Int J CARS (2010) 5:335341

DOI 10.1007/s11548-010-0476-x

REVIEW ARTICLE

3D printing based on imaging data: review of medical applications

F. Rengier A. Mehndiratta H. von Tengg-Kobligk
C. M. Zechmann R. Unterhinninghofen
H.-U. Kauczor F. L. Giesel

Received: 25 January 2010 / Accepted: 21 April 2010 / Published online: 15 May 2010
CARS 2010

Abstract
Purpose Generation of graspable three-dimensional objects
applied for surgical planning, prosthetics and related applications using 3D printing or rapid prototyping is summarized
and evaluated.
Materials and methods Graspable 3D objects overcome the
limitations of 3D visualizations which can only be displayed
on flat screens. 3D objects can be produced based on CT or
MRI volumetric medical images. Using dedicated post-processing algorithms, a spatial model can be extracted from
image data sets and exported to machine-readable data. That
spatial model data is utilized by special printers for generating the final rapid prototype model.

F. Rengier A. Mehndiratta H. von Tengg-Kobligk

C. M. Zechmann F. L. Giesel (B)
Department of Radiology E010,
German Cancer Research Center Heidelberg (dkfz),
Im Neuenheimer Feld 280, 69120 Heidelberg, Germany
e-mail: [email protected]
F. Rengier H. von Tengg-Kobligk H.-U. Kauczor F. L. Giesel
Department of Diagnostic and Interventional Radiology,
University Hospital Heidelberg, Im Neuenheimer Feld 110,
69120 Heidelberg, Germany
A. Mehndiratta
School of Medical Science and Technology,
Indian Institute of Technology, Kharagpur 721302, India
C. M. Zechmann F. L. Giesel
Department of Nuclear Medicine,
University Hospital Heidelberg, Im Neuenheimer Feld 400,
69120 Heidelberg, Germany
R. Unterhinninghofen
Institute of Computer Science and Engineering,
University of Karlsruhe, Haid-und-Neu-Str. 7,
76131 Karlsruhe, Germany

Results Patientclinician interaction, surgical training, medical research and education may require graspable 3D
objects. The limitations of rapid prototyping include cost and
complexity, as well as the need for specialized equipment and
consumables such as photoresist resins.
Conclusions Medical application of rapid prototyping is feasible for specialized surgical planning and prosthetics applications and has significant potential for development of new
medical applications.
Keywords Rapid prototyping Patient care Prostheses
and implants Medical education Computer-assisted image
processing
Introduction
Medical imaging has evolved dramatically in the past few
decades. With the evolution of Multidetector Computed
Tomography (MDCT) and Magnetic Resonance Imaging
(MRI), radiological diagnosis has become less invasive and
more informative [1,2]. High-resolution three-dimensional
image data can be acquired within a single breath-hold.
Image processing plays a very critical role in diagnostic
imaging [3,4]. 3D visualization, multiplanar reformation and
image navigation help radiology to be pivotal for many clinical disciplines [5]. Todays image guided surgeries illustrate
how radiology has become integrated in a therapeutic team
together with different surgical specialists. However, we are
limited by the use of flat screens for the visualization of threedimensional imaging data. An emerging technique, referred
to as 3D printing or rapid prototyping, overcomes this limitation by producing graspable three-dimensional objects [6].
This article illustrates the technique of generating 3D objects
based on radiological image data and reviews its applications
in the medical field as well as its limitations.

