Review

Digital Workflow in Maxillofacial Prosthodontics—An Update

on Defect Data Acquisition, Editing and Design Using
Open-Source and Commercial Available Software
Corina Marilena Cristache 1,*,†, Ioana Tudor 1,2,†, Liliana Moraru 3,4,*,†, Gheorghe Cristache 5, Alessandro Lanza 6
and Mihai Burlibasa 1

1 Department of Dental Techniques, Faculty of Midwifery and Medical Assisting (FMAM), “Carol Davila”
University of Medicine and Pharmacy, 8, Eroilor Sanitari Blvd, 050474 Bucharest, Romania;
[email protected] (I.T.); [email protected] (M.B.)
2 Smart Biomaterials and Applications Master Program, Faculty of Medical Engineering, University

Politehnica of Bucharest, 1-7 Gh. Polizu Street, 011061 Bucharest, Romania

3 Faculty of Dental Medicine, “Titu Maiorescu” University, 67A Gheorghe Petrascu Street,

040051 Bucharest, Romania

4 Oral and Maxillofacial Surgery Department, “Carol Davila” Central Military Emergency Hospital,

134 Plevnei Ave., 010825 Bucharest, Romania

5 ENT Department, Batistei Medical Center, 28 Tudor Arghezi Street, 020947 Bucharest, Romania; gicris-

[email protected]
6 Department of Medical, Surgical and Oral Sciences, Campania University Luigi Vanvitelli (ex Second

University of Naples), 6 Via Luigi De Crecchio, 80138 Napoli, Italy; [email protected]

* Correspondence: [email protected] (C.M.C.); [email protected] (L.M.); Tel.:
+40-723-227-020 (C.M.C.); +40-723-629-999 (L.M.)
† These three authors contributed equally to this work.

Abstract: Background: A maxillofacial prosthesis, an alternative to surgery for the rehabilitation of

Citation: Cristache, C.M.; Tudor, I.; patients with facial disabilities (congenital or acquired due to malignant disease or trauma), are
Moraru, L.; Cristache, G.; Lanza, A.: meant to replace parts of the face or missing areas of bone and soft tissue and restore oral functions
Burlibasa, M. Digital Workflow in
such as swallowing, speech and chewing, with the main goal being to improve the quality of life of
Maxillofacial Prosthodontics—An
the patients. The conventional procedures for maxillofacial prosthesis manufacturing involve sev-
Update on Defect Data Acquisition,
eral complex steps, are very traumatic for the patient and rely on the skills of the maxillofacial
Editing and Design Using
team. Computer-aided design and computer-aided manufacturing have opened a new approach to
Open-Source and Commercial
Available Software. Appl. Sci. 2021,
the fabrication of maxillofacial prostheses. Our review aimed to perform an update on the digital
11, 973. https://doi.org/10.3390/ design of a maxillofacial prosthesis, emphasizing the available methods of data acquisition for the
app11030973 extraoral, intraoral and complex defects in the maxillofacial region and assessing the software used
for data processing and part design. Methods: A search in the PubMed and Scopus databases was
Received: 4 January 2021 done using the predefined MeSH terms. Results: Partially and complete digital workflows were
Accepted: 19 January 2021 successfully applied for extraoral and intraoral prosthesis manufacturing. Conclusions: To date,
Published: 21 January 2021 the software and interface used to process and design maxillofacial prostheses are expensive, not
typical for this purpose and accessible only to very skilled dental professionals or to comput-
Publisher’s Note: MDPI stays neu-
er-aided design (CAD) engineers. As the demand for a digital approach to maxillofacial rehabili-
tral with regard to jurisdictional
tation increases, more support from the software designer or manufacturer will be necessary to
claims in published maps and insti-
create user-friendly and accessible modules similar to those used in dental laboratories.
tutional affiliations.

Keywords: maxillofacial prosthodontics; anaplastology; maxillary obturator; CAD; CAM; design

software
Copyright: © 2021 by the authors.
Licensee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms and 1. Introduction
conditions of the Creative Commons Maxillofacial prosthesis production for the rehabilitation of patients with facial
Attribution (CC BY) license disabilities (congenital or acquired due to malignant disease or trauma) is often chal-
(http://creativecommons.org/licenses
/by/4.0/).

Appl. Sci. 2021, 11, 973. https://doi.org/10.3390/app11030973 www.mdpi.com/journal/applsci

Appl. Sci. 2021, 11, 973 2 of 19

lenging and complex, depending on the type of defect. These prostheses are meant to
replace parts of the face, such as the nose, ear, eye and surrounding tissues or missing
areas of bone and soft tissue, restoring oral functions such as swallowing, speech and
chewing, with the main goal being to improve the quality of life of the patient [1].
Conventional procedures for maxillofacial prosthesis manufacturing involve several
complex steps which are costly, time-consuming, very traumatic for the patient and rely
on the skills of the maxillofacial team, dental clinician and maxillofacial technician [2].
The complexity of conventional maxillofacial prosthodontics production requires
several weeks and a great number of visits by the patient for try-ins, functional and es-
thetic adjustments [3]. For most patients, surgical correction is not an option, and the ex-
tent of their defects induce a lack of self-confidence, impairing their daily activities and
social lives [4].
Despite their great role in the social integration of the patients and preserving ana-
tomical structures after surgical treatments, maxillofacial prostheses, being classified as
cosmetic devices, are not covered by health insurance in many countries. The conven-
tional fabrication protocol has a great number of limitations, primarily related to the high
technical expertise required, time, effort, and cost, plus retention and esthetic problems,
making it less accessible to the global patient community. Only a small number of these
patients can afford the high cost of the prosthesis, and even fewer of them can get access
to such sophisticated devices in a timely manner.
Advancements in the fields of computer-aided design (CAD) and computer-aided
manufacturing (CAM) and the implementation of these technologies in medicine offered
new methods for design and construction, and new options for materials and technolo-
gies were rapidly introduced in all dental fields [5]. However, many aspects of these
technological advancements have still not been entirely functional for maxillofacial
prosthetic rehabilitation [6,7] despite the acute necessity for reducing production costs,
shortening the time, improving comfort and increasing patients’ accessibility.
The present scoping review aimed to perform an update on the digital design of
maxillofacial prostheses, emphasizing the available methods of data acquisition for the
extraoral, intraoral and complex defects in the maxillofacial region and assess the soft-
ware used for data processing and part design.

2. Materials and Methods

The general question asked in the present review was the following: Is the full dig-
ital workflow an option for maxillofacial prosthesis manufacturing? This was followed
by a secondary question: Is the used software accessible to all dental technicians involved
in maxillofacial prosthodontics?
For the search protocol, a search in the PubMed and Scopus databases was per-
formed using the following MeSH terms: maxillofacial prosthesis; digital technology;
imaging, three-dimensional; computer-aided design (CAD); computer-assisted manu-
facturing (CAM); and printing, three-dimensional. A manual search in relevant pros-
thetic journals, such as the Journal of Prosthetic Dentistry, Journal of Prosthodontics, Journal of
Prosthodontic Research, Journal of Prosthodontics-Implant Esthetic and Reconstructive Dentis-
try, Journal of Advanced Prosthodontics, International Journal of Prosthodontics, as well as in
the reference lists of the included papers, was also done.
Randomized clinical trials, case reports, case series, technical notes, letters to the
editor and reviews including humans in the English language with detailed descriptions
of the data acquisition and the software used for data processing and maxillofacial
prosthesis part design were included in this review.
The inclusion criteria were as follows: a digital workflow for facial, nasal, ocular and
auricular prostheses; maxillary obturator and mandibular defect replacement prostheses,
including dental structure replacement; and complex facial and maxillary prostheses.
The conventional manufacturing workflow, surgical templates for tumor excision
planning and guides for implant insertion were excluded.
Appl. Sci. 2021, 11, 973 3 of 19

2.1. Classification of the Maxillofacial Defects

For clarity and a more comprehensive description of maxillofacial prosthesis recon-
struction, the defects were classified as extraoral (missing nose, eye, orbit, ear or face
parts), intraoral (missing parts of the maxilla, middle face and mandible) and complex
(missing extraoral and intraoral anatomical parts), as shown in Figure 1. For the intraoral
maxillary and midface defects, Brown and Shaw classification, based on the vertical ex-
tent defect measure (classes I–VI) and the horizontal extent defect measure (a–d), was
used [8]. For mandibular defects, Cantor and Curtis classification, proven to be useful for
guiding surgical and prosthetic rehabilitation [9–11], was considered.

(A)

(B)
Appl. Sci. 2021, 11, 973 4 of 19

(C)
Figure 1. (A) Classification of the maxillofacial defects in extraoral, complex and intraoral cases (including extraoral
complex and intraoral prostheses). (B) The intraoral maxilla and midface defects, classified according to Brown and Shaw
classification in six classes [8]: vertical classification, with a maxillectomy not causing an oronasal fistula (I); not involving
the orbit (II); involving the orbital adnexae with orbital retention (III); with orbital enucleation or exenteration (IV); with
an orbitomaxillary defect (V); and with a nasomaxillary defect (VI), and for horizontal classification, only a palatal defect
not involving the dental alveolus (a); less than or equal to a half unilateral (b); less than or equal to a half bilateral or
transverse anterior (c); a greater than half maxillectomy (d). (C) The intraoral mandibular defects, classified according to
Cantor and Curtis classification in six classes [10,11]: radical alveolectomy with preservation of mandibular continuity (I);
lateral resection of the mandible distal to the cusp area (II); lateral resection of the mandible to the midline (III); lateral
bone graft and surgical reconstruction (IV); anterior bone graft and surgical reconstruction (V); and anterior mandibular
resection without surgical reconstruction (VI).

