|Year : 2020 | Volume
| Issue : 2 | Page : 127-133
Knowledge and practices of 3d printing in dental practitioners of Maharashtra: A cross-sectional study
Amol A Dhokar1, Swarali Y Atre2, Sunanda Bhatnagar1, Nikhil V Bhanushali3
1 Department of Oral Medicine and Radiology, T.P.C.T's Terna Dental College, Nerul, Navi Mumbai, Maharashtra, India
2 Intern, T.P.C.T's Terna Dental College, Nerul, Navi Mumbai, Maharashtra, India
3 Department of Public Health Dentistry, T.P.C.T's Terna Dental College, Nerul, Navi Mumbai, Maharashtra, India
|Date of Submission||25-Mar-2020|
|Date of Decision||24-May-2020|
|Date of Acceptance||25-May-2020|
|Date of Web Publication||27-Jun-2020|
Dr. Amol A Dhokar
T.P.C.T'S Terna Dental College, Phase II, Sector-22, Nerul, Navi Mumbai - 400706, Maharashtra
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: 3D printing has revolutionized dentistry. Along with 3D imaging, its use ranges from surgical planning, dental implants, and aligners to prosthodontic appliances and even study models. Aims: To assess the knowledge and practices of dental practitioners regarding the use of 3D printing in dentistry. Settings and Design: A cross-sectional study was conducted in the form of a self-administered online questionnaire consisting of 19 questions which was circulated among the dental practitioners of Maharashtra. Methods and Material: The survey's Google link was generated and sent to the willing participants via various social media platforms and e-mails. Statistical Analysis: SPSS version 17 software was utilized and Chi-square test was applied. Results: 85.2% of the respondents were aware about dental 3D printing. 47.6% knew its working principle. 52.5% knew the pre-requisites, while 58.7% were unaware of the best material for dental 3D printing. Only 55.5% were aware of all of its indications. Just 38.7% had an experience of either observing or working with this technology of which 78.7% thought that it had enhanced their ability to execute the surgical procedure. 61.3% had no experience of this technology, the reason mostly being unavailability in their area of practice and the technology being expensive. A statistical difference was found in the knowledge and practices based on age, sex, education, and experience with P value <= 0.05. Conclusion: Knowledge of 3D printing in the dental fraternity is necessary due to its wide applications in multitude of dental specialities. Its introduction at an institutional level with optional hands-on trainings shall ensure its use efficiently.
Keywords: 3D printing, cross-sectional study, dentists, knowledge, practices, questionnaire
|How to cite this article:|
Dhokar AA, Atre SY, Bhatnagar S, Bhanushali NV. Knowledge and practices of 3d printing in dental practitioners of Maharashtra: A cross-sectional study. J Indian Acad Oral Med Radiol 2020;32:127-33
|How to cite this URL:|
Dhokar AA, Atre SY, Bhatnagar S, Bhanushali NV. Knowledge and practices of 3d printing in dental practitioners of Maharashtra: A cross-sectional study. J Indian Acad Oral Med Radiol [serial online] 2020 [cited 2020 Jul 7];32:127-33. Available from: http://www.jiaomr.in/text.asp?2020/32/2/127/288139
| Introduction|| |
Technological advances have been resonating with the modern day dentistry for a long time now. Dental practice is no longer just about the conventional skills of the dental practitioners but has gone beyond it with the incorporation of latest technological advances to make the treatment experience a unique one for patients expecting quick and quality results. The use of 3D printer is one such technology which is set to completely transform the manufacturing process.
The amalgamation of modern day imaging modalities like cone beam computed tomography  and intra-oral scanners , with 3D printing have shown promising results in the field of dentistry. 3D printing has whole heartedly been embraced in implant dentistry and endodontics  completely transforming diagnosis and treatment with the help of surgical guides which can be produced by providing volumetric data to the 3D printers using these imaging modalities. This makes the surgical procedure more predictable and less invasive. This technology has also infiltrated other aspects of dentistry by facilitating the production of precise crown copings and partial denture frameworks, diagnostic models, and casts and in digital orthodontics.,,,
The penetration of any new technological advancement is a time-consuming phenomenon majorly due to inadequate knowledge and awareness. Thus, hampering innovative research required to assess its credibility. We have considered multiple reviews addressing the applications of 3D printing in dentistry.,,, However, the existing lacunae of previously done studies assessing the cognizance of 3D printing among dental practitioners necessitates this study which aims at assessing the knowledge of dental practitioners in Maharashtra about the use of 3D printers and their experience with it. This would encourage further research of this high potential modality that could completely transform the face of dentistry making it more patient and clinician friendly.
| Materials and Methods|| |
A descriptive cross-sectional questionnaire -based study was conducted among dental practitioners in Maharashtra, India following the standard statements of the STROBE guidelines.
