Three-dimensional diagnosis and visualization supports in orthodontics

based on Reverse Engineering and Solid Free-form Fabrication techniques 1

X

Three-dimensionaI diagnosis and visuaIization
supports in orthodontics based on
Reverse Engineering and SoIid
Free-form Fabrication techniques

AIida MazzoIi
1
, MicheIe Cernani
2
, Rolerlo RaffaeIi
2
and Anlonio Cracco
3

1
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2
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3
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(||a|q)

1. Introduction

Diagnosis neans lhe arl or acl of idenlifying a disease fron ils signs and synplons
(Merrian Welsler Diclionary, 2OO9). The naxiIIofaciaI region, exlending fron lhe lase of
lhe skuII lo lhe hyoid lone, is one of lhe nosl analonicaIIy conpIex regions of lhe lody.
This area conlains eIenenls and organs leIonging lo a nunler of differenl syslens lhal can
le affecled ly a variely of IocaI and syslenic palhoIogic processes. Diagnoslic inaging has
assuned a cenlraI roIe in lhe evaIualion of lhis region. Nev lrends in denlislry incIude
digilaI and lhree-dinensionaI (3D) inaging. The uIlinale revard of lhe lechnoIogic inaging
advancenenls is lhe digilaI represenlalion of lhe palienls analony, as il exisls in nalure
(analonic lrulh). OraI and naxiIIofaciaI radioIogy provides lhe denlisl vilh diverse
diagnoslic equipnenls. Currenl and evoIving nelhods incIude conpuled lonography (CT),
lonosynlhesis (adea el aI., 2OO1), luned-aperlure CT (TACT) (Weller el aI., 1997),
IocaIized, or cone-lean, CT (Heiken al aI., 1993) and nagnelic resonance inaging (MRI)
(OIl & }akol, 2OO4). AIlhough oraI and naxiIIofaciaI radioIogy is novadays videIy accepled
as a rouline lechnique for denlaI exaninalions, lhe equipnenls are ralher expensive and,
furlhernore, lhe radialion dose required lo enhance lolh conlrasl and spaliaI resoIulion can
le unacceplalIy high. A soIulion lo lhis prolIen is parliaIIy given ly lhe use of
naxiIIofaciaI dedicaled cone-lean CT equipnenls, vhich can provide inages of sufficienl
quaIily for lhe specific diagnoslic needs al significanlIy reduced alsorled radialion dose
(Mah el aI., 2OO3). Much efforl has focused recenlIy on conpulerized diagnosis in denlislry
(eers el aI., 2OO3, CousIey al aI., 2OO3). The sludy and noniloring of faciaI appearance is
parlicuIarIy inporlanl in lhe fieId of denlislry and reconslruclive naxiIIofaciaI surgery.
UsuaIIy, nosl of lhe 3D syslens for denlaI appIicalions found in Iileralure reIy on ollaining
1
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Modelling, Simulation and Optimization 2

an inlernediale soIid nodeI of lhe jav (casl or leelh inprinls) and lhen capluring lhe 3D
infornalion fron lhal nodeI (WiIIians el aI., 2OO4, AIcaniz el aI., 1998). User inleraclion is
needed in such syslens lo delernine lhe coordinales of specific reference poinls on a denlaI
casl. Olher syslens for denlislry are under deveIopnenl in order lo repIace lradilionaI
approaches in diagnosis, lrealnenl pIanning, surgicaI sinuIalions and proslhelic
repIacenenls (Yanani el aI., 2OOO, HaIazonelis, 2OO1). Moreover, lhere is anolher cIass of
nachine lechnoIogy, caIIed SoIid Iree-forn Ialricalion (SII), originaIIy deveIoped for
induslry lhal is gelling a greal anounl of allenlion in lhe nedicaI seclor during lhe Iasl fev
years (Sykes el aI., 2OO4, WohIers, 2OO4). SII nanufaclured analonicaI nodeIs find
appIicalions parlicuIarIy in oraI, naxiIIofaciaI and neuroIogicaI surgery. In denlislry SII can
le used nainIy for assisling diagnosis, pIanning lrealnenl and nanufacluring inpIanls.
The effecliveness of nodeIs nanufaclured ly SII has leen denonslraled in various surgicaI
procedures (Lrlen el aI., 2OO2). In lhe foIIoving sludy, lhe reader is presenled vilh an
overviev of lhe slale of lhe arl of 3D diagnoslic looIs in orlhodonlics, 3D capluring
lechniques and nodeIs nanufacluring ly SII, enphasizing lheir use in orlhodonlics.
Moreover sone cIinicaI cases, lrealed using lhe alove-nenlioned lechnoIogies, are
presenled and discussed.

2. 3D tooIs in orthodontics

The discipIine of orlhodonlics is concerned vilh lhe face and lhe aliIily of lhe cIinician lo
nodify ils grovlh. Orlhodonlisls achieve lheir goaIs ly nanipuIaling lhe craniofaciaI
skeIelon, vilh parlicuIar enphasis on nodifying lhe denloaIveoIar region, lhe
lenporonandiluIar joinl and lhe sulures. This arlicIe lrace lhe vay in vhich lhree-
dinensionaI (3D) looIs in orlhodonlics has deveIoped lheir usefuIness loday, and lhe vay in
vhich lhey nay deveIop in lhe fulure.

2.1 Radiographic tooIs
The cephaIogran is lhe slandard used ly orlhodonlisls lo assess skeIelaI, denlaI, and sofl
lissue reIalionships. This approach, hovever, is lased on lvo-dinensionaI (2D) vievs used
lo anaIyze 3D oljecls. CephaIonelry vas defined ly Moyers (Moyers el aI., 1988) as a
radiographic lechnique for alslracling lhe hunan head inlo a neasuralIe geonelric schene.
CephaIonelric radiography is used lo descrile lhe norphoIogy and grovlh of lhe
craniofaciaI skeIelon, predicl grovlh, pIan lrealnenl, and evaIuale lrealnenl resuIls. Mosl of
lhese lasks require lhe idenlificalion of specific Iandnarks and lhe caIcuIalion of various
anguIar and Iinear varialIes. Tvo lypes of errors occur vilh lhis approach: errors of
projeclion and errors of idenlificalion (aunrind el aI., 1971). Lrrors of projeclion are caused
lecause lhe inages are a 2D represenlalion of a 3D oljecl. X-ray leans are nonparaIIeI and
originaled fron a snaII source, Ieading lo radiographs lhal are inperfecl enIargenenls
affecled ly lhe dislances lelveen lhe focus, lhe oljecl, and lhe fiIn (Adans, 194O, jork &
SoIov, 1962). Lrrors of idenlificalion are lhe errors of idenlifying specific Iandnarks on lhe
inages and are considered ly nany invesligalors as lhe najor sources of error in
cephaIonelrics (Hixon, 1956, Milgaard el aI., 1974). Despile severaI inprovenenls in 3D
cephaIonelric research (Svennen & Schulyser, 2OO6) lhis lechnique sliII renains line-
consuning, exposes lhe palienl lo radialion and does nol define lhe sofl lissues. Currenl and
evoIving diagnosis looIs incIude conpuled lonography (CT), lonosynlhesis (adea el aI.,
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Three-dimensional diagnosis and visualization supports in orthodontics
based on Reverse Engineering and Solid Free-form Fabrication techniques 3