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Generation of 3D objects
Source data acquired with any imaging modality typically
is visualized in two dimensions. With post-processing tools
and algorithms, it is possible to produce multiplanar reformations and three-dimensional views of the anatomy. The
process chain involved from image acquisition to production
of a three-dimensional rapid prototype model consists of the
following three steps and will be discussed in detail in the
next sections: Image acquisition, Image post-processing
and 3D printing.
Image acquisition
Image acquisition is a very important step in generation of
3D objects as the quality of the object depends on the quality
of the data. Today, clinical image acquisition can be done
at ultra-high spatial resolution (400600 microns) with good
quality contrast. Slice thickness of less than 1 mm and isotropic voxels are important parameters to be accounted for minimizing the partial volume effect during post-processing [7].
Although MDCT and MRI are equally good imaging modalities for data acquisition, MDCT is widely applied for rapid
prototyping because image post-processing is less complex
for MDCT data.
Cone Beam Computed Tomography (CBCT), Positron
Emission Tomography (PET), Single Photon Emission Computed Tomography (SPECT) and Ultrasonography (US) are
other non-invasive imaging modalities that can be used
for data acquisition. Without regard to imaging modality,
acquired data is saved in the common DICOM format (Digital Imaging and Communications in Medicine).
Image post-processing
Dedicated high performance workstations equipped with
post-processing tools are used for processing the DICOM
images generated during acquisition. The 3D post-processing tools common in practice include segmentation tools
often based on simple region growing as well as visualization tools such as surface/volume rendering, maximal/minimal intensity projection and multiplanar reformation. A wide
area of application lies in the surgical field, vascular surgery,
orthopedic surgery, pediatric surgery, where these tools are
routinely used in clinic practice for planning and executing
surgery [5,8]. Additionally, advanced post-processing algorithms have been proposed, e.g., for low resolution or nonenhanced images [9].
The contours of a segmented region of interest can be computationally transformed into a 3D triangle mesh [10], i.e., the
shape of a part is approximated using triangular facets. Obviously, tiny triangular facets produce a smoother surface, but
increase the size of the data. The mesh data may be further

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processed using CAD (Computer-Aided Design) software.

This may include automatic mesh optimization or manual
modifications of the geometry. Finally, the data is sent to the
3D printing machine for production, where the STL (Surface
Tesselation Language) file format is commonly used.
3D printing
3D printing is a methodology using three-dimensional CAD
data sets for producing 3D haptic physical model. It is also
referred to as rapid prototyping, solid free form, computer
automated or layered manufacturing depending on the kind
of production method used. The principle of rapid prototyping is to use 3D computer models for the reconstruction of
a 3D physical model by the addition of material layers [11].
With additive fabrication, the machine reads in data from
a CAD drawing and lays down successive layers of liquid,
powder, or the sheet material, and in this way builds up the
model from a series of cross sections (Fig. 1). These layers,
which correspond to the virtual cross section from the CAD
model joined together, create the final shape. The primary
advantage of additive fabrication is its ability to create almost
any complex shape or geometric feature.
The word rapid has to be taken rather relatively: construction of a model with contemporary methods can take from
several hours to days, whereas additive systems for rapid
prototyping can typically produce models in few hours. The
eventual construction time depends on the specific method
used, as well as the size and complexity of the model.
Rapid prototyping includes a number of established
manufacturing techniques and a multitude of experimental
technologies either in development or used by small groups of
individuals. Each technique has its own limitations and applications in producing prototype models. Established rapid
prototyping techniques are summarized in Table 1. Stereolithography (SLA) uses photopolymers that can be cured by
UV laser (systems e.g., by 3D Systems, Rock Hill, SC, USA).
Selective Laser Sintering (SLS) is based on small particles of
thermoplastic, metal, ceramic or glass powders that are fused
by a high power laser (systems e.g., by EOS GmbH, Munich,
Germany). Materials include polymers such as nylon, glassfilled nylon or polystyrene, or metals such as steel, stainless steel alloys, bronze alloys or titanium. Fused Deposition Modeling (FDM) works by extruding small beads of
fused thermoplastic materials or eutectic metals that immediately bond to the layer below (systems e.g., by Stratasys
Inc., Eden Prairie, MN, USA). Laminated Object Manufacturing (LOM) uses layers of paper or plastic films that are
glued together and shaped by a laser cutter (systems e.g.,
by Cubic Technologies, Torrance, CA, USA). Inkjet printing techniques are based on different kinds of fine powders
such as plaster or starch (systems e.g., by Z Corporation,
Burlington, MA, USA). After a layer of the powder has been