The participants of this study were dental practitioners in Maharashtra including graduates (BDS), postgraduate (MDS), and certified implantologists (operational definition was used for certified implantologists including all those dental practitioners who have undergone some training to carry out implant procedures). As per the DCI, there are 40,457 registered dentists in the state of Maharashtra of which those dental practitioners were included who were willing to give a written informed consent and could access the online survey. The study excluded dental practitioners who couldn't be reached through any social media for the online survey, those not willing to participate in the study and those who responded beyond the completion of the set duration of the study.
The self-administered questionnaire comprised of 19 questions out of which 4 questions were demographic, 9 questions were related to their knowledge about 3D printing, and the remaining 6 were pertaining to their current practices regarding the same [Questionnaire page 1], [Questionnaire page 2], [Questionnaire page 3]. The psychometric properties of these questions were analyzed for reliability and for face and content validity. The Cronbach's alpha as reliability of questionnaire was 0.80 for knowledge and 0.79 for attitude.
The questionnaire was pretested with the help of a pilot survey  conducted among 50 randomly selected dental practitioners. The finalization of the questionnaire was done after ambiguous and unsuitable questions were modified based on the result of pretest. Based on the results of the pilot study sample size was determined to be 656 which was further rounded off to 700 and was calculated using the following formula:
n = z 2 pq/d 2
z = 1.96, at 95% confidence level; P = awareness about 3D printing as determined from pilot study = 82%; q = 100-p; d = allowable error = 3%
The total duration of the study was 3 months. Convenience sampling was followed and this self-explanatory questionnaire was made accessible to the practitioners in the form of a Google link. This online survey link was promoted through email, websites, social media, or online discussion platforms and potential survey participants were invited to participate in the survey. On reaching the desired sample size, responses were not accepted.
The data procured from the pretested questionnaires was coded and entered into Statistical Package for Social Sciences (SPSS) version 17 software. A P value less than 0.05 was considered significant. Normality of the data was assessed prior to analysis using Shapiro–Wilk's test/Kolmogorov–Smirnov test. Descriptive analysis through frequency distribution was calculated and Chi-Square test was applied.
| Results|| |
A total of 700 responses were received after the circulation of the pretested questionnaire in the form of a Google form link. The inclusion of mandatory fields in the online survey form ensured that no incomplete responses were accepted.
| Knowledge|| |
Out of the 700 respondents, 596 who correspond to 85.2% were aware about the use of 3D printing technology in dentistry. 88.5% practitioners below or of 35 years of age were aware as compared to 74.8% of those above 35 years (P < = 0.001) and 91.3% of those aware were females. This might be due to the access of the younger generation to internet, seminars, conferences, etc. When assessed on the basis of education, 97.9% of postgraduates showed knowledge regarding it (P < = 0.001) which might be because of its use and study during specialization. Those practising for less than 15 years (>80%) had better awareness as opposed to those with more than 15 years (61.7%) (P < = 0.001) [Table 1]. Surprisingly, only 61.7% of these respondents were aware of the non-dentistry related application of 3D printers with a significant difference in terms of all demographic characteristics (P < 0.05) [Table 1].
|Table 1: Awareness among dental practitioners about uses of 3D printing in dentistry, non-dentistry related uses and working principle of 3D printers|
Click here to view
333 (47.6%) of the respondents knew the principle behind the working of 3D printers with majority of them being females (60.2%). A significant difference was noted in the knowledge of graduates, postgraduates, and implantologists with 80.1% postgraduates and 63.3% implantologists being aware of it as opposed to 24.1% graduates (P < = 0.001). Majority of practitioners with knowledge about working principle (62%) were with 6–10 years of experience (P = 0.007) [Table 1]. The respondents (70%) were of the opinion that a combination of seminars, lectures, live demonstrations, and workshops was the best approach to enhance their knowledge about 3D printing in dentistry.