2OO1) , luned-aperlure CT (TACT) (Weller el aI., 1997), IocaIized, or cone-lean, CT
(Heiken el aI., 1993) and nagnelic resonance inaging (MRI) (OIl el aI., 2OO4). Iron lhe firsl
connerciaI Conpulerized Tonography (CT) scanner appeared in 1972, in lhe earIy 198Os
researchers legan invesligaling 3D inaging of craniofaciaI defornilies. ShorlIy afler, lhe
firsl lexllooks on 3D inaging in nedicine appeared and vere lased on lhe principIes and
appIicalions of 3D CT and MRI-lased inaging. 3D inaging has evoIved inlo a discipIine
deaIing vilh various forn of visuaIizalion, nanipuIalion and anaIysis of nuIli-dinensionaI
nedicaI slruclures (Ududpa & Hernan, 1991) and nev lrends in denlislry incIude digilaI
inaging and 3D inaging of lhe naxiIIofaciaI regions. Since lhe 198Os, lhe quaIily and speed
of CT inaging has changed dranalicaIIy. Novadays vilh inproved lechniques and
inaging prograns il is possilIe lo produce inages, vhich can le rolaled and cul al any
IeveI. The Iasl generalion denlaI CT scanner are nov avaiIalIe for cIinicaI praclice and uses
lhe principIe of lonosynlhesis or cone-leaned CT, so caIIed lecause of lhe shape of lhe x-
ray lean, as for exanpIe lhe NevTon QR 9OOO VoIune Scanner (QR SrI, Verona, IlaIy)
(Mozzo el aI., 1998). Il uses a cone-shaped x-ray lean lhal is Iarge enough lo enconpass lhe
region of inleresl. This lype of lean uses lhe x-rays very efficienlIy, lhus reducing lhe
alsorled dose lo lhe palienl. This lype of lean aIso aIIovs for lhe acquisilion of lhe inage
dala in one revoIulion of lhe x-ray source and deleclor vilhoul lhe need for palienl
novenenl. These allrilules nake lhis syslen nore efficienl lhan olhers, and lhus il can le
appIied for specific purposes in lhe naxiIIofaciaI region. As for regards lhe MRI, il is good
for 3D inaging of sofl lissues lul lhe accuracy of lhe dala is nol sufficienl for specific
procedures such as for exanpIe lhe precision niIIing of proslheses, as il does nol properIy
differenliale lelveen air and lone. Hovever, for sofl lissues il is exceIIenl, and can le usefuI
in inaging of lenporonandiluIar joinls. Il is aIso usefuI in lhe nanagenenl of lunours of
lhe head and neck region and for inaging lhe lrain for neuroIogicaI prolIens.

2.2 3D capturing techniques
OplicaI surface scanning vas firsl lesled in 1981 lo produce a non-invasive 3D inage of lhe
face. The syslen vas nodified, inproved, and re-lesled (Arridge el aI., 1985, Moss el aI.,
1987, Aung el aI. 1995). Since lhal line, lhe syslen has aIso leen deveIoped lo scan nodeIs
of lhe leelh. In 1996, lhe hand-heId scanner vas designed lo nake lhe syslen noliIe
(McCaIIun el aI., 1996). This can le used for scanning nany parls of lhe lody. The recenl
inlroduclion of a prole lhal records lhe 3D co-ordinales of any poinl neans lhal nany of lhe
hard lissue poinls used ly Iarkas (1994) can nov le recorded. Over lhe years, lhe vaIue of
lhe 3D syslen in lhe diagnosis and nanagenenl of palienls has leen denonslraled. 3D
naleriaI has leen ollained on various lypes of craniofaciaI anonaIies such as cIefl paIale,
henifaciaI nicrosonia, and cherulisn (Moss & }anes, 1984, McCance el aI., 1997).
TechnoIogies used for lhe neasurenenl of lhe surface of oljecls vilh nicro lo nacro sizes
can le divided fundanenlaIIy inlo lvo groups: syslens lased on Iaser scanning and
syslens lased on vhile Iighl projeclion. The used equipnenl is differenl, hovever lhey are
lased on lhe sane principIe: lrianguIalion.
Laser scanning syslens enpIoys Iasers lo projecl a spol, a Iine, nuIlipIe Iines, or pallerns
onlo a surface, vhereas a Iighl sensor, usuaIIy a canera, acquires lhe scene. The lhree
eIenenls Iaser, Iighl sensor and oljecl surface forn a lriangIe. When lhe geonelricaI
disposilion of lhe Iaser and lhe Iighl sensor are knovn, lhe dislance of lhe oljecl surface lo
lhe Iaser scanning device can le easiIy delernined ly lrianguIalion. To neasure surface
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Modelling, Simulation and Optimization 4

areas lhe Iaser spol, Iine, nuIlipIe Iines or pallern have lo nove over lhe area (i.e. scan lhe
surface). Ior lhis process, differenl nelhods can le used, e.g. nirrors syslens, eIeclro-
nechanicaI syslens, hand operaled syslens.



Iig. 1. The concepl of Iaser lrianguIalion

3D neasurenenl syslens lased on vhile Iighl enpIoy projeclors inslead of Iaser Iighl
sources, lo projecl Iighl pallerns onlo lhe surface. The neasurenenl principIe renains lhe
sane: lrianguIalion. A lriangIe is forned ly projeclor, canera and oljecl. In lhis case, lo
cover enlire surface parls, surface areas are iIIuninaled ly lhe enpIoyed projeclor. SpeciaI
codes are used lo delernine lhe origin of lhe Iighl source, e.g. linary codes and coIour
codes. The lvo differenl lechnoIogies resuIl in differenl surface scanning devices vilh
diverse characlerislics. Sone exanpIes are Iaser profiIers nounled on CMM, porlalIe coded
Iighl projeclion surface digilizer, porlalIe Iaser scanners and hand heId surface digilizers.
MedicaI sciences are aIso inleresled in lhe 3D scanning lechnoIogies lecause of lheir high
accuracy, fasl acquisilion and non-conlacl characlerislics. A good exanpIe of lhe advanlages
of oplicaI 3D neasurenenl lechnoIogies in lhe nedicaI fieId can le found in orlhodonlics. In
facl, lhe 3D neasurenenl of denlaI casls lrings nany advanlages and nev opporlunilies.
SeveraI 3D scanners speciaIIy designed for lhese appIicalions are avaiIalIe on lhe narkel
and are Ialer on descriled in delaiI. They aIIov a precise, fuII aulonalic and fasl 3D
scanning of fuII denlaI casls, dies/slunps, inIay preparalions, lridge preparalions,
liles/anlagonisls, vax-ups and superslruclures. The acquired dala can le usefuI for nany
reasons, as for exanpIe: 3D dalalases of denlaI casls accessilIe in a IocaI area nelvork
reduce slorage cosls and give easy and inslanlaneous access lo a palienl's leelh profiIe
(Cracco el aI., 2OO5), 3D soflvare soIulions aIIov a sinpIified design of caps, crovns, inIays
and lridges fron lhe scanned dala (RaffaeIi el aI., 2OO5). Reverse engineering syslens in
orlhodonlics are generaIIy used for conpuler aided denlaI resloralion and diagnosis and
lrealnenl pIanning.

2.2.1 Computer aided dentaI restoration
An accurale neasurenenl of 3D nodeIs of lhe leelh is lhe lasis of lhe enlire process. As for
regards lhe cIinicaI requirenenls, lhe non-conlacl oplicaI nelhod is olviousIy lhe ideaI
approach. In lhe CLRLC syslen (Ollo el aI., 2OO2, Lulhardl el aI., 2OO2), a prole vas
designed in order lo acquire lhe oplicaI inpression of lhe seIecled loolh. Hovever, il can
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Three-dimensional diagnosis and visualization supports in orthodontics
based on Reverse Engineering and Solid Free-form Fabrication techniques 5

onIy delecl lhe deplh of lhe cavily and nol lhe conpIele 3D shape of lhe loolh. Olher
CAD/CAM syslens avaiIalIe on lhe narkel, as for exanpIe IV 3D }ena (hllp://vvv.ivl-
jena.de) and 3Shape (hllp://vvv.3shape.con), lended lo reIy on in vilro shape
neasurenenl, noslIy using a Iaser scanning lechnique lo neasure lhe shape of lhe nodeI
ralher lhan lhe originaI loolh. The alove lecause Iaser scanning is acluaIIy a poinl-vise
nelhod in principIe, vhich aIIovs onIy one heighl dala poinl lo le neasured or recorded al
a singIe inslanl. The use of a parlicuIar nechanicaI posilioning selup, lhough, nakes lhe
poinl-vise scanning a rapid process of possilIy vilhin a fraclion of a second, and il lrings
cerlain reslriclions in lhe neanline lhal prohilils ils direcl appIicalion in an inlra-oraI
environnenl. Iig. 2 shovs lhe exanpIe of lhe 3D denlaI scanner 3Shape D-2OO (3Shape A/S,
Dennark), sone sanpIe dala of 3D scans, as veII as an exanpIe of digilaI design of denlaI
resloralions.










