Morphometric characterization of normal and dysplastic canine coxofemoral joint using radiography, and 3D printed models

doi:10.21203/rs.3.rs-3950632/v1

Background: The present study aimed to differentiate between normal and dysplastic canine coxofemoral joints by assessing the corresponding bone specimens and digital X-rays moreover, our study provides a substitute teaching strategy using 3D-printed models of canine coxofemoral joints. This work was conducted on twenty-eight mixed breed dogs, sixteen dogs were used for bone preparation samples by boiling method, then these bones were scanned to create relatively identical 3D printed models. twelve dogs were anesthetized for the radiological study. An extended ventrodorsally radiograph of the coxofemoral joint was obtained to calculate the Norberg angle, Centre-edge angle, and dorsal acetabular femoral head coverage width and area indices.

Results: The study's results illustrated the normal conformational anatomic criteria associated with healthy coxofemoral joints versus dysplastic joints in both bone specimens and 3D-printed models. In a normal joint, the coxofemoral articulation was congruent and smoothly margined with the acetabulum being deep and the femoral head being hemispherical. However, the dysplastic coxofemoral joint showed shallow acetabular fossa and a deformed, flattened femoral head with associated osseous proliferation and joint incongruity. The Norberg angle, Centre-edge angle, dorsal acetabular femoral head coverage width, and area indices differed significantly between normal and dysplastic joints. In normal coxofemoral joints, the mean ± (standard deviation) SD value of the Norberg angle was 115.5± 3.05 a, and the Centre-edge angle was 32.57± 3.54 a. The indices of dorsal acetabular femoral head coverage area and width were 52.94± 3.41 a, and 58.32± 5.33 arespectively.

Conclusion: Finally, this work presented alternative teaching models (3d printing) that play an important role in the veterinary field and assist in the understanding of the normal structure and dysplastic state of canine coxofemoral joint. Also, some parameters were measured in x-rays of normal and dysplastic coxofemoral joint to detect hip dysplasia, which helps exclude the highly diseased dogs before breeding.

coxofemoral joint

3d models

canine hip dysplasia

radiography

Norberg angle

Centre-edge angle

acetabular femoral head coverage

The canine coxofemoral joint is a ball and socket joint formed by the femur's convex hemispherical head that fits into the deep cotyloid cavity of the acetabulum. It is a very flexible joint with a remarkable range of motion. (1, 2, 3). Canine hip dysplasia is a common orthopedic condition characterized by atypical development or malformation of the coxofemoral joint, which can cause variable degrees of pain, lameness, subluxation, and instability causing osteoarthritis. The disease can influence dogs of all sizes and breeds; however, larger breed dogs such as German Shepherds, Great Danes, Saint Bernards, and Labrador Retrievers are more predisposed to hip dysplasia (4, 5, 6). Genetic and environmental factors, such as weight gain, intense exercise on hard surfaces, and slippery flooring work together to conform to the development of the disease (7, 8, 9). Many clinical signs, including a lower step height, bunny hopping, trouble getting upstairs, difficulty in walking and running, and thigh muscle atrophy were noticed in dogs suffering from hip dysplasia. (7, 10). Pelvic radiography has been reported to be the most widely used modality to diagnose and monitor hip dysplasia in dogs (11, 12, 13, 14, 15, 16). Several radiographic techniques have been utilized to screen coxofemoral joints in dogs, such as the PennHIP method used to evaluate hip joint laxity (HJL) and included 3 views of the animal: hip-extended, compression, and distraction. In the distraction view, the distance between the femoral head centers, and the acetabulum is divided by the radius of the femoral head distance was used for calculating the distraction index (DI). (13), In the half axial position (HAP) method, the dogs placed in dorsal recumbency the coxofemoral (CFJ) were displaced laterally by the distractor, and the joint laxity was calculated by a similar method of the distraction index (DI). (17, 18), The Flückiger method was used to assess the laxity degree with a method analogous to DI which is identified as the subluxation index (19), and the dorsal acetabular rim method was used to evaluate the dorsal part of the acetabulum and calculate the slope of the dorsal acetabular rim (DAR) which in normal CFJ should be less than 7.5. (20, 21)