2.2. Digital Versus Conventional Workflow for Maxillofacial Prosthesis Design and
Manufacturing
2.2.1. Conventional Workflow
A conventional workflow for maxillofacial prosthesis production includes the fol-
lowing steps (Figure 2). An accurate impression of the area requiring prosthesis is
achieved by selecting a suitable impression material (hydrocolloid alginates or elastic
silicone polymers are the most-used materials) according to the type of defect, size and
presence or absence of any undercuts in the respective area, with a custom tray often
being required. Some anatomic undercuts are blocked so as to remove the impression
without damaging the surrounding tissue. After pouring the impression, the gypsum
cast is obtained, and a wax model of the anatomic part to be replaced is fabricated. For
reproducing the natural morphological details of the defect, the wax is carved, followed
by a try-in of the maxillofacial prosthesis wax-up with the corresponding adjustments for
marginal fit and esthetic appearance. The molds are produced using the final retouched
wax-up by applying the lost wax method, where gypsum is poured over the wax model
Appl. Sci. 2021, 11, 973 5 of 19

and the wax is then simply removed with hot water [12]. The final prosthesis is obtained
using the adequate material. For intraoral and complex defects including a part or the
complete dental arch, an impression of the opposite arch and the mounting in a
semi-adjustable articulator is also necessary before the try-in. Complex defects, including
intraoral and extraoral missing anatomical parts, require the use of materials with dif-
ferent characteristics, such as acrylic resins or silicones.

Figure 2. Comparison of conventional and digital workflows for nasal extraoral prosthesis manu-
facturing. For the conventional technique (left), an impression is taken of the defect and sur-
rounding tissue, followed by a casting and wax-up of the prosthesis with a holding support for fa-
cilitating the try-in, creating the mold. For the digital technique (right), 3D scanning is performed
with a Bellus Arc 1 facial scanner, followed by importing the files into a computer-aided design
(CAD) program, designing the prosthesis and printing the mold (indirect path) or the final nasal
prosthesis directly using a 3D printer.

2.2.2. Digital Workflow

The digital manufacturing of maxillofacial prostheses requires the same general
steps. Defect data acquisition can be obtained via medical scans and surface scans [12].
Medical scanning includes computed tomography (CT) with the version that requires a
lower radiation dose and is specific to the maxillofacial region; cone beam computed
tomography (CBCT) or magnetic resonance imaging (MRI) [13], generating files in the
Digital Imaging and Communication in Medicine (DICOM) format; and convertible 3D
models of a patient’s specific anatomy. Surface scanners (e.g., laser scanners, structured
light scanners, facial scanners and intraoral scanners) are a good option for defect data
acquisition [14]. Photogrammetry—the extraction of three-dimensional measurements
from two-dimensional images of the anatomical parts using specific software—is also
used in producing 3D surface models of patients’ faces [15].
The design of the external or internal maxillofacial prosthesis is obtained using a
wide variety of existing CAD programs and software suites, either open-source (OS) or
commercially available (CA) (Table 1). Rapid prototyping, particularly additive manu-
facturing, is used to obtain the final prosthesis. Maxillofacial prostheses, be they external,
internal or complex according to the proposed digital workflow and the material utilized,
are manufactured indirectly by obtaining a model of the prosthesis or the mold, followed
by the conventional workflow for anatomic part processing, or directly by 3D printing
Appl. Sci. 2021, 11, 973 6 of 19

with adequate material (e.g., silicone-based elastomers and acrylic resins, among others)
(Figure 2).

Table 1. Data acquisition, editing, design and manufacturing of maxillofacial prostheses.

Type of Ex- Data Processing Type of Soft-

Direct or Indirect
Author, Year ternal Pros- Data Acquisition (Editing) and De- ware (OS or Type of Study
Manufacturing
thesis sign CA)
Facial scanner
(3dMDflex
System; 3dMD LLC) Software program Indirect 3D printed
McHutchion and and laser scanner (SG (Form2; Formlabs
Auricular CA CS (5 patients)
Aalto, 2020 [16] (Shape Grabber Central; Quality Inc., Somerville, MA,
Ai310; Quality Vision Vision Intl) USA)
Intl, Rochester, NY,
USA)
MIMICS and
3-matics (Materi-
alize)
Auricular, Slicer 4.10.2 for
Digital data acquired CA Only virtual compar-
Farook et al., 2020 orbital and CT, MITK work-
from previous records vs ison of the designed POC
[1] maxillary ob- bench (GCRC,
(not provided) OS prostheses was done
turator Heidelberg, Ger-
many) for CBCT
and Meshmixer
2.1 for CAD
PlastyCAD,
(3DIEMME.
Figino Serenza,
Neena et al., Maxillary CBCT, desktop scan- CA CAD or CAM direct
Italy) CS (6 patients)
2020 [17] obturator ner OS vs. conventional
Meshmixer (Au-
toDesk Inc., Mill
Valley, CA, USA)
IOS (TRIOS; 3Shape, Indirect-conventional
Brucoli et al., 2020 Maxillary
Copenhagen, Den- Not provided n/a on 3D-printed digital CS (28 patients)
[18] obturator
mark) cast
Artec Studio 11
Professional (Ar- Indirect 2 type of
Artec Spider
tec) and CAD 3D-printed molds:
Cruz et al., 2020 structured light scan-
Auricular software Cinema CA PLA with silicone CS (6 participants)
[19] ner (Artec Group,
4D R18 (MAXON pouring and ABS
Luxembourg )
Computer GmbH, with silicone injection
Hesse, Germany)
Artec Studio 12
Professional (Ar-
Artec Space Spider
tec 3D) and CAD
handheld full color 3D Indirect 3D-printed
Weisson et al., software Ge-
Orbital scanner CA ABS with Ultimaker CS (3 patients)
2020 [20] omagic Studio 12
(Artec 3D, Luxem- 3D printer
(3D Systems,
burg)
Rock Hill, SC,
USA)
Structured light scan-
ner 3-Matic Indirect-conventional
Wang et al., Maxillary
(3DSS-MINILED-III, 9.0 (Materialise, CA on 3D printed digital CS (10 patients)
2019 [21] obturator
Digital Manufactur- Leuven, Belgium ) cast
ing, Shanghai, China)
Palin et al., 2019 Maxillary CBCT of midface Mimics (Material- CA Indirect 3D-printed CR
Appl. Sci. 2021, 11, 973 7 of 19

[22] obturator ize) CA cast

SpaceClaim
(SpaceClaim Inc.,
Concord, MA.
USA)
Structured light 3D
Indirect-conventional
Koyama et al., Maxillary scanner (Rexcan DS2, Dental Lab Tools
CA on 3D-printed digital CR
2019 [23] obturator RapidScan 3D, Signal 4.0
cast
Hill, CA, USA)
Meshmixer (Au- Indirect-conventional
Farook et al., 2019 Maxillary
CBCT toDesk, Mill Val- OS on 3D-printed digital CR
[24] obturator
ley, CA, USA) cast
IOS-Trios 3Shape Meshmixer (Au- Indirect-conventional
Ubbink, Maxillary OS
(Copenhagen, Den- toDesk) on 3D-printed digital CS (5 patients)
2019 [25] obturator OS
mark) 3D Slicer cast
Geomagic (Ge- Indirect nasal mold
Abdullah et al., CT scan and digital
Nasal omagic Inc., Mor- CA 3D printed using POC
2019 [26] library
risville, NC, USA) FDM
Intraoral laser scanner
Ballo et al., 2019 for a healthy ear (Tri- Meshmixer v2.1
Auricular OS n/a TR
[27] os3; 3Shape) for mir- (AutoDesk)
roring
POC (7 patients
3D photogrammetry Geomagic (Ge-
Matsuoka et al., CA with no defects
Nasal (3dMD face System, omagic Inc.) n/a
2019 [28] CA and 7 with nasal
Atlanta, GA, USA) Zbrush (Pixlogic)
defects)
CMF Pro Plan Direct temporary
Nuseir et al., 2019 (Materialise) CA prosthesis with 3D
Nasal CT scan CR
[29] Makerware OS printer J750 (Stratasys
(Makerbot inc.) Ltd.)
Light intensity scan-
ZBrush 4R7 (Pix-
ner (Cara Scan 3.2,
ologic Inc.) Direct DLP 3D printer
Kulzer Inc. Hanau, CA
Ko et al., 2019 [30] Ocular Photoshop CS4 DS131 (Carima Inc., POC
Germany) CA
(Adobe Systems Seoul, Korea)
Slit lamp biomicro-
Inc.)
scope (Haag-Streit)
Direct rapid
Alam et al., 2018 Mimics (Material- manufacturing ma-
Ocular CT scan CA POC
[31] ise) chine (PolyJet 3D
printing)
Dental Wings Indirect-conventional
Michelinakis et al.,Maxillary IOS (Lava COS; 3D
Productivity CA on milling of PEEK CR
2018 [32] obturator Espe, USA).
Package blanks
Indirect-conventional
Kortes et al., Maxillary CT and MRI scan im- 3-Matic
CA on 3D-printed digital CR
2018 [33] obturator age fusion 12.0 (Materialise)
cast
Conventional impres-
sion and digitalization Indirect-a model of
with Laser Scanner the anatomical part
Jamayet et al., Rapidworks64, CR (letter to the
Auricular (Next Engine Desktop CA was printed with
2018 [34] (3D System, Inc.) editor)
3D Scanner, NextEn- Objet30 Scholar
gine Inc., Santa Mon- 3D Printer (Stratasys)
ica, CA, USA)
3D photogrammetry Indirect-negative
(3dMDface System; Geomagic Studio mold from polyamide
Liu et al., 2018 [35] Orbital CA TR
3dMD) (Geomagic Inc.) using a 3D printer
Intraoral scanner (EOS P500)
Appl. Sci. 2021, 11, 973 8 of 19

