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Man Saves Wife's Sight By 3D Printing Her Tumor

An anonymous reader writes: Michael Balzer, a former software engineer and Air Force technical instructor, found himself unsatisfied with a doctor's diagnosis of a small tumor behind his wife's left eye. Balzer had recently become proficient at creating 3D models, so he asked the doctor for the raw medical imaging data and took a look himself. In addition to correcting a later misdiagnosis, Balzer 3D printed models of his wife's cranium and helped neurosurgeons plan a procedure to remove the tumor, instead of waiting to see how it developed, like previous doctors had recommended. During the procedure, surgeons found the tumor was beginning to entangle her optic nerve, and even a six-month wait would have had dire consequences for her eyesight.

Medical researchers like Dr. Michael Patton believe this sort of prototyping will become "the new normal" in a very short time. He says, "What you can now do through 3D printing is like what you're able to do in the software world: Rapid iteration, fail fast, get something to market quickly. You can print the prototypes, and then you can print out model organs on which to test the products. You can potentially obviate the need for some animal studies, and you can do this proof of concept before extensive patient trials are conducted.

38 of 164 comments (clear)

  1. This could be fun.... by ColdWetDog · · Score: 4, Interesting

    Most medical imaging equipment will dump out a DICOM file, which, IIRC, can be translated into the more typical 3D formats. So pretty much everybody that gets a CT or MRI could get the data. Then you just have to set up the printer.

    I could see this as a growth industry for hospitals (hey, we need the money) - instead of getting some miserable little CD with your image, you get a plastic skeleton (or plastic squishy part). Coffee table discussion item or new D&D figurine?

    --
    Faster! Faster! Faster would be better!
    1. Re:This could be fun.... by JaredOfEuropa · · Score: 4, Funny

      Fun and tasty! There's already a company that will turn your raw CT scans into a 3d model of your brain... printed in chocolate.

      --
      If construction was anything like programming, an incorrectly fitted lock would bring down the entire building...
    2. Re:This could be fun.... by Lumpy · · Score: 4, Insightful

      And knowing the medical industry, you will be charged $5500 for the printing and $9100 for the "medical 3d modeling specialist" that stands there watching it print.

      And the 3D printer will have to be FDA approved and cost well over 22 million dollars.

      --
      Do not look at laser with remaining good eye.
    3. Re:This could be fun.... by operagost · · Score: 2

      May you always roll a natural 20 on your saving throw.

      --

      Gamingmuseum.com: Give your 3D accelerator a rest.
    4. Re:This could be fun.... by ColdWetDog · · Score: 4, Insightful

      And the 3D printer will have to be FDA approved and cost well over 22 million dollars.

      Not quite... Since it's not actually PART of the imager itself, it needn't be FDA approved. However, if it were .... yes. We had a generic hard drive fail on our CT. Just a typicall 400 GB SATA drive. We had literally dozens of them hanging around but we couldn't use it because they were not special FDA approved generic SATA hard drives. No special firmware needed - the console for the CT runs a GE version of Linux (you can see this as it boots). All the drive did was hold the images temporarily. It couldn't kill the patient unless you threw it at them. But we had to shut the machine down for 48 hours until they could FexEx a drive to Anchorage and commercial jet it in.

      So, we'd probably only charge $2000 for the gizmo (the specialist time would be included since they are not a doctor - you can only add special charges for doctors).

      See, you feel better already.

      --
      Faster! Faster! Faster would be better!
    5. Re:This could be fun.... by Penguinisto · · Score: 4, Funny

      Cool - now can they turn a skull MRI of some guy I dislike, and turn it into a goblet?

      *That* would be hilarious (okay, maybe I'm really odd for wanting to drink from the skulls of my enemies, even if only on a semi-metaphorical level, but...)

      --
      Quo usque tandem abutere, Nimbus, patientia nostra?
    6. Re:This could be fun.... by eclectro · · Score: 5, Informative

      I could see this as a growth industry for hospitals (hey, we need the money)

      Not really, according to 60 minutes. Hospitals have no problem getting money. They're rolling in the dough and can afford to pay their CEOs millions of dollars. So called non-profit hospitals mark up prices many times. Really, don't fool yourself with a statement like that.