Artificial intelligence (AI) is considered the branch of computer science focusing primarily on creating intelligent machines that behave and react similarly to humans, these machines implement many tasks such as understanding learning, planning, and solving issues. (22, 23) AI has many unique advantages in education, such as deep learning and accessible replacement provided by adding 3D images to visual learning or integrating them with 3D printing to make realistic, precise models of anatomical body parts. The 3D printing technology has been recently used widely in medicine and education (24). Nowadays, anatomy laboratories use 3D-printed anatomical models as an additional educational tool to boost more traditional ones like dissection (25). It is anticipated that 3D printing technologies will improve anatomy instruction with more detailed illustrations. (26, 27) 3D printing is a quick and efficient method of real prototyping that produces 3D solid replica materials from a digital file (28). In veterinary medicine, high-quality 3D-printed models have many benefits. They can be used as effective alternative teaching materials because they are easily manipulated and can be readily obtained and used to substitute animal specimens (29). The 3-D printed models can also enhance the efficiency and accuracy of teaching at a relatively lower cost compared to real specimens (29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41)

In addition, junior orthopedic surgeons and practitioners can improve their skills by reviewing surgical procedures on 3D models before doing the actual surgery. (30, 42, 43) Therefore, the objective of the current study was to demonstrate the differences between a normal canine coxofemoral joint and a coxofemoral joint affected with hip dysplasia via utilizing prepared real bone specimens, 3D printed models of a canine hip joint, and ventrodorsal pelvic radiographs. Our potential plan is to utilize simulating 3D printed models of canine coxofemoral joints for teaching and research purposes, as well as to help with diagnostic and surgical interventions via training of both undergraduate and postgraduate veterinarians.

Animals

Our study was applied to twenty-eight adult mixed-breed dogs over 1-year-old were collected from different shelters and were investigated via clinical examination and radiography to select normal and dysplastic coxofemoral joints. Sixteen normal and dysplastic dogs (confirmed via radiography) were euthanized for bone specimen preparation. twelve dogs with and without hip dysplasia/OA (confirmed via radiography) were used for radiographic assessment of their coxofemoral joints. The study protocol was approved by the Veterinary Medicine Cairo University Institutional Animal Care and Use Committee (Vet-CU-25122023843).

Bone specimen preparation (boiling method)

Dogs were euthanized with I/V injection of Sodium Pentobarbitone solution 150–200 mg/kg (PENBITAL EUTHA 400 mg/ ml, joint-stock company Bioveta, Czech) (44, 45, 46). The dogs were eviscerated, and the pelvic regions were separated from the rest of the body. The skin, muscles, and soft tissues of each hip region were removed to expose the os coxae and femurs as previously described (47, 48, 49). The bones were boiled in a metal container filled with water and a small amount of sodium carbonate for 3 hours until softening the flesh then left to dry in the air (49). The bony samples were degreased in an acetone solution for 3 days and then were left in the air to dry (50). Finally, the bones were bleached by immersing them in 10% hydrogen peroxide solution for 3–6 days. (47, 48, 51, 52). This process lasted for 10–15 days to obtain all bone specimens.

3D printed models.

The bony specimens were digitalized and scanned using the EINSCAN PRO 2X MULTI-FUNCTIONAL HANDHELD 3D SCANNER (SHINING 3D) (SHINING 3D Tech Co., Ltd. Hangzhou, China) (29, 47, 53, 54). The average scanning time was approximately 30 minutes (47, 53). The images taken by the 3D scanner were handled and processed by a software program called Prusa Slicer 2.5.2 (PRUSA RESEARCH by JOSEF PRUSA, Czech). The material used for the 3D model production was polylactic acid (PLA) with 50% infill (30, 55, 56, 57). The printing nozzle size on the software was 0.15 mm to increase the accuracy of the printed model, with the printing temperature being 215 C and the printing time for getting a 3D replica being 10 hours. The printing machine was an Original Prusa i3 MK3S + 3D printer (PRUSA RESEARCH by JOSEF PRUSA, Czech). (25, 29, 54, 47, 53, 55). The software and printer parameters are summarized in Table 1.