(TRIOS 2.0; 3Shape)

Free Form Soft- Indirect 3D-printed
Sanghavi et al., CT scan, conventional ware System ear model following
Auricular CA CR
2018 [36] impression (SensAble Tech- the conventional
nologies) workflow
Artec Studio
Indirect 3D-printed
Unkovskiy et al., Laser Scanner (Artec Software (Artec CA
Auricular mold SLS (SPro 60 CR
2018 [37] Spider, Artec 3D) 3D) CA
HD, 3D Systems)
Zbrush (Pixologic)
3D photogrammetry
(pritiface; pritidenta Direct printing
Unkovskiy et al.,
Nasal GmbH) Light scanner Zbrush (Pixlogic) CA (Drop-on-Demand CR
2018 [38]
(Artec Spider; Artec ACEO)
3D)
Indirect 3D-printed
Abdulameer and model (RBX01CEL
Tukmachi, 2017 Nasal CT scan Zbrush (Pixlogic) CA Robox 3D) following CR
[39] the conventional
workflow
Indirect where the
Autodesk 123D
mold is 3D printed
Chiu et al., 2017 Catch OS CR (letter to the
Orbital 3D photogrammetry with
[40] ZBrush, Pixologic CA editor)
thermoplastic poly-
Inc.
mer
Yadav et al., 2017 3D modeling Indirect 3D printing
Auricular CT scan CA CR
[41] Software Osteo3D mold with SLS
CT, IOS (iTero, Align Indirect-conventional
Ye et al., Maxillary Mimics Research
Technology, Inc, San CA on 3D-printed digital CS (12 patients)
2017 [42] obturator v17.0 (Materialise)
Jose, CA, USA) cast
Rodney and Indirect-conventional
Maxillary Mimics (Material-
Chicchon, 2017 CT CA on 3D-printed digital CR
obturator ise)
[43] cast
Geomagic Studio,
3D Systems Indirect-conventional
Park et al., Maxillary IOS (Trios3,
LAPtools software CA on 3D-printed digital CR
2017 [44] obturator 3Shape)
(SensAble Tech- cast
nologies)
Indirect-conventional
Elbashti et al., Maxillary IOS scanner (Lava Artec Studio (Ar-
CA on 3D-printed digital CR
2016 [3] obturator COS) tec 3D)
cast
Autodesk 123D Indirect face model
Monoscopic photo-
Salazar-Gamarra Catch OS printed in Duraform
orbital grammetry technique CR
et al., 2016 Autodesk Mesh- OS Polyamide with SLS
with mobile phone
mixer (3D Systems)
VX Elements V1.1,
(Creaform), Pow-
ershape (Delcam), Indirect ear mold
Auricular and Surface scanner SolidWorks CAD CA fabricated with ProJet
Daniel and Egg- TR (on phantom
bar-clip reten- (HandyScan3D, software, CA 3000 Plus and laser
beer, 2016 [45] head)
tion Creaform) FreeForm Plus CA melting for bar
(Version 2013, structure
Geomagic) for bar
design
Mimics (Material- Indirect 3D-printed
Ruiters et al., 2016
Ocular CT scan ise, Leuven, Bel- CA mold with Objet CR
[46]
gium) Connex350 3D printer
Wang et al., 2015 Auricular CT scan, Geomagic Studio CA Indirect cast SLS ma- CR
Appl. Sci. 2021, 11, 973 9 of 19

[47] 3D photogrammetry 12.0 (Geomagic chine

(3DSS; Digital Manu Inc.)
Corp)
Indirect mold manu-
Magics
3D photogrammetry factured by binder
Grant et al., 2015 Nasal and (Materialise); CA
(3dMDcranial system; jetting additive man- CR
[48] facial Freeform CA
3dMD) ufacturing technique
(Geomagic)
(ProJet 460)
Indirect mold fabri-
In-house de- cated with an SLS
Laser scanner intelligentized veloped soft- machine (AFS-360;
Bai et al., 2014 [49] Auricular CS (15 patients)
(3DSS-STD-II) simulation design ware and li- Longyuan Automat-
brary ed Fabrication Sys-
tem)
ClayTools system:
MRI, Freeform Model-
Indirect mold RP
Ciocca and Scotti, laser scanner (Nex- ing Plus software
Orbital CA machine (Phantom CR
2014 [50] tEngine, Santa, Mon- and Phantom
Desktop)
ica) desktop haptic
device (Sensable)
Slic3r
OS Indirect 3D-printed
He et al., 2014 [51] Auricular Laser scanner Rhinoceros POC
CA mold from ABS
(Mcneel)
Indirect, where the
model of the patient’s
Palousek et al., 3D Photogrammetry Rhinoceros nose is fabricated by
Nasal CA TR
2014 [52] (ATOS scanner) (McNeel) 3D printing (ZPrinter
310 Plus; Z
Corporation)
Indirect, where the
Watson and 3D model ear is
Laser scanner (3 Shape Z-Build (v7.5;
Hatamleh 2014, Auricular CA printed with an CR
R700) Z-Corp)
[53] in-house 3D printer
(Z-Corp 310 plus)
Mimics, Magics
Tam et al., 2014 Indirect 3D printing
Auricular CT scan and RSM (Materi- CA CS (6 patients)
[54] ear model
alise)
Indirect, where resin
pieces of the molds
3D photogrammetry: and the combined 3D
Bi et al., Geomagic Studio
Orbital 3D scanning system CA ocular models were CR (3 patients)
2013 [55] (Geomagic Inc.)
(3DSS-STD-II) fabricated with an
SLA machine
(SPS350)
CA, In-house
Laser scanner (G-scan; Geomagic POC and nose
Reitemeier et al., developed Indirect 3D-printed
Nasal IVB Jena, Stadtroda, epiTecture (Ge- database creation
2013 [56] software and wax model
Germany) omagic Inc.) (202 persons)
library
3D laser scanner
Indirect, with mold
(NextEngine Santa Rapidform XOS CR and creating
Fantini et al., 2013 CA and substructure
Nasal Monica), Laser scan- (Inus), Rhinoceros the Ear&Nose
[57] CA printing used from
ner Konica Minolta (McNeel) Digital Library
ABS using FDM
VI-9i
Indirect, with SLA
Sun et al., 2013 Structured laser scan- C++ and Visual used to fabricate a Literature review
Nasal OS
[58] ner Toolkit (VTK) facial slip prototype and CR
for casting pattern to
Appl. Sci. 2021, 11, 973 10 of 19

form a silicon rubber

mold
3D photogrammetry FreeForm Model- Indirect 3D printing
Eggbeer et al.,
Nasal (3DMD, Face Capture ing Plus (SensA- CA mold (ProJet HD 3000 CR
2012 [59]
system) ble) Plus, 3D-Systems)
Indirect, where the
mold was fabricated
Qiu et al., 2011 Mimics (Material-
Nasal CT scan CA with STL (RS4500) at CR
[60] ise) Geomagic
a commercial rapid
prototyping center
Laser scanner, 3D are- Indirect CAD model
Sun et al., 2011 al scanner SimPlant 12.02 fabricated using
Nasal CA POC
[61] (TDOS-FaceScan II), (Materialise) FDM-FORTUS 360
CT scan mc system (Stratasys)
Laser scanner (Nex-
Rapidform (INUS Indirect, with molds
tEngine Desktop 3D
Ciocca et al., 2010 Technology), CA obtained through
Auricular Scanner), laser scanner CR
[62] Rhinoceros CA FDM from ABS (P400
Konica Minolta VIVID
(McNeel) jet, Stratasys)
9i
Indirect, with molds
Laser scanner (Next
Ciocca et al., obtained through
Nasal Engine scanner, Santa Rapidform XOS CA CR
2010 [63] FDM from ABS (P400
Monica)
jet, Stratasys)
Polygon Editing Indirect, where a sili-
CA
Singare et al., 2010 Laser scanner (Konica Tool, Geomagics cone rubber mold is
Auricular CA TR
[64] Minolta VIVID 910) Studio Unigraphic fabricated using the
CA
Software SLA model as pattern
Indirect, with SLS for
Geomagic Studio the patient’s model
Feng et al., 2010 Orbital and Structured light scan-
10.0 software CA and wax for the facial CR
[65] facial ner
(Geomagic Inc.) prosthesis model
(AFS-360 3D printer)
Laser scanner (Nex-
Ciocca et al., Rapidform (INUS Indirect 3D-printed
Nasal tEngine Desktop 3D CA CR
2009 [66] technology) mold
Scanner)
3DDoctor (Able Indirect, where the
Software Corp), prototype for the ab-
Turgut et al., 2009 CA
Auricular CT scan and MRI FreeForm Model- sent auricle was ob- CS (10 patients)
[67] CA
ing Plus System tained via SLS (DTM
(SensAble) Corp)
Polygon Editing Indirect definitive
Ciocca and Scotti, Laser scanner (Minol- Tool (Minolta), CA acrylic ear cast using
Auricular CR
2004 [68] ta VIVID 900) Rapidform (INUS CA Z Printer 310 (Z
technology) Corp)
Indirect physical
Reitemeier et al., 3D Photogrammetry SURFACER (al- model printed on
Orbital CA CR
2004 [69] (kolibri-mobile; IVB) phacam; GmbH) ThermoJet; 3D Sys-
tems
Indirect two-way
DUCT and Cop-
fabricating RP ear POC and litera-
Kai et al., 2000 [70]Auricular Laser surface scanner yCAD (Delcam CA
pattern or RP of a ture review
International)
two-part mold
Endoplan work-
station, Medical Indirect milling of the
Penkner et al.,
Auricular CT scan Diagnostic Com- n/a model from a block of CR
1999 [71]
puting (MDC), polyurethane
Zeiss Group
Appl. Sci. 2021, 11, 973 11 of 19