52.5% of the respondents gave a correct response regarding the prerequisites of 3D printers stating the use of CBCT, intra-oral scanners, casts and models for 3D printing. Of those who answered correctly 62% were females, 77.3% were postgraduates and 71% have been practising from 6 to 10 years (P < = 0.001) [Figure 1].
58.7% practitioners were unaware of the best material for dental 3D printing while nearly 14% of the respondents considered light cure resin and thermoplastic materials to be best suited for 3D printing. Majority of those unaware were graduates, with postgraduates being comparatively more aware. However, more awareness is required both at UG and PG level. Practitioners with more than 15 years in practice (75% unaware) knew less about the best material than the fresh graduates. Age played a significant factor about this knowledge, with 70.8% of those older than 35 years being unaware. More males were unaware, 64.5% as opposed to 52% females with a P value of < = 0.001 [Table 2].
The knowledge of dental practitioners about applications of 3D printing showed varied results. 39% of the participants were aware about its use to print surgical guides to be used for dental implant procedures most of them having an experience of 11–15 years, more certified implantologists and postgraduates being aware of this use. Just 29.2% acknowledged its use in printing diagnostic models and casts. 28.2% and 21% were aware about its use in crown and bridge fabrication and partial denture framework fabrication, respectively, of which majority of practitioners had 6–10 years of experience and were postgraduates and implantologists (P < 0.05). Just 17.5% were aware of its use of graft volume assessment in cleft repair and 33% about pre-surgical assessment and planning in maxillofacial reconstruction surgeries with post graduates and those with experience of 6–10 years showing significantly more knowledge than the rest. Regarding its use in digital orthodontics those aware were 27.3%. 55.5% were aware of all of its indications while 11.1% were aware about none of them [Figure 2].
|Figure 2: What do you think are the possible applications of 3D printers in your practice?|
Click here to view
42.1% were aware about the procedural expenses when this technology is used in clinical practice with postgraduates and those with 6–10 years of experience showing significantly better knowledge than the others. 30.6% were aware of commercially available facility in their area of practice [Table 3].
Just 38.7% of these practitioners had an experience of either observing or working with this technology in the form of 3D printers of models most being postgraduates and having an experience of 6–10 years [Table 3]. 43.4% of them had used it in preparation of surgical guides, 31.3% in designing of customized prosthesis, 25.6% used it to prepare models for surgical planning, and 16.4% had used it for all these procedures [Figure 3].
|Figure 3: How was 3D printing used in surgical intervention or preparation?|
Click here to view
Surprisingly, 78.7% of those who had used 3D printed models thought the use of it had enhanced their ability to execute the surgical procedure. 28% of them noted additional morphological defects or unexpected variations when these models were used, 41.3% did not notice any additional feature while 30.7% did not know [Table 3].
61.1% found the current 3D printing softwares user friendly with those less than 35 years of age finding these significantly easier to use as compared to those above 35 years of age (P < = 0.001) [Table 3].
Out of the 64% with no experience with this technology, the reason for their inexperience was mostly unavailability in their area of practice and the technology being expensive [Figure 4].
| Discussion|| |
3D printing is a computer-controlled process in which successive layers of materials are added to create 3D objects. The use of this technology spans over a plethora of fields ranging from aerospace, eco-friendly buildings to life-saving medical implants, and even artificial organs using layers of human cells.,,, Additive manufacturing is gaining rapid potential as it encompasses the field of dentistry with its application in all aspects of dentistry such as printing of surgical guides for implants, systems such as Invisalign ® which provide an aesthetic alternative to labial fixed appliances by fabricating series of custom made clear aligners in orthodontics,, anatomical models, and bio-printing.,,, In the field of forensic odontology too this technology is of great importance as it can be utilized to create 3D replicas of human remains which can accurately depict the evidence without loss of information as opposed to when 2D photographs are used. Recreation of bite marks; lip prints or even skulls and bones of the victims using post-mortem CT scans have proved to be a vital aid in reaching the culprits. Advanced imaging modalities such as CBCT and intra-oral scanners have facilitated its use in the oral cavity., Innovations such as 4D printing make this technology a promising one. 4D printing adds the dimension of transformation over time by creation of functional objects rather than static ones. It is therefore a type of programmable matter, wherein after the fabrication process, the printed product reacts within the environment (humidity, temperature, etc.) and changes its form accordingly.,, However, being associated with Oral and Maxillofacial Radiology we come across several clinicians who had limited knowledge and unclear concepts about 3D printing which propelled this study to assess their level of awareness and find a solution to increase the same.