Table 1

The parameters associated with the utilized software and 3D printer.
Software parameters		Printer Parameters
support	Everywhere	Temperature	215 C
infill	50%	Time	12 h
the material used	PLA (polylactic acid)	Cost	1000 EGP
Nozzle	0.15 mm	Nozzle	0.4 mm
		Type of bed	Smooth

Radiographic procedures

The dogs were sedated for the radiographic study using atropine sulfate (0.04 mg/kg, S/C) (Atocan®, Sishui Xierkang Pharma, China) and 0.5 mg/kg of xylazine hydrochloride (Xylazine 20 Inj®, Kepro, Holland) I/M. An extended ventrodorsal radiographic view of the pelvis was obtained to evaluate the corresponding coxofemoral joint. All digitized radiographs were assessed for quality and positioning with the femurs being parallel and no pelvic tilting. The radiographs were categorized into normal and dysplastic/OA coxofemoral joints based on the radiographic findings associated with each category previously described (5, 13, 58, 59, 60). The radiographic criteria of coxofemoral joint in normal dogs show a well-formed acetabulum with little joint space and a deeply seated femoral head working together perfectly. The femoral head is nearly entirely covered by the acetabulum and the craniolateral acetabular edge seems sharp and slightly smoothed. (20, 61)

But in dogs with a mild degree of CHD, the radiograph displays incongruency between the acetabulum and femoral head, so the femoral head was partially covered by the acetabulum and mild symptoms of osteoarthrosis (OA) and a little flattening of the craniolateral acetabular rim. In dogs with moderate CHD degrees, there is a noticeable incongruity between the acetabulum and the femoral head. a shallow acetabulum was marginally occupied by the femoral head and the presence of subluxation. Secondary arthritic alterations typically occur in the femoral head and neck. In the case of severe canine hip dysplasia, there is an apparent flattening in the cranial acetabular rim and mushroom shape of the femoral head in addition to the femoral head protruding entirely or partially from a shallow acetabulum. Around the femoral neck and head, as well as the acetabular rim, there are significant secondary arthritic bone alterations. (61).

All radiographic measurements (Norberg angle, center-edge angle, and dorsal acetabular femoral head coverage width and area indices) were performed using Image J software (ImageJ 1.41/Java 1.6.0_21). The Norberg angle (NA) {α} measured between two lines, the first line joining the femoral head centers {A} and the other line joining the femoral head center to the corresponding craniolateral acetabular edge {B}. (Figure. 5). (5, 20)

The Modified center-edge (CE) angle {θ} is located between two lines starting from the center of the femoral head, one was parallel to the long axis of the matching ilium's body {a} and the other tangential to the lateral acetabular rim {b}. (Figure. 6) (5, 62)

The dorsal AFH coverage width was measured by dividing the width of the dorsal AFH coverage {w} by the corresponding femoral head diameter {di} that divides and is perpendicular to the dorsal acetabular rim. (Figure. 7. A) (5, 12)

The dorsal AFH coverage area was computed by dividing the area of the femoral head which is covered by the dorsal acetabular edge and acetabulum {a} by the total corresponding femoral head area {A}. (Figure. 7. B&C). (5, 12)

Statistical Analysis :

The radiographic measurements were analyzed using (Graph- Pad Prism version 8.00, La Jolla, California, United States). A one-way analysis of variance (ANOVA) was conducted, and Tukey’s post hoc test was employed to compare the radiographic measurements among the four groups of coxofemoral joints (normal and mildly, moderately, and severely dysplastic joints). Mean ± SD values of all parameters were calculated, and a significant difference was set at a P-value < 0.05.

Bone specimens and 3D-printed models

The gross anatomy differed significantly between normal and dysplastic coxofemoral joints in both real bone specimens and the corresponding 3D printed models of the joints. The normal acetabular fossa of the bone specimen and associated 3D printed model showed a deep, smooth cotyloid cavity (Fig. 1. A&C / 8). Likewise, the femoral head specimen and corresponding 3D printed model showed a convex hemispherical shape with a smoothly margined femoral head and neck (Fig. 1. B&D / 12). The femoral-acetabular articulation appeared congruent in the prepared joint specimen and the corresponding 3D-printed model.

