Suitable materials for the creation of neurosurgical phantoms using the example of a 3D printed simulation model of the posterior fossa

doi:10.21203/rs.3.rs-6991325/v1

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Method Article

Suitable materials for the creation of neurosurgical phantoms using the example of a 3D printed simulation model of the posterior fossa

https://doi.org/10.21203/rs.3.rs-6991325/v1

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Background

In the preceding 15 years, the implementation of 3D printing has undergone a steady increase across a variety of disciplines. In the medical domain, its use has become particularly prominent, for instance in the development of anatomical phantoms to visualize pathological conditions or to evaluate new surgical procedures. In order to identify a material that specifically mimics cranial bone, a literature review of existing skull phantoms was conducted. This was followed by a pilot study using a custom-developed phantom of the posterior fossa for the evaluation of a suitable material.

Methods

A literature search was conducted using the PubMed database for existing 3D printed skull phantoms. The search terms "3D printed," "skull phantom," and "neurosurgery," among others, were utilized. A total of 1,741 publications were identified in the initial review. The initial pool of articles was then narrowed down based on several inclusion criteria, including language. For the experimental study on the phantom, test blocks made from various materials were produced and subjected to craniotomy procedures. The materials were evaluated by an experienced neurosurgeon based on their drilling characteristics. The highest-rated material (White V4 resin by Formlabs) was selected for the fabrication of the final skull phantom.

Results

A total of 68 articles satisfied the inclusion criteria and were thus included in the analysis. The results indicated that approximately half of all phantoms, irrespective of their intended application, were fabricated using PLA. Subsequent to this, ABS and various resins from Formlabs were introduced. For the material evaluation study, nine neurosurgeons were tasked with performing a craniotomy on the phantom and assessing the material in comparison to real bone. The material (White V4 by Formlabs) was evaluated using a self-selected Likert scale, resulting in an average rating of 7.2 out of 10 points. This rating indicates that the material is deemed suitable.

Conclusion

The findings demonstrate that the materials used for the fabrication of skull phantoms vary significantly depending on multiple factors. However, the material testing conducted in this study led to the identification of a resin that offers favorable properties both in terms of manufacturing feasibility and cost-efficiency. This material can effectively serve as a bone substitute for neurosurgical training purposes. The results of this study may serve as a foundation for the future development of skull models, particularly in contexts where drilling characteristics similar to those of real bone are desired.

3D print

3D printed head phantom

neurosurigal phantom

head phantom

phantom

additve manufacturing

In the past 15 years, there has been an exponential increase in the number of publications focusing on the topic of 3D printing [1]. This development spans a wide range of sectors, including architecture, the automotive and toy industries, as well as biology and medicine. The field of medicine offers a vast spectrum of applications, including implants [2, 3], orthoses [4, 5], and prostheses [6, 7]. Another significant domain of application pertains to phantoms or simulation models, which can be utilized, for instance, to represent various anatomical structures or to evaluate novel therapeutic approaches and surgical instruments. In this context, it is imperative to reproduce the relevant anatomical region as realistically as possible to ensure the validity and clinical relevance of such tests. Consequently, the identification of 3D printable materials capable of accurately replicating specific anatomical structures is of particular interest. This would facilitate the development of simplified yet realistic models of organs such as the liver, brain, or bone. Given our proximity to the field of neurosurgery, the replication of the brain and skull is of significant importance. This is particularly salient in the case of the skull, which is opened in virtually all neurosurgical procedures. It is imperative that this structure be replicated with the utmost fidelity when designing a simulation model. This ensures that the training scenario closely resembles actual surgical conditions.

The objective of this study was twofold: first, to conduct a comprehensive literature review of skull models produced via 3D printing over the past 15 years, with a particular focus on the materials used. In light of the findings from this review, and in consideration of the 3D printers and materials at our disposal, we initiated an experimental study. In the preliminary phase, a series of materials were evaluated through simulated craniotomies to ascertain which material most closely replicates the mechanical properties of authentic bone. In the subsequent phase, a phantom was fabricated using the most suitable material. Subsequently, a team of nine neurosurgeons from the Department of Neurosurgery at Leipzig University Hospital performed a standardized craniotomy on this phantom and evaluated the material in terms of its realism.