A study by Parikh Maitry et al. assessed the knowledge, attitude, and practices of 3D printing among orthodontists in India. This study stated 47.5% of the orthodontists had utilized this technology, whereas the current study shows just 38.7% of the dental practitioners having some experience of it which might be due to the inclusion of all graduates and postgraduates. While their study concentrates on just the orthodontists, the current study makes an effort to incorporate all practising dentists and doesn't limit its usage to orthodontic appliances.
Some significant findings of the current study one needs to ponder upon were that in spite of 85.2% of the respondents being aware about this technology only 38.7% of the dental practitioners had some experience of 3D printing. 47.6% of them knew its working principle, 52.5% knew of the prerequisites, and 41.3% being aware of the best material clearly indicates how several of them were still deprived of complete knowledge regarding 3D printing. Similar results were seen regarding the knowledge about its applications. Thus, the primary outcome of the study is that in spite of the literature available about applications of 3D printing in dentistry the actual knowledge of the practitioners is inadequate to utilize it in routine practice.
Although some difference in opinion exists among those who have utilized this regarding its use to detect additional morphological defects, it is noteworthy that 78.7% of the clinicians who had utilized this technology found it to enhance their procedure. Thus, indicating it to be worthy of potential use and research. With the main reason for it not being as popular, being, the unavailability in the area of practice followed by it being expensive clearly indicated the need for further research and affordability of 3D printers.
To the best of our knowledge, the lack of studies assessing the knowledge and practices of dental practitioners of Maharashtra about 3D printing make it pertinent to explore. The study includes dentists from all dental specialities and thus provides comprehensive data about the use of this technology. The study population of dental practitioners ensures that there is increased chances of those included already utilizing this technology in their routine practice or were likely to incorporate it in the future. The data collected via online survey forms reduced response errors and entry errors.
The study has some limitations with it being not accessible to those who couldn't be reached via some social platform or e-mails. The study population has been constrained to practitioners of Maharashtra. The questionnaire doesn't venture much into the clinical efficiency and usefulness of 3D printing focusing more about the knowledge of the practitioners.
Further studies can be directed toward the clinical efficiency in terms of cost efficiency, ease of diagnosis, and treatment and prognosis; technical aspects and patient's response after being treated using 3D printed models or appliances. A study on larger sample size carried across the country would help provide a clear picture about the inclusion of this technology in routine dentistry.
| Conclusion|| |
To recapitulate, the knowledge of dental practitioners of Maharashtra regarding 3D printing in dentistry is limited. The precise knowledge of 3D printing along with imaging modalities is required for enhanced prediction and treatment outcomes as well as better patient perception and satisfaction in the dental fraternity and is of great importance due to its wide applications and profound potential in multitude of dental specialities.
At an institutional level its introduction at undergraduate and postgraduate level with optional hands-on trainings shall ensure that dental practitioners use this technique in an efficient way. Awareness of 3D printing in dental fraternity and necessity to include it in the curriculum is the need of the hour. It is further recommended that academicians in different dental colleges should actively participate and organize special training and orientation programs for dentists to increase their awareness toward 3D printing as well as different imaging modalities. Dental practitioners must gain more knowledge about indications and restrains of this technology thus facilitating further innovations to overcome the limitations.
The approval for conducting this study was obtained from the Institutional Ethics Committee of T.P.C.T's Terna Dental College (Approval no.: TDC EC/57/2019).
Financial support and sponsorship
Conflicts of interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
| References|| |
Elluru V, Elluru SV. Cone beam computed tomography: Basics and applications in dentistry. J Istanb Univ Fac Dent 2017;51(3 Suppl 1):S102–21.
Mangano F, Gandolfi A, Luongo G, Logozzo S. Intraoral scanners in dentistry: A review of the current literature. BMC Oral Health 2017;17:149.
Zimmermann M, Mehl A, Mormann WH, Reich S. Intraoral scanning systems - a current overview. Int J Comput Dent 2015;18:101-29.
Patel S, Durack C, Abella F, Shemesh H, Roig M, Lemberg K. Cone beam computed tomography in Endodontics - A review. Int Endod J 2015;48:3-15.