In mild and moderate degrees of canine hip dysplasia, real bone specimens and 3D printed models showed a limited reduction in the concaveness of the acetabular fossae exhibiting relatively shallower acetabula compared to those of normal joints (Fig. 2&3. A&C / 8). Furthermore, femoral heads exhibited variable (mild and moderate) degrees of flattening and thickened femoral necks (Fig. 2&3. B&D / 12). There were bone spurs of variable sizes (according to the degree of coxarthrosis “OA”) associated with the acetabular rims and femoral heads and necks. In severe hip dysplasia/OA, the acetabular fossa was flat, shallow, and lost its concaveness (Fig. 4. A&C / 8). Additionally, the femoral head was deformed and mushroom-shaped (Fig. 4. B&D / 12) with extensive bone spurs identified along the acetabular rim and femoral head and neck. All real joint specimens with mild, moderate, and severe coxarthrosis, as well as their corresponding 3D printed models, revealed variable degrees of joint incongruity. Additional anatomical details of the bone specimens and the corresponding 3D printed models are illustrated in all figures.

Three-D-printed models of a canine coxofemoral joint revealed a relatively better impact in some aspects related to sample manipulation and preservation, animal rights, hygiene, sample weight, preparation time, effort, and cost. However, a real canine coxofemoral joint revealed better mobility, accurate anatomic joint configuration, and disease grading (Table 2).

Table 2

A comparison between the real bone specimens of a canine coxofemoral joint and the corresponding 3D-printed model.
Differentiation aspect	Real coxofemoral joint	3D-printed coxofemoral joint
Limitation for manipulation	Present	Absent
Limitation for preservation	Present	Absent
Movability of hip joint	More movable	Less movable
Protect the animals’ 3 Rights	No	Yes
Sanitary and hygiene	Absent	Present
Accuracy of anatomic configuration	Present	Absent
Accuracy of grading hip dysplasia	Present	Absent
Weight	Heavier	Lighter
Preparation time, effort, and cost	Longer time, high effort, and cost	Short time, low effort, and cost

Radiographic procedures:

Mean (± SD) values for all reported radiographic measurements are summarized in Table 3. There was a significant difference in the Norberg angle, center edge, dorsal acetabular femoral head coverage width index, and dorsal acetabular femoral head coverage area index measurements between the normal group and dysplastic groups. Furthermore, there was no significant difference in dorsal acetabular femoral head coverage width (mm), femoral head diameter (mm), and dorsal acetabular femoral head coverage area (mm²) between the normal and dysplastic groups reported in this study.

Statistical analysis:

Table (3) shows the mean ± SD and 95% CI values of all the radiographic parameters. Different letters were utilized between groups to signify the significance at a level of P ≤ 0.05.

	Normal (N = 3)		Mild (N = 3)		Moderate (N = 3)		Severe (N = 3)		P-value / Power
	mean ± SD	95% CI	mean ± SD	95% CI	mean ± SD	95% CI	mean ± SD	95% CI	P-value / Power
Norberg angle (degree)	115.5 ± 3.05 a	112.3 -118.7	102.3 ± 2.63 b	99.58–105.1	97.41 ± 3.96 b	93.25–101.6	95.10 ± 7.84 b	86.87–103.3	0.0001/ 0.19
Center edge angle (degree)	32.57 ± 3.54 a	28.84–36.29	15.33 ± 1.30 b	13.96–16.70	13.70 ± 1.98 b	11.62–15.78	10.64 ± 7.05 b	3.24–18.05	< 0.0001/ 0.19
Dorsal acetabular femoral head coverage width (mm)	11 ± 1.43a	9.50–12.51	9.04 ± 1.37 a	7.60 -10.49	9.036 ± 3.91 a	4.92–13.15	9.60 ± 1.57 a	7.94–11.25	0.4282 / 0.168
Femoral head diameter (mm)	18.86 ± 1.79 a	16.98–20.74	22.60 ± 3.95 a	18.45–26.75	21.84 ± 10.63 a	10.68–32.99	26.95 ± 7.29 a	19.30–34.61	0.3172/ 0.168
Dorsal acetabular femoral head coverage width index	58.32 ± 5.33 a	52.72–63.92	40.42 ± 5.30 b	34.85–45.99	42.77 ± 4.25 b	38.30–47.23	37.63 ± 12.33 b	24.69–50.57	0.0112/ 0.29
Dorsal acetabular femoral head coverage area (mm²)	160.6 ± 27.62 a	131.6–189.6	160.7 ± 50.97 a	107.2–214.2	140.1 ± 92.18 a	43.40–236.9	166.1 ± 46.82 a	117.0–215.3	0.766/0.23
Femoral head area (mm²)	303.7 ± 51.40 a	249.7 -357.6	386.6 ± 121.0 a	259.6–513.6	449.2 ± 345.0 a	87.20–811.3	542.8 ± 245.0 a	285.7–800.0	0.36/ 0.23
Dorsal acetabular femoral head coverage area index	52.94 ± 3.41 a	49.35–56.52	41.67 ± 3.78 b	37.70–45.65	33.34 ± 4.209 b	28.92–37.75	33.60 ± 11.98 b	21.03–46.16	0.0074/0.16