Titan Vistra image

processor (Kubota
Indirect la-
Chen et al., 1997 Facial and Laser scanner Surflac- Computer) and
n/a ser-polymerized resin CR
[72] orbital er VMR-301 (UNISN) NURBS CAD
model of the defect
software (Kubota
Computer)
CT = computed tomography; CBCT = cone beam computed tomography; MRI = magnetic resonance imaging; IOS = in-
traoral scanner; OS = open source; CA = commercially available; CS = case series; CR = case report; POC = proof of con-
cept; TR = technical report; FDM = fused deposition modeling; DLP = digital light processing; SLS = selective laser sin-
tering; SLA = stereo lithography; PLA = polylactic acid; and ABS = acrylonitrile butadiene styrene.

3. Results
The digital workflow for extraoral prosthesis anaplastology (nose, ear or orbital,
ocular or facial replacement) was described in 46 scientific papers, including case reports,
case series, technical reports, proofs of concept and, for intraoral prosthesis, in 13 papers.
However, the digital workflow was only used for removable prostheses for maxillary
and midface defects (obturators). The mandibular defects were restored preferably
through patient-specific implants [73,74] or surgical reconstruction techniques. No digital
workflow description on Cantor and Curtis class I, II, III and IV prosthetic restorations
has been found so far.

3.1. Anatomic Data Acquisition

The data available from the existing literature revealed the following acquisition
modalities: CT scans [26,29,31,36,39,41,43,46,54,60,67,71], MRIs, CBCTs (for maxillary
obturators) [22,24], structured light scanners [19–21,23,58], laser scanners
[37,49,51,56,57,62–64,68,70], light intensity scanners [30], facial scanners, intraoral scan-
ners (IOSs) [3,18,25,27,32,44,53], desktop scanners [34,66], 3D photogrammetry
[28,40,52,55,59,69], the monoscopic photogrammetry technique with a mobile phone [15]
or two (or more) of the following combined registration modalities: CT and a facial
scanner [61], CT and an intraoral scanner [42], CT and an MRI [33], an MRI and a laser
scanner [50], CT and 3D photogrammetry [47], CBCT and IOS [17], 3D photogrammetry
and a structured light scanner [38], 3D photogrammetry and an intraoral scanner [35],
and a facial scanner and a laser scanner [16].

3.2. Collected Data Editing Software

For the medical scans data, DICOM files were collected and the editing was per-
formed using the following software:
• Commercially available software: Mimics (Materialise, Leuven, Belgium)
[22,31,42,43,46,54,60], 3-Matic 12.0 (Materialise, Leuven, Belgium) [21,33], CMF Pro
Plan (Materialise, Leuven, Belgium) [29], Geomagic Studio (Geomagic, owned by 3D
Systems, Rock Hill, SC, USA) [26,47], Free Form Software (SensAble Technologies,
owned by 3D Systems, Rock Hill, USA) [36], the ClayTools system (SensAble Tech-
nologies, owned by 3D Systems, Rock Hill, USA) [50], 3DDoctor (Able Software
Corp, Lexington, USA) [67], Zbrush (Pixlogic Inc.) [39] and Osteo3D (Karnataka,
India) [41], (Table 1);
• Open-source software: Meshmixer (AutoDesk Inc.) [24].
For surface registration, facial scanners, IOSs, structured light scanners, desktop
scanners, with the dedicated software and commercially available packages, for data
acquisition, were used (Table 1).
The described techniques—3D photogrammetry and monoscopic photogramme-
try—used the open-source software 123D Catch (Autodesk Inc., Mill Valley, CA. USA) to
build a 3D volume for the 2D captured data [15,40].
Appl. Sci. 2021, 11, 973 12 of 19

Two other pieces of open-source software, 3D Slicer (The Slicer Community) and
Slic3r, were used for data processing and editing in two studies by Ubbink [25] and He et
al. [51].

3.3. Prosthesis Design Software

Several pieces of CAD software were used by the authors to assist in the design of
the anatomic replacement parts, and they are as follows (Table 1):
• Commercially available software: Geomagic Studio (3D Systems, Rock Hill, USA)
[20,35,44,47,55,56,60,64,65], Zbrush (Pixlogic Inc.) [28,30,37–40], Rapidform (INUS
Technology, 3D Systems, Rock Hill, USA) [34,57,62,63,66], Rhinoceros (Robert
McNeel & Associates) [51,52,57,62], Free Form (SensAble Technologies, owned by
3D Systems, Rock Hill, USA) [36,45,59,67], Magics (Materialise, Leuven, Belgium)
[48,54], 3-Matic (Materialise, Leuven, Belgium) [21,33], Solidworks (Dassault Sys-
tèmes) [45] and Cinema 4D R18 (MAXON Computer, GmbH) [19];
• Open-source software: Meshmixer (AutoDesk Inc.) [15,24,25,27,40], Makerware
(Makerbot Inc.) [29] and C++ and Visual Toolkit (VTK) [58].

3.4. Prosthesis Manufacturing

The large majority of the published papers described indirect manufacturing of the
final prosthesis. For fabricating the model of the defect, the missing anatomic part or the
mold, different types of rapid prototyping techniques were used, with additive manu-
facturing (AM) mostly being used. Among the available AM techniques [75], the fol-
lowing procedures were employed: fused deposition modeling (FDM) [26,57,61–63];
digital light processing (DLP) [30]; selective laser sintering (SLS) [15,37,41,47,49,65,67];
and stereo lithography (SLA) [55,60,64].

4. Discussion
Due to the early detection of malignant pathology and greater surgical predictability
for solving cancer lesions, the demand for maxillofacial prostheses, as defined by The
Glossary of Prosthodontic Terms, Ninth Edition [76], is “any prosthesis used to replace
part or all of any stomatognathic and/or craniofacial structures”, and it has dramatically
increased.
A digital workflow became used more and more in maxillofacial prosthodontics in
recent years. However, compared with the great progress and popularity registered by
the CAD and CAM technology in other dental specialties, such as fixed and removable
prosthodontics, aesthetics, dental implantology and orthodontics, its development in
maxillofacial prosthetics was, to date, limited and slow [77].
Among the first published cases on digital technologies in maxillofacial prostho-
dontics, Penkener et al. [71] described in 1999 a technique for obtaining an individual,
life-sized, three-dimensional ear model using the CT scan of the patient and a work-
station, Endoplan (Medical Diagnostic Computing, Zeiss, Germany), with a semiauto-
matic contouring program for CBCT segmentation of the soft tissue, based on Hounsfield
units (HU) thresholding.
Several technical notes, case reports and even case studies have been published since
then, but the existing literature is scarce in presenting a reliable protocol for the use of
CAD and CAM technology in the rehabilitation of patients with maxillofacial defects.
Digital obturator developments occurred only in recent years by Elbashti et al. (2016) [3],
Park et al. (2017) [44], Rodney and Chicchon (2017) [43] and Ye et al. (2017) [42], but with
promising results.
Adopting digital workflows is often challenging and sometimes prone to errors,
which need to be identified and reported so the mistakes are not repeated [78,79]. The
sample size of participants in the published papers on CAD and CAM in maxillofacial
prosthodontics is low.
Appl. Sci. 2021, 11, 973 13 of 19

From the reviewed literature on digital workflows in maxillofacial prosthodontics,

most of the papers published so far were case reports (with one to three participants),
case series or proofs of concept (Table 1). In the majority of the papers, no direct com-
parison of patient outcomes to the conventional treatment method was provided. One
exception is the paper published by Eggbeer et al., who compared the prostheses fabri-
cated by 3D printing for a patient with rhinectomy (total nose removal) to a prosthesis
made by conventional techniques [59]. For the computer-aided workflow, an indirect
approach produced a mold via AM. The final prosthesis was judged by experts to be
clinically acceptable and was rated as superior to the conventional one [59]. McHutchion
and Aalto simulated the surrounding tissue movements in the design of auricular pros-
theses and compared them to a conventionally manufactured ear epithesis in a case series
of five participants [16]. The digitally designed and conventionally designed prostheses
were assessed by both the clinician and the participant for the acceptability of its fit,
shape and retention and, based on the findings, a workflow for manipulating scan data
was developed [16].
In addition, the great number of trauma cases in the maxillofacial region, with fre-
quent permanent deficits and potential disfigurements [80], made several research
groups determined to develop digital workflows, which include computer-assisted sur-
gical planning and intraoperative navigation for increasing the predictability of defect
restoration and improving a patient’s quality of life [81].
We aimed in the present review to analyze the available published data, taking into
consideration the key elements of the digital workflow for maxillofacial prosthesis pro-
duction: data collection, editing (visualization), design, manufacturing and evaluation
(assessment of accuracy), with a deeper focus on the first three aspects.