      --
      Take the cheese to sickbay, the doctor should see it as soon as possible - B'Elanna Torres, "Learning Curve"
    7. Re:This could be fun.... by Penguinisto · · Score: 2

      I can see the benefit: It's one thing to use virtual 'hands' with a 3D mesh on a two-dimensional screen, but if you're the guy who has to get in there with your hands and actually do the job? A couple of practice runs on a tactile 3D model of the real thing would make the job a hell of a lot easier when it comes time to actually do it.

      If I were the patient, and it were the inside of my skull that they were getting all handsy with, I'd damned well insist on it.

      --
      Quo usque tandem abutere, Nimbus, patientia nostra?
    8. Re:This could be fun.... by TheCarp · · Score: 2

      Often I think it comes less down to the FDA and more to the interpretation. If you are a hospital using a device that comes with a certification from a vendor saying that you have to buy their drives to maintain certification, a few hundred bucks extra isn't worth the risk of it not being a bluff.

      When I was working for a hospital we had a box running an ancient version of rhel (AS 2.1 if I remember) that the vendor swore could not be upgraded or security patched because of fda certs. What did we do? We made an exception.

      --
      "I opened my eyes, and everything went dark again"
    9. Re:This could be fun.... by flink · · Score: 2

      How does the FDA draw the line between 'must be approved' and 'not our problem' for devices that connect to a greater or lesser degree to other equipment?

      I can only speak to IT software since I am a software developer, but I worked for many years in the field writing both practice management (scheduling, claims processing, etc) and clinical (IHEs, patient records, RX) software. The way it worked at the time is that you basically told the FDA if you wanted to be regulated. i.e. it was up to the company to say: yes, this software constitutes a medical device and should be regulated.

    10. Re:This could be fun.... by vux984 · · Score: 2

      How does the FDA draw the line between 'must be approved' and 'not our problem' for devices that connect to a greater or lesser degree to other equipment?

      The FDA itself, believe it or not, is actually pretty reasonable on that specific issue.

      For example:

      do you need magic FDA CD-R blanks and flash drives

      If the device specifications that the vendor wrote and documented and validated, specified a specific brand and model of CD-R blank as being validated. Then you need that brand and model of CD-R blank to be valid.

      If the device specifications specify that the saving of images to the disk doesn't impact patient safety, and any CD that supports the CD-RW standard xyz will work, then you can use anything suitable.

      Unfortunately the manufacturers too often just take the path of least resistance; and assume the safest most conservative position; all under the advice of their lawyers and FDA consultants. It doesn't hurt that it creates a revenue stream being able to supply that particular model at an inflated price.

    11. Re:This could be fun.... by hawguy · · Score: 3, Interesting

      And the 3D printer will have to be FDA approved and cost well over 22 million dollars.

      Not quite... Since it's not actually PART of the imager itself, it needn't be FDA approved. However, if it were .... yes. We had a generic hard drive fail on our CT. Just a typicall 400 GB SATA drive. We had literally dozens of them hanging around but we couldn't use it because they were not special FDA approved generic SATA hard drives. No special firmware needed - the console for the CT runs a GE version of Linux (you can see this as it boots). All the drive did was hold the images temporarily. It couldn't kill the patient unless you threw it at them. But we had to shut the machine down for 48 hours until they could FexEx a drive to Anchorage and commercial jet it in.

      So, we'd probably only charge $2000 for the gizmo (the specialist time would be included since they are not a doctor - you can only add special charges for doctors).

      See, you feel better already.

      If physicians are using the 3D printed model to plan their surgery, how could it not require approval? If the printer sometimes misprints by a mm that could make the difference between a successful surgery and accidentally severing an important nerve, so it seems that the manufacturer would need to test and certify a printer to ensure that it creates accurate models, otherwise they have no assurance that whatever cheap 3D printer the hospital buys at Walmart prints accurately with their software.

      The FDA regulates computer monitors used to view medical imaging, so I don't see why they wouldn't regulate 3D printers used to "print" that same imaging data.

    12. Re:This could be fun.... by plover · · Score: 3, Informative

      My wife recently went in for an ultrasound, and the machine clearly booted up Windows XP. I'm sure they can't install updates it without it being a certified upgrade, so they do nothing.

      Meanwhile, whatever hackers are finding their ways into the hospital's network probably aren't quite so fussy about the certification of their malware.