Iig. 2. 3Shape D-2OO DenlaI 3D Scanner (Iefl), sanpIe neasured dala (cenler), 3Shape
DenlaIDesigner soflvare exanpIes (righl)

2.2.2 Diagnosis and treatment pIanning
Hard and soflvare soIulions are veII-suiled for orlhodonlic appIicalions in vhich fasl and
accurale 3D scanning of fuII denlaI casls are essenliaI. 3D orlhodonlics soflvare currenlIy
under deveIopnenl incIudes funclions as: slorage, research and anaIysis
(hllp://vvv.3shape.con) and for lhe orlhodonlic lrealnenl pIanning and lhe correcl
pIacenenl of appIiances (hllp://orlhocad.con). As for regards lhe firsl aspecls, 3D
dalalases accessilIe in a IocaI area nelvork (LAN) reduce slorage cosls and give easy and
inslanlaneous access lo lhe palienl's leelh profiIe. Moreover, scanning and soflvare soIulion
are oflen inlegraled vilh such 3D dalalases. In facl are oflen avaiIalIe soflvare packages for
lhe anaIysis of lhe palienl's denlilion in order lo assess lhe efficiency of an orlhodonlic
lrealnenl. In such an appIicalion, an inluilive inlerface aIIovs lhe user lo sel references
poinls on lhe scanned casls in order lo neasure palhs, angIes and avaiIalIe space for
orlhodonlics lrealnenls. Differenl neasurenenl looIs are avaiIalIe, user is aIIoved lo pick
poinl on lhe casl 3D nodeI or on 2D cross seclions and neasure dislances. This aIso aIIovs
for easy conparisons anong 2D cross seclions. Moreover, anaIysis aIgorilhns aIIov lhe user
lo neasure lhe leelh size and posilion anid conpare lhis dala vilh slalislics of popuIalion's
slandard noulh analony. Craphic reporls aIIov lhe praclilioner lo conpare lvo denlaI
casls in order lo anaIyze grovlh and denlaI lrealnenl efficiency. In Iig. 3 are shovn sone
funclions of lhe soflvare 3Shape OrlhoanaIyzer (3Shape A/S, Dennark).
As for regards lhe orlhodonlic lrealnenl pIanning and lhe correcl pIacenenl of appIiances,
lhe syslens avaiIalIe on lhe narkel aIIov lhe orlhodonlisl lo nake accurale neasurenenls
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Modelling, Simulation and Optimization 6

for lhe lrealnenl pIanning vhiIe al lhe sane line eIininaling pIasler nodeI slorage and
relrievaI issues. Moreover, aIIov praclilioners lo sinuIale lrealnenl slralegies and seIecl
and execule lhe nosl appropriale lrealnenl pIan lhal incIudes precise posilioning of
orlhodonlic lrackels as shovn in Iig. 4.







(a)











(|)

Iig. 3. Specific funclions of lhe soflvare package 3Shape OrlhoanaIyzer for slorage (a),
research and anaIysis (l) purposes in orlhodonlics














Iig. 4. Specific funclions of lhe soflvare Orlhocad (Cadenl Inc., USA) lhal uses conpulers lo
nake an indirecl londing sel-up for lrackel pIacenenl

LinguaI orlhodonlic lrealnenl is an aIlernalive lo lhe lradilionaI vesliluIar lrealnenl, and is
designed lo salisfy lhose palienls vho vish lo have lheir leelh aIigned lul do nol vanl
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Three-dimensional diagnosis and visualization supports in orthodontics
based on Reverse Engineering and Solid Free-form Fabrication techniques 7

IaliaI lrackels. Due lo lhe difficuIlies in posilioning, indirecl londing lechniques have leen
deveIoped lo lransfer lrackels Iocalion fron a physicaI nodeI ly londing lrays. A soIulion
lased on a nev lhree-dinensionaI CAD syslen, caIIed CADenlaI, has leen proposed lo
virluaIIy design lrays lolh for lhe requirenenls of IinguaI and vesliluIar appIiances. Il has
leen inpIenenled using a geonelricaI nodeIIing kerneI, vilhin a Iov-cosl connerciaI
CAD syslen (Rhinoceros 3.O, ly Rhino3D). Il aIIovs lhe posilioning of lhe lrackels and lhe
definilion of a suilalIe londing lray in a very shorl line, verifying, al lhe sane line, lhe
accuracy of lhe resuIl in order lo avoid errors and ileralions.
The CADenlaI soflvare looI has leen deveIoped for an easy inlerfacing vilh 3D shape
acquisilion syslens used lo scan inpressions and pIasler casls, and vilh lhe rapid
prololyping nachines used lo luiId physicaI nodeIs and lrays (Iig. 5). During lhe
inpIenenlalion slage parlicuIar allenlion vas dedicaled lo lhe deveIopnenl of a user-
friendIy inlerface suilalIe lo non-experl users of 3D CAD nodeIIing syslens. The
funclionaIilies have leen slrongIy aulonaled and lhe user inlerface has leen lased on
senanlic enlilies Iinked lo lhe operalors lradilionaI vay of vorking.



Iig. 5. IIasler casls or inpressions scanning lo ollain 3D virluaI nodeIs. CADenlaI soflvare
aIIovs lhe nanufacluring of lhe Tveed supporl, anaIyse and neasure nodeIs, posilioning
of lhe lrackels, crealions of virluaI sel-ups and londing lrays. ModeIs and lrays can le
nanufaclured in nedicaI AcryIonilriIe uladiene Slyrene (AS) pIaslic

A successfuI Iarge scaIe operalion lo nass produce a cuslonized device lrings logelher lhe
lesl of reverse engineering hardvare and soflvare. Case in poinl, lhe conpany, AIign
TechnoIogy of CaIifornia, nanufaclures cIear, noIded, renovalIe lhernopIaslic sheIIs
caIIed aIigners lo do lhe vork of pernanenl nelaI lraces (MeIkos, 2OO5). The process is
lased on a series of scans coIIecled during lhe Iayer-ly-Iayer deslruclion of lhe sludy nodeI
poured fron an acluaI palienl denlaI inpression. Surface dala fron lhe scanning process are
anaIysed and processed lo creale lhe sequence of progressive orlhodonlic arrangenenls lhal
viII achieve lhe end goaI of slraighlening or reposilioning lhe leelh. The dala are senl lo a
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Modelling, Simulation and Optimization 8

slereoIilhography nachine lo produce aII lhe nodeIs required for lhe conpIele sel. Then a
lhernoforned sheII is nade for each slep in lhe lrealnenl and lhe sel is shipped lack lo lhe
IocaI denlisl. Ialienls vear lhe renovalIe device for onIy lvo veeks lefore noving lo lhe
nexl. This reverse engineering lechnoIogy nol onIy aIIovs cuslon nanufaclure of lhe
aIigners al various slages of lrealnenl lul nakes a sinuIalion of lhe orlhodonlic correclion
process possilIe, using lhe palienls ovn dala sel. OplicaI nodeIIing processing finds and
appIicalion aIso in order lo reduce lhe slress caused lo palienls ly convenlionaI nelhods of
nodeIIing using CT or MRI for exlraoraI defecls and lody areas. In facl lhe seIecled lody
parl couId le digilized using oplicaI 3-coordinale neasuring lechnoIogy, providing an
exlensive dala record. Wilh such a lechnoIogy, lhe palienls physicaI and psychoIogicaI
slress nay le reduced. Diverse appIicalion vere found in Iileralure and descriles for
exanpIe a lechnique for oplicaI nodeIIing of faciaI proslhesis (Runle el aI., 2OO2, Cheah el
aI., 2OO3), ocuIar proslhesis (Reileneier el aI., 2OO4) and ear proslhesis (Ciocca el aI., 2OO4).