4.1. Data Acquisition

For the conventional workflow, the extent of the defect and the use of different types
of materials make this procedure very difficult and challenging for the medical team and
uncomfortable and painful for the patient. For an auricular defect, an impression of the
contralateral healthy ear is needed for guiding the handcraft of the wax or the negative
pattern of the ear prosthesis, with no direct mirroring being achievable. Potential errors
occurring with traditional processes also include distortion of the facial soft tissues
caused by the pressure of the impression material [27]; obstruction of the airway when
the defect is close to it; aspiration of the impression material; difficulties associated with
retentive undercut, sometimes requiring additional surgery for impression material re-
moval; or an impaired impression due to a reduced mouth opening after scar contracture
or radiotherapy for intraoral or complex defects [18]. Impression taking is also extremely
difficult for the patients, especially when they have large defects or claustrophobia [28].
Moreover, for young and uncooperative individuals, a conventional impression taking
procedure is usually not tolerated without sedation [48].
The digital workflow requires the acquisition of the three-dimensional data of the
patient, depending on the type of defect. If it is intraoral, further information on neigh-
boring teeth or surrounding bone structures also needs to be registered.
In most of the published studies, at least two capture methods were used to pre-
cisely register the anatomical structures (Table 1). Liu et al. proposed the use of two
capture systems—a face capture system (3dMDface System; 3dMD) and an intraoral
scanner (TRIOS 2.0; 3Shape)—for restoring an orbital defect. The digital impression was
performed in three steps: a scan of the face by using a facial scanner, a scan of the unaf-
fected orbit with an intraoral scanner and matching of the two scans in Geomagic Studio
2014 software, based on the best-fit algorithm provided by a color-coded deviation map
[35].
Medical scanning (CT, MRI and CBCT) was used in many reported cases
[22,24,26,29,31,36,39,41,43,46,50,54,60,67,71] for defect data acquisition. The choice of
image data is extremely important, with low-resolution images resulting in discrepancies
Appl. Sci. 2021, 11, 973 14 of 19

from the actual anatomy, and a high resolution requires greater radiation exposure in the
case of CT and CBCT scans [13]. However, for intraoral and complex defects, the use of a
CBCT scan is mandatory to collect all the necessary information. Besides that, if the defect
was generated by the excision of a malignant lesion, a postoperative CBCT is performed
anyway for assessing the risk of tumor recurrence [82].
Surface scanners are the most-used devices for defect data acquisition (Table 1).
However, the laser scanners used are unable to penetrate and register deeper defects and
detect concavities, as medical scanners do [58]. As such, most of the time, both types of
data acquisition means are necessary [17].

4.2. Visualization of the Defect and Design Software

For converting the DICOM data obtained from medical scanning (e.g., CBCT) and
generating a surface mesh (Stereolithography file format - STL), an image editing pro-
gram is used, with a threshold tool allowing a range of values to be set from the data to be
retained while ignoring data that falls outside the range [13,83]. This is a very useful tool
for retaining or removing areas of interest, corresponding to the density values of tissue
types [84], and due to recent advances in segmentation software, it can be done auto-
matically or semi-automatically [85]. Commercially available software was preferred,
with Mimics (Materialise, Belgium) being used in most of the published reports
[22,31,42,43,46,54,60]. The open-source software 3D Slicer (The Slicer Community) and
Slic3r were each used in one case.
Farook et al. [1] compared a digital workflow using open-source software with the
same workflow performed with commercially available software for designing five
prosthetic templates of maxillofacial defects. The open-source software consisted of
Slicer 4.10.2 for CT, MITK workbench (GCRC, Germany) for CBCT and Meshmixer 2.1
(Autodesk Inc., USA) for CAD. The commercially available software used was the soft-
ware package developed by Materialise (MIMICS and 3-matics). The authors managed to
design the templates for all the defects using both types of software. For less complex
defects, such as auricular replacement, both the open-source and commercially available
software were theoretically capable of producing accurately reproducible prostheses for
patients. For more complex defects, the commercially available software had significantly
improved abilities [1]. This fact could explain the extensive use of commercially available
software (Table 1).
At least two different categories of software were used in the digital workflow of
maxillofacial prosthesis fabrication: software for reverse engineering the patients’ data
into a digital format (data editing) and CAD software. To date, one of the major draw-
backs is the requirement of skilled dental technicians familiar with CAD or a digital de-
sign engineer for assisting through the entire process.
The software and interface used to assist the design of the maxillofacial prostheses
were often intended for medical or general purposes, which made the designing process
more complicated and required more originality. Despite being used in a great number
of dental laboratories, the dental design software does not provide specific features for
maxillofacial surgery or prosthodontics. Machado et al. (2019) [86] described a case with
the use of 3Shape software (Coppenhagen, Danemark) and adapted its features for de-
signing a surgical template for implant insertion for facial prosthesis retention.
The great advantage of most of the frequently used CAD dental software is that the
different types of files (e.g., DICOM, STL, OBJ) could be superimposed [87,88], provid-
ing useful and detailed information of the area to be rehabilitated and eliminating the
use of multiple pieces of visualization software.
For anatomic part design, a CAD-assisted mirroring and merging technique is fre-
quently used for auricular prostheses, orbital prostheses or if the defect is limited to the
midline. For other types of defects, such as those of the nose or the maxillary obturator,
creating an accessible library is extremely useful. The lack of a library makes the design
challenging and requires the creation of anatomic parts from scratch [1].
Appl. Sci. 2021, 11, 973 15 of 19

A few research groups created such databases (or libraries). Fantini et al. 2013 [57]
created the Ear&Nose Digital Library of real anatomic models by scanning plaster casts
from conventional impressions taken during the annual hands-on educational course of
Maxillofacial Prosthodontics at the Dental School of the University of Bologna.
Reitemeier et al. 2013 [56] created a digital nose database at the Dresden University
Hospital with a collection of 100 digital noses of male test persons and 102 noses of fe-
male test persons between the ages of 13 and 70 years, obtained by scanning the face of
each test person with a stripe light scanner (G-scan; IVB Jena, Germany). Elbashti et al.
2016 [3] proposed a database for edentulous maxillary obturators. Grant et al. [48], in the
attempt to digitally restore a facial defect for a young girl, did not find a model matching
the defect in the library of existing templates. Therefore, a digital image of a staff mem-
ber’s 6-year-old daughter was acquired.
The main advantage of using the library is that clinicians and digital designers can
choose a reference model according to the correct anatomy of the patient, in terms of
both size and shape, and the final result can be visualized by the patient and the medical
team before attempting customization to the defect [62].
Moreover, when a surgical excision of an anatomic part is planned, it is always
recommended to carry out a laser scan of the face before intervention for surgical re-
moval of the tumor [77].

4.3. Prosthesis Manufacturing and Materials

Manufacturing a prosthesis based on digital designs can be carried out directly by
printing the prosthesis itself and indirectly by printing prosthesis prototypes or molds
(Figure 2). The literature search revealed the fact that most of the maxillofacial prostheses
were obtained indirectly (Table 1).
For extraoral prostheses, 3D-printed silicones with suitable prosthetic properties are
currently under development. However, Unkovskiy et al. 2018 [38] validated a directly
printed nasal prosthesis using a pure silicone free of solvents (ACEO Silicone General
Purpose; Wacker Chemie AG, Munich, Germany) with a drop-on-demand 3D printer
(ACEO; Wacker Chemie AG). The final epithesis was clinically acceptable, but some
manufacturing finishing was required, and the marginal adaptation was lacking in some
areas.
Eggbeer et al. [59], in comparing direct and indirect techniques for a nasal prosthe-
sis, found that conventionally packed silicone was more resistant to wear and tear than
directly printed silicone. The soft, transparent, acrylate-based material (TangoPlus) for
the PolyJet modeling 3D printing process (Objet Connex 500, Objet Geometries, Rehevot,
Israel), which was used for direct printing, was not approved for clinical application at
the time of the study.
However, for an optimal esthetic look, the hand of an artistically gifted operator is
mandatory, and all the direct extraoral prostheses require enhancement and cosmetic
adjustments with the presence of the patient [29,38].