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337

Fig. 1 The process chain

involved from image acquisition
to production of a rapid
prototype model consists of
three major steps: image
acquisition, image
post-processing and rapid
prototyping. Images are
acquired using CT or MRI.
Image raw data can then be
transferred to a dedicated image
post-processing workstation. On
the workstation, 3D
segmentation and visualization
are performed and a
Computer-Aided Design (CAD)
model of the segmented
structures can be generated.
Such data can then be used by
rapid prototyping machines to
create the 3D solid object by the
addition of material layers
Table 1 Overview of established rapid prototyping techniques used in the medical arena
Accuracy

Cost

Advantages

Disadvantages

Stereolithography (SLA)

+++

$$

Large part size

Moderate strength

Selective Laser Sintering (SLS)

++

$$$

Large part size, variety of materials, good strength

High cost, powdery surface

Fused Deposition Modeling (FDM)

++

Low cost, good strength

Low speed

Laminated Object Manufacturing (LOM)

Low cost, large part size

Limited materials

Inkjet printing techniques

Low cost, high speed, multimaterial capability

Moderate strength

The characteristics can vary depending on the specific printing system used

dispended by a piston, the parts of this layer belonging to

the 3D object are bonded by an adhesive liquid deposited by
another piston. Inkjet printing techniques can also be used to
generate a 3D scaffold with different types of tissue by printing living cells and biomaterials simultaneously [12,13].
Some fabrication techniques use two materials in the
course of constructing parts. The first material is the part
material and the second is the support material (to support
overhanging features during construction), the support material is later removed by heating or dissolved with a solvent
or water. This is not required in techniques where a powder
bed provides the support such as in SLS and inkjet printing techniques. Depending on the fabrication technique it is
also possible to combine materials of different elasticity or
color in one model. This can be useful to create more realistic
models for educational or research purposes, or for naturally
looking prostheses.
Medical applications of 3D objects
Rapid prototyping has been recently introduced in health care
application when compared to its long-standing use in the
manufacturing industries. In the last decades, rapid prototyping has been used in a variety of medical applications

including individual patient care, research and as an educational and training tool.

Individual patient care

Surgical planning
Rapid prototyping has recently been introduced into the surgical arena as a tool for better understanding of complex
underlying anomaly. This can improve and facilitate the diagnostic quality and help in pre-surgical planning. Its application and benefit in craniofacial and maxillofacial surgery
[1420] has been proven. First studies in pelvic surgery
[21,22], neurosurgery (Fig. 2) [23,24], spine surgery [25],
cardiovascular surgery [26,27] and visceral surgery [28]
demonstrated a significant improvement in diagnosis and
treatment due to better 3D appreciation of pathological structure, increased accuracy and possibility of pre-planning. Simulating all complicated surgical steps in advance [17] using
prototype models can help to foresee intra-operative complications. This may result in reduced operating time and
hence allowing a cost-effective use of operating rooms [29].
Moreover, rapid prototyping is a helpful tool in radiotherapy

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nique. In patients with anotia, a mirrored scan of the contralateral auricle is used for producing a flesh-like rapid prototyping ear model. Application of rapid prototyping in creating
tissue scaffolds for cellular growth is also widely explored
[12,13]. Future applications may include generation of whole
artificial organs adapted to the individual patient anatomy
and needs. However, further research and development are
needed until functional and viable tissues can be produced
and applied in clinical practice.
Fig. 2 MRT image data set of the ventricular system of a child with
DandyWalker malformation was transferred to a dedicated workstation. The software on the workstation provided a 3D visualization and
segmentation. The exported segmentation could be used by a rapid prototyping printer to create a 3D print of the 3D ventricular system. Such
a print offers the unique possibility of a truly 3D appreciation and palpation of the complex ventricular morphology. Both 3D visualization
and 3D print can help the parents and clinicians to understand the exact
nature of childs anatomical abnormalities