      --
      John
    13. Re:This could be fun.... by Smauler · · Score: 2

      "Non-profit" does not mean they're not paying their employees massive salaries, and never did. I don't know where people got the idea that non-profits had to pay their employees less.

  2. 3D models are incredibly helpful by Hadlock · · Score: 4, Informative

    I'm not a vet student, but I did spend a night helping one study the sinuses of a large animal (they split in to large animal (farm) and small animal (pet) specialties) and some of the learning materials are a little difficult to wrap your brain around, in particular how the sinuses (voids in the skull) exist inside the skull, how they connect (or don't) and simply where they are. The brain has enough trouble understanding negative spaces, even more trouble trying to conceptualize the winding, twisting 3D negative spaces you can't ever directly view without cutting apart a skull to do so. Even then doing so only gives you half the picture, and in negative space.
     
    There are some videos online showing the sinuses in "positive 3D space" but it's still only a reference (Everyone is different) so I would imagine having a 3D positive space model of a tumor you've never seen and can't see without cutting open someone's head would be incredibly helpful, especially since you can't just buy off the shelf reference material for human tumors like you can bovine sinuses.

    --
    moox. for a new generation.
  3. Anyone else concerned? by JustNiz · · Score: 3, Interesting

    Is ist just me or is anyone else actually concerned that a have-a-go engineer can apparently quite easily achieve significantly bettr results than a team of so-called expert doctors in their own field?

    1. Re:Anyone else concerned? by ibpooks · · Score: 5, Insightful

      Not concerned at all, he helped them to develop and use a tool they didn't understand how to use and didn't have access to previously. It's how progress is really made. Experts from two different fields find a way to work together to solve problems that neither could solve independently.

    2. Re:Anyone else concerned? by gstoddart · · Score: 4, Insightful

      Not being constrained by traditional things, having skin in the game, and having a skillset which differs from what the doctors do -- all of these combine for him to take a whack at it in a way they'd never think of.

      If anything, this highlights how a breakthrough can come from an outsider.

      And I bet all of a sudden a lot of medical people are saying "wait, he did what?" and "where can I get one?".

      --
      Lost at C:>. Found at C.
    3. Re:Anyone else concerned? by war4peace · · Score: 2

      I call it "approaching a problem without previously existing > polluting the outcome".
      Doctors have tunnel vision sometimes. They rely on past experience (be it work- or document-based) too heavily.

      With that being said, these occurrences are likely rare and a minority, statistics-wise.

      --
      ...gis sdrawkcab (usually not responding to ACs; don't bother posting as AC)
    4. Re:Anyone else concerned? by TheMeuge · · Score: 3

      Is ist just me or is anyone else actually concerned that a have-a-go engineer can apparently quite easily achieve significantly bettr results than a team of so-called expert doctors in their own field?

      RTFA please.
      The description does indeed try to imply that the above is the case. But it's far from the truth, as much as internet armchair experts would like to believe.

      The article itself appears to state that the problem was that 1) the initial advice was to wait, which after (appropriately) consulting with a number of experts they had done, and a followup showed progression. Even the first advice was not totally misplaced. Then what happened was that he suggested that the neurosurgeons basically invent a procedure specifically for him, and used 3D printing to create a model for them. The result was he did find someone willing to try (my guess is they refused the conventional approach) a less invasive procedure that removed 95% of the tumor. Now that may sound revolutionary, but neurosurgery is a tricky business, and depending on the tumor 95% may be equivalent to buying a little time while doing nothing at all, especially since they already knew that the tumor was growing aggressively. If the conventional approach would have had more of a chance of removing more of the tumor, possibly all of it with negative margins, that would be a far more definitive approach. Doctors aren't always right, but if you get a sufficiently experienced expert opinion, it'll usually reflect what is possible to do currently, with a reasonable margin of both safety and success.

    5. Re:Anyone else concerned? by JaredOfEuropa · · Score: 4, Interesting

      No surprise here. I've recently had to deal with doctors of various kinds, and found many (though not all) to be myopic, stubborn and deeply conservative, reluctant to consult outside their own area of expertise, prone to seek the cause of unknowns outside their own area of expertise ("It's not X, go see a specialist for Y"), and having a disturbing lack of curiosity. Maybe I expect too much of them, but doctors act a lot more like technicians than scientists or researchers. There was an article (in the Economist I believe) about health care being one of the least innovative disciplines. The science of medicine has progressed, but there's been relatively little progress in the way we diagnose and treat patients. Some doctor proudly spoke about how they now employ checklists similar to those being used by pilots, to reduce errors in surgery. A great innovation... which they could have known about and implemented about 50 years ago.