5. Conclusions and Future Directions

The viability of changing a conventional workflow from being highly
skill-dependent, time-consuming, labor-intensive, expensive and uncomfortable for the
patients to a simplified and predictable digitalized protocol was demonstrated by the
papers published in the last 20 years on maxillofacial prosthesis production using CAD
and CAM technology.
To date, the software and interface used for the process and design of maxillofacial
prosthetics are expensive and not typically used for this purpose, making the process
more complicated, requiring more originality and being accessible only to very skilled
dental professionals or to CAD engineers.
As the demand for a digital approach into maxillofacial rehabilitation increases,
more support from the software designer or manufacturer will be necessary to create
Appl. Sci. 2021, 11, 973 16 of 19

more user-friendly and accessible modules for the existing dental software, similar to
those frequently used in dental clinics and laboratories.
For facilitating the design of different anatomic parts, hospitals, universities and
health services can create 3D libraries of various morphological variations and make
them available upon request to laboratories or clinicians.
In spite of the progress registered in digital technology, important steps need to be
made toward simplifying and improving data acquisition methods, making design
software more accessible in terms of cost and user-friendly platforms, improving the es-
thetic aspects and marginal fit of the final prosthesis and providing biocompatible mate-
rials for the direct printing of maxillofacial prostheses.
To fulfill the esthetic outcomes similar to those obtained with the analogical path, in
most of the cases, for the final extraoral prosthesis, the indirect approach with a
3D-printed mold for silicone injection, using conventional procedures and followed by
manual color individualization, is necessary.

Author Contributions: Conceptualization, C.M.C., L.M. and I.T.; methodology, C.M.C., G.C. and
M.B.; software, I.T.; validation, C.M.C., M.B., G.C. and A.L.; formal analysis, L.M.; investigation,
C.M.C.; resources, L.M.; data curation, C.M.C., G.C.; writing—original draft preparation, C.M.C.,
M.B., L.M.; writing—review and editing, I.T.; visualization, I.T. and A.L.; supervision, C.M.C.;
project administration, G.C.; funding acquisition, L.M. All authors have read and agreed to the
published version of the manuscript.
Funding: This research received no external funding.
Informed Consent Statement: Not applicable.
Data Availability Statement: Not applicable
Conflicts of Interest: The authors declare no conflict of interest.

References
1. Farook, T.H.; Jamayet, N.B.; Abdullah, J.Y.; Asif, J.A.; Rajion, Z.A.; Alam, M.K. Designing 3D prosthetic templates for
maxillofacial defect rehabilitation: A comparative analysis of different virtual workflows. Comput. Biol. Med. 2020, 118, 103646,
doi:10.1016/j.compbiomed.2020.103646.Coward, T.J.
2. Jindal, S.K.; Sherriff, M.; Waters, M.G.; Smay, J.E.; Development of a 3D printable maxillofacial silicone: Part II. Optimization
of moderator and thixotropic agent. J. Prosthet. Dent. 2018, 119, 299–304, doi:10.1016/j.prosdent.2017.04.028.
3. Elbashti, M.; Hattori, M.; Sumita, Y.; Aswehlee, A.; Yoshi, S.; Taniguchi, H. Creating a digitized database of maxillofacial
prostheses (obturators): A pilot study. J. Adv. Prosthodont. 2016, 8, 219–223, doi:10.4047/jap.2016.8.3.219.
4. Hooper, S.M.; Westcott, T.; Evans, P.L.L.; Bocca, A.P.; Jagger, D.C. Implant-supported facial prostheses provided by a
maxillofacial unit in a U.K. regional hospital: Longevity and patient opinions. J. Prosthodont. 2005, 14, 32–38,
doi:10.1111/j.1532-849X.2005.00004.x.
5. Alghazzawi, T.F. Advancements in CAD/CAM technology: Options for practical implementation. J. Prosthodont. Res. 2016, 60,
72–84.
6. Aldaadaa, A.; Owji, N.; Knowles, J. Three-dimensional Printing in Maxillofacial Surgery: Hype versus Reality. J. Tissue Eng.
2018, 9, 2041731418770909, doi:10.1177/2041731418770909.
7. Zardawi, F.M.; Xiao, K. Optimization of Maxillofacial Prosthesis. In Prosthesis; IntechOpen: London, UK, 2020.
8. Brown, J.S.; Shaw, R.J. Reconstruction of the maxilla and midface: Introducing a new classification. Lancet Oncol. 2010, 11,
1001–1008.
9. Cantor, R.; Curtis, T.A. Prosthetic management of edentulous mandibulectomy patients. Part I. Anatomic, physiologic, and
psychologic considerations. J. Prosthet. Dent. 1971, 25, 446–457, doi:10.1016/0022-3913(71)90236-8.
10. Cantor, R.; Curtis, T.A. Prosthetic management of edentulous mandibulectomy patients. Part II. Clinical procedures. J.
Prosthet. Dent. 1971, 25, 546–555, doi:10.1016/0022-3913(71)90213-7.
11. Cantor, R.; Curtis, T.A. Prosthetic management of edentulous mandibulectomy patients. Part III. Clinical evaluation. J.
Prosthet. Dent. 1971, 25, 670–678, doi:10.1016/0022-3913(71)90132-6.
12. Cruz, R.L.J.; Ross, M.T.; Powell, S.K.; Woodruff, M.A. Advancements in Soft-Tissue Prosthetics Part A: The Art of Imitating
Life. Front. Bioeng. Biotechnol. 2020, 8, 121.
13. Marro, A.; Bandukwala, T.; Mak, W. Three-Dimensional Printing and Medical Imaging: A Review of the Methods and
Applications. Curr. Probl. Diagn. Radiol. 2016, 45, 2–9.
14. Ciocca, L.; Mingucci, R.; Gassino, G.; Scotti, R. CAD/CAM ear model and virtual construction of the mold. J. Prosthet. Dent.
2007, 98, 339–343, doi:10.1016/S0022-3913(07)60116-4.
Appl. Sci. 2021, 11, 973 17 of 19