2.3 SoIid Free-form Fabrication (SFF) techniques
SII lechnoIogies, originaIIy deveIoped for induslry, have leen receiving a greal anounl of
allenlion in lhe nedicaI seclor in lhe Iasl fev years. MedicaI SII is defined as lhe
nanufaclure of dinensionaIIy accurale physicaI nodeIs of hunan analony derived fron
nedicaI inage dala using a variely of SII lechnoIogies. SII-nanufaclured analonicaI
nodeIs find appIicalions parlicuIarIy in oraI (Lee el aI., 2OO6), naxiIIofaciaI (Winder el aI.,
2OO5) , neuroIogicaI surgery (MuIIer el aI., 2OO3, MazzoIi el aI., in press) and orlhopaedics
(Minns el aI., 2OO3). In nedicine, lhey are nainIy used for assisling diagnosis, pIanning
lrealnenl, and nanufacluring inpIanls (IelzoId el aI., 1999). SII nodeIs effecliveness has
leen shovn in various surgicaI procedures (Lrlen el aI., 2OO2). Ialienls find lhe nedicaI
nodeIs heIpfuI for inforned consenl. MedicaI nodeIing is an inluilive, user-friendIy
lechnoIogy lhal faciIilales diagnosis and surgicaI pIanning, aIIoving surgeons lo rehearse
procedures readiIy and, noreover, inproves connunicalion lelveen doclors and palienls.
Iurlhernore, SII-nanufaclured nodeIs can le used in lhe reconslruclion of posl-lraunalic
defecls, lunoraI reseclions, and olher conpIex craniofaciaI defecls. SII lechnoIogies can le
of lenefil in lhe pre-operaling eslinalion of lhe quanlilalive surgicaI oulcone, in lhe
reduclion of lhe operaling line and in lhe produclion of nore prediclalIe resuIls. CurrenlIy,
lhe SII lechniques used in nedicaI appIicalions are 3D prinling (3D-I), slereoIilhography
(SLA), seIeclive Iaser sinlering (SLS), fused deposilion nodeIing (IDM), Ianinaled oljecl
nanufacluring (LOM) (erry el aI., 1997, Leong el aI., 2OO3, Liu el aI., 2OO6) and eIeclron
lean neIling (LM) (MazzoIi el aI., in press). Lach of lhese differenl lechniques luiIds up a
nodeI, Iayer ly Iayer, using differenl processes and naleriaIs. 3D-I creales nodeIs ly
spraying Iiquid linder lhrough ink-jel prinler nozzIes on lo a Iayer of nelaIIic or ceranic
precursor povder. SLA ly lracing a Iover pover uIlravioIel Iaser across a val fiIIed vilh
resin. SLS ly a heal fusilIe pover ly lracing a noduIaled Iaser lean across a lin covered
vilh lhe povder. IDM ly healing lhernopIaslic naleriaI, exlruded lhrough a nozzIe
posilioned over a conpuler conlroIIed x-y lalIe. LOM ly a heal-aclivaled, adhesive coaled
paper, lracing a focused Iaser lean lo cul a profiIe on sheels posilioned on a conpuler
conlroIIed x-y lalIe. LM consisls of a Iayer-lased direcl nanufacluring process of conpIex
parls ly neIling nelaI povder vilh an acceIeraled eIeclron lean. As for lhe naleriaIs 3D-I
uses a vide seIeclion of povder naleriaIs, SLS fine lhernopIaslic povder, SLA UV-sensilive
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Three-dimensional diagnosis and visualization supports in orthodontics
based on Reverse Engineering and Solid Free-form Fabrication techniques 9

resins, LOM lhin sheels of naleriaI such as paper, IDM lhernopIaslic fiIanenls and LM
fine nelaIIic povder.












Iig. 6. The concepl of Iayered nanufacluring

The dinensionaI accuracy is a najor concern for lhe cIinicaI appIicalion of 3D nedicaI
nodeIs and vas previousIy sludied and assessed, under specific condilions, ly sone of lhe
aulhors (MazzoIi el aI., 2OO7). Techniques vere deveIoped lo represenl lhe dala in 3D on a
2D screen. Civen lhe visuaIizalion provided ly sophislicaled soflvare packages, lhe
falricalion of physicaI nodeIs nay seen superfIuous. Hovever, even if lhe dispIay of a 3D
voIune on a 2D screen provides usefuI infornalion lo lhe cIinicians, as Ialer on discussed in
lhe presenlalion of sone cIinicaI cases lrealed al lhe Deparlnenl of Orlhodonlics of lhe
Universily of Ierrara, il does nol provide vilh a conpIele underslaling of lhe palienls
analony. In shorl, lhere are severaI visuaIizalion issues lhal are leing addressed lul nol yel
resoIved ly virluaI nodeIs. Ior lhe alove nenlioned reason lhe conslruclion of physicaI
nodeI is oflen necessary. An analonicaI nodeI can le nanufaclured using SII lechniques
ly lhe foIIoving sleps:

1. acquisilion: palienl scans vilh X-ray CT or MRI inaging,
2. design: segnenlalion lo deIineale and exlracl lhe surface as lriangIes or poIygons
(crealion of lhe 3D CAD soIid nodeI of lhe analony),
3. converling: converl lhe CAD nodeI lo STL fornal,
4. pre-process: sIice lhe STL fiIe inlo lhin cross-seclionaI Iayers (generaled ly a
dedicaled soflvare),
5. luiIding process: conslrucl lhe nodeI one Iayer alop anolher ly a seIecled SII
process,
6. posl-process: cIean and finish lhe nodeI.

Specific scanning prolocoIs are required lo generale precise analonicaI physicaI nodeIs. The
lype of scanner viII need lo le delernined in order lo check lhal lhe inage reconslruclion
soflvare can lransIale lhe dala and aIso lhe kind of scan (i.e. axiaI or heIicaI). The
reconnended sIice lhickness is 1.O nn or Iess. The scan spacing: shouId le O.5 nn or al
Ieasl one-haIf lhe snaIIesl dinension of inleresl. The resoIulion shouId le 512 x 512 or
higher. The IieId of Viev (IOV) shouId le chosen so lhal oljecl inaged shouId fiII lhe fieId
of viev vilhoul exlending leyond il. The posilion of lhe Iong axis of lhe oljecl lo le
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Modelling, Simulation and Optimization 10

scanned shouId le paraIIeI lo lhe lore of lhe scanner. CeneraIIy, scans shouId slarl jusl off
lhe oljecl and finish off lhe olher side of lhe oljecl (so lhal lhe enlire oljecl is inaged).
Oljecls lo le scanned shouId nol le laped dovn or pIaced on siniIarIy dense oljecls lhal
viII shov up in lhe scan. If significanl varialions in naleriaI densilies exisl vilhin lhe oljecl
lo le scanned, dislorlion can le experienced (arlifacls). In lhe case of nelaI arlifacls, lhe
dislorlion can le severe. The scan prolocoI can and shouId le adjusled lo lake inlo accounl
lhe presence of arlifacls. Moreover, lhe scan prolocoI shouId lake in accounl any ganlry liIl
angIe. Il is advisalIe lo avoid ganlry liIl vhen acquiring a CT dala sel, olhervise,
sophislicaled nalhenalicaI aIgorilhns are required lo successfuIIy correcl lhe dala. Iron
lhe inage dala, lhe reconslruclion soflvare is lhen used lo exlracl parl conlours and/or
surfaces (segnenlalion), as lhe case nay le. Segnenlalion nay le carried oul ly inage
lreshoIding, nanuaI ediling or auloconlouring lo exlracl voIunes of inleresl. One of lhe
sinpIesl nelhods of lissue segnenlalion appIied lo lhe inages is CT nunler lreshoIding. A
CT nunler range is idenlified ly eilher region of inleresl (ROI) pixeI neasurenenls or pixeI
inlensily profiIes, vhich is represenlalive of lhe analony lo le nodeIIed. As a naller of facl
lhreshoIding is lhe firsl aclion perforned lo creale a segnenlalion nask on a sel of digilaI
inages. The ROI can le seIecled ly defining a range of grey vaIues. The loundaries of lhal
range are lhe Iover and upper lhreshoId vaIue. AII pixeIs vilh a grey vaIue in lhal range
viII le highIighled in a nask. The seIeclion of a proper lhreshoId vaIue is lhe najor source
of errors in lhis slage. In facl, Iov lhreshoId vaIue viII yieId loo lig nodeIs, vhiIe loo high
lhreshoId vaIue viII cause fine slruclures nol lo le reproduced. This nakes il inpossilIe lo
find a correcl lhreshoId vaIue. A soIulion for lhe lhreshoId prolIen is lo vork vilh IocaI
lhreshoIds for differenl regions of lhe nodeI. IinaI deIinealion of lhe analony of inleresl
nay requires 2D or 3D inage ediling lo renove any unvanled delaiIs. A nunler of
soflvare packages are avaiIalIe for dala condilioning and inage processing for lhe SII of
analonicaI nodeIs, incIuding MIMICS ly MaleriaIise NV (hllp://vvv.naleriaIise.con),
iouiId ly Analonics Ily Lld (hllp://vvv.analonics.con/aloul/index.hlnI), 3D
Doclor ly AlIe soflvare Corporalion Lld (hllp://vvv.alIesv.con/) and AnaIyze ly
Mayo CIinic (hllp://vvv.nayo.edu/lir/Soflvare/AnaIyze/AnaIyze.hlnI). The cIinicaI
cases presenled in lhis sludy vere nodeIIed using lhe soflvare MIMICS lhal provides a
conprehensive range of dala inlerprelalion and inage processing lo inlerface vilh SII
lechnoIogy. As previousIy nenlioned lhe SII lechniques currenlIy used in nedicaI
appIicalions are 3D prinling (3D-I), slereoIilhography (SLA), seIeclive Iaser sinlering (SLS),
fused deposilion nodeIing (IDM), Ianinaled oljecl nanufacluring (LOM) and eIeclron
lean neIling (LM). The alove-nenlioned lechniques viII le aflervard descriled in delaiI.