N, number of animals; SD, standard deviation; CI, confidence interval

In the present study, we have been shown the difference between the normal and abnormal (dysplastic) canine coxofemoral joint that was composed of two bones the os coxae and femur bone. In the normal case, the acetabular fossa showed a deep cotyloid cavity while the head of the femur appeared as a convex hemispherical shape these results are in agreement with (1, 2, 3).

Our investigation reported different degrees of canine hip dysplasia which were variable from mild, moderate, and severe. In the cases of mild to moderate degrees, some flattening in the femoral head was noticed, and the acetabular fossa displayed a minor decrease in concavity and flattening that was not typical while in dogs that suffer from a severe degree of dysplasia, the femoral head showed distortion, and the acetabular fossa lost its concave shape and became flattened the same was reported by (7, 54, 63, 64).

The performed studies on dogs revealed that 3D-printed models are beneficial in veterinary medicine for several reasons. They are an effective teaching tool that makes models easily manipulable, and readily available, helping in substituting live animal samples and saving anatomical samples that are valuable and uncommon. In addition to aiding in studying gross anatomy, this result is similar to (29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40).

Our study recorded that there are many educational techniques such as plastic models (3D printing models) that are made from polylactic acid have replaced the conventional lectures and whole-body dissection used in anatomy curriculum teaching which act as an important basis for self-directed learning which students are more likely than the traditional method and these 3d models help in retaining the material they are studying (deep learning), Deep learning would be provided by Artificial intelligence (AI) systems by combining 3-D photos with 3D printing to create accurate, lifelike replicas of anatomical body parts in agreement with those (65, 66, 67, 68, 69, 70)

Our printed hip bones presented great accuracy in the copying, where it sustains the similar width, thickness, and length of the original bones that helped in anatomy learning. Besides, the 3d printed models were lighter than the original bone pointing to the storage stability and movability of greater animal bones. This was confirmed by (54, 55) on the other hand, (71) stated that there is a difference between the prototypical and the actual anatomy. As revealed in this study, 3D-printed models can help as references for research including orthopaedical operating preparation. (72) Otherwise, in the opinion of (73) the 3D models do not show the biological difference and absence of pathological reality which may cause incorrect diagnoses and practices in actual clinical situations. However, the advantages of 3D models cover different other sides as the costs correlated to creating anatomical models are minor than the cost of $ 4189 producing plastinated samples (25). We found that the filament used is more resistant than real bone. during the printing process using the PLA, we noticed no hurtful substances that may hurt human health (55)

the development of the 3D anatomical models of CHD required the complete dominion of the suitable software for the right generation of the desired deformities, always preserving the proper sizes and preserving bone and structural esthetics. (54)

According to the British Veterinary Association, the Kennel Club (BVA/KC), the Orthopedic Foundation for Animals (OFA), and the Federation Cynologique Internationale ((FCI), the most common diagnostic method used in canine coxofemoral joint evaluation is Extended ventrodorsally (VD) pelvic X-ray (13, 15, 19, 74, 75, 76)

The current investigation revealed that many measurements are used to detect canine hip dysplasia (CHD), such as Norberg angle (NA), Centre-edge angle (CE), dorsal acetabular femoral head (AFH) coverage width index, and dorsal acetabular femoral head (AFH) coverage area index.

The Norberg angle is calculated by two lines, the first line between the two femoral heads' centre, and another line runs from the center of the femoral head to the cranial edge of the ipsilateral acetabulum, in our study the dogs with a normal coxofemoral joint the mean ± SD value of the NA angle was 115.5 ± 3.05 a. while in case of canine hip dysplasia was below 115.5 ± 3.05 a, these outcomes mirrored those that had previously been reported by (14, 16, 20, 77, 78, 79, 80)

The Centre-edge (CE) angle is located between two straight lines one of the two straight lines that originate from the femoral head's center connects it to the lateral margin of the acetabulum, while the other line runs parallel to the related iliac body’s long axis. the mean ± SD value of this angle in normal canine coxofemoral joint was 32.57 ± 3.54 a. These findings support those that were previously reported by (12) otherwise, (5, 58, 59, 60) mentioned that the Centre-edge (CE) angle in Labrador Retrievers and German Shepherds dogs with CHD is below 27° and 21.8° respectively.