15. Salazar-Gamarra, R.; Seelaus, R.; Da Silva, J.V.L.; Da Silva, A.M.; Dib, L.L. Monoscopic photogrammetry to obtain 3D models
by a mobile device: A method for making facial prostheses. J. Otolaryngol.-Head Neck Surg. 2016, 45, 33,
doi:10.1186/s40463-016-0145-3.
16. McHutchion, L.; Aalto, D. Simulation of tissue-prosthesis margin interface by using surface scanning and digital design for
auricular prostheses. J. Prosthet. Dent. 2020, in press, doi:10.1016/j.prosdent.2020.01.045.
17. Neena, A.F.; Alshimy, A.M.; Khamis, M.M.; Ekram, A.M. Digital evaluation of dimensional accuracy and intimacy of fit of
single-piece closed hollow bulb obturators fabricated by CAD/CAM additive manufacturing. Alexandria Dent. J. 2020, 45, 68–
74.
18. Brucoli, M.; Boffano, P.; Pezzana, A.; Corio, C.; Benech, A. The use of optical scanner for the fabrication of maxillary obturator
prostheses. Oral Maxillofac. Surg. 2020, 24, 157–161, doi:10.1007/s10006-020-00836-9.
19. Cruz, R.L.J.; Ross, M.T.; Skewes, J.; Allenby, M.C.; Powell, S.K.; Woodruff, M.A. An advanced prosthetic manufacturing
framework for economic personalised ear prostheses. Sci. Rep. 2020, 10, 11453, doi:10.1038/s41598-020-67945-z.
20. Weisson, E.H.; Fittipaldi, M.; Concepcion, C.A.; Pelaez, D.; Grace, L.; Tse, D.T. Automated Noncontact Facial Topography
Mapping, 3-Dimensional Printing, and Silicone Casting of Orbital Prosthesis. Am. J. Ophthalmol. 2020, 220, 27–36,
doi:10.1016/j.ajo.2020.06.032.
21. Wang, Y.; Yang, X.; Gan, R.; Liu, H.; Wu, G.; Yu, Q.; Wang, Z.; Lu, X.; Jing, J.; Ma, W.; et al. Digital planning workflow for
partial maxillectomy using an osteotomy template and immediate rehabilitation of maxillary Brown II defects with prosthesis.
J. Oral Rehabil. 2019, 46, 1133–1141, doi:10.1111/joor.12850.
22. Palin, C.L.; Huryn, J.M.; Golden, M.; Booth, P.R.; Randazzo, J.D. Three-dimensional printed definitive cast for a silicone
obturator prosthesis: A clinical report. J. Prosthet. Dent. 2019, 121, 353–357, doi:10.1016/j.prosdent.2018.04.017.
23. Koyama, S.; Kato, H.; Harata, T.; Sasaki, K. A workflow for fabricating a hollow obturator by using 3D digital technologies. J.
Prosthet. Dent. 2020, 123, 648–652, doi:10.1016/j.prosdent.2019.05.020.
24. Farook, T.H.; Mousa, M.A.; Jamayet, N.B. Method to control tongue position and open source image segmentation for
cone-beam computed tomography of patients with large palatal defect to facilitate digital obturator design. J. Oral Maxillofac.
Surgery, Med. Pathol. 2020, 32, 61–64, doi:10.1016/j.ajoms.2019.09.009.
25. Ubbink, J.T. The Development of a Digital Design Workflow for the Surgical Obturator. Master’s Thesis, University of Twente,
Enschede, The Netherlands, 2019.
26. Abdullah, A.M.; Mohamad, D.; Din, T.N.D.T.; Yahya, S.; Akil, H.M.; Rajion, Z.A. Fabrication of nasal prosthesis utilising an
affordable 3D printer. Int. J. Adv. Manuf. Technol. 2019, 100, 1907–1912, doi:10.1007/s00170-018-2831-y.
27. Ballo, A.M.; Nguyen, C.T.; Lee, V.S.K. Digital Workflow of Auricular Rehabilitation: A Technical Report Using an Intraoral
Scanner. J. Prosthodont. 2019, 28, 596–600, doi:10.1111/jopr.13057.
28. Matsuoka, A.; Yoshioka, F.; Ozawa, S.; Takebe, J. Development of three-dimensional facial expression models using morphing
methods for fabricating facial prostheses. J. Prosthodont. Res. 2019, 63, 66–72, doi:10.1016/j.jpor.2018.08.003.
29. Nuseir, A.; Hatamleh, M.M.; Alnazzawi, A.; Al-Rabab’ah, M.; Kamel, B.; Jaradat, E. Direct 3D Printing of Flexible Nasal
Prosthesis: Optimized Digital Workflow from Scan to Fit. J. Prosthodont. 2019, 28, 10–14, doi:10.1111/jopr.13001.
30. Ko, J.S.; Kim, S.H.; Baek, S.W.; Chae, M.K.; Yoon, J.S. Semi-automated fabrication of customized ocular prosthesis with three–
dimensional printing and sublimation transfer printing technology. Sci. Rep. 2019, 9, 2968, doi:10.1038/s41598-019-38992-y.
31. Alam, M.S.; Sugavaneswaran, M.; Arumaikkannu, G.; Mukherjee, B. An innovative method of ocular prosthesis fabrication by
bio-CAD and rapid 3-D printing technology: A pilot study. Orbit 2017, 36, 223–227, doi:10.1080/01676830.2017.1287741.
32. Michelinakis, G.; Pavlakis, M.; Igoumenakis, D. Rehabilitation of a maxillectomy patient using intraoral scanning impression
technology and a computer-aided design/computer-aided manufacturing fabricated obturator prosthesis: A clinical report. J.
Indian Prosthodont. Soc. 2018, 18, 282.
33. Kortes, J.; Dehnad, H.; Kotte, A.N.T.; Fennis, W.M.M.; Rosenberg, A.J.W.P. A novel digital workflow to manufacture
personalized three-dimensional-printed hollow surgical obturators after maxillectomy. Int. J. Oral Maxillofac. Surg. 2018, 47,
1214–1218, doi:10.1016/j.ijom.2018.03.015.
34. Jamayet, N.B.; Abdullah, J.Y.; Rahman, A.M.; Husein, A.; Alam, M.K. A fast and improved method of rapid prototyping for
ear prosthesis using porTable 3D laser scanner. J. Plast. Reconstr. Aesthetic Surg. 2018, 71, 946–953.
35. Liu, H.; Bai, S.; Yu, X.; Zhao, Y. Combined use of a facial scanner and an intraoral scanner to acquire a digital scan for the
fabrication of an orbital prosthesis. J. Prosthet. Dent. 2019, 121, 531–534, doi:10.1016/j.prosdent.2018.05.019.
36. Sanghavi, R.; Shingote, S.; Abhang, T.; Thorat, P.; Vathare, A. An innovative technique for fabricating a mirror image wax
pattern using three-dimensional printing technology for an auricular prosthesis. SRM J. Res. Dent. Sci. 2018, 9, 91–95,
doi:10.4103/srmjrds.srmjrds_7_18.
37. Unkovskiy, A.; Brom, J.; Huettig, F.; Keutel, C. Auricular Prostheses Produced by Means of Conventional and Digital
Workflows: A Clinical Report on Esthetic Outcomes. Int. J. Prosthodont. 2018, 31, 63–66, doi:10.11607/ijp.5446.
38. Unkovskiy, A.; Spintzyk, S.; Brom, J.; Huettig, F.; Keutel, C. Direct 3D printing of silicone facial prostheses: A preliminary
experience in digital workflow. J. Prosthet. Dent. 2018, 120, 303–308, doi:10.1016/j.prosdent.2017.11.007.
39. Abdulameer, H.M.; Tukmachi, M. Nasal Prosthesis Fabrication using Rapid Prototyping and 3D Printing (A Case Study). Int.
J. Innov. Res. Sci. Eng. Technol. (08 2017) 2016, 6, doi:10.15680/IJIRSET.
40. Chiu, M.; Hong, S.C.; Wilson, G. Digital fabrication of orbital prosthesis mold using 3D photography and computer-aided
design. Graefe’s Arch. Clin. Exp. Ophthalmol. 2017, 255, 425.
Appl. Sci. 2021, 11, 973 18 of 19

41. Yadav, S.; Narayan, A.I.; Choudhry, A.; Balakrishnan, D. CAD/CAM-Assisted Auricular Prosthesis Fabrication for a Quick,
Precise, and More Retentive Outcome: A Clinical Report. J. Prosthodont. 2017, 26, 616–621, doi:10.1111/jopr.12589.
42. Ye, H.; Ma, Q.; Hou, Y.; Li, M.; Zhou, Y. Generation and evaluation of 3D digital casts of maxillary defects based on
multisource data registration: A pilot clinical study. J. Prosthet. Dent. 2017, 118, 790–795, doi:10.1016/j.prosdent.2017.01.014.
43. Rodney, J.; Chicchon, I. Digital Design and Fabrication of Surgical Obturators Based Only on Preoperative Computed
Tomography Data. Int. J. Prosthodont. 2017, 30, 111–112, doi:10.11607/ijp.5066.
44. Park, J.-H.; Lee, K.-S.; Lee, J.-Y.; Shin, S.-W. Fabricating a Maxillary Obturator Using an Intraoral Digital Impression: A Case
History Report. Int. J. Prosthodont. 2017, 30, 266–268, doi:10.11607/ijp.5213.
45. Daniel, S.; Eggbeer, D. A CAD and AM process for maxillofacial prostheses bar-clip retention. Rapid Prototyp. J. 2016, 22, 170–
177, doi:10.1108/RPJ-03-2014-0036.
46. Ruiters, S.; Sun, Y.; De Jong, S.; Politis, C.; Mombaerts, I. Computer-aided design and three-dimensional printing in the
manufacturing of an ocular prosthesis. Br. J. Ophthalmol. 2016, 100, 879–881, doi:10.1136/bjophthalmol-2016-308399.
47. Wang, S.; Leng, X.; Zheng, Y.; Zhang, D.; Wu, G. Prosthesis-guided implant restoration of an auricular defect using computed
tomography and 3-dimensional photographic imaging technologies: A clinical report. J. Prosthet. Dent. 2015, 113, 152–156,
doi:10.1016/j.prosdent.2014.08.014.
48. Grant, G.T.; Aita-Holmes, C.; Liacouras, P.; Garnes, J.; Wilson, W.O. Digital capture, design, and manufacturing of a facial
prosthesis: Clinical report on a pediatric patient. J. Prosthet. Dent. 2015, 114, 138–141, doi:10.1016/j.prosdent.2014.04.031.
49. Bai, S.; Feng, Z.; Gao, R.; Dong, Y.; Bi, Y.; Wu, G.; Chen, X. Development and application of a rapid rehabilitation system for
reconstruction of maxillofacial soft-tissue defects related to war and traumatic injuries. Mil. Med. Res. 2014, 1, 11,
doi:10.1186/2054-9369-1-11.
50. Ciocca, L.; Scotti, R. Oculo-facial rehabilitation after facial cancer removal: Updated CAD/CAM procedures. A pilot study.
Prosthet. Orthot. Int. 2014, 38, 505–509, doi:10.1177/0309364613512368.
51. He, Y.; Xue, G.H.; Fu, J.Z. Fabrication of low cost soft tissue prostheses with the desktop 3D printer. Sci. Rep. 2014, 4, 6973,
doi:10.1038/srep06973.
52. Palousek, D.; Rosicky, J.; Koutny, D. Use of digital technologies for nasal prosthesis manufacturing. Prosthet. Orthot. Int. 2014,
38, 171–175, doi:10.1177/0309364613489333.
53. Watson, J.; Hatamleh, M.M. Complete integration of technology for improved reproduction of auricular prostheses. J. Prosthet.
Dent. 2014, 111, 430–436, doi:10.1016/j.prosdent.2013.07.018.
54. Tam, C.K.; McGrath, C.P.; Ho, S.M.Y.; Pow, E.H.N.; Luk, H.W.K.; Cheung, L.K. Psychosocial and quality of life outcomes of
prosthetic auricular rehabilitation with CAD/CAM technology. Int. J. Dent. 2014, 2014, 393571, doi:10.1155/2014/393571.
55. Bi, Y.; Wu, S.; Zhao, Y.; Bai, S. A new method for fabricating orbital prosthesis with a CAD/CAM negative mold. J. Prosthet.
Dent. 2013, 110, 424–428, doi:10.1016/j.prosdent.2013.05.003.
56. Reitemeier, B.; Götzel, B.; Schöne, C.; Stockmann, F.; Müller, R.; Lexmann, J.; Meissner, H. Creation and utilization of a digital
database for nasal prosthesis models. Onkologie 2013, 36, 7–11, doi:10.1159/000346668.
57. Fantini, M.; De Crescenzio, F.; Ciocca, L. Design and Rapid Manufacturing of anatomical prosthesis for facial rehabilitation.
Int. J. Interact. Des. Manuf. 2013, 7, 51–62, doi:10.1007/s12008-012-0159-7.
58. Sun, J.; Chen, X.; Liao, H.; Xi, J. Template-based framework for nasal prosthesis fabrication. Rapid Prototyp. J. 2013, 19, 68–76,
doi:10.1108/13552541311302914.
59. Eggbeer, D.; Bibb, R.; Evans, P.; Ji, L. Evaluation of direct and indirect additive manufacture of maxillofacial prostheses. Proc.
Inst. Mech. Eng. Part H J. Eng. Med. 2012, 226, 718–728, doi:10.1177/0954411912451826.
60. Qiu, J.; Gu, X.Y.; Xiong, Y.Y.; Zhang, F.Q. Nasal prosthesis rehabilitation using CAD-CAM technology after total rhinectomy:
A pilot study. Support. Care Cancer 2011, 19, 1055, doi:10.1007/s00520-011-1157-1.
61. Sun, J.; Xi, J.; Chen, X.; Xiong, Y. A CAD/CAM system for fabrication of facial prostheses. Rapid Prototyp. J. 2011, 17, 253–261,
doi:10.1108/13552541111138379.
62. Ciocca, L.; De Crescenzio, F.; Fantini, M.; Scotti, R. CAD/CAM bilateral ear prostheses construction for Treacher Collins
syndrome patients using laser scanning and rapid prototyping. Comput. Methods Biomech. Biomed. Eng. 2010, 13, 379–386,
doi:10.1080/10255840903251304.
63. Ciocca, L.; Fantini, M.; de Crescenzio, F.; Persiani, F.; Scotti, R. New protocol for construction of eyeglasses-supported
provisional nasal prosthesis using CAD/CAM techniques. J. Rehabil. Res. Dev. 2010, 47, 595–604,
doi:10.1682/JRRD.2009.11.0189.
64. Singare, S.; Zhong, S.; Xu, G.; Wang, W.; Zhou, J. The use of laser scanner and rapid prototyping to fabricate auricular
prosthesis. In Proceedings of the 2010 International Conference on E-Product E-Service and E-Entertainment, ICEEE2010,
Henan, China, 7–9 November 2010.
65. Feng, Z.; Dong, Y.; Zhao, Y.; Bai, S.; Zhou, B.; Bi, Y.; Wu, G. Computer-assisted technique for the design and manufacture of
realistic facial prostheses. Br. J. Oral Maxillofac. Surg. 2010, 48, 105–109, doi:10.1016/j.bjoms.2009.05.009.
66. Ciocca, L.; Bacci, G.; Mingucci, R.; Scotti, R. CAD-CAM construction of a provisional nasal prosthesis after ablative tumour
surgery of the nose: A pilot case report. Eur. J. Cancer Care (Engl.) 2009, 18, 97–101, doi:10.1111/j.1365-2354.2008.01013.x.
67. Turgut, G.; Sacak, B.; Kran, K.; Bas, L. Use of rapid prototyping in prosthetic auricular restoration. J. Craniofac. Surg. 2009, 20,
321–325, doi:10.1097/SCS.0b013e3181992266.
Appl. Sci. 2021, 11, 973 19 of 19