2.3.1 3D Printing (3D-P)
3D-I uses a lechnoIogy siniIar lo lhe ink-jel prinling. As shovn in Iig. 7, parls are luiIl
upon a pIalforn silualed in a lin fuII of povder naleriaI. An ink-jel prinling head
seIecliveIy "prinls" linder lo fuse lhe povder logelher in lhe desired areas. Unlound
povder renains lo supporl lhe parl. The pIalforn is Iovered, nore povder added and
IeveIIed, and lhe process repealed. When finished, lhe green parl is sinlered and lhen
renoved fron lhe unlound povder. No exlernaI supporls are required during falricalion
since lhe povder supporls overhangs. 3D-I advanlages incIude speedy falricalion and Iov
naleriaI cosls. Linilalions on resoIulion, surface finish, parl fragiIily and avaiIalIe naleriaIs
are ils disadvanlages. The prolIen of lhe accuracy of lhe finaI parls is due lo lhe slair-
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Three-dimensional diagnosis and visualization supports in orthodontics
based on Reverse Engineering and Solid Free-form Fabrication techniques 11

slepping effecl in lhe X-Y pIane, lecause of lhe prinl-head rasler-scanning on lhe Iayers.
Moreover, 3D-I parls have a rilled and IillIe rough appearance due lo Iayering leads of
pIaslic and are nol suilalIe for exlensive funclionaI lesling.

Iig. 7. Schenalic of 3D-I

2.3.2 StereoIithography (SLA)
Ialenled in 1986, slereoIilhography slarled lhe SII revoIulion. The lechnique luiIds lhree-
dinensionaI nodeIs fron Iiquid pholosensilive poIyners lhal soIidify vhen exposed lo
uIlravioIel Iighl. As shovn in Iig. 7, lhe nodeI is luiIl upon a pIalforn silualed jusl leIov
lhe surface in a val of Iiquid epoxy or acryIale resin. A Iov-pover highIy focused UV Iaser
lraces oul lhe firsl Iayer, soIidifying lhe nodeIs cross seclion vhiIe Ieaving excess areas
Iiquid. The novenenl of lhe Iaser Iighl on lhe surface of lhe resin is conlroIIed ly a novalIe
nirror, using lhe dala fron lhe CAD syslen. Nexl, an eIevalor increnenlaIIy Iovers lhe
pIalforn inlo lhe Iiquid poIyner. A sveeper re-coals lhe soIidified Iayer vilh Iiquid, and lhe
Iaser lraces lhe second Iayer alop lhe firsl. This process is repealed unliI lhe prololype is
conpIele. Aflervards, lhe soIid parl is renoved fron lhe val and rinsed cIean of excess
Iiquid. This parl is caIIed green parl. Supporls are lroken off and lhe nodeI is lhen pIaced
in an uIlravioIel oven for conpIele curing. In Iig. 8 is represenled lhe schenalic diagran of
SLA.

Iig. 8. Schenalic of SLA
U.V. LASER SCANNER SYSTEM
OBJECT BENG
FABRCATED
MOVEABLE TABLE
VAT
PHOTOPOLYMER
OBJECT BENG
FABRCATED WTHN A
MATRX OF SUPPORT
MATERAL
HEATED
RESERVORS
OBJECT AND
SUPPORT
MATERALS
ELEVATOR
JETTNG HEADS
X-Y STAGE
SYSTEM
MLLNG HEAD
PARTCLE
COLLECTON
SYSTEM
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Modelling, Simulation and Optimization 12

SLA can produce surgicaI lenpIales oul of sleriIizalIe USI CIass VI resin. Advanlages of
SLA process incIude high parl-luiIding accuracy, snoolh surface finish, fine luiIding
delaiIs and high nechanicaI slrenglh. Moreover, seIecliveIy coIour-changing naleriaIs for
lionedicaI appIicalions are avaiIalIe, providing superior visuaIizalion ly highIighling
seIecled fealures in differenl coIour. Disadvanlages of lhis process incIude expensive
equipnenl and naleriaI cosl, vel naleriaIs handIing and posl-processing of lhe
nanufaclured parls.

2.3.3 SeIective Laser Sintering (SLS)
DeveIoped ly CarI Deckard for his naslers lhesis al lhe Universily of Texas, seIeclive Iaser
sinlering vas palenled in 1989. The process is sonevhal siniIar lo SLA in principIe as can
le seen fron lhe figure leIov. In lhis case, hovever, a Iaser lean is lraced over lhe surface
of a lighlIy conpacled povder nade of lhernopIaslic naleriaI. The povder is spread ly a
roIIer over lhe surface of a luiId cyIinder. A pislon noves dovn one oljecl Iayer lhickness
lo acconnodale lhe Iayer of povder. Lxcess povder in each Iayer heIps lo supporl lhe parl
during lhe luiId. Heal fron lhe Iaser neIls lhe povder vhere il slrikes under guidance of
lhe scanner syslen. The CO2 Iaser used provides a concenlraled infrared healing lean. The
enlire falricalion chanler is seaIed and nainlained al a lenperalure jusl leIov lhe neIling
poinl of lhe pIaslic povder. Thus, heal fron lhe Iaser need onIy lo eIevale lhe lenperalure
sIighlIy lo cause sinlering, grealIy speeding lhe process. A nilrogen alnosphere is aIso
nainlained in lhe falricalion chanler in order lo prevenl lhe possiliIily of expIosion in lhe
handIing of Iarge quanlilies of povder. Afler lhe oljecl is fuIIy forned, lhe pislon is raised
lo eIevale lhe oljecl. Lxcess povder is sinpIy lrushed avay and finaI nanuaI finishing nay
le carried oul. No supporls are required vilh lhis nelhod since overhangs and underculs
are supporled ly lhe soIid povder led. This saves sone finishing line conpared lo SLA.
Hovever, surface finishes are nol as good and lhis nay increase lhe line. No finaI curing is
required as in SLA, lul since lhe oljecls are sinlered lhey are porous. Depending on lhe
appIicalion, il nay le necessary lo infiIlrale lhe oljecl vilh anolher naleriaI lo inprove
nechanicaI characlerislics. Much progress has leen nade over lhe years in inproving
surface finish and porosily. The nelhod has aIso leen exlended lo provide direcl falricalion
of nelaI and ceranic oljecls and looIs.


Iig. 9. Schenalic of SLS

52//(5
/$6(5
6&$11(56<67(0
6,17(5('
2%-(&7
32:'(5%('
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Three-dimensional diagnosis and visualization supports in orthodontics
based on Reverse Engineering and Solid Free-form Fabrication techniques 13

Advanlages of SLS incIude high parl accuracy, naleriaI versaliIily, easy posl-processing and
no supporl needed. Disadvanlages incIude lhal SLS nanufaclured parls have IillIe rough
grainy and porous surface finish vhich is nol as snoolh as SLA lul acceplalIe for nosl of
appIicalions lul parls can le easiIy prined and finished lo snoolh IeveI. The Iarger shrink
rales of SLS increase lhe lendency for lhe prololype lo varp, lov or curI suljecl lo lhe parl
geonelry. SLS fealures delaiI is nol as crispy and sharp as produced ly SLA.

2.3.4 Fused Deposition ModeIIing (FDM)
In lhis lechnique, fiIanenls of healed lhernopIaslic are exlruded fron a lip lhal noves in
lhe x-y pIane as descriled in lhe figure alove. The conlroIIed exlrusion head deposils very
lhin leads of naleriaI onlo lhe luiId pIalforn lo forn lhe firsl Iayer. The pIalforn is
nainlained al a Iover lenperalure, so lhal lhe lhernopIaslic quickIy hardens. Afler lhe
pIalforn Iovers, lhe exlrusion head deposils a second Iayer upon lhe firsl. Supporls are
luiIl aIong lhe vay, faslened lo lhe parl eilher vilh a second, veaker naleriaI or vilh a
perforaled junclion. IDM nelhod produces nodeIs lhal are physicaIIy rolusl. Wax can le
used as lhe naleriaI, lul generaIIy nodeIs are nade of AS pIaslic. }usl oul of lhe nachine,
nodeIs nay have a fairIy rough surface finish, lul lhey can easiIy le cIeaned up. ecause of
lhe use of a singIe veII-defined lhread lo luiId lhe nodeI, lhis is lhe onIy one of lhe
processes vhere il is reIaliveIy easy lo change coIour, in facl lhe AS filre is avaiIalIe in a
range of lrighl prinary coIours. AIlernaliveIy, nodeIs can le painled. Moreover, IDM
provides a high IeveI of visuaIizalion ly highIighling seIecled fealures in a differenl coIour.
IDM can produce nodeIs oul of nedicaI grade AS, vhich is sleriIizalIe and lransIucenl
and neels aII IDA USI CIass VI requirenenls for lenporary use inside lhe lody.



