The advent of smart biomaterials, and advanced cell culturing, along with 3D printing, is creating a range of new opportunities in dentistry by enabling patient-specific treatments. Not only can biomaterial be printed in patterns tailored precisely to meet each patient’s needs, it can incorporate living cells, and can be engineered to enhance the bio-integration and healing process on a cellular level.[i]
For the oral surgeon and implant dentist, this burgeoning technology offers exciting possibilities for the treatment of edentulous patients with a severely atrophic jaw. 3D printing, and fabrication based on digital scans has enabled bespoke restorations for many years. The 3D printing of biomaterials can also be used to create patient-specific meshes to regenerate bone and tissue defects, such as those in a severely resorbed alveolar ridge.i The technology is fast growing, and knowledge of bioprinting is likely to form an essential part of the skillset of an advanced practitioner.
The development of bioprinting
Since 1988, scientists have been developing bioprinting – the clinical application of 3D printing – with increasing success. 3D printing, or stereolithography, was invented in 1984 by Charles Hull.[ii] This technology uses 3D digital constructs created by CAD software to direct the layering of materials into real objects. Over time, this has moved from the creation of liquid photopolymer machine components, to the manufacture of bespoke biocompatible or bioactive materials, organs, bone and tissue for implant or transplant.i
The technology continues to open up new opportunities within dentistry and systemic medicine, offering new hope for patients with a range of needs. Human skin tissue, a 3D printed heart with blood vessels and a 3D printed lung air sac have all been developed within the last 7 years.i
2015 marked the use of bioprinting in the treatment of a large periodontal osseous defect. The procedure was completed using a 3D printed bioresorbable patient-specific polymer scaffold and signalling growth factor (a biologically active molecule affecting the growth of cells). This was the first such use of the technology on a human subject.[iii]
Bone tissue engineering materials
3D bioprinting uses hydrogels, or ‘bioinks’, which consist of cells that feature a modifiable chemical composition, along with adjustable mechanical and biodegradation properties. This versatility allows for the creation of tailored materials suitable for various applications in tissue engineering and regenerative medicine.i
Bioinks can be tailored to produce various geometries to fit any tissue defect. They can construct complex inner tissue structure to emulate different cells in the body, making bioprinted material an excellent scaffold.i For this reason, bioprinting has demonstrated huge potential in bone remodelling.[iv]
Normal bone tissue is made up of natural materials such as collagen and hydroxyapatite. The use of different types of natural and artificial biomaterials has been explored to enable the regeneration of bone defects. Biomaterials can be derived from metals, polymers, ceramics, and natural materials.iv
Natural polymer materials like chitosan, alginate, and collagen are used in hydrogels. While biocompatible, non-toxic and immunogenic, these materials have poor mechanical properties, and so are commonly used in combination with alloplastic, or artificial, biologically inert materials like polylactic acid, polylactic acid, and polycaprolactone (PCL) or polycaprolactone–tricalcium phosphate (PCL-TCP).iv
Treatment of alveolar bone defects using bioprinting
Treatment of alveolar bone defects using bioprintingFor patients experiencing bone tissue loss, alveolar ridge augmentation is essential for regenerating bone and restoring the alveolar ridge, which helps ensure the long-term stability of implants. The current gold standard for grafting is autogenous bone due to its predictability, biocompatibility, shorter healing times, and lower costs compared to alternative graft materials.[v]
Concerns about donor site morbidity, chair and recovery time can be mitigated through new harvesting techniques, such as piezoelectric surgery. However, in autogenic bone harvesting, the volume of material acquired is usually limited, and the replacement rate of those autografts may be unpredictable.[vi]
Bioprinting has been suggested as a solution to the high demand for these bone grafts, while overcoming some of the challenges posed by grafting materials. The complex anatomy surrounding the oral cavity and the multidirectional forces faced by oral–maxillofacial bone tissues during jaw movement present some of these challenges. Bioprinted combinations of PCL and adipose-derived mesenchymal stem cells (AD-MSCs) have been proposed to counter this, and these materials have already shown promising results in laboratory tests.[vii]
Evidence-based learning
While research and development is ongoing in these areas, clinicians are already implementing various 3D printed solutions in practice. The ICE Postgraduate Dental Institute and Hospital is offering a hands-on course focusing on 3D patient-specific customised grafting for the reconstruction of the resorbed alveolar ridge. Led by eminent specialist oral surgeon Professor Cemal Ucer, assisted by faculty with expertise in Biomedical Engineering, the course provides an evidence-based knowledge of different strategies used for the treatment of hard and soft tissue alveolar ridge defects. Delegates will also critically appraise the different classes of regenerative biomaterials; xenografts, allografts and synthetics.