      There are plenty of examples of desperate patients nudging their doctors in the right direction after doing some self-diagnosis and research online. There are also some examples of extraordinary breakthroughs in medical science made by engineers with no medical background.

      --
      If construction was anything like programming, an incorrectly fitted lock would bring down the entire building...
    6. Re: Anyone else concerned? by GodInHell · · Score: 2

      Well... that plus decades of experience.

    7. Re:Anyone else concerned? by angel'o'sphere · · Score: 3, Insightful

      Sorry, but if the CT software / computer is not hopeless outdated, the doctors should have been able to see at a 3D visualization and hardly had need for a 3D printed model.
      Your parent is quite right, it is a scandal that the doctors missinterpreted the data and wanted to wait 6 more month to see how "it develops"
      Bottom line they IM(ns)HO simply wanted to increase the costs for the insurance and hence earn kore money (at cost of the patients eye sight!)

      --
      Cost free eBook I read (by iBook/Kobo/Amazon/ObookO/Gutenberg etc.): "The Green Odyssey" by Philip Jose Farmer.
    8. Re:Anyone else concerned? by ColdWetDog · · Score: 4, Interesting

      but doctors act a lot more like technicians than scientists or researchers.

      Doctors are much more like technicians. You don't want doctors "experimenting" on you unless you really, really need that. Physicians are typically not brought up in a 'science' environment (question assumptions, learning how to research a topic, critical thinking.) Doctors are brought up in 'cram mode'. Dump a lot of into down your throat. You're expected to believe it. They are increasingly taught to 'follow the protocol' which amazingly, is what technicians do.

      Yes, there are 'physician scientists' but they aren't treating the majority of patients and you don't want them to be ('hey that looks interesting, what happens when I tug on it?').

      This case is interesting as the husband of the patient kicked the docs out of 'technician' mode. And, of course, used a 3D printer.

      ALWAYS ask your doc questions about stuff you don't understand.

      --
      Faster! Faster! Faster would be better!
    9. Re:Anyone else concerned? by Overzeetop · · Score: 4, Insightful

      Not at all. A technically minded person who's entire career is solving problems throws several hundred hours at solving a problem vs a doctor who is allotted 2-6 hours to solve the same problem and has a hundred other patients who are clamoring for his time. Which do you think would solve a complex problem?

      I encounter it every day as a professional engineer who designs buildings. I get $600 (about 4 hours of time) to solve the entire wind and seismic resisting system on a small building and if you decide the entire first floor will be all glass I'll tell you you can't do it. If you're an engineer (but not necessarily a structural one) and decide to design a system yourself and you spend 400 hours on it there's a good chance you'll come up with a solution. For $40,000 in your time, you've solved problem worth $600 on the open market.

      And, FWIW, I can solve that kind of problem in under 40 hours - maybe $6000 - but if you offer me $600 to solve the problem, I'm going to tell you that it can't be done [for that money].

      --
      Is it just my observation, or are there way too many stupid people in the world?
    10. Re:Anyone else concerned? by JustNiz · · Score: 2

      ...except the difference here is that we're talking about someone's life not just a few bucks, and also the doctors didn't say they couldn't do it for the money, they misdiagnosed it the first time, then just said they couldn't do it at all.

    11. Re:Anyone else concerned? by Rakarra · · Score: 2

      Except when it turns out to NOT be unnecessary :\

      So do you do ten unnecessary surgeries under the assumption one of them will turn out to be needed? Who pays, and where is the line drawn?

  4. 3d printing irrelevant by sonicmerlin · · Score: 4, Insightful

    It sounds to me like the actual 3d printing was less important than the 3d model. I'm not sure what the first doctor's problem was. Usually an MRI gives you a detailed model that you can look at from multiple angles. You don't just measure the size from one point of view. That doesn't even make sense.

    1. Re:3d printing irrelevant by Anonymous Coward · · Score: 4, Interesting

      The key to success here might have been simply the push for a second opinion. People don't understand that doctors often base their decisions on best practices, and in this case maybe the normal thing for an oncologist would be wait and see how the tumor developed, working out better for 99% of cases. Getting an actual neurosurgeon to look into it was probably the biggest thing, and the 3d print was only useful in catching their attention.