planning [30,31] and generating individual radiation shields

[32].
Implant and tissue designing
The rapid prototyping technique is also serving in medical prosthesis and implant designing. The potential of the
rapid prototyping technique lies within the possibility of
customized prostheses. Standard sized bone implants are
commercially available solving the requirement in most surgical procedures and for many of the patients, but might not
be used in all the cases. Reasons emphasizing the need of
customized implants are (1) patients outside the standard
range with respect to implant size- or disease-specific special requirements, (2) improved surgical outcome because of
individual fitting and adequate match with individual anatomical needs.
The rapid prototyping technique has been applied in
reconstruction for various anatomical structures especially in
facial surgery like customized prostheses were successfully
used for mandible [15,33] and dental restoration [34]. Hip
[35], femoral [36], hemi-knee joint reconstruction [37,38]
are other surgical areas potentially benefiting from the prototyping technique. Biocompatible materials include metals,
ceramics and polymers. Bioceramics such as hydroxyapatite
currently are the preferred material for bone reconstruction
[39]. The biodegradable polymer polycaprolactone may be
used for bone and cartilage repair [11]. Metals like titanium
can be used particularly in load-bearing areas, e.g., for hip
reconstruction.
The rapid prototyping technique is beneficial not only for
bone reconstructions but also for replacing soft tissues, as
rapid prototyping can be applied on a variety of materials.
Individual auricular prostheses [40,41] probably provide the
most vivid impression on the potential usefulness of this tech-

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Medical research
Rapid prototyping opens new opportunities for scientific
research activities. Research with phantoms produced by
rapid prototyping can help to elucidate physiological processes that are not yet fully understood (Fig. 3) [42,43] along
with a better understanding of complex pathologies [27,42,
44]. The latter are characterized by either a complex morphology or functional consequences. Complex morphologies
may be better depicted on 3D solid models in hand rather than
on 2D or 3D visualizations tools [27]. Hemodynamics can
be investigated, e.g., by velocity-encoded MRI or by optical
flow measurements in transparent models [45]. Compliant
models can be manufactured using materials such as silicon
or polyurethane to mimic the elastic properties of vessels
[26,46]. Physiological and pathophysiological processes as
well as post-operative hemodynamics can be assessed with
patient-based phantoms simulating in vivo conditions and
compared to computational fluid dynamics [42,47]. This may
give new insights into hemodynamic or aerodynamic aspects
of cardiovascular or airway diseases [48].
Medical education and training
Surgical procedures require a thorough knowledge of human
anatomy and topographical relations of various anatomical
structures. This comprehensive knowledge is traditionally
taught by the preparation of human cadavers in the preclinical studies of medical school and then put into vivid practice
and intensified during real surgery. However, gaining greater
experience and expertise in the special area of interest before
operating the patient is desirable. 2D or 3D visualizations on
a computer screen can be insufficient for obtaining an intuitive understanding of complex anatomical details [27,49].
Rapid prototyping objects enhance 3D learning especially in
challenging anatomical and pathological conditions (Fig. 4).
Furthermore, the possibility of training surgical procedures
in general as well as patient-specific procedures in very
complex cases improves the surgeons abilities and results
[50]. Rapid prototyping models allow for intensive training
of young surgeons, e.g., for endovascular stent implantation simulating in vivo conditions and real tissues without
any risk of patient complications [26,46,51,52]. After being

Int J CARS (2010) 5:335341

Fig. 3 Rapid prototyping can be used in medical research for creating 3D models of living organs. In this work, a CT image data set of
the bronchial tree was processed for rapid prototyping. A 3D model of
the human trachea and bronchial tree was produced. The model was

Fig. 4 3D visualization and 3D rapid prototyping of the aorta in a

patient with thoracic aortic aneurysm (arrow). 3D models are helpful in
demonstrating complex pathologies. Vascular surgeons may find models useful for evaluation of the best treatment strategy as well as for
training. Individual patient care can benefit from rapid prototyping by
providing a graspable model, thus helping the patient to understand the
pathology and to give informed consent for surgical interventions

adequately trained on models, surgeons feel more confident

while going to the operating room for actual surgery. Besides,
the pre-operative simulation of a specific and complex surgery provides a unique opportunity to employ surgical steps
in order to determine the best operating strategy [17], again
increasing the surgeons confidence during the operation.