Our study demonstrated that indices of dorsal AFH coverage width and area are measured to determine the % of dorsal AFH coverage. The dorsal AFH coverage width index is defined as the dorsal AFH coverage width divided by the diameter of the same femoral head. while the dorsal AFH coverage area index is defined as the dorsal AFH coverage area divided by the total area of the same femoral head. the mean ± SD value of indices of dorsal AFH coverage width and area in the normal hip joint were 58.32 ± 5.33 a, and 52.94 ± 3.41 a respectively these results were in agreement with (14), whereas (5, 12) reported that the dorsal AFH coverage width and area indices in Labrador Retrievers and German Shepherds suffering from CHD were less than 51 and 49%, and < 53 and < 50%, respectively.

Through this study, we conclude that the 95% CI of Centre-edge or Norberg angle less than 28⁰ or 112⁰, correspondingly, would indicate a possibility of the incongruity of the canine coxofemoral joint and inadequate lateral AFH coverage. 95% CI of the indices of dorsal acetabular femoral head coverage width or area less than 52% or 49%, respectively, would mean inadequate dorsal covering and potential incompatibility of the coxofemoral joints. The lateral and dorsal acetabular femoral head coverage measurements would advise using both methods to assess the total femoral head acetabular coverage in strategy for screening.

Three-dimensional specimens, which closely mimic real bone specimens, are considered a modern educational method to help students in topographical anatomy learning and trainee surgeons recognize the anatomy of the surgical site where surgery will be performed. It is expected that in the future it could become an alternative to cadaver samples and thus this will reduce the number of animals killed to obtain bones.

AI	Artificial intelligence
3D	Three dimensional
CF	Coxofemoral
VD	Ventrodorsal
CHD	Canine hip dysplasia
IV	Intravenous
CFJ	Coxofemoral joint
PLA	Polylactic acid
AFH	Acetabular femoral head
FH	Femoral head
CE	Centre edge
NA	Norberg angle
OFA	Orthopedic Foundation for Animals
FCI	Federation Cynologique Internationale
BVA/KC	British Veterinary Association, the Kennel Club
SD	Standard deviation
HJL	Hip joint laxity
DI	Distraction index
HAP	Half Axial Position
OA	Osteoarthrosis

Ethical Approval

All animals were treated and used by following ethical approval from the Veterinary Medicine Cairo University Institutional Animal Care and Use Committee (Vet- CU- IACUC) with an approval number 25122023843.

Consent to participate: All the authors have read and approved the manuscript.

Consent for publication: Not applicable

Availability of data and materials

All data collected or analyzed during this study are included in this published paper. the authors confirm that the data supporting the findings of this study are available within the article. Raw data that support the findings of this study are available from the corresponding author, upon reasonable request.

Conflict of interest

There are no conflicts of interest to declare.

Funding

Open access funding is provided by the Science, Technology & Innovation Funding Authority (STDF) in cooperation with The Egyptian Knowledge Bank (EKB).

Acknowledgments

Not applicable

Authorship contribution statement

Noor and Shaker created the idea for the article. Mostafa, Shaker, Tolba, Noor, Farid, and Abouelela designed the research work, Mostafa, and Gebriel performed the x-ray andTolba, Abouelela, and Gebriel performed the 3D models.Farid, Abouelela, and Shaker revised the manuscript draft. All authors reviewed and approved the last version of the manuscript.

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No competing interests reported.

Morphometric characterization of normal and dysplastic canine coxofemoral joint using radiography, and 3D printed models

Status:

Version 1

Abstract

Figures

Introduction

Materials and methods

Animals

Bone specimen preparation (boiling method)

Radiographic procedures

Statistical Analysis :

Results

Bone specimens and 3D-printed models

Radiographic procedures:

Statistical analysis:

Discussion

Conclusion

Abbreviations

Declarations

References

Additional Declarations

Status:

Version 1