      Granted, 99% of people who tried something like this would have the neurosurgeon look at it, pat them in the head for a good job on the print and then get sent back, as that's the right thing to do. Those are not newsworthy, but that doesn't mean this exception will be the new rule.

      I'd bet on VR to be more useful for doctors as you can see the results right away instead of waiting for the print though.

  5. What it takes to justify tech toy purchase to wife by JoeyRox · · Score: 2

    This sets a high bar for other husbands trying to convince their wives that the house needs that shinny new 3D printer :)

  6. rubbish by Anonymous Coward · · Score: 5, Informative

    this entire story is nonsense, speaking as a qualified medical physicist in radiotherapy with decades of experience. First of all, for him to make a 3D model of a tumour, he is having to decide based on CT and/or MRI data what is or isnt the tumour, which by the way you might have noticed is the same information from the CT and/or MR scan that qualified radiologists and oncologists look at, and using treatment diagnosis and planning software (including auto segmentation techniques). So unless this guy suddenly read a book one night and became a fucking oncologist, he didnt pick out SHIT from a CT data set that a qualified oncologist "missed". Nor did he tell surgeons "how to get at" the tumour in a way that implies that was the holdup, like he figured it out while people who work with this for decades didnt get it.

    ah now wait a minute, halfway down the article

    "So although the first doctors told them to wait, Balzer and Scott sent the MRI results to a handful of neurologists around the country. Nearly all of them agreed that Scott needed surgery."

    correct. OTHER QUALIFIED DOCTORS diagnosed the issue. Not some fucking clown with a 3D printer.

    "The tumor had grown substantially, which indicated a far more grave condition than was initially diagnosed. But back at home, Balzer used Photoshop to layer the new DICOM files on top of the old images, and realized that the tumor hadn’t grown at all — the radiologist had just measured from a different point on the image."

    this makes no sense at all and has either been misreported, or he went to a pretend hospital staffed by retards. NO INFORMATiON WHATSOEVER came to light from a 3D printed model of the SAME FUCKING DATA thats in the image. If someone measured wrong on a scan thats an error, just go back and review the images, or send them off again for a 2nd opinion rather than waste your time printing a fucking useless model

    he sent a 3d model /image round when instead all he had to do was send the SOURCE DICOM files to these other doctors, which would have resulted in the exact same solution.

    Fuck, every single time you see a story in your own field and realise its utter bullshit, you realise that ALL stories must be fucking bullshit, its just that you cant check up on stuff youre not involved with so easily

    1. Re:rubbish by hilather · · Score: 2

      this entire story is nonsense, speaking as a qualified medical physicist in radiotherapy with decades of experience. First of all, for him to make a 3D model of a tumour, he is having to decide based on CT and/or MRI data what is or isnt the tumour, which by the way you might have noticed is the same information from the CT and/or MR scan that qualified radiologists and oncologists look at, and using treatment diagnosis and planning software (including auto segmentation techniques). So unless this guy suddenly read a book one night and became a fucking oncologist, he didnt pick out SHIT from a CT data set that a qualified oncologist "missed". Nor did he tell surgeons "how to get at" the tumour in a way that implies that was the holdup, like he figured it out while people who work with this for decades didnt get it.

      ah now wait a minute, halfway down the article

      "So although the first doctors told them to wait, Balzer and Scott sent the MRI results to a handful of neurologists around the country. Nearly all of them agreed that Scott needed surgery."

      correct. OTHER QUALIFIED DOCTORS diagnosed the issue. Not some fucking clown with a 3D printer.

      "The tumor had grown substantially, which indicated a far more grave condition than was initially diagnosed. But back at home, Balzer used Photoshop to layer the new DICOM files on top of the old images, and realized that the tumor hadn’t grown at all — the radiologist had just measured from a different point on the image."

      this makes no sense at all and has either been misreported, or he went to a pretend hospital staffed by retards. NO INFORMATiON WHATSOEVER came to light from a 3D printed model of the SAME FUCKING DATA thats in the image. If someone measured wrong on a scan thats an error, just go back and review the images, or send them off again for a 2nd opinion rather than waste your time printing a fucking useless model

      he sent a 3d model /image round when instead all he had to do was send the SOURCE DICOM files to these other doctors, which would have resulted in the exact same solution.