We have yet to experience the whole potential of bioprinting to treat alveolar bone defects, as well as a range of conditions affecting bone and soft tissue. To ensure a complete understanding of the ways in which these exciting innovations are advancing is a must to be part of this revolutionary technology.
Please contact Professor Ucer at ucer@icedental.institute or Mel Hay at mel@mdic.co
01612 371842
Professor Cemal Ucer (BDS, MSc, PhD, Oral Surgeon, ITI Fellow)
Cemal Ucer first established an implant referral centre in 1995. He was awarded an MSc in Implantology at Manchester Dental Hospital following his research into guided bone regeneration and osteopromotion. He later gained a PhD for his clinical and laboratory studies into the factors affecting the success of implant treatment in iliac grafts and the investigation of the effect of skeletal bone density on implant survival. He has personally trained and mentored more than 1,000 dentists in implant dentistry as one of the main providers of implant education in the UK.
Cemal’s current clinical research interests include immediate implant placement, reconstructive bone surgery, nerve damage and the effect of bone density on the success of implant treatment. Academically, he has gained European recognition for his work on the development of a new framework for teaching and assessment of clinical competence in implantology. He is a co-author of the consensus paper produced by the Association for Dental Education in Europe (ADEE) following the first pan-European collaboration between EU universities to establish common training and assessment standards in dental implantology. He is an invited member of the working group convened by the FGDP (UK) and the General Dental Council (GDC) to update the Training Standards in Implant Dentistry (TSID) guidelines in 2012 and 2016.
Cemal is a Fellow of the Dental Trainers Faculty of the Royal College of Surgeons of Edinburgh (RCSEd) and a Fellow of the International Team for Implantology (ITI) and a member of Megagen’s MINTEC UK & I Board for education and clinical research. He is a member of the editorial board of JOMR (Journal of Oral & Maxillofacial Research) and the chair of the editorial advisory board of Implant Dentistry Today. Cemal is Professor and Clinical Lead of the MSc programme in Dental Implantology and a member of the Faculty of Examiners of the Royal College of Surgeons of Edinburgh’s Diploma in Implant Dentistry. He is a past president of The Association of Dental Implantology (ADI) (2011-2013).
Cemal has been appointed by FGDP (UK) to lead the working group to develop the “national standards in implant dentistry” which is due to be published later in 2018 following the completion of an external consultation process.
[i] Nesic D, Schaefer BM, Sun Y, Saulacic N, Sailer I. 3D Printing Approach in Dentistry: The Future for Personalized Oral Soft Tissue Regeneration. J Clin Med. 2020 Jul 15;9(7):2238. doi: 10.3390/jcm9072238. PMID: 32679657; PMCID: PMC7408636.
[ii] Stereolithography The First 3D Printing Technology. ASME Historic Mechanical Engineering Landmark The American Society of Mechanical Engineers. May 2016. Available at: https://www.asme.org/wwwasmeorg/media/resourcefiles/aboutasme/who%20we%20are/engineering%20history/landmarks/261-stereolithography.pdf Accessed November 24
[iii] Rasperini G, Pilipchuk SP, Flanagan CL, et al. 3D-printed Bioresorbable Scaffold for Periodontal Repair. Journal of Dental Research. 2015;94(9_suppl):153S-157S. doi:10.1177/0022034515588303
[iv] Khalaf AT, Wei Y, Wan J, Zhu J, Peng Y, Abdul Kadir SY, Zainol J, Oglah Z, Cheng L, Shi Z. Bone Tissue Engineering through 3D Bioprinting of Bioceramic Scaffolds: A Review and Update. Life (Basel). 2022 Jun 16;12(6):903. doi: 10.3390/life12060903. PMID: 35743934; PMCID: PMC9225502.
[v] Misch, Craig M. DDS, MDS. Autogenous Bone: Is It Still the Gold Standard?. Implant Dentistry 19(5):p 361, October 2010. | DOI: 10.1097/ID.0b013e3181f8115b
[vi] Sheikh Z, Hamdan N, Ikeda Y, Grynpas M, Ganss B, Glogauer M. Natural graft tissues and synthetic biomaterials for periodontal and alveolar bone reconstructive applications: a review. Biomater Res. 2017 Jun 5;21:9. doi: 10.1186/s40824-017-0095-5. PMID: 28593053; PMCID: PMC5460509.
[vii] Lau CS, Chua J, Prasadh S, Lim J, Saigo L, Goh BT. Alveolar Ridge Augmentation with a Novel Combination of 3D-Printed Scaffolds and Adipose-Derived Mesenchymal Stem Cells—A Pilot Study in Pigs. Biomedicines. 2023; 11(8):2274. https://doi.org/10.3390/biomedicines11082274