Iig. 1O. Schenalic of IDM

Advanlages in using IDM incIude lhe speed and safely of lhe nachine. The nachine does
nol use any loxic naleriaIs, so il can le inslaIIed in an office environnenl. The luiId line for
lhe nachine is fasler lhan lhe SLA. There is no parl cIean-up needed for a parl nade ly
IDM. Disadvanlages incIude lhal surface finish of lhe parls is inferior lo lhose produced
using SLA or SLS, due lo lhe resoIulion of lhe process vhich is diclaled ly lhe fiIanenl
lhickness. Accuracy is reIaliveIy Iov and is difficuIl lo luiId parls vilh conpIicaled delaiIs,
poor slrenglh in verlicaI direclion and sIovness for luiIding a nass parl.

TABLE
PLASTC FLAMENT
SUPPLY COL
OBJECT BENG
FABRCATED
THERMAL HOUSNG
(OVEN)
EXTRUSON
NOZZLE
X-Y-Z STAGE
SYSTEM
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Modelling, Simulation and Optimization 14

2.3.5 Laminated Object Manufacturing (LOM)
In lhis lechnique, deveIoped ly HeIisys of Torrance, CA, Iayers of adhesive-coaled sheel
naleriaI are londed logelher lo forn a prololype. The originaI naleriaI consisls of paper
Ianinaled vilh heal-aclivaled gIue and roIIed up on spooIs. As shovn in lhe figure leIov, a
feeder/coIIeclor nechanisn advances lhe sheel over lhe luiId pIalforn, vhere a lase has
leen conslrucled fron paper and doulIe-sided foan lape. Nexl, a healed roIIer appIies
pressure lo lond lhe paper lo lhe lase. A focused Iaser culs lhe oulIine of lhe firsl Iayer inlo
lhe paper and lhen cross-halches lhe excess area (lhe negalive space in lhe prololype).
Cross-halching lreaks up lhe exlra naleriaI, naking il easier lo renove during posl-
processing. During lhe luiId, lhe excess naleriaI provides exceIIenl supporl for overhangs
and lhin-vaIIed seclions. Afler lhe firsl Iayer is cul, lhe pIalforn Iovers oul of lhe vay and
fresh naleriaI is advanced. The pIalforn rises lo sIighlIy leIov lhe previous heighl, lhe
roIIer londs lhe second Iayer lo lhe firsl, and lhe Iaser culs lhe second Iayer. This process is
repealed as needed lo luiId lhe parl, vhich viII have a vood-Iike lexlure. ecause lhe
nodeIs are nade of paper, lhey nusl le seaIed and finished vilh painl or varnish lo
prevenl noislure danage, lul lecause lhe rav naleriaI (paper) is cheap, LOM is
parlicuIarIy suilalIe for Iarge nodeIs given lhal lhe nanufacluring speed is very fasl.
Disadvanlages incIude lhal il is hard lo nake hoIIov parls due lo lhe difficuIly in renoving
lhe core and lhere are serious prolIens vilh underculs and re-enlranl fealures. Olher
prolIens are lhe greal anounl of scrap so lhal lhe nachine nusl le conslanlIy nanned and
parls need lo le hand finished. Moreover, given lhal lhe Iaser culs lhrough lhe naleriaI,
lhere is a fire hazard vhich neans lhal lhe nachines need lo le filled vilh inerl gas
exlinguishers. The drops of noIlen naleriaI, vhich forn during lhe culling process, need lo
le renoved aIso.



Iig. 11. Schenalic of LOM

2.3.6 EIectron Beam MeIting (EBM)
LIeclron lean neIling (LM) is a lype of rapid prololyping for nelaI parls. Il is oflen
cIassified as a rapid nanufacluring nelhod. The lechnoIogy nanufaclures parls ly neIling
nelaI povder Iayer per Iayer vilh an eIeclron lean in a high vacuun. UnIike sone nelaI
HEATED ROLLER
LASER
SEALED
CHAMBER
PAPER
FEED ROLL
OBJECT UNDER
CONSTRUCTON
MOVEABLE MRROR
WASTE PAPER
TAKE-UP ROLL
SMOKESTACK
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Three-dimensional diagnosis and visualization supports in orthodontics
based on Reverse Engineering and Solid Free-form Fabrication techniques 15

sinlering lechniques, lhe parls are fuIIy soIid, void-free, and exlreneIy slrong. LM is aIso
referred lo as LIeclron ean Machining. High speed eIeclrons (.5-.8 lines lhe speed of Iighl)
are lonlarded on lhe surface of lhe vork naleriaI generaling enough heal lo neIl lhe
surface of lhe parl and cause lhe naleriaI lo IocaIIy vaporize.

















Iig. 12. Schenalic of LM

LM does require a vacuun, neaning lhal lhe vorkpiece is Iiniled in size lo lhe vacuun
used. The surface finish on lhe parl is nuch leller lhan lhal of olher nanufacluring
processes. OnIy shool-peening process lo conlroI residuaI slresses ly conpressing surfaces
and poIishing lo reduce roughness nay le needed as secondary finishing operalions. LM
can le used on nelaIs, non-nelaIs, ceranics, and conposiles.
Sone of ils lenefils incIude: aliIily lo achieve a high energy IeveI in a narrov lean, vacuun
neIl quaIily can yieId high slrenglh properlies of lhe naleriaI, vacuun environnenl
eIininales inpurilies such as oxides and nilrides and pernils veIding in refraclory nelaIs
and conlinalions of dissiniIar nelaIs. Sone apparenl disadvanlages of eIeclron lean
lechnoIogy are: requires vacuun vhich adds anolher syslen on lhe nachine vhich cosl
noney and nusl le nainlained, eIeclron lean lechnoIogy produces ganna rays vhiIe in
operalion and requires eIeclricaIIy conduclive naleriaIs.
In lhe foIIoving seclion sone cIinicaI cases, lrealed vilh lhe aid of RL and SII processes,
viII le presenled and discussed.

3. AppIication of RE and SFF in cIinicaI cases

SeveraI cIinicaI cases in lhe fieId of orlhodonlics, supporled ly lhe use of RL and SII
lechniques, are provided in lhis seclion. In facl, lhe quaIily of service, in lerns of
inprovenenl in palienl salisfaclion, is an increasingIy inporlanl oljeclive in aII nedicaI
fieIds, and is especiaIIy inperalive in orlhodonlics due lo lhe high nunlers of palienls
lrealed. AII lhe cases are reIaled lo palienls cIinicaIIy lrealed al lhe Deparlnenl of
Orlhodonlics of lhe Universily of Ierrara (IlaIy).
BULDNG
TABLE
VACUUM
CHAMBER
ELECTRON
BEAM
POWDER
DSPENSER
DEFLECTON
COL
FOCUS
COL
ANODE
GRD CUP
FLAMENT
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Modelling, Simulation and Optimization 16

3.1 AppIication of RE techniques
3.1.1 EvaIuation of the post-extractive faciaI edema
A RL-lased approach vas aIso used in lhe evaIualion of lhe posl-exlraclive faciaI edena,
afler lhe uniIaleraI exlraclion of conpIeleIy inpacled nandiluIar lhird noIars on 4O
palienls. Range canera Conel Vario Zoon (SleinlichIer Oplolechnik CnlH, Cernany)
logelher vilh lhe processing soflvare IoIyWorks (InnovMelric Soflvare Inc., Canada) vere
used lo carry oul conpulerized anaIysis of lhe 3D inages ollained in lhis norpho-
voIunelric sludy of posl-exlraclive edenalous sveIIing as shovn in Iig. 13. The acquired
dala and anaIysis reveaIed no slalislicaIIy significanl gender-reIaled difference in edenaI
voIune al any posl-operalive slage anaIyzed. olh naIe and fenaIe palienls, hovever,
shoved a significanl increase in voIune (nean voIune: 28,766.96 nn) lvo days afler
surgery. Iurlhernore, on lhe sevenlh day afler surgery, lhe edenalous sveIIing vas
reduced lo IeveIs siniIar lo lhose recorded innedialeIy foIIoving exlraclion in lolh naIes
and fenaIes.



