Selection Criteria for the Material Review

A systematic literature search was conducted using the PubMed database to identify the materials used in the fabrication of skull phantoms for neurosurgical applications. The search encompassed entries listed between 2010 and 2025 (as of May 26, 2025). The following search terms were used: "3D printed skull neurosurgery," "3D printed skull phantom," "3D printed skull phantom in neurosurgery," "3D printed skull simulator," "3D printed skull simulator in neurosurgery," "three dimensional printed skull neurosurgery," "three dimensional printed skull phantom," "three dimensional printed skull phantom in neurosurgery," "three dimensional printed skull simulator," and "three dimensional printed skull simulator in neurosurgery." This preliminary investigation yielded a total of 1,741 publications. In preparation for further analysis, all duplicates and publications not available in English were excluded. Furthermore, articles that were not freely accessible were removed from consideration. The remaining studies were subjected to a more thorough review, and additional exclusion criteria were implemented. Specifically, articles were excluded if they involved the replication of animal skulls (e.g., rat or canine models), described only the maxilla or mandible, failed to report specific materials or did not clearly associate the materials with cranial replication, presented schematic or idealized representations of the skull, focused solely on the creation of 3D printed surgical guides, or addressed skull models used exclusively for cranioplasty fabrication. The latter group was excluded because the material properties in such cases were irrelevant, as only the anatomical form of the skull was of interest.

3D printed simulation model of the posterior cranial fossa

A preliminary evaluation of various materials was conducted to inform the subsequent practical assessment. This evaluation was facilitated with the assistance of a neurosurgeon. Preliminary findings from this study informed the subsequent execution of a multi-participant study, which utilized a self-designed phantom. A phantom design, which had been meticulously planned in advance, was utilized for this purpose. The final phantom comprised the following components, as illustrated in Fig. 1: a housing that incorporated a support structure for the cerebellum (gray), two interchangeable modules (blue), clamping brackets (yellow), and a schematic representation of the cerebellum (red).

The modules depicted in blue in the figure delineate the region in which the craniotomy was to be performed in order to evaluate the material. These modules replicate the contour and thickness of the human skull, rendering them well suited for testing purposes.

Material selection for the phantom

A drilling study was conducted to preselect a suitable material for the phantom, particularly for the interchangeable modules. This drilling study utilized a methodology similar to that described by Dissanayaka, Maclachlan, et al. [8]. The initial selection of candidate materials was based on the elastic modulus of cortical bone, which is reported to range from 6 to 30 GPa [9, 10]. In addition to matching the elastic modulus, the material under consideration had to be compatible with the 3D printing technologies available to us. The applicable printing methods, along with compatible materials and their respective elastic moduli, are summarized in Table 1.

Table 1
Material selection based on the existing printing processes
Printing method	Material	Producer	E-modulus in GPa
Inverted vat polymerization (SLA)	Tough 1500	Formlabs (Somerville, USA)	1,50 [11]
	White V4		2,80 [12]
	Biomed White		2,02 [13]
Material extrusion (FDM)	PLA	Polymaker (Changshu, China)	1,99 [14]
Material extrusion (FDM)	PA	BASF (Ludwigshafen am Rhein, Germany)	2,42 [15]
Powder bed fusion	PA 12	HP (Paolo Alto, USA)	1,70 [16]

The available materials exhibited lower elastic moduli than those typically reported in the literature for cortical bone. Nevertheless, test blocks with dimensions of 50 × 30 × 10 mm were printed from each of the materials listed in the table. Test blocks were fabricated from filament materials and printed with an infill density of 30%. The test drilling was performed using a surgical craniotome. The haptic evaluation of the materials was carried out and verified by a neurosurgeon (F.A.) at Leipzig University Hospital. Figure 2 presents the test blocks subsequent to drilling.

It was determined that the materials PA (e) from BASF (Ludwigshafen am Rhein, Germany) and PA 12 (f) from HP (Paolo Alto, USA) exhibited a hardness that was significantly higher than the desired level. Upon contact with the craniotome, the surface melted, thereby preventing proper engagement. PLA (d) from Polymaker (Changshu, China) and Tough 1500 (c) from Formlabs (Somerville, USA) were also found to be unsuitable due to their excessive softness. The materials White V4 (b) and Biomed White (a) from Formlabs were both found to be highly realistic and accurate in terms of haptic feedback. Given its higher Young's modulus, White V4 was ultimately selected for use in the craniotomies. For the remaining portions of the phantom, PA 12 and PLA were employed.