Dawood A, Marti B, Sauret-Jackson V, Darwood A. 3D printing in dentistry. Br Dent J 2015;219:521-9.
Oberoi G, Nitsch S, Edelmayer M, Janjic K, Muller A, Agis H. 3D printing—encompassing the facets of dentistry. Front Bioeng Biotechnol 2018;6:172.
Kohli T. 3D printing in dentistry – an overview. Acta Sci Dent Sci 2019;3:35-41.
Zaharia C, Gabriel A, Gavrilovici A, Stan A, Idorasi L, Sinescu C, et al
. Digital dentistry- 3D printing applications. J Interdisciplinary Med 2017;2:50-3.
Cuschieri S. The STROBE guidelines. Saudi J Anaesth 2019;13(Suppl 1):S31–4.
Tavakol M, Dennick R. Making sense of Cronbach's alpha. Int J Med Educ 2011;2:53-5.
Hassan ZA, Schattner P, Mazza D. Doing a pilot study: Why is it essential? Malays Fam Physician 2006;1:70-3.
Yee LY, Yong S, Heang K, Zheng K, Xue YL, Wai YY, et al
. 3D printed bio-models for medical applications. Rapid Prototyping J 2017;23:227-35.
Shahrubudina N, Lee TC, Ramlana R. An Overview on 3D printing technology: Technological, materials, and applications. Procedia Manufacturing 2019;35:1286-96.
Ventola CL. Medical application for 3D printing: Current and projected uses. Pharmacy and Therapeutics 2014;39:704-11.
Papadimitriou A, Mousoulea S, Gkantidis N, Kloukos D. Clinical effectiveness of Invisalign® orthodontic treatment: A systematic review. Prog Orthod 2018;19:37.
Kumar K, Bhardwaj S, Garg V. Invisalign: A transparent braces. J Adv Med Dental Sci Res 2018;6:141-3.
Kačarević ZP, Rider PM, Alkildani S, Retnasingh S, Smeets R, Jung O. et al.
An introduction to 3D bioprinting: Possibilities, challenges and future aspects. Materials (Basel) 2018;11:2199.
Derakhshanfar S, Mbeleck R, Xu K, Zhang X, Zhong W, Xing M. 3D bioprinting for biomedical devices and tissue engineering: A review of recent trends and advances. Bioact Mater 2018;3:144-56.
Patra S, Young V. A Review of 3D printing techniques and the future in biofabrication of bioprinted tissue. Cell Biochem Biophys 2016;74:93-8.
Li J, Chen M, Fan X, Zhou H. Recent advances in bioprinting techniques: Approaches, applications and future prospects. J Transl Med 2016;14:271.
Sunali K, Prita D. Exploring the 3rd dimension: Application of 3D printing in forensic odontology. J Forensic Sci Criminal Inves 2017;3:555616.
Wesemann C, Muallah J, Mah J, Bumann A. Accuracy and efficiency of full-arch digitalization and 3D printing: A comparison between desktop model scanners, an intraoral scanner, a CBCT model scan, and stereolithographic 3D printing. Quintessence Int 2017;48:41-50.
Ryakhovskiy AN, Kostyukova VV. Comparative analysis of 3D data accuracy of single tooth and full dental arch captured by different intraoral and laboratory digital impression systems. Stomatologiia (Mosk) 2016;95:65-70.
Chae MP, Hunter-Smith DJ, De-Silva I, Tham S, Spychal RT, Rozen WM. Four-dimensional (4D) printing: A new evolution in computed tomography-guided stereolithographic modeling. Principles and application. J Reconstr Microsurg 2015;31:458-63.
Zhang Z, Demir KG, Gu GX. Developments in 4D-printing: A review on current smart materials, technologies, and applications. Int J Smart Nano Mater 10:205-24.
Haleem A, Javaid M. 4D printing applications in dentistry. Curr Med Res Pract 2019;9:41-42.
Parikh M, Kulkarni N, Parikh M. Knowledge, attitude, and practice on 3D printing among orthodontist in India – An online questionnaire study. Int J Adv Res Dev 2019;4:26-30.
Martelli N, Serrano C, Brink H, Pineau J, Prognon P, Borget I, et al
. Advantages and disadvantages of 3-dimensional printing in surgery: A systematic review. Surgery 2016;159:1485-500.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3]