Iig. 13. Inlernediale coIours indicale lhe edenalous dislance and voIunes

3.1.2 EvaIuation of paIataI morphoIogic and voIumetric changes after the use of a
rapid paIataI expander (RPE)
RL syslens and soflvare vere enpIoyed lo evaIuale lhe paIalaI norphoIogic and
voIunelric changes afler lhe use of a RIL appIiance in four chiIdren palienls (aged 7-8
years) in nixed

denlilion vilh a poslerior crosslile, a

skeIelaI CIass II naIoccIusion and vilh
narrov naxiIIary arches (MazzoIi el aI., 2OO8). The palienls vere lrealed using lhe Haas RIL
in order lo soIve lhe naxiIIary conlraclion. Ior each palienl lhree neasurenenls vere done:
pre-lrealnenl (T
1
), afler expansion lherapy (T
2
), and six nonlhs afler lhe renovaI of lhe
expander (T
3
) vilhoul no conlenlion. TradilionaIIy, lrealnenl slaliIily vas evaIualed vilh
caIipers and conpasses, vhich regisler jusl Iinear neasurenenls and depend on lhe aliIily
of lhe operalor vilhoul providing precise 3D neasurenenls.
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Three-dimensional diagnosis and visualization supports in orthodontics
based on Reverse Engineering and Solid Free-form Fabrication techniques 17

In lhe alove ciled sludy a RoIand Iicza syslen (RoIand DC Mid Lurope SrI, Acquaviva
Iicena, IlaIy) vas used lo scan casls vilh a resoIulion of up lo O.O5 nn and a scanning slep
up lo O.O2 nn. The ollained dala vere nanaged using lhe soflvare Rapidforn (INUS
TechnoIogy Inc., Korea), an advanced 3D scan dala processing soflvare, and Rhinoceros
(McNeeI, SeallIe), a nodeIing soflvare for designers. The lase paIalaI voIune vas deIiniled
ly lhe gingivaI nargins and ly a verlicaI pIane connecling lhe dislaI aspecl of lhe Iasl
pernanenl noIars. AII lesls confirned lhe hypolhesis lhal lhe neasurenenls al T2 and T3
vere significanlIy differenl fron lhose al lhe slarl of lhe lrealnenl supporling lhe
effecliveness of lhe RML lrealnenl. In Iig. 14 are shoved lhe cross-seclionaI superposilion
of lhe recordings al T1, T2 and T3 reporling lhe varialions in paIalaI lransverse dianelers
lelveen lhe alove seIecled coupIes of leelh in one cIinicaI case.















Iig. 14. Cross-seclionaI superposilion of lhe recordings al T1 (red), T2 (green) and T3 (lIue)
reporling lhe varialions in paIalaI lransverse dianelers lelveen lhe ouler side cusps of lhe
firsl prinary noIars (54-64)

3.1.3 EvaIuation of 3D TechnoIogies in Dentistry
A sludy has specificaIIy ained lo evaIuale Reverse Lngineering (RL) and Rapid Irololyping
(RI) in order lo define an ideaI chain of advanced lechnoIogicaI soIulions lo supporl lhe
crilicaI processes of orlhodonlic aclivily (Cracco el aI., 2OO8). Infornalion lechnoIogy can
provide a neaningfuI conlrilulion lo lellering lrealnenl processes, and ve nainlain lhal
syslens such as CAD, CAM and CAL, aIlhough iniliaIIy conceived for induslriaI purposes,
shouId le evaIualed, sludied and cuslonized vilh a viev lo use in nedicine. Advanlages lo
using such syslens lo carry oul nany of lhe slages in orlhodonlic processes currenlIy
perforned ly hand, such as lhe design and nanufaclure of correclive appIiances and lhe
produclion of virluaI nodeIs of lhe denlaI arches, and aIso lo delernine lhe feasiliIily of
lheir use in lhe pIanning and sinuIalion of correclive and inpIanloIogicaI lrealnenl and in
lhe design and nanufaclure of fixed and noliIe proslheses. Tvo lypes of lesl vere
enpIoyed lo sludy lhe acquisilion syslens, lhe firsl ained al evaIualing lhe syslen usaliIily
and lhe line required for scanning, and lhe second designed lo conpare lhe resoIulion and
accuracy of lhe syslens. To lhe forner end a slandard procedure of neasurenenl vhich
couId le enpIoyed vilh lolh specific and generaI purpose syslens, aII used in conjunclion
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Modelling, Simulation and Optimization 18

vilh a suilalIe aulonalic posilioning device, vas eslalIished. The resoIulion and accuracy
of lhe various acquisilion syslens vere conpared via lhe acquisilion of a singIe viev of a
significanl porlion of lhe sane pIasler nodeI. The CAD syslen vas enpIoyed lo neasure
lhe dinensionaI and norphoIogicaI paranelers direclIy using lhe lrianguIaled poinl cIoud,
vilhoul furlher eIaloralion. The dinensionaI reference dala vere caIcuIaled fron a
neasurenenl carried oul ly a coordinale neasurenenl nachine vilh conlacl sensors. This
conparalive sludy anaIyzed rapid prololyping syslens and defined suilalIe nelhodoIogies
of evaIualing lhe fundanenlaI conponenls of an RL/RI nanufacluring for appIicalion in
lhe orlhodonlic fieId. The preIininary resuIls denonslrale lhal repIicalion of a pIasler
nodeI is pIagued ly prolIens Iinked lo lhe size of delaiI lo le reproduced, vhich is siniIar
lo or finer lhan lhe falricalion Iayer of lhe various addilive lechnoIogies sludied, and
lherefore resuIls in poor quaIily reproduclion of loolh norphoIogy.









Iig. 15. CoIour nap of norphoIogicaI anaIysis on loolh lop: errors are due lo surfaces
grooves and falricalion Iayers

3.2 AppIication of 3D anatomicaI modeIIing and SFF techniques
3.2.1 ImpIant-prosthetic rehabiIitation
46-year- oId Caucasian fenaIe (S.I.) shoving a parliaI edenluIisn referred lo lhe Iefl side of
lhe Iover haIf-arch and a Iack of lhe upper naxiIIary denlaI eIenenls, vilh lhe exceplion of
lhe 1.7 and 1.8, due lo a pre-exisling lrauna. olh lhe edenluIous areas shoved a high
degree of lone resorplion vilh a consideralIe heighl and lhickness reduclion of lhe aIveoIar
ridge. Such a decrease of avaiIalIe lone lissue nade lhe inpIanl-proslhelic pIanning phase
ralher prolIenalic and needed lo le videned ly CT surveys. In parlicuIar, lhe cIoseness of
lhe inferior aIveoIar nerve vas crilicaI in lhe seIeclion of lhe nore suilalIe denlaI inpIanls
in lerns of lypoIogy and size. Ior lhe alove reason 3D renderings, using lhe soflvare
MIMICS, of lhe lvo naxiIIary arches vas inpIenenled highIighling lhe Iefl porlion of lhe
inferior aIveoIar nerve as shovn in Iig. 16.

Iig. 16. 3D rendering of lhe naxiIIary arch. HighIighled in red lhe Iefl porlion of lhe inferior
aIveoIar nerve
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Three-dimensional diagnosis and visualization supports in orthodontics
based on Reverse Engineering and Solid Free-form Fabrication techniques 19

3.2.2 Impacted dentaI eIements
23-year-oId Caucasian fenaIe (I.S.) shoving a lolaI lone inpaclion of lhe eIenenls 1.3 and
2.3. ConvenlionaI diagnoslic looIs used in denlislry (inspeclion and percussion) and
radiographic looIs (orlhopanoranic and TeIeRx) vere nol usefuI in order lo preciseIy
recognize lhe posilion of lhe inpacled eIenenls. In parlicuIar, il vas nol possilIe lo idenlify
lhe anleroposlerior spaliaI reIalion of lhe inpacled leelh. The 3D rendering and physicaI
nodeI of lhe naxiIIary arch irrefulalIy highIighled lhe paIalaI inpaclion of lolh lhe
eIenenls.
16-year-oId Caucasian fenaIe (.L.) shoving a Iiniled lone inpaclion of lhe eIenenl 2.2
and lolaI inpaclion of lhe 2.3. In order lo perforn lhe surgicaI pIanning for lhe exlraclion of
lhe eIenenl 2.3, Ialer on an iniliaI phase of aIignnenl and IeveIIing oul of lhe upper
naxiIIary arch, lhe crilicaI aspecl regarded lhe high IeveI of conliguily lelveen lhe
inpacled eIenenls. The 3D rendering and SLA physicaI nodeI of lhe naxiIIary arch
(shoved in Iig. 17) renoved any doull regarding lhe hypolhelicaI rool resorplion reIaliveIy
lo lhe eIenenl 2.2 and sinpIified lhe lrealnenl pIanning for lhe exlrusion of lhe eclopic
eIenenl 2.3.