68. Ciocca, L.; Scotti, R. CAD-CAM generated ear cast by means of a laser scanner and rapid prototyping machine. J. Prosthet.
Dent. 2004, 92, 591–595.
69. Reitemeier, B.; Notni, G.; Heinze, M.; Schöne, C.; Schmidt, A.; Fichtner, D. Optical modeling of extraoral defects. J. Prosthet.
Dent. 2004, 91, 80–84, doi:10.1016/j.prosdent.2003.10.010.
70. Chua, C.; Meng, C.S.; Ching, L.S.; Teik, L.S.; Aung, S.C. Facial prosthetic model fabrication using rapid prototyping tools.
Integr. Manuf. Syst. 2000, 11, 42–53, doi:10.1108/09576060010303668.
71. Penkner, K.; Santler, G.; Mayer, W.; Pierer, G.; Lorenzoni, M. Fabricating auricular prostheses using three-dimensional soft
tissue models. J. Prosthet. Dent. 1999, 82, 482–484, doi:10.1016/S0022-3913(99)70038-7.
72. Chen, L.H.; Tsutsumi, S.; Iizuka, T. A CAD/CAM technique for fabricating facial prostheses: A preliminary report. Int. J.
Prosthodont. 1997, 10, 467–472.
73. Memon, A.R.; Wang, E.; Hu, J.; Egger, J.; Chen, X. A review on computer-aided design and manufacturing of patient-specific
maxillofacial implants. Expert Rev. Med. Devices 2020, 17, 345–356.
74. Grecchi, F.; Zecca, P.A.; Macchi, A.; Mangano, A.; Riva, F.; Grecchi, E.; Mangano, C. Full-digital workflow for fabricating a
custom-made direct metal laser sintering (Dmls) mandibular implant: A case report. Int. J. Environ. Res. Public Health 2020, 17,
2693, doi:10.3390/ijerph17082693.
75. Cristache, C.M.; Grosu, A.R.; Cristache, G.; Didilescu, A.C.; Totu, E.E. Additive Manufacturing and Synthetic Polymers for
Bone Reconstruction in the Maxillofacial Region. Mater. Plast. 2018, 55, 555–562.
76. Ferro, K.J.; Morgano, S.M.; Driscoll, C.F.; Freilich, M.A.; Guckes, A.D.; Knoernschild, K.L. The Glossary of Prosthodontic
Terms: Ninth Edition. J. Prosthet. Dent. 2017, 117, e1–e105, doi:10.1016/j.prosdent.2016.12.001.
77. Chen, P.H.; Seidenfaden, J.C.; Kase, M.T.; Sooudi, I. Fabricating a partial nasal prosthesis with a custom nasal dilator design. J.
Prosthet. Dent. 2020, doi:10.1016/j.prosdent.2020.05.029.
78. Burton, H.E.; Peel, S.; Eggbeer, D. Reporting fidelity in the literature for computer aided design and additive manufacture of
implants and guides. Addit. Manuf. 2018, 23, 362–373.
79. Cicciù, M.; Fiorillo, L.; D’Amico, C.; Gambino, D.; Amantia, E.M.; Laino, L.; Crimi, S.; Campagna, P.; Bianchi, A.; Herford, A.S.;
et al. 3D Digital Impression Systems Compared with Traditional Techniques in Dentistry: A Recent Data Systematic Review.
Materials (Basel) 2020, 13, 1982, doi:10.3390/ma13081982.
80. Fama, F.; Cicciu, M.; Sindoni, A.; Nastro-Siniscalchi, E.; Falzea, R.; Cervino, G.; Polito, F.; De Ponte, F.; Gioffre-Florio, M.
Maxillofacial and concomitant serious injuries: An eight-year single center experience. Chin. J. Traumatol.-Engl. Ed. 2017, 20, 4–
8, doi:10.1016/j.cjtee.2016.11.003.
81. Herford, A.S.; Miller, M.; Lauritano, F.; Cervino, G.; Signorino, F.; Maiorana, C. The use of virtual surgical planning and
navigation in the treatment of orbital trauma. Chin. J. Traumatol.-Engl. Ed. 2017, 20, 9–13, doi:10.1016/j.cjtee.2016.11.002.
82. Zhao, X.; Rao, S. Surveillance imaging following treatment of head and neck cancer. Semin. Oncol. 2017, 44, 323–329.
83. Mallepree, T.; Bergers, D. Accuracy of medical RP models. Rapid Prototyp. J. 2009, 15, 325–332, doi:10.1108/13552540910993842.
84. Kim, H.J.; Jo, Y.J.; Choi, J.S.; Kim, H.J.; Park, I.S.; You, J.S.; Oh, J.S.; Moon, S.Y. Virtual reality simulation and augmented
reality-guided surgery for total maxillectomy: A case report. Appl. Sci. 2020, 10, 6288, doi:10.3390/APP10186288.
85. Abdullah, J.Y.; Abdullah, A.M.; Hadi, H.; Husein, A.; Rajion, Z.A. Comparison of STL skull models produced using
open-source software versus commercial software. Rapid Prototyp. J. 2019, 25, 1585–1591, doi:10.1108/RPJ-08-2018-0206.
86. Machado, V.; de Castro Bettoni, F.C.; Jaeger, C.; Rodrigues, E.A.; Silva, N. CAD/CAM Beyond Intraoral Restorations:
Maxillofacial Implant Guide. Compend. Contin. Educ. Dent. (Jamesburg NJ 1995) 2019, 40, 466–472.
87. Oancea, L.; Burlibasa, M.; Petre, A.E.; Panaitescu, E.; Cristache, C.M. Predictive model for occlusal vertical dimension
determination and digital preservation with three-dimensional facial scanning. Appl. Sci. 2020, 10, 7890,
doi:10.3390/app10217890.
88. Cristache, C.M.; Totu, E.E.; Iorgulescu, G.; Pantazi, A.; Dorobantu, D.; Nechifor, A.C.; Isildak, I.; Burlibasa, M.; Nechifor, G.;
Enachescu, M. Eighteen Months Follow-Up with Patient-Centered Outcomes Assessment of Complete Dentures
Manufactured Using a Hybrid Nanocomposite and Additive CAD/CAM Protocol. J. Clin. Med. 2020, 9, 324,
doi:10.3390/jcm9020324.