Rehearsal T (min)
10 128 1 89
20 101 2 92
30 134 3 102
40 112 4 88
50 115 5 102
60 142 6 79
70 123 7 82
80 126 8 98
90 98 9 95
100 105 10 100
110 141 11 87
120 105 12 81
130 113 13 78
140 124 14 97
150 99 15 103
160 133 16 91
170 90 17 101
180 131 18 120
190 102 19 85
200 129 20 94

Statistical processing was performed using SPSSv17 for these operative times, similar
to Section 3.1, in the comparative look between the necessary time without rehearsal previ-
ous to the procedure (T0 ), i.e., for Group 2, and when implant procedures on patients were
performed after such a rehearsal on 3D-printed models (T), i.e., for Group 1. Descriptive
statistics were performed for the numerical variables and comparisons between these series
of pair values using the non-parametric Wilcoxon Signed Ranks test (Table 7).

Table 7. Descriptive statistics regarding the operative time without rehearsals (T0 ) and with per-
formed simulations/rehearsals on 3D-printed models (T).

Time N Mean (min) SD (min) Minimum (min) Maximum (min)

T0 20 117.55 15.55 90 142
T 20 93.2 10.21 78 120

The mean time T0 mean required for implant placement with a simultaneous sinus lift
procedure in patients of Group 2 (i.e., without rehearsals) was 117.55 min. The mean time
Tmean needed for the same procedure in the cases of the patients of Group 1 (i.e., with
rehearsals on 3D-models prior to the real surgery) was 93.2 min. The 24.35 min difference
between these two values, as well as the relative decrease (T0 mean − Tmean )/T0 mean equal
to 20.71% from the T0 surgery time indicates the benefit of applying the rehearsal procedure
for patients.
The results were considered significant for a value of p < 0.05 (Table 8). The differ-
ence between these distances was statistically significant (Wilcoxon Signed Ranks Test,
p < 0.001).
Table 8. Ranks regarding the T0 and the T operative times.

N Mean Rank Sum of Ranks

Negative Ranks 18a 11.25 202.50
Positive Ranks 2b 3.75 7.50
T0 versus T
Ties 0c
Total 20
Remarks: a T < T0 ; b T > T0 ; c T = T0 .
J. Clin. Med. 2021, 10, 4718 11 of 15

4. Discussion and Conclusions

Surgeons often use different 3D-printed human organs before surgery, for example
in craniofacial reconstruction [26,27] and implant-site assessment [28]. Thus, they can
provide a more detailed picture of certain anatomical aspects than when using classical
two-dimensional (2D) models or 3D computer imagery. Using 3D-printed parts, surgeons
can physically feel the replicas of those organs, bone structures, or other aspects of interest.
Thus, they can perform the surgery protocol as a training procedure. An alternative is to
perform implant surgical training and research on a cadaver specimen.
With 3D printing, dental medicine can also evolve in terms of the quality of future
implant surgical treatments, and this has been approached in numerous studies [12,29–34].
Materials and manufacturing procedures have been explored [35,36], as well as safety and
efficacy issues [37]. Accuracy evaluations of 3D-printed models for mandibular models
were also performed, using a range of methods [38].
On the other hand, oral implantology is not a stand-alone branch; it depends equally
on the future prosthetic treatment that must be consistent with the insertion of implants [39].
Tissue engineering is another aspect to be considered, both for bone [7–9,40–42] and soft
tissue [43]. Clearly, in oral implantology, various clinical situations may arise that require
optimal thinking and the calculation of the treatment plan.
The present study approached the utility of the 3D-printed models in the visualization
of the complex maxillary anatomical structures and the impact of the surgery simulation
before the in vivo operative time. Both maxillary implant insertion combined with sinus
augmentation procedures require an accurate technique. Guidance is necessary to achieve
the appropriate angulation and position in relation to the adjacent teeth, as well as a
preplanned design and positioning of the lateral window for approaching the sinus.
Due to the realistic form of the 3D-printed models, the technical steps of sinus aug-
mentation and implant insertion could be performed on the corresponding model prior to
surgery. Technical steps of the procedure were rehearsed in the simulation using the 3D
model (as detailed in the Materials and Methods section): shape and size of antrostomy,
implant insertion, and grafting. As pointed out, several operative phases could not be
rehearsed on the 3D-printed model: incision, flap elevation, sinus membrane elevation,
flap repositioning, and suture (Figure 5).
In this work, we analyzed the compliance of the ideal mezio-distal position of the
implant due to its crucial role for the final prosthetic restoration and the health of the tissue
around it [28]. The statistical data in Tables 2–5 demonstrated that no significant differences
were obtained between simulations and clinical procedures. Thus, the preplanned posi-
tioning of the implant on the 3D-printed model was transferred in the in vivo operative
time. The design and position of the lateral window during the sinus lift procedure have
significant roles in avoiding intra- and post-surgical complications [44,45]. This is the
reason why we have chosen to analyze the compliance of the ideal position of the lateral
window. This method allowed us to assess the thickness of the lateral maxillary wall and
its convexity from the practical scene. From the considered clinical cases, in four of them,
the buccofacial dimensions of the lateral maxillary wall were thicker than 4.5 mm. In
these specific cases, the 3D models allowed to undergo the osteotomies and to practice
this challenging mandatory step of sinus augmentation. The thick lateral maxillary wall
changed the standard surgical procedure, meaning the necessity of thickness reduction of
the trap-door window, a time-consuming maneuver. In the other three cases, we found
a convexity of the lateral maxillary sinus wall. The 3D models again proved useful, as
they allowed to evaluate the surgical access to the sinus by considering the high risk of
Schneiderian membrane perforation.
As an overall result, the statistical data showed no significant differences between the
3D-printed model and postoperative CBCTs.
The first hypothesis of the study was proved: using implant simulations allows for a
superior quality of future prosthetic restorative treatments on dental implants. The second
hypothesis was also confirmed: a significant reduction of the intervention time of around
J. Clin. Med. 2021, 10, 4718 12 of 15

