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case report I Excellentfitwith3-Ddesigning The success of the proposed design was to a large extent reliant on obtaining an excellent fit for each piece.Thisisthereasonwhytheroleof3-Ddesignand manufacture was so essential in this procedure. The parts of the right and left sections that meet the rami had to be exactly adapted to the form of their corre- spondinganatomicstructures.Eachofthemhadtobe formed in such a way that can fold over the edges of theramusandembraceitenoughforapropersupport. Using 3-D design as well guaranteed the perfect con- tacts between three pieces which otherwise might have been an area of concern for a design of this na- ture. Giventhenecessityforincludingaprostheticsolu- tion and considering the patient’s limited mouth opening,themostfeasiblesolutionwastoincorporate the artificial teeth into the structure of the mandibu- lar implant. As described above, during the surgical procedureandafterscrewingleftandrightpiecesover the rami, the two overlapping front ends of left and rightpartswerefullyfixedinplacebyaddingthemid- dle segment. The idea for the final design was to in- cludetheartificialteethaspartofthismiddlesection. However to eliminate the risk of any force or pres- surethatwouldhavecompromisedthesuccessofthe surgery, a temporary or surgical middle piece was de- signedtobeplacedovertheleftandrightsectionatthe surgical session (Fig. 5). The function of this piece was simply to hold two pieces in place at the front (Fig 6) before being replaced with the prosthetic, permanent middlesections(Fig.7). Theprosthodonticcomponent On the surgical team’s recommendation, the mandibular dentition included in the design of the middlesectiononlycomprisedtenteethincludingin- cisors,caninesandpremolarsonbothsides(Fig.7).Due to the size of third surgical piece and its function of uniting the other two sections, only incisors and ca- nines are in contact with the interconnecting surface ofthemiddlepart.Sowhenthemiddleprostheticpiece is seen independently, the premolars look unsup- portedinthemannerofacantileverbridge. However, after insertion of this enfolding middle part over the overlapped arms of left and right pieces, the premolars become tightly in contact with left and right sections; this prevents any destructive lever function from taking place. Again such close contact has only been enabled by the accuracy of 3-D design- ingandthefollowing3-Dprintprocedure. The particular design of arms of left and right pieces, which collectively form the body of the mandible,isalsoworthyofnote.Thesearmsfeaturea 90 degree twist in the approximate area of molars. In this way they can adopt to both the thinner posterior partwhichisanchoredovertheramusandthefrontal part that required a broader width for carrying the teeth.Suchtwistalsoofferedasolutionfortherelative lack of space in the posterior part of the mouth. This curvecanaswellbolsterthephysicalresistanceofthe mandibularimplanttothemechanicalpressures. 3-Dprinting As the designing procedure finished, the designed implant had to be manufactured and delivered to the surgical team. All three pieces were 3-D printed in Ti- taniumGrade5usingEBMtechnology.Alsobeforein- stallingtheimplant,patient’sfacialskeletonneededto be reproduced in a plastic material. It was 3-D printed bymeansofSLStechnology.Thisreplicawasproduced in order to give the surgeon a better idea of the surgi- calsiteandthereforefacilitatethesurgicalprocess. After the healing period, the time comes for inser- tionoftheprostheticcomponent.Atthisstagethesur- gical middle part will be unscrewed and removed (Fig. 8) and the prosthetic middle section, carrying the teeth,willbeinserted(Fig.9)andfixedinplace(Fig.10 &11).Aftercheckingtheocclusionthepatient’sbiteis to be registered. The sizes of the teeth have to be ad- justed accordingly. As the next step, a layer of porce- lain should be added to the teeth to finalise the pros- theticphaseandtherebythetreatmentprocess. _Summary In brief, the 3-D design has paved the way for de- visingunorthodox,novelsurgicalandprosthodontics solutions, as exemplified by the case presented in this article. Such alternative solutions could not be achieved through traditional technology with the samelevelofaccuracy,whichisessentialforachieving thedesiredoutcome. The3-Ddesigningand3-Dprintingthereforehave infinitelywidenedthescopeofmaxillofacialsurgeries by expanding and improving the potentials for cus- tomisation.Hence,itisnowofutmostimportancefor maxillofacialsurgeonstogetfurtherfamiliarwithar- easofapplicationoftheseempoweringtoolsandlearn aboutopportunitiesforenlistingitsassistance._ I 27implants3_2015 contact Dr Saeid Kazemi DRSK GroupAB Kasernvagen 2,SE-281 35 Hassleholm,Sweden Tel.:+46 705 129909 www.drsk.com Kasernvagen 2,SE-28135 Tel.:+46705129909