Imaging-Based 3-Dimensional Printing for Improved Maxillofacial Presurgical Planning: A Single Center Case Series  Will Guest, MD, PhD, Diana Forbes, MD, Colin Schlosser, BASc, Stephen Yip, MD, PhD, Robin Coope, PhD, Jason Chew, MBChB  Canadian Association of Radiologists Journal  Volume 70, Issue 1, Pages 74-82 (February 2019) DOI: 10.1016/j.carj.2018.10.002 Copyright © 2018 Canadian Association of Radiologists Terms and Conditions

Figure 1 (A) Steps in study protocol. The workflow for production of 3-dimensional (3-D) models is shown in the middle column. (B) Anonymized DICOM CT files are imported into InVesalius software and segmentation performed of the anatomic structures of interest as specified by the surgeon (region in green). (C) Once all relevant structures are segmented, an STL file is generated that defines the volume to be printed. (D) STL file is uploaded to the 3-D printer; components of the model are then printed and manually assembled if needed to produce the final model; in this case showing an adult patient who had a left orbital tumour resected as a young child, with resulting growth deformity. This figure is available in colour online at http://carjonline.org/. Canadian Association of Radiologists Journal 2019 70, 74-82DOI: (10.1016/j.carj.2018.10.002) Copyright © 2018 Canadian Association of Radiologists Terms and Conditions

Figure 2 Model assembly strategy for a technically challenging case. (A) Esthesioneuroblastoma of the right maxillary sinus (shaded in purple). (B) The model was printed in 2 parts separated by an oblique plane passing through the right maxillary sinus, enabling the tumour to be placed in the sinus and the 2 bony components of the model to be assembled around it (a duplicate of the printed tumour is in the foreground of the image). (C) Oblique view of the assembled model showing the tumour in position through the thin medial wall of the right orbit. This figure is available in colour online at http://carjonline.org/. Canadian Association of Radiologists Journal 2019 70, 74-82DOI: (10.1016/j.carj.2018.10.002) Copyright © 2018 Canadian Association of Radiologists Terms and Conditions

Figure 3 Post reconstruction from a facial gunshot wound. (A) The plastic surgeon requested that the patient's skin surface contour be included in the model as a baseline for future surgeries, so model segmentation included the skin surface of the lower face (blue) in addition to the bony structures of the mandible (green) and facial bones (orange). (B) Assembled model with the skin surface printed in translucent plastic, overlying the bony structures printed in black. This figure is available in colour online at http://carjonline.org/. Canadian Association of Radiologists Journal 2019 70, 74-82DOI: (10.1016/j.carj.2018.10.002) Copyright © 2018 Canadian Association of Radiologists Terms and Conditions

Figure 4 Case #4 segmented with (A) and without (B) plate. (C) Mandible showing support bars. (D) Detail of hinge with addition of cylinders to skull base and holes to mandible. This figure is available in colour online at http://carjonline.org/. Canadian Association of Radiologists Journal 2019 70, 74-82DOI: (10.1016/j.carj.2018.10.002) Copyright © 2018 Canadian Association of Radiologists Terms and Conditions

Figure 5 Assessment of model physical build quality by surgeons and patients on a 5-point Likert scale (1 = Poor quality, 5 = Excellent quality). The red bar indicates the median response, the blue box the interquartile range (not shown for surgeon responses as it was zero), and the red + an outlier as determined by Dixon's q-test. 3-D = 3-dimensional. This figure is available in colour online at http://carjonline.org/. Canadian Association of Radiologists Journal 2019 70, 74-82DOI: (10.1016/j.carj.2018.10.002) Copyright © 2018 Canadian Association of Radiologists Terms and Conditions

Figure 6 Surgeon questionnaire responses on a 5-point Likert scale (1 = Not at all, 5 = Very helpful/very accurately). The red bar indicates the median response, the blue box the interquartile range (not shown for the third question, as it was zero), the black dotted line the total data range (also not shown for the third question, as it was zero) and the red + an outlier as determined by Dixon's q-test. 3-D = 3-dimensional. This figure is available in colour online at http://carjonline.org/. Canadian Association of Radiologists Journal 2019 70, 74-82DOI: (10.1016/j.carj.2018.10.002) Copyright © 2018 Canadian Association of Radiologists Terms and Conditions

Figure 7 Patient questionnaire responses on a 5 point Likert scale (1 = Not at all, 5 = Very helpful/very interested). The red bar indicates the median response, the blue box the interquartile range, and the black dotted line the total data range. 3-D = 3-dimensional. This figure is available in colour online at http://carjonline.org/. Canadian Association of Radiologists Journal 2019 70, 74-82DOI: (10.1016/j.carj.2018.10.002) Copyright © 2018 Canadian Association of Radiologists Terms and Conditions