Three-Dimensional Printing in Pediatric Medical and Surgical Applications - a Systematic Review

Background: Three-dimensional printing (3DP) technology is revolutionizing the medical field with applications ranging from surgical implants to patient education. This systematic review examines patient-specific applications of 3DP in the field of pediatrics, both medical and surgical.

Methods: Terms related to “three-dimensional printing” and “pediatrics” were searched on PubMed, Scopus, Ovid MEDLINE, Cochrane CENTRAL, and Web of Science on January 14, 2018, returning 2122 unique articles. An initial title weed resulted in 819 abstracts for review. Inclusion and exclusion criteria concentrated on patient-specific pediatric applications of 3DP, yielding 367 articles for full-text review; 143 met all criteria for inclusion.

Results: Two independent raters conducted an abstract weed (Cohen’s kappa = 0.78) and a full text weed (kappa = 0.96), yielding 143 studies with six unique pediatric, patient-specific applications of 3DP: pre-procedural planning (n=96), intraoperative use (n=49), patient education (n=8), medical team education (n=2), external devices including prosthetics and orthodontics (n=18), and tissue engineering (n=2). Thirty-five studies incorporated multiple 3DP applications; for example, 17 studies utilized 3DP in both pre-operative planning and intraoperative execution. Pre-procedural use (n=96) was further subdivided into three categories: planning (n=68), simulation (n=15), and pre-molding (n=13). Of the 175 total uses described in these 143 unique papers, 145 (82.6%) were related to preprocedural planning or operative use. 3DP was most commonly used in plastic surgery (n=33), dentistry  (n=32), and cardiac surgery (n=23). Within plastic surgery, cranio/maxillofacial applications were most common, comprising 90.9% of studies. Studies reported variable approaches to manufacturing and utilized a wide range of printers and 3DP materials, reflected in the range of production time and costs . However, across studies, production trends emerged. Most commonly, CT was used for pre-operative analysis (n=87, 60.8%), Mimics was used for printer softwares (n=40, 28%), and Stratasys-brand 3D printer was used to manufacture 3DP products (n=20, 14%). The average production time was 11.8 hours but varied widely (SD=12.5). The majority of studies had no information about manufacturing variables including cost (n=127), time (n=131), software (n=47), or printer used (n=60).

Conclusions: Patient-specific 3DP offers innovative applications capable of changing the face of pediatric care, ranging from patient education to intraoperative ease. In this review, plastic surgery emerged as a leader among subspecialties, contributing the highest volume of patient-specific 3DP use compared to other fields. In particular, 3DP was utilized most commonly to enhance the quality of care to cranio/maxillofacial patients. Studies exhibited a wide range of manufacturing variables; this variability suggests that clinicians may have significant latitude in regards to manufacturing decisions, allowing them to tailor product design to an patient’s individual needs. This study demonstrates the wide range of applications and enhanced quality of care provided by 3DP models, and highlights the impact 3DP has on plastic surgery.