Manufacturing of the phantom

The fabrication of the phantom was accomplished through the application of all previously mentioned techniques. The interchangeable modules on the sides were manufactured using the inverted vat polymerization method, specifically stereolithography (SLA). As previously stated, the material selected for this application was White V4 from Formlabs (Somerville, USA). The printer utilized was the Form 3BL, also manufactured by the same company. The clamping brackets were produced using the material extrusion method, specifically fused deposition modeling (FDM), with the UltiMaker S7 printer from UltiMaker (Utrecht, Netherlands). PLA from Polymaker (Changshu, China) was selected as the material for the brackets. The remaining components of the phantom, the housing, was created using the powder bed fusion method with a Multi Jet Fusion (MJF 5200) printer from HP (Palo Alto, USA). As previously stated, the material utilized for this component was PA 12. The fabrication of the cerebellum was excluded from the description, as it had no impact on the material testing and was created solely for visual purposes.

Table 2
Presentation of the manufacturing method and the materials used for each component of the phantom
Manufacturing method	Component/ object	Printer	Material
Inverted vat polymerization (SLA)	Interchangeable modules (both sides)	Form 3BL (Formlabs - Somerville, USA)	White V4 (Formlabs - Somerville, USA)
Material extrusion (FDM)	Clamping brackets	UltiMaker S7 (UltiMaker - Utrecht, Netherlands)	PLA (Polymaker - Changshu, China)
Powder bed fusion	Housing	MJF 5200 (HP - Paolo Alto, USA)	PA 12 (HP - Paolo Alto, USA)
	Mounting of the cerebellum
	Mold for the cerebellum

Table 2 provides an overview of the individual components, the manufacturing methods employed, and the materials utilized. In the final stage of the manufacturing process, magnets were affixed to the corresponding cavities through the use of an adhesive, while threaded inserts were soldered into position. To ensure optimal storage and facilitate positioning adjustments, the phantom was affixed to a camera mount (MH494) from Manfrotto (Cassola, Italy), which was then secured to a metal plate. The Fig. 3 depicts the completed three-dimensional (3D) printed simulation model for the posterior cranial fossa.

Material Review

Based on the defined selection criteria, a total of 68 publications from the years 2015 to 2025 were identified that described both the fabrication of a skull phantom and the materials used. The phantoms described in these studies were developed for various purposes. Therefore, the publications were first categorized into six distinct groups according to the application of the respective simulator. The groups are defined as follows:

Phantoms for the evaluation of new therapeutic methods and their accuracy [17–26]
Phantoms for surgical planning [27–38]
Phantoms for education and hands-on training [39–60]
Phantoms for imaging, calibration, and dosimetry purposes [61–64]
Phantoms for testing and validation of new surgical tools [65–68]
Phantoms for the simulation and visualization of pathological conditions [8, 69–83]

The individual groups, along with the distribution of the 68 publications among them, are visualized in Fig. 4.

The results indicate that approximately one-third of the identified publications employed phantoms for educational purposes or training in specific surgical procedures. Subsequent to this, applications pertaining to the visualization of pathological conditions, accounting for nearly one-fifth of the studies. The following materials (Fig. 5) were utilized in the creation of the various simulation models, irrespective of the application areas.

The data presented in the figure indicates that approximately half of all fabricated skull phantoms were produced using PLA. Subsequently, the ABS and various resins from Formlabs (White, Grey, and Clear) are utilized. A comprehensive overview of all materials and their corresponding printing technologies is provided in Table 3.