Discussion
Diverse applications of rapid prototyping have been emerging throughout the last decade. It is regarded as one of the

339

then used as a flow phantom for gas flow experiments with hyperpolarised helium (3He) MRI to study the flow pattern through trachea and
bronchial tree

most promising techniques to be associated with medical

imaging. Although medical application of rapid prototyping
is still in an early phase its potential has already been demonstrated in several studies [18,21,29].
The process chain from imaging to 3D prototype modeling
is a multidisciplinary field involving knowledge ranging from
acquisition of imaging data, image post-processing and manufacturing of the prototype models by various techniques.
Radiologists play a pivotal role in this process chain connecting engineering to health care. Nevertheless, the process
chain runs smoothly with close association and collaboration
of radiologists, clinicians, computer scientists and material
scientists together. Recent work demonstrated that the whole
workflow can be integrated into clinical routine [53].
The application of rapid prototyping in surgery is valuable for diagnosis, treatment planning and intra-operative
surgical navigation especially for complex cases where 2D
images or 3D virtual visualization are insufficient to provide
a complete understanding of the pathology [1523,2528].
Besides, rapid prototyping models are helpful for training
surgeons while simulating surgical procedures in a very realistic manner [17]. However, the benefit of 3D objects compared to 3D visualization regarding better 3D appreciation
is still unclear. Furthermore, 3D objects usually do not adequately simulate human tissue and surrounding structures.
On the one hand, customized implant and prosthetics are
one of the other widely explored areas for application of rapid
prototyping [3338,40,41]. Also, 3D prototype models may
be beneficial for the communication between clinicians and
patients for demonstrating required treatment and consenting
for the procedure. On the other hand, commercially available
implants are suitable for most patients.
Medical research has already benefited from rapid prototyping providing a new vision into physiological and pathological processes [42,43]. Efforts have been made on the
development of artificial organs and tissues using rapid

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prototyping [11,44,54]. However, application of artificial

tissues is very limited so far, and the issue still is in an early
stage of research.
The medical school teaching of normal human anatomy
by use of cadavers does not reflect the variations encountered in a clinical scenario. Medical imaging is getting its
way in anatomical class rooms giving a good idea of normal
anatomical and pathological variations to medical students.
Thus, rapid prototyping can serve as the medium to bring the
anatomical variations from clinics into the preclinical studies in order to improve the understanding of anatomy. The
available number of models at university or hospital is very
limited by costs though [55]. And individual 3D models only
represent one individual anatomy. Furthermore, 3D objects
are often fragile. Thus, its real hands-on use in large student
classes does not seem reasonable.

Limitations
A number of limitations have already been discussed. There
are further limitations of rapid prototyping that apply to rapid
prototyping in general. Nevertheless, at least some of those
limitations might be overcome by future technological developments.
To begin with, rapid prototyping can only be applied to
structure not exceeding certain dimension as 3D printers are
not able to produce extremely large, e.g., whole body, models.
The limitation is currently overcome by producing a miniature version of large structure by post-processing or by
dividing the whole model into smaller parts which can be
combined after printing.
The major limitation of rapid prototyping lies within time
and cost spent in generation of 3D objects. At present, a widespread use of rapid prototyping for surgical planning or individual implant design does not seem to be justified because
standard planning procedures or standard implants are sufficient. However, in complicated cases, additional costs of
rapid prototyping may be compensated by reduced operating times and higher success rate of the surgical procedure.
The time needed for producing a 3D object also limits its
use in surgery to elective cases and makes it unsuitable for
emergency cases.

Conclusions
Rapid prototyping is an emerging technique with a variety of
medical applications such as surgical planning and training,
implant design, biomedical research and medical education.
Due to its current limitations, rapid prototyping is not used in
everyday clinical practice yet. However, with respect to the
enormous potential of the technique, the near future promises

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growing utilization and development of new applications in

the fields of individual patient care, as well as academic and
research activities.
Acknowledgments Fabian Rengier received a grant from the
German Research Foundation within the Research training group
1126: Intelligent SurgeryDevelopment of new computer-based methods for the future workplace in surgery. We further acknowledge the
support by the Klaus Tschira Foundation and by 4D concepts, Gross
Gerau, Germany, in particular Rainer Neumann.

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