      Fuck, every single time you see a story in your own field and realise its utter bullshit, you realise that ALL stories must be fucking bullshit, its just that you cant check up on stuff youre not involved with so easily

      IANAD, and appreciate your analysis of the article, and generally agree with the points you make about the article. Articles are written by journalists that generally the reports end up coming out like a school yard game of telephone. But I think the 3d printed representation of the tumor may have been useful. I myself find physical objects and representations much easier to understand and comprehend than virtual equivalents.

  7. Which shows the failure of capitalist medicine by gestalt_n_pepper · · Score: 5, Insightful

    Doctors make no profit out of difficult diagnoses. They have a business to run. They're a mill. Get 'em in. Get 'em out. If it looks like something even slightly nonstandard, shove them off to another specialist so that they can bear the cost, and liability. That neurologist isn't going to bother to read the journals, or keep up with technology, or make any extra effort at all. He's got 25 other people to see today and he's already running late and there's a hiring meeting in 20 minutes because the single good support employee his practice has is threatening to quit, and there's another meeting with the lawyer this afternoon about the tumors he missed because he was just too rushed that day.

    Socialized medicine has its own problems, but at least you can get a doctor focused on medicine.

    --
    Please do not read this sig. Thank you.
    1. Re:Which shows the failure of capitalist medicine by BarbaraHudson · · Score: 3, Insightful

      Canada has socialized medicine. Family doctors are paid a flat amount per patient visit by the government.

      I'll let you guess how motivating a difficult diagnosis is for a doctor here vs "My timmy has a cold!"

      Your same failure is a failure in any environment where people are paid for their labour. About the only case where it doesn't fail that I can think of is communism.

      And the family doctor (if you have one - I don't) will quickly refer you to a specialist because that's the right thing to do. Doesn't waste your time or his/her time. Or if it's serious, go to the ER and you'll see a specialist the same day. And if you need a doctor for follow-up care, isn't it better to have a specialist doing it rather than the delays associated with a G.P. playing broken telephone with the specialists?

      I have 4 different specialists who I see on a regular basis, and if something crops up between regular visits, I just have to make a phone call. They answer my questions, they describe what's going on, and I think they're all great.

      It's funny because this is SO in contrast to the experiences of some of the people I know who have nothing to do but complain about their doctors. Same Canadian system, even the same hospitals, but you wouldn't believe it listening to them. I think a big part of that problem is their attitude. They go to the doctor and they already have it in their heads what the doctor should do, and if the doctor doesn't, "they're crap." Me, when I go, I say "I think I need your help", ask questions in a non-confrontational way, thank them, and follow their directions. Just like I talk to and thank the technicians, the resident doctors, the nurses, the medical secretaries, and the receptionists.

      Attitudes matter. I've seen people get mad because we had to wait a few hours because our doctor was called out. The reason - emergency surgery on a newborn's eyes. Me, I figure "Hey take all the time you need."

      --
      "Transparent" is a shit show that trades on every stereotype going. A man in drag is NOT a transsexual.
    2. Re:Which shows the failure of capitalist medicine by gestalt_n_pepper · · Score: 2

      Oddly, I actually agree here. If I had to enforce anything that I though would help, it would be price transparency and published outcomes. That would also reduce the "run them through the mill" problem. Outcomes here can get pretty lousy.

      --
      Please do not read this sig. Thank you.
  8. Hey another medical speciality by Virtucon · · Score: 2

    "Imaging printer technologist" that can charge me $1000/hr to generate 3d models of my tumors.. I don't think most doctors or hospitals will let you DIY.

    --
    Harrison's Postulate - "For every action there is an equal and opposite criticism"
  9. I'll take that baby in the store front... by __aaclcg7560 · · Score: 3, Interesting

    I drove past a store front in Silicon Valley that offered to print a 3D model of an unborn child from ultrasound scans. Alrighty...

  10. 3D imaging + 3D printing = missing bone parts by ModelX · · Score: 2

    About two years ago I was at a presentation by a surgeon who used 3d imaging to produce a 3d model of a partially missing bone and a complete symmetric bone. He mirrored the model of the symmetric bone to approximate the part of the missing bone. The part was printed on 3d printer and used to prepare a mold for the appropriate alloy for the implant.