Table 3
List of the materials used in the publications and their printing processes ([17] was excluded - no specific information about the material (plaster powder) available)
	Material	Printing method
PLA	PLA ^{[8, 18–22, 27–30, 39–47, 61–66, 69–75]}	material extrusion
ABS	ABS ^{[23, 24, 31–33, 48, 49, 76]}	material extrusion
Formlabs-Resin	White Resin ^{[25, 34, 50]}	inverted vat polymerization
	Grey Resin ^{[35, 77]}
	Clear Resin ^{[36, 78]}
Plaster Powder	ZP 150 Powder ^{[26, 51, 79, 80]}	binder jetting
Plaster Powder	ZP 130 Powder ^[52]	binder jetting
PolyJet Material	Med610 Resin ^[37]	material Jetting
PolyJet Material	Vero White ^{[53–55, 81]}	material Jetting
PA12 basiert	Duraform PA ^[67]	powder bed fusion
	PA12 ^[56]
	Polyamid nylon with glass beads ^[57]
	PA2200 ^[82]
VisiJet Material	VisiJet PXL core ^{[38, 83]}	material jetting
VisiJet Material	VisiJet C4 Spectrum ^[58]	material jetting
Others	PET-G ^[59]	metarial extrusion
	PVC ^[68]	N.A.
	Eleegoo photopolymer resin ^[60]	inverted vat polymerization

In Fig. 6, the various materials are presented in relation to the previously defined application categories, allowing for the identification of potential trends. The data reveal that PLA is utilized across all categories. Furthermore, it is evident that the greatest variability in material choice is found within the domains of visualization and educational training.

Practical Testing on the Phantom

A survey was conducted among nine neurosurgeons at the Department of Neurosurgery, University Hospital Leipzig, with the objective of evaluating the visual and haptic properties of the model. The assessment was conducted employing a Likert scale ranging from 0 to 10 (0 = does not apply at all, poorly represented; 10 = fully applies, highly realistic). The evaluation process entailed two craniotomies and the milling of a predefined area, simulating a retrosigmoid approach for the treatment of an acoustic neuroma.

The results are presented in Fig. 7. Overall, the material was rated as realistic, with a mean score of 7.2. One participant noted that the material appeared slightly too rigid and criticized the absence of an internal porous structure (spongiosa).

A comprehensive review of the extant literature reveals a broad array of materials and printing technologies that have been employed. To provide a more comprehensive contextual analysis, Fig. 8 presents a graphical representation of the distribution of the various manufacturing methods.

Given the prevalence of PLA and ABS, material extrusion—particularly the Fused Deposition Modeling (FDM) process—emerges as the prevailing printing technique, accounting for approximately 60% of the cases. The phenomenon under discussion can be attributed to several factors. Firstly, the financial burden of materials and printers is relatively minimal. Secondly, there is a wide availability of suppliers and compatible materials. Thirdly, FDM devices are comparatively simple to operate and handle. Furthermore, FDM has become one of the most widely used additive manufacturing techniques around the world. The second most prevalent printing technologies are inverted vat polymerization and material jetting. These methods find application in resins from companies such as Formlabs, as well as in PolyJet and VisiJet materials. Despite the higher cost of these processes compared to FDM, they provide distinct advantages in terms of resolution and surface quality, enabling the fabrication of more intricate models. Additionally, material jetting enables the fabrication of multicolored models in a single print, a feature that is particularly advantageous for educational and demonstrative applications. Binder jetting and powder bed fusion—particularly the Selective Laser Sintering (SLS) process—are utilized with reduced frequency for the fabrication of neurosurgical skull phantoms. This occurrence can be attributed to the significant financial investments necessary for acquiring the essential equipment and materials, as well as the limited availability of suitable materials. Additionally, the post-processing, maintenance, and cleaning requirements for these devices are relatively intensive, rendering them less suitable for the production of individual models.