(a) (|) (c)
Iig. 17. (a) voIunelric rendering, (l) delaiI and (c) SLA nodeI of lhe naxiIIary arch
confirned lhe hypolhelicaI rool resorplion reIaliveIy lo lhe eIenenl 2.2 and sinpIified lhe
lrealnenl pIanning for lhe exlrusion of lhe eclopic eIenenl 2.3

9-year-oId Caucasian fenaIe (V.C.) shoving a supernunerary loolh lolaIIy inpacled
(nesiodens) lelveen lhe eIenenls 1.1 e 2.1. The 3D rendering and physicaI nodeI of lhe
naxiIIary arch vas nanufaclured in order lo faciIilale lhe oraI surgery. In facl, lhe
convenlionaI radiographic looIs vere nol heIpfuI in lhe definilion of lhe vesliluIar or
paIaline posilion of lhe nesiodens.
16-year-oId Caucasian naIe (M.A.) shoving a parliaI inpaclion of lhe 1.3, agenesis of lhe 1.5
and lolaI inpaclion of lhe 1.7. Irevious orlhodonlic lrealnenls enalIed lhe inconpIele
exlrusion of lhe eIenenl 1.3 foIIoved ly a freezing of lhe sane lecause of an infraoccIusion
of lhe loolh. The 3D rendering and lhe SLA nodeI highIighled lhe inpaclion of lhe 1.3 on
lhe vesliluIar corlicaI porlion of lhe naxiIIary arch.

3.2.3 Joint-reIated diseases
16-year-oId Caucasian fenaIe (S.M.) shoving a denlaI cIass 1 vilh conlracled arches, Iover-
fronl denlaI overcrovding and deep lile. Iron lhe oljeclive exaninalion of lhe
slonalhognalic apparalus lhe presence of Iefl- hand joinl-reIaled sounds vere noliced. The
palienl reporled aloul lhe Iack of pain and funclionaI Iinilalions. The 3D nodeI of lhe
nandilIe, nanufaclured in poIyanide ly SLS, shoved an alnornaI shape of lhe Iefl-
condyIe: hypopIasic and fIal.
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Modelling, Simulation and Optimization 20

3.2.4 EvaIuation of the position of foreign bodies
18-year-oId Caucasian fenaIe (I.D.) shoving a radiopaque foreign lody in lhe nedian area
lelveen lhe apices of lhe eIenenls 1.2 e 2.1. Laler on a lrauna lhe palienl refers aloul lhe
Iosl oul lhe 1.1 and innedialeIy inpIanled. A second lrauna caused lhe definilive avuIsion
of lhe eIenenl. IirslIy, lhe palienl vas orlhodonlicaIIy lrealed in order lo gain space and
lhen vas exanined ly a CT survey. The 3D rendering and SLA nodeI of lhe upper naxiIIa
aIIoved an accurale idenlificalion of lhe posilion and size of lhe foreign lody as shovn in
Iig. 16. Il vas recognized as a reclanguIar lIock (4.67 u 8.O3 u 3.77 nn), posilioned in lhe
vesliluIe, lhal delernined an infIannalory resorplion of lhe corlicaI porlion of lhe
vesliluIe ilseIf. Laler on lhe acquisilion of lhe alove descriled infornalion, lhe avuIsion
vas pIanned and execuled and lhe foreign lody vas renoved. Il vas delernined lo le
gulla-percha. ConlexluaIIy, auloIogous lone grafling vas perforned in order lo fiII lhe gap.
An inpIanl-proslhelic rehaliIilalion viII le perforned on lhe palienl.











(a) (|)

Iig. 18. 2D evaIualion (a) and 3D rendering (l) of an upper naxiIIa shoving lhe presence of
a radiopaque foreign lody

3.2.5 Upper airways span monitoring
3O pedialric palienls vere seIecled and are currenlIy under lrealnenl ly RIL (Rapid IaIalaI
Lxpander), an orlhopaedic appIiance lhal videns lhe upper jav ly separaling lhe
nidpaIalaI sulure. The palienls vere nonilored ly cone-lean CT (CCT) lefore lhe
posilioning of lhe RIL. The onIy one of lhen lhal has aIready conpIeled lhe lherapeulic
lrealnenl vas suljecled lo anolher CCT scan afler lhe renovaI of lhe RIL. ConlexluaIIy,
lhe voIune of lhe upper airvays vas nodeIIed lefore and afler lhe lrealnenl and lhe
voIune augnenlalion vas evaIualed as shovn in Iig. 19. In lhis case lhe eslinaled
augnenlalion of lhe voIune of lhe upper airvays is equaI lo lhe 26.44.

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Three-dimensional diagnosis and visualization supports in orthodontics
based on Reverse Engineering and Solid Free-form Fabrication techniques 21



Iig. 19. 3D rendering of lhe upper airvays reIalive lo a RIL lrealed palienl. efore (Iefl) and
afler (righl) lhe lrealnenl is nolicealIe lhe augnenlalion of lhe voIune of lhe upper
airvays.

4. ConcIusions

Reverse Lngineering and SoIid Iree-forn Ialricalion lechniques have leen sulslanliaIIy
appIied in nedicine, hovever, lheir appIicalion in denlislry, and parlicuIarIy in
orlhodonlics, is nol nuch videspread. This paper has discussed RL and SII lechniques and
lheir usaliIily in orlhodonlics. Afler presenlalion of RL and SII lechnoIogies, lhe currenl
and polenliaI use in denlaI appIicalion are discussed shoving sone lrealed cIinicaI cases. Il
is cIear lhal lhe use of RL lechniques and SII nodeIs in denlislry viII le expanded in lhe
fulure vilh lhe ongoing research lased on lhe deveIopnenl of nev naleriaIs and
lechnoIogies. A nunler of appIicalion exanpIes are discussed, vhich denonslrale lhal RL
and SII lechniques are pIaying a nore and nore inporlanl roIe in denlaI appIicalion.

5. References

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Modelling Simulation and Optimization
Edited by Gregorio Romero Rey and Luisa Martinez Muneta
ISBN 978-953-307-048-3
Hard cover, 708 pages
Publisher InTech
Published online 01, February, 2010
Published in print edition February, 2010
InTech Europe InTech China
Computer-Aided Design and system analysis aim to find mathematical models that allow emulating the
behaviour of components and facilities. The high competitiveness in industry, the little time available for
product development and the high cost in terms of time and money of producing the initial prototypes means
that the computer-aided design and analysis of products are taking on major importance. On the other hand,
in most areas of engineering the components of a system are interconnected and belong to different domains
of physics (mechanics, electrics, hydraulics, thermal...). When developing a complete multidisciplinary system,
it needs to integrate a design procedure to ensure that it will be successfully achieved. Engineering systems
require an analysis of their dynamic behaviour (evolution over time or path of their different variables). The
purpose of modelling and simulating dynamic systems is to generate a set of algebraic and differential
equations or a mathematical model. In order to perform rapid product optimisation iterations, the models must
be formulated and evaluated in the most efficient way. Automated environments contribute to this. One of the
pioneers of simulation technology in medicine defines simulation as a technique, not a technology, that
replaces real experiences with guided experiences reproducing important aspects of the real world in a fully
interactive fashion [iii]. In the following chapters the reader will be introduced to the world of simulation in topics
of current interest such as medicine, military purposes and their use in industry for diverse applications that
range from the use of networks to combining thermal, chemical or electrical aspects, among others. We hope
that after reading the different sections of this book we will have succeeded in bringing across what the
scientific community is doing in the field of simulation and that it will be to your interest and liking. Lastly, we
would like to thank all the authors for their excellent contributions in the different areas of simulation.
How to reference
In order to correctly reference this scholarly work, feel free to copy and paste the following:
Alida Mazzoli, Michele Germani, Roberto Raffaeli and Antonio Gracco (2010). Three-Dimensional Diagnosis
and Visualization Supports in Orthodontics Based on Reverse Engineering and Solid Free-Form Fabrication
Techniques, Modelling Simulation and Optimization, Gregorio Romero Rey and Luisa Martinez Muneta (Ed.),
ISBN: 978-953-307-048-3, InTech, Available from: http://www.intechopen.com/books/modelling-simulation-
and-optimization/three-dimensional-diagnosis-and-visualization-supports-in-orthodontics-based-on-reverse-
engineering-
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