20% was obtained (Tables 7 and 8) when rehearsals on 3D-printed models were performed,
compared to the situation when they were not utilized.
In the complex clinical cases approached, the 3D-printed models allowed for a precise
plan of the surgery. Also, the transfer of the accuracy in the real operation field was made
possible. Therefore, using 3D-printed models, implants can be inserted in vivo in full
compliance with future prosthetic treatment. Improving the surgical operative time, as
obtained in this study, is a real benefit to both the patient and the surgeon. An accurate
sinus lift procedure along with reduced tissue manipulation leads to a better perception
during the recovery time.
In conclusion, the use of 3D-printed models can benefit implant practitioners, as well
as students taking a course in Oral Implantology. Also, it can be a support to students
of dental medicine in implantology to simulate implant insertions. Thus, 3D-printed
models can play a significant role in the educational field. The anatomical models mitigate
the inconvenience of cadaveric dissection, allowing the student to focus only on the
structural anatomy and to relate it with its functional role [45]. In contrast, commercial
anatomical models, compared with the 3D models, are only illustrative and unable to
reproduce the biological particularities [46]. For a more pragmatic model used for a hands-
on simulation, creating a double-material 3D model could be more appropriate. In the
cases considered in our work, this would imply simulating the solid bone and the elastic
Schneiderian membrane. However, a printer that could create models that are able to match
the properties of the tissues involved in the operation represents a major issue, because the
current 3D printing technologies do not incorporate fluids into their 3D-printed objects.
Printing with dissectible hydro-gel materials could get us closer to models which could be
felt and could deform similar to living tissues [47].
We expect that further progress in the field will lead to the development of both
soft and hard printable materials that mimic the haptics of biological tissues. The cost-
effective availability of 3D printers may allow practitioners to enhance their surgical skills
on 3D-printed models, with a resolution similar to one of the original dissectible structures.
For the imaging part, future work in this direction in our group includes using com-
bined Optical Coherence Tomography (OCT) [48–50] and 3D CBCT [51] for the assessment
of the results of such clinical procedures, as we have demonstrated both the complementar-
ity [52] and the optimization [53] of the latter imaging technique by using the former.

Author Contributions: Conceptualization and methodology, D.F.N., V.-F.D. and C.S.; clinical proce-
dures, D.F.N.; investigations and imaging, D.F.N., A.G.G. and V.G.T.; data validation and analysis,
D.F.N. and V.-F.D.; statistics, A.T.; resources, D.F.N., C.S. and V.-F.D.; writing—original draft prepara-
tion, D.F.N. and V.-F.D.; writing—review and editing, V.-F.D.; supervision, V.-F.D. and C.S.; project
administration and funding acquisition, V.-F.D. All authors have read and agreed to the published
version of the manuscript.
Funding: This study was supported by the Romanian Ministry of Research, Innovation and Digitization,
CNCS/CCCDI–UEFISCDI, project PN-III-P4-ID-PCE-2020-2600 (http://3om-group-optomechatronics.
ro/; accessed on 9 September 2021). The APC was funded by the “Victor Babes” University of
Medicine and Pharmacy of Timisoara, Romania.
Institutional Review Board Statement: The study was conducted according to the guidelines of the
Declaration of Helsinki and was approved by The Ethics Commission for Scientific Research of the
“Victor Babes” University of Medicine and Pharmacy of Timisoara, Romania, following the Ethical
protocol of the University, with the CECS Approval no. 09/02.03.2018.
Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.
Data Availability Statement: Data are available on request from D.F.N.
Acknowledgments: This paper is based on a presentation prepared for the “1st International
Conference–Advances in 3OM: Opto-Mechatronics, Opto-Mechanics, and Optical Metrology”, 13–16
December 2021, Timisoara, Romania.
J. Clin. Med. 2021, 10, 4718 13 of 15

Conflicts of Interest: The authors declare no conflict of interest. The funders had no role in the design
of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or
in the decision to publish the results.

Abbreviations
Three dimensional 3D
Cone Beam Computed Tomography CBCT
Computer-Aided Design CAD
Computer-Aided Manufacturing CAM
Additive manufacturing AM
Distance from the anterior tooth to the middle of the implant D1-3D
Distance from the ridge margin to the sinus window D2-3D
Distance from the anterior tooth to the middle of the implant D1-P
Distance from the ridge margin to the sinus window D2-P
Standard deviation (SD)
Operative time without 3D-model-based rehearsal T0
Operative time with prior-performed rehearsal T
Optical Coherence Tomography OCT

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