A comparison of the application domains (Fig. 6) with the materials employed reveals no direct correlation. A notable example is the field of education and hands-on training, where surgical procedures are simulated, exhibiting significant variability in the materials utilized. This variation can be attributed to several factors, such as cost, the availability of specific printers, and material accessibility. However, a paucity of publications has been observed in the extant literature regarding the evaluation of material properties during drilling or milling. This may be attributable to the fact that the skull replicas were principally designed for visual purposes or that manipulation with surgical instruments was not necessary. Consequently, a meticulous study was undertaken to assess the material that received the highest ratings during the preliminary selection process. The material was evaluated by an experienced neurosurgeon (White V4 by Formlabs) through a hands-on testing process conducted by multiple neurosurgeons. The material was generally well-received. Among the nine participants, two perceived the substance as moderately hard, with one specifically noting the absence of an internal porous structure (spongiosa). In contrast, three participants regarded it as somewhat too soft. The divergent evaluations can be attributed to a number of factors. One potential explanation for this observation is the anatomical location of the defined surgical access. The test entailed a retrosigmoid approach, which intersects with the mastoid bone by approximately one-third. This region of the cranium is characterized by substantial thickness, which complicates excision. In the present configuration, the drilling point was situated within this region, necessitating increased exertion and potentially impacting the subjective perception of drilling resistance. Another potential factor in the variability of responses is the wear of the craniotome used. It is important to note that a single craniotome, and thus a single cutting tool, was available for the entirety of the testing period. Consequently, it is plausible that the tool experienced wear over time, leading to subsequent participants perceiving the material as harder. Finally, and perhaps most significantly, individual subjective experience plays a critical role in interpreting the results. For instance, the influence of prior surgical interventions on the participant's evaluation is a potential confounding factor. In the event that a surgeon has recently performed surgery on a patient with particularly soft bone, a consequence of advanced age or other underlying conditions, the surgeon may assess the material as overly hard, or vice versa.

The utilization of three-dimensional printing in the fabrication of medical phantoms and simulation models has undergone a substantial increase over the past 15 years. This trend can be attributed to three factors. First, there has been a growing diversity of 3D printing technologies. Second, there has been an expansion of the range of materials. Third, there has been improved accessibility. In the design of such models, the creation of anatomically realistic visual and haptic representations is of paramount importance. To this end, a comprehensive literature review of PubMed-listed articles on 3D printed skull models was conducted to gain an overview of the materials used. A total of 68 publications were identified. The analysis revealed that nearly 50% of the skull models described in the articles—regardless of their intended use—were made from PLA. This was followed by ABS at approximately 13% and resins from the company Formlabs at 10%. The prevalence of PLA can be attributed to its compatibility with a straightforward and widely accessible printing process, as well as its comparatively low cost. However, it should be noted that PLA does possess the drawback of not always providing sufficient mechanical strength to realistically replicate cranial bone. To identify a suitable material for the skull phantom, test drilling was performed using a craniotome on various materials and printing methods that were available. Subsequent to the analysis of the results, a phantom was fabricated using the material that demonstrated the most promising results. The bone replica was subsequently evaluated by nine neurosurgeons at the University Hospital Leipzig. The evaluation utilized a custom-developed Likert scale to assess the strength and realism of the replica. The final phantom was produced using White V4 resin from Formlabs. The material in the study was evaluated as relatively realistic, receiving a rating of 7.2. However, a certain degree of variation in assessments was observed. Two participants perceived the material to be too hard in comparison to real bone, while three others found it to be too soft. This variability may be attributed, for example, to the wear of the cutting instrument used. Additionally, the evaluation process was inherently subjective and may have been influenced by prior surgical interventions or individual experiences.

In summary, a range of materials can be utilized in the fabrication of skull models. The selection is influenced by several factors, including cost, compatible printing technologies, and intended application. The present study demonstrated that White V4 from Formlabs is a suitable material for replicating drillable cranial bone.

Ethics approval and consent to participate

Not applicable

Consent for publication

Not applicable

Availability of data and materials

The data are given in the paper and can be received on request.

Competing interests

The authors declare that they have no competing interests.

Funding

Open Access funding enabled and organized by Project DEAL. The study was carried out as part of project 16KN081071 under the ZIM funding program of the German Federal Ministry for Economic Affairs and Climate Protection.

Authors’ contributions

Author Svenja Jung wrote the main manuscript and is responsible for the research and the 3D printing. Svenja Jung is also co-responsible for the design process of the simulation model. Maike Stummer is responsible for the construction of the simulation model and co-responsible for the design process. Dirk Winkler, Erdem Güresir and Felix Arlt accompanied the clinical part of the study and provided their expertise in the medical background. Ronny Grunert and Felix Arlt prepared the methodology of the project.

Acknowledgements

Not applicable

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Reviewers agreed at journal
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Suitable materials for the creation of neurosurgical phantoms using the example of a 3D printed simulation model of the posterior fossa

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Background

Methods

Selection Criteria for the Material Review

3D printed simulation model of the posterior cranial fossa

Material selection for the phantom

Manufacturing of the phantom

Results

Material Review

Practical Testing on the Phantom